West German Study Group Phase III PlanB Trial: First Prospective Outcome Data for the 21-Gene Recurrence Score Assay and Concordance of Prognostic Markers by Central and Local Pathology Assessment

PURPOSE

The 21-gene Recurrence Score (RS) assay is a validated prognostic/predictive tool in early hormone receptor-positive breast cancer (BC); however, only a few prospective outcome results have been available so far. In the phase III PlanB trial, RS was prospectively used to define a subset of patients who received only endocrine therapy. We present 3-year outcome data and concordance analysis (among biomarkers/RS).

PATIENTS AND METHODS

Central tumor bank was established prospectively from PlanB (intermediate and high-risk, locally human epidermal growth factor receptor 2-negative BC). After an early amendment, HR-positive, pN0-1 patients with RS ≤ 11 were recommended to omit chemotherapy.

RESULTS

From 2009 to 2011, PlanB enrolled 3,198 patients with a median age of 56 years; 41.1% had node-positive and 32.5% grade 3 disease. In 348 patients (15.3%), chemotherapy was omitted based on RS ≤ 11. After 35 months median follow-up, 3-year disease-free survival in patients with RS ≤ 11 and endocrine therapy alone was 98% versus 92% and 98% in RS > 25 and RS 12 to 25 in chemotherapy-treated patients, respectively. Nodal status, central and local grade, the Ki-67 protein encoded by the MKI67 gene, estrogen receptor, progesterone receptor, tumor size, and RS were univariate prognostic factors for disease-free survival; only nodal status, both central and local grade, and RS were independent multivariate factors. Histologic grade was discordant between central and local laboratories in 44%. RS was positively but moderately correlated with the Ki-67 protein encoded by the MKI67 gene and grade and negatively correlated with progesterone receptor and estrogen receptor.

CONCLUSION

In this prospective trial, patients with enhanced clinical risk and omitted chemotherapy on the basis of RS ≤ 11 had excellent 3-year survival. The substantial discordance observed between traditional prognostic markers and RS emphasizes the need for standardized assessment and supports the potential integration of standardized, well-validated genomic assays such as RS with clinicopathologic prognostic factors for chemotherapy indication in early hormone receptor-positive BC.

Abstract P6-05-11: Run-in phase of prospective WSG-ADAPT HR+/HER2- trial demonstrates feasibility of early endocrine sensitivity prediction by recurrence score and conventional parameters in clinical routine

Background: Despite promising evidence regarding outcome prediction, endocrine sensitivity, as determined by proliferation response to short-term preoperative endocrine therapy, is currently not included in adjuvant chemotherapy decisions in early HR+/HER2- breast cancer (BC).

Methods: The prospective WSG-ADAPT HR+/HER2- trial includes early BC patients with 0-3 positive LN who are candidates for adjuvant chemotherapy based on clinical-pathological criteria alone; it aims to spare chemotherapy in a substantial proportion utilizing a combination of genomic assessment by Oncotype DX and endocrine sensitivity testing. All patients received 3-week preoperative endocrine induction therapy (ET): aromatase inhibitors (AI) if postmenopausal, tamoxifen if premenopausal. Patients with low (0-11) Recurrence Score (RS) or intermediate RS (12-25) and ET response (centrally tested, post-therapy Ki-67 <10%) are recommended to forego adjuvant chemotherapy (“low-risk” patients). Distribution of RS, responder percentages in each group, and impacts of RS, ET regimen, and initial Ki-67 on post-therapy Ki-67 are reported here.

Results: As of 6/2013, 380 patients from 30 study centers had been enrolled in the ADAPT HR+/HER2- trial. Median age was 54 years. At first pre-planned analysis (5/2013), paired Ki-67 measurements (pre-/post-therapy) were available in 241 patients; RS was available in 208 cases (201 with paired Ki-67). RS was low in 21.6%, intermediate in 57.7%, and high in 20.7%; the respective risk group responder percentages (post-treatment Ki 67 <10%) were 84.1%, 73.9%, and 40.0% (p<0.001 when comparing low/intermediate vs. high, chi-square). In particular, these percentages support the pre-trial estimate of >70% endocrine responders in the intermediate genomic risk group, who could potentially be spared adjuvant chemotherapy. Median Ki 67 level decreases (as percentage of pre-treatment value) were 25% in premenopausal patients (tamoxifen, n = 101) vs. 75% in postmenopausal patients (AI, n = 115) (p<0.001, Mann-Whitney); median decreases by RS group were similar, 61% (low), 53% (intermediate) and 56% (high), respectively (p = 0.81, Kruskal-Wallis). In linear regression, pre-treatment Ki-67, endocrine regimen/menopausal status, and RS were all independent predictors for post-treatment Ki 67. Final run-in-phase analysis and validation will be presented after completion of endocrine induction therapy in 400 patients.

Conclusions: The Run-In Phase of the WSG ADAPT HR+/HER2- trial confirms trial design estimates of RS and proliferation response to induction ET. It indicates that the multicenter prospective ADAPT concept combining static and dynamic biomarker assessment for individualized therapy decisions in early BC is feasible. Proliferation response was strongly associated with therapy group (AI/post-menopausal vs. tamoxifen/pre-menopausal). Survival non-inferiority of intermediate Recurrence Score proliferation responders vs. low Recurrence Score patients (active control) will be tested in the ADAPT main phase to determine if adjuvant chemotherapy can be spared in 70% of patients with 0-3 positive LN classified as “intermediate risk” by conventional factors.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-11.

Immune checkpoint targets on circulating epithelial cells in early and late breast cancer

e22201

Background: Our ongoing investigation of circulating epithelial cells(CEC) in early and late breast cancer with the MAINTRAC method (1ml blood, RBC lysis and fluorometric detection) has shown that CEC evade by hypoxia driven EMT (epithelial mesenchymal transition).We saw CEC with EMT and stemcellmarkers in early and late breast cancer. These cells can be found also in non cancer conditions. So far no differences in marker expression of CEC in cancer and noncancer conditions were found. This underlines the need for extended(e.g four color) analysis and allows searching for new promising targets like the immune checkpoint target PD-L1. Methods: We slightly adapted the basic MAINTRAC methodology to allow four color detection on the AMNIS FlowSight device.The IDEAS software allows comprehensive analysis of the populations. Beside four color analysis of single cells, TCA (tumor cell aggregates ) can be detected and characterized. The basic panel (EPCAMAF660.CD45PE,ALDH1FITC,DAPI) allows detection of living and death CEC and expression of the stemcell marker ALDH1. A second panel allows detection of other targets like PD-L1. Results: With the three color based original method the blood of 188 patients with early and 62 with late breast cancer were examined. No differences between conventional subgroups nor molecular subtype groups were found. In a large non cancer (n=256) control group we found high CEC counts in a group of patients with liver affections (mostly NAFLD). In these patients CEC showed the same marker ecpression .In late breast cancer only 60% of patients showed detctable cell counts.In patients with agressive disease (triple negative or HER2 enriched) mostly none or small CEC numbers were detectable.With our recently started (so far n=48) four color assay we detected coexpression of ALDH1 and PD-L1 which are more specific markers then CD44high or vimentin. Conclusions: Extended four color analysis on CEC allows monitoring of living CEC with stemcellmarker expression. Detection of immune checkpoint determinants like PD-L1on CEC is possible, further unraveling the biology of early and late breast cancer.

ADAPT: Adjuvant dynamic marker-adjusted personalized therapy trial optimizing risk assessment and therapy response prediction in early breast cancer

TPS655^

Background: Indication of (neo-)adjuvant therapy is based on risk profile, hormone receptor and HER2 status at time of primary diagnosis. Data indicate dynamic proliferation changes after short-term induction therapy are superior to static initial biopsy results in predicting outcome and tumor response following neoadjuvant CTx in distinct BC subtypes. First generation trials such as TAILORx, MINDACT, NNBC-3, WSG planB utilize information of new prognostic/predictive tests to reduce overtreatment by CTx. Results still pending. ADAPT is a second generation trial addressing individualization of adjuvant decision-making in early BC by utilizing optimized pre-therapeutic biomarker information and early biomarker changes in a second core biopsy after 3-week subtype specific induction therapy. It aims at reducing over-/undertreatment in luminal tumors and optimizing therapy in HER2+ (T-DM1, pertuzumab) / TNBC (nab-paclitaxel + platinum/gemcitabine). Methods: Design: ADAPT combines static prognosis assessment by conventional markers (nodal status) and Recurrence Score (HR+) with dynamic measurement of proliferation changes after a short 3-week induction therapy, using the baseline diagnostic and repeat core biopsy following induction. ADAPT is a prospective, multi-center, controlled, non-blinded, randomized phase II/III trial, comprising an umbrella trial and 4 sub-trials (HR+/HER2-, HR+/HER2+, HR-/HER2+, TNBC). Eligibility criteria: Pre-/postmenopausal women with histologically confirmed unilateral primary invasive BC. Pts requiring CTx/targeted therapy with no contraindications. Statistics: Assumption across sub-protocols: CTx spared in 1120 HR+/HER2-, pCR achieved in 170 HER2+/TNBC pts. Outcome of good-proliferation responders/pCR pts will be compared to reference group (n=640 HR+/HER2- pts: low RS, no CTx, 94% 5yr survival). One-sided test of non-inferiority (3.2% margin, 90.8%) with alpha=0.05 will have 80% power. Present/target accrual:By 01/2013: 16/35 sites initiated. ADAPT HR+/HER2-: 161/4000 pts recruited. ADAPT HER2+/HR+: 9/380 pts recruited. ADAPT HER2+/HR- or TNBC: start of recruitment planned for Q2 2013. Clinical trial information: NCT01781338.

Abstract 1444: High-throughput four color detection and analysis of circulating epithelial cells in early and late breast cancer

The Maintrac technique (RBClysis,fluorometric detection and analysis on Olympus ScanR) detects more circulating epithelial cells (CEC) then other enrichment- based methods. In our ongoing early breast cancer study (n=177), we found >125 CEC/ml in 35% of patients. In advanced breast cancer 60% of patients had cell counts>125 cells/ml . In controls (n=98) we found 125-250 cells/ml in 2%. Extended evaluation of a non cancer control group showed >125 cells/ml in 90% of patients with liver affections such as nonalcoholic fatty liver disease(NAFLD) . Using a three colour- based technique living and dead (DAPI) EPCAM + cells coexpressing vimentin and in parallell EPCAM+ cells coexpressing Vimentin and CD44 were measured. We saw a very inhomogeneous EPCAM+ population with different expression patterns,which made analysis very tedious. Moreover, there was no detectable difference between the CEC in early and late breast cancer and in liver affections, in both situations CEC had epithelial-mesenchymal transition (EMT)- and stem cell characteristics. We aimed to perform a more comprehensive analysis of these CEC by introducing a fourth color.We modified the basic procedure of the Maintrac technique in order too allow analysis and detection of CEC on the AMNIS FlowSight. Cells are aspirated from 96 well microplates allowing four color detection and automated analysis with AMNIS IDEAS software. Total plate run is completed within 9 hours. Beside the fastness new items like detection of tumor microemboli (TME) and EPCAM- independent analysis of cells with a stem cell phenotype (CD44high,CD24 low) or metabolic markers (HIF-1,carboanhydrase 9) is possible. We currently use DAPI, EPCAMAF660, vimentin -PE and CD45-FITC as basic combination . A second run uses CD24-PE, CD45-FITC, CD44-PacBlue and EPCAM- AF660 . Double measurement of the EPCAM+CD45neg population as basic population for comparison is achieved . Comprehensive analysis of more defined circulating stem cells (CSC) is thus possible.This approach will clarify the differences between liver- and tumor-derived CEC thus avoiding false positive CTC counts in early breast cancer . Our preliminary results show detectable differences between patients with advanced cancer and NAFLD concerning highly defined CEC with with "stemness" expression (CD44high, CD24low, EPCAM+, CD45neg). Our focus is on a cell type with very high "dotted " expression of CD44, EPCAM and vimentin, seen already with three colour analysis. We are currently introducing other markers like ALDH1 and beta-catenin for better definition of CSC. Furthermore, detection of Her2 or other targets like PD-1 or phosphatidylserine are possible on this defined CEC. We will present extended data with the four color approach for CEC analysis in early and late breast cancer at the conference.

Citation Format: Leo Habets, Wolfgang Körber, Bettina Frenken, Ilham El Ghali, Mahmoud Danaei, Manfred Kusche, Uwe Peisker, Torsten Kroll, Katharina Pachmann. High-throughput four color detection and analysis of circulating epithelial cells in early and late breast cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1444. doi:10.1158/1538-7445.AM2013-1444

Abstract P1-07-16: Liver derived epithelial cells as source of false positive circulating tumor cells in early breast cancer

The MAINTRAC technique as introduced by our coworkers from Jena (RBC lysis, fluorometric detection and analysis on Olympius ScanR) detects more circulating epithelial cells than techniques using enrichment. Also cells with a low EPCAM expression are detected and not only the typical cells with bright expression found after immunomagnetic enrichment. The relative cheapness and reproducibility allows frequent monitoring during and after therapy Using 3 colour detection (EPCAMfitc, DAPI, Vimentin PE) living and dead circulating epithelial cells in EMT, or cells in EMT with stemcell markers (EPCAMfitc, Vimentin-PE, CD44PacBlue) can be detected. In early breast cancer (n = 135) cells can be found in 60% of patients and in 40% higher cell counts (>100 ml are detectable. A control population(n = 100) showed low numbers in 98% (e.g (<100 CECin 1 ml blood). Expression of the mesenchymal marker (vimentin) ranges between 10 and 40% with different expression. CD44 shows also a wide range of expression. Two main cell types can be distinguished: type 1 shows generalized but weaker expression patterns and a second type with very bright dotted expression. The clinical relevance of these subsets is not known and their behavior under therapy has not been analysed in depth yet. In advanced breast cancers high cell counts were detectable in most patients with a less agressive disease course. In the rapidly progressing unfavorable subtypes (TN and Her2+. HRneg) less or none cells were found. During crossvalidation in non cancer patients we found high cell numbers in several forms of liver affections (n = 108). The expression patterns of markers on these cells were not differing from those in cancer patients. So this same cell type merging EMT, stemcell an hypoxic stress markers is detectable in advanced and early breast cancer (n = 40) and in benign disease. These cells disappear or decrease after response to chemo or anti-hormonal therapy in cancer or antioxidant therapy in NAFLD. We believe that the evasion of these cells is driven by the same force in cancer as in non cancer conditions. We suggest that this are the wellknown hypoxic and hyperacidic conditions causing epithelial mesenchymal transition. Cancer cell hijack this functions occurring normally under these conditions to survive and to facilitate evasion. More comprehensive analysis (four colour analysis on the AMNIS Flowsight) is needed and should show differences in expression patterns of liver derived epithelial cells (LDEC) and real tumor derived epithelial cells (TDEC). Further clarification of these phenomena should give new insights of the biological events in early disease and the possibilities and reliability of “fluid biopsy”.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-07-16.

A circulating epithelial cell type merging stem cell, EMT, and hypoxic stress markers in early and advanced breast cancer

10600

Background: MAINTRAC as developed by our coworkers from Jena finds more CETC. They found CETC in 90% of high risk patients. Circulating cells in epithelial mesenchymal transition (EMT+) should be detectable in early disease. Methods: 2 colours (7AAD, EP-FITC) detected living and dead cells. Cells in EMT (EP-FITC, Vim-PE) were analysed in paralell. Complex marker expression urged us to introduce a three colour technique. 1. EPCAM-FITC, Vimentin-PE and DAPI , marking living or dead cells in EMT. 2. EP-FITC, Vim-PE and CD44 PB for stemness. ACA9 (hypoxia) and PARP-1 expression (genotox) were used too. Results: In the 2 colour phase we examined CEC in 110 patients with early disease and 44 patients with metastasis. Cells were detectable in both disease situations in 50 and 60% of patients, in a control population only in few patients low numbers were found. In non cancer situations e.g liver disease high numbers of EMT+cells were found.The results of 3 colour analysis are shown in the table. No clear differences between the classical risk groups are found, other subgroups are too small yet to be considered. Conclusions: Our findings show that in both disease situations cells merging EMT, stemcells ( EP+,Vim+.CD44+) and other markers are detectable. This cell type however is found also in non cancer conditions.We hypothesize that hypoxia is the common driver. Metastasis gives different patterns. Highly aggressive cancers show often none or few cells. In less agressive disease high cell numbers are found. We need to characterize the "benign" EMT phenomenon, as it could mingle with "real" CTC. Definitely liver is the source of these benign cells. Multi colour analysis will reveal the differences. Nevertheless monitoring of this special cell type could give new insights in the metastatic process in early and late disease. [Table: see text]

Marker molecules of human endometrial differentiation can be hormonally regulated under in-vitro conditions as in-vivo

An established cell culture system of isolated human endometrial stromal and epithelial cells has been used to study the effects of oestrogen and progesterone, as well as their antagonists, upon endometrial cells. Normal hormonal regulation in vivo was investigated simultaneously in endometrial tissue samples taken at different phases of the menstrual cycle. Several marker molecules analysed by immunohistochemistry appeared to depend strongly on endocrine regulation and could be traced in culture. Immunohistochemically, basic parameters of cell biology were identified in vitro, e.g. cell proliferation (Ki-67), adhesion molecules (beta3 integrin) and paracrine factors (leukaemia inhibitory factor). The most reliable parameters to assess hormonal influences were oestrogen and progesterone receptor molecules. Immunohistochemical localization could be improved by molecular biological analysis using RT-PCR. In the presence of oestrogen, a significant expression of hormone receptors was also shown by RT-PCR, and withdrawal of oestrogens and addition of gestagen, i.e. medroxyprogesterone acetate, caused receptor downregulation. Addition of the anti-oestrogen ICI 182.780 to cell-culture medium significantly decreased the synthesis of progesterone receptors.

Establishment of a human endometrial cell culture system and characterization of its polarized hormone responsive epithelial cells

Uterine epithelial cells from normal human endometrium were cultured as a primary cell culture in a dual-chambered system. The epithelial cells were isolated from endometrial tissue of the proliferative phase obtained by hysterectomy. The epithelial cells were seeded on Millicell CM filters coated with the extracellular matrix Matrigel. Depending on the culture conditions, the epithelial cells formed a polarized cell monolayer on Matrigel or gland-like structures in Matrigel. The epithelial cell polarity was maintained during culture, which could be proved by electron microscopy. The progesterone and estrogen receptors as typical marker molecules for physiologically intact endometrial epithelial cells could be detected immunohistochemically as well as by RT-PCR in vitro and were down-regulated by medroxyprogesterone acetate (MPA) used as progesterone analogue. As this cell culture system exhibits morphological and immunohistochemical characteristics, typical for the in vivo situation, and since it can be modulated by hormone treatment under the in vitro conditions described, it represents a valuable tool for investigating processes that are essential for endometrial differentiation and reproductive functions.

Expression of gap junction connexins in the human endometrium throughout the menstrual cycle

Expression of connexins, the proteins which comprise gap junction channels, is regulated by ovarian hormones in the female reproductive tract of rodents. In order to determine if these hormones also affect connexin expression in the human uterus, the distribution patterns of different connexins (cx26, cx32, cx43) were investigated by immunohistochemistry in human endometrial tissue collected throughout the menstrual cycle. During the early proliferative phase of the cycle extremely low staining for connexin 43 was observed and connexin 26 antigens could not be detected. An increase in the amount of connexin 43 in stromal cells and of connexin 26 in glandular and luminal epithelial cells was seen from days 11-15 of the cycle. Following ovulation, the expression of both connexins was suppressed and was completely abolished in the late secretory phase. Weak staining for connexin 32 was found mainly in the late proliferative and the early secretory phase and was restricted to the basal membrane region of the glandular cells. These results suggest that the different connexins could represent cell biological markers for the proliferation and differentiation of the human endometrium throughout the menstrual cycle.

[The effect of tubal sterilization on ovarian function]

Disturbances of menstrual cycle, as well as premature onset of climacterial symptoms, are discussed as late complications of diverse techniques of tubal sterilisation. A disturbance of the ovarian function is regarded as cause for the disorder known as "post-tubal ligation syndrome". This study should help to clarify if tubal sterilisation via bipolar high-frequency current influences the course of perimenopause. 109 patients were examined, who had been sterilised by this technique at the Department of Gynaecology and Obstetrics of the University of Cologne during the period 1980 to 1984. 103 patients formed the comparison group, all of whom had neither undergone tubal sterilisation nor hysterectomy. The age of these women of both groups ranged between 36 and 51. Patients of both groups were interviewed personally with regard to cycle irregularities, climacteric symptoms, and onset of menopause in the form of transverse examination. Simultaneously, blood tests were performed to establish the endocrinological status, and to examine FSH and 17-beta-oestradiol levels. Summing up, this study led to the following conclusions: 1. Menstrual disturbances, climacteric symptoms after tubal sterilisation during perimenopause do not occur more frequently than in a comparative group of the same age. 2. In comparison with a group of women with no surgical history, neither did cycle anomalies and ovarian deficiency symptoms in terms of climacteric complaints occur earlier, nor did early onset of menopause take place more often in this examined group of sterilised women. 3. Hormone analysis could not establish any significant differences between both groups in respect of endocrinological parameters in the perimenopause.(ABSTRACT TRUNCATED AT 250 WORDS)

Biosynthesis of heparin. Purification of a 110-kDa mouse mastocytoma protein required for both glucosaminyl N-deacetylation and N-sulfation

The polymer modification process in the biosynthesis of heparin/heparan sulfate is initiated by N-deacetylation, followed by N-sulfation, of N-acetylglucosamine units. Chromatography of a detergent extract from mouse mastocytoma on wheat germ agglutinin-Sepharose yielded a protein fraction, eluted with 0.3 M N-acetylglucosamine, that expressed N-deacetylase activity, but only after recombination with proteins that did not bind to the lectin column. In subsequent purification of the active lectin-bound component, all assays were performed following addition of the unbound protein fraction. After two additional chromatography steps, on blue Sepharose and 3',5'-ADP-agarose, the lectin-binding N-deacetylase component had been purified about 4300-fold with an 11% yield and showed essentially a single band, corresponding to an apparent molecular weight of approximately 110,000 on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Analysis of the purified 110-kDa protein showed that it contained, in addition to the N-deacetylase, N-sulfotransferase activity; however, the expression of N-sulfotransferase activity was independent of additional proteins. Backtracking the N-sulfotransferase through the purification scheme previously applied to the N-deacetylase showed the two enzyme activities to the N-deacetylase showed the two enzyme activities to be cofractionated in each separation step. It is proposed that the expression of glucosaminyl N-deacetylase activity depends on the concerted action of (at least) two protein components, one of which also possesses glucosaminyl N-sulfotransferase activity.

Biosynthesis of heparin. Enzymatic sulfation of pentasaccharides

Heparin-derived pentasaccharides with the general structures GlcN-GlcA/IdoA-GlcN-GlcA/IdoA-GlcN (where GlcA represents D-glucuronic acid and IdoA represents L-iduronic acid) and GlcNSO3-GlcA/IdoA-GlcNSO3-GlcA/IdoA- GlcNSO3 (where -NSO3 represents an N-sulfate group) were tested as exogenous sulfate acceptors in incubations with adenosine 3'-phosphate 5'-[35S]phosphosulfate and microsomal enzymes from a heparin-producing mouse mastocytoma. No transfer occurred to the N-unsubstituted pentasaccharide containing only L-iduronic acid, but the other three isomers incorporated various amounts of 35S, which was totally present in N-sulfate groups. After complete chemical N-sulfation, all four pentasaccharides served as acceptors in O-sulfotransferase reactions and incorporated from 20 to greater than 200 times as much radioactivity as did the nonsulfated parent compounds. The C-6 position of the internal glucosamine unit was labeled preferentially, irrespective of the structures of the adjacent hexuronic acid units. Significant 2-O-35S-sulfation of IdoA units occurred in both -IdoA-Glc-NSO3-GlcA- and -GlcA-GlcNSO3-IdoA- sequences, whereas no significant sulfation of GlcA residues was detected. The pentasaccharide GlcNSO3-GlcA-Glc-NSO3-GlcA-GlcNSO3 thus can be used as a selective substrate in assays for glucosaminyl-6-O-sulfotransferase activity. The antithrombin-binding region, essential for the blood anticoagulant activity of heparin, has been identified as a pentasaccharide sequence with the predominant structure GlcNR(6-OSO3)-GlcA-GlcNSO3(3,6-di-OSO3)-++ +IdoA(2-OSO3)-GlcNSO3(6-OSO3) (where R represents either a sulfate or an acetyl group and -OSO3 represents an O-sulfate/ester sulfate group, with locations of O-sulfate groups indicated in parentheses) (Lindahl U., Thunberg, L., Bäckström, G., Riesenfeld, J., Nordling, K., and Björk, I. (1984) J. Biol. Chem. 259, 12368-12376). The products of [35S]sulfate transfer to the pentasaccharide GlcNSO3-GlcA-GlcNSO3-IdoA-GlcNSO3 contained molecules with high affinity for antithrombin, corresponding to 0.3-0.5% of the total label. Structural analysis suggested the occurrence of O-[35S]sulfate groups at both C-6 of the nonreducing terminal glucosamine unit and C-3 of the internal glucosamine unit. No products with high affinity for antithrombin were formed from the pentasaccharides that had a different monosaccharide sequence than the binding region; and moreover, these oligosaccharides appeared unable to incorporate glucosaminyl 3-O-sulfate groups. These findings point to the importance of the uronic acid sequence in the generation of the antithrombin-binding region of heparin.

Biosynthesis of heparin. Use of Escherichia coli K5 capsular polysaccharide as a model substrate in enzymic polymer-modification reactions

A capsular polysaccharide from Escherichia coli K5 was previously found to have the same structure, [-(4)beta GlcA(1)----(4)alpha GlcNAc(1)-]n, as that of the non-sulphated precursor polysaccharide in heparin biosynthesis [Vann, Schmidt, Jann & Jann (1981) Eur. J. Biochem. 116, 359-364]. The K5 polysaccharide was N-deacetylated (by hydrazinolysis) and N-sulphated, and was then incubated with detergent-solubilized enzymes from a heparin-producing mouse mastocytoma, in the presence of adenosine 3'-phosphate 5'-phospho[35S] sulphate ([35S]PAPS). Structural analysis of the resulting 35S-labelled polysaccharide revealed the formation of all the major disaccharide units found in heparin. The identification of 2-O-[35S]sulphated IdoA (L-iduronic acid) as well as 6-O-[35S]sulphated GlcNSO3 units demonstrated that the modified K5 polysaccharide served as a substrate in the hexuronosyl C-5-epimerase and the major O-sulphotransferase reactions involved in the biosynthesis of heparin. The GlcA units of the native (N-acetylated) E. coli polysaccharide were attacked by the epimerase only when PAPS was present in the incubations, whereas those of the chemically N-sulphated polysaccharide were epimerized also in the absence of PAPS, in accord with the notion that N-sulphate groups are required for epimerization. With increasing concentrations of PAPS, the mono-O-sulphated disaccharide unit-IdoA(2-OSO3)-GlcNSO3- was progressively converted into the di-O-sulphated species -IdoA(2-OSO3)-GlcNSO3(6-OSO3)-. A small proportion of the 35S-labelled polysaccharide was found to bind with high affinity to the proteinase inhibitor antithrombin. This proportion increased with increasing concentration of PAPS up to a level corresponding to approximately 1-2% of the total incorporated 35S. The solubilized enzymes thus catalysed all the reactions required for the generation of functional antithrombin-binding sites.

[Analysis of motivation of sterilized women requesting sterilization reversal]

Within the framework of this exploratory study, 37 sterilised women wishing to be refertilised, were questioned thoroughly on what had indicated their sterilisation and why they wish to be refertilised. Assuming the existence of an interactive behaviour pattern, we concentrated on the psycho-social circumstances accompanying the definitive decision to be sterilised. Here, a critical situation in the relationship between the partners at the time of sterilisation could be established as a prognostically unfavourable factor. Accordingly, 20 of the 37 patients developed the wish to be refertilized because of a new partnership. Those who felt induced by their gynaecologist or partner to undergo sterilisation had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, after repeated consultations, had enough time and possibilities to make their own decision concerning contraception. Furthermore, sterilisation due to medical indication could be suggested as another highly critical factor, especially where the gynaecologist failed to give sufficient explanation of its medical necessity. With regard to the time set for the sterilisation, the study revealed that the patient's psychological condition after the operation was significantly worse, when sterilisation was carried out immediately after a delivery or an abortion. The fact that in such cases sterilisation is often followed by an increase in psychosomatic trouble and depressive states, of mind is also confirmed by literature. The results of the study are a practical contribution towards improving preoperative consultation and coordinating the course of action to be taken where a patient has the wish to be sterilised.

Biosynthesis of heparin. O-sulfation of D-glucuronic acid units

Incubation of a microsomal fraction from murine mastocytoma, with UDP-[1-3H]GlcA, UDP-GlcNAc, and adenosine 3'-phosphate 5'-phosphosulfate (PAPS), yielded labeled, N-sulfated polysaccharides, in which most of the incorporated O-sulfate groups were located at C2 of L-iduronic acid and at C6 of D-glucosamine units. Analysis by anion-exchange high pressure liquid chromatography of disaccharides, generated by deaminative cleavage of these polysaccharides, revealed that, in addition, an appreciable portion of the -GlcNSO3-HexA-GlcNSO3- sequences in the intact polymers contained O-sulfated (at C2 or C3) D-glucuronic acid units. Calculations based on such compositional analysis of the N- and O-sulfated biosynthetic product, isolated by chromatography on DEAE-cellulose, showed that glucuronosyl 2/3-O-sulfate accounted for approximately 12% of the total incorporated O-sulfate groups. With [35S]PAPS (at a low total PAPS concentration) as an alternative source of label, the sulfated glucuronic acid residues were again detectable, albeit in much smaller amounts (1.8% of the total O-sulfate groups). Incorporation of label from UDP-[5-3H]GlcA was retained by the O-sulfated glucuronic acid units, thus demonstrating that these components had in fact been formed by sulfation of glucuronic acid residues and not by "back epimerization" of sulfated iduronic acid units. Structural analysis of polysaccharide intermediates at various stages of biosynthetic polymer modification, separated by ion-exchange chromatography, showed O-sulfation of glucuronic and iduronic acid units to appear simultaneously and before the 6-O-sulfation of glucosamine residues.

Diurnal salivary cortisol patterns during pregnancy and after delivery: relationship to plasma corticotrophin-releasing-hormone

The circadian rhythm of salivary cortisol was studied in 10 healthy women every 4 weeks throughout pregnancy. In addition, in 12 women the diurnal patterns of salivary cortisol, serum cortisol, plasma ACTH, plasma CRH and serum progesterone were analysed in late third trimester pregnancy and again 3-5 days after delivery. Salivary cortisol profiles exhibited a clear circadian rhythm during pregnancy with an increase in mean salivary cortisol from the 25th to 28th week onwards reaching concentrations in late pregnancy more than twice as high as in non-pregnant controls, rapidly returning to normal concentrations after delivery. The coefficient of variation of salivary cortisol profiles decreased in third trimester pregnancy due to a parallel upward shift of cortisol concentrations (40.2 +/- 3.4% vs 77.6 +/- 6.6% after delivery, P less than 0.01). A diurnal pattern was also found for plasma ACTH and serum cortisol before and after delivery with lower concentrations post-partum (P less than 0.01). In late pregnancy, progesterone concentrations were significantly higher in the evening (930 +/- 85 nmol/l vs 813 +/- 74 nmol/l at 0900 h, P less than 0.01) but showed no diurnal variation post-partum. Plasma CRH was significantly elevated in late third trimester pregnancy (1.22 +/- 0.23 micrograms/l at 0900 h) but showed no diurnal change (1.30 +/- 0.28 micrograms/l at 1900 h). Moreover, no correlation between the free cortisol increase in late pregnancy and plasma CRH was noted despite a wide range of CRH levels (0.13-3.60 micrograms/l). In contrast, a significant correlation was observed between the serum progesterone increase and the salivary cortisol increase in late pregnancy (r = 0.70, P less than 0.05). These findings demonstrate that placental CRH is not the only regulator of maternal ACTH and cortisol release. Instead, our study suggests that placental CRH has little influence on baseline maternal adrenocortical function in pregnancy. The elevated salivary cortisol levels in pregnancy may be explained by glucocorticoid resistance owing to the antiglucocorticoid action of high progesterone concentrations.

Biosynthesis of heparin. Availability of glucosaminyl 3-O-sulfation sites

Heparin preparations isolated from pig intestinal mucosa and from bovine lung were fractionated with regard to affinity for antithrombin. The resulting fractions, with high (HA) or low (LA) affinity for the proteinase inhibitor, were analyzed by 13C NMR or by identification of di- and tetrasaccharides obtained through deaminative cleavage with nitrous acid. Structural differences between corresponding HA and LA fractions were essentially restricted to minor constituents, in particular 3-O-sulfated glucosamine units that occurred (1 or 2 residues/chain) in all HA preparations but were scarce or absent in LA heparin. The HA fractions also consistently showed higher contents of nonsulfated iduronic acid and, to a lesser extent, N-acetylated glucosamine units than the LA fractions. The two tetrasaccharide sequences, -IdoA-GlcNAc(6-OSO3)-GlcA-GlcNSO3- and -IdoA-GlcNAc(6-OSO3)-GlcA-GlcNSO3(6-OSO3)- , recently implicated as part of the acceptor site for glucosaminyl 3-O-sulfate groups (Kusche, M., Bäckström, G., Riesenfeld, J., Petitou, M., Choay, J., and Lindahl, U. (1988) J. Biol. Chem. 263, 15474-15484), were identified in mucosal LA heparin; it was calculated that the preparation contained approximately one potential acceptor site/polysaccharide chain. Yet this material did not yield any labeled HA components on incubation with adenosine 3'-phosphate 5'-phospho-[35S]sulfate in the presence of glucosaminyl 3-O-sulfotransferase, solubilized from a mouse mastocytoma microsomal fraction. The failure to incorporate any 3-O-sulfate groups could conceivably be explained by the occurrence of a D-glucuronic rather than L-iduronic acid unit linked at the reducing ends of the above tetrasaccharide sequences. Alternatively, 3-O-sulfation may be restricted by other, as yet unidentified, inhibitory structural elements that are preferentially expressed in polysaccharide sequences selected for the generation of LA heparin.

Hormone levels in women after hysterectomy

The serum levels of FSH, LH and estradiol-17 beta (E2) were determined in 110 women aged between 38-48 years who had been hysterectomized 2-10 years previously and were compared with a control group (n = 112). In hysterectomized women both FSH and LH levels were higher than in controls during the whole 12 year period. These differences were significant up to 43 years of age. The hypergonadotropism in hysterectomized women correlates with the higher incidence of climacteric symptoms reported in the literature.

Biosynthesis of heparin. O-sulfation of the antithrombin-binding region

The antithrombin-binding region in heparin is a pentasaccharide sequence with the predominant structure GlcNAc(6-OSO3)-GlcA-GlcNSO3(3,6-di-OSO3)-IdoA -(2-OSO3)-GlcNSO3(6-OSO3) (where GlcA and IdoA represent D-glucuronic and L-iduronic acid, respectively), in which the 3-O-sulfate residue on the internal glucosaminyl unit is a marker group for this particular region of the polysaccharide molecule. A heparin octasaccharide which contained the above pentasaccharide sequence was N/O-desulfated and re-N-sulfated and was then incubated with adenosine 3'-phosphate 5'-phospho[35S]sulfate in the presence of a microsomal fraction from mouse mastocytoma tissue. Fractionation of the resulting 35S-labeled octasaccharide on antithrombin-Sepharose yielded a high affinity fraction that accounted for approximately 2% of the total incorporated label. Structural analysis of this fraction indicated that the internal glucosamine unit of the pentasaccharide sequence was 3-O-35S-sulfated, whereas both adjacent glucosamine units carried 6-O-[35S]sulfate groups. In contrast, the fractions with low affinity for antithrombin (approximately 98% of incorporated 35S) showed no consistent O-35S sulfation pattern and essentially lacked glucosaminyl 3-O-[35S]sulfate groups. It is suggested that the 3-O-sulfation reaction concludes the formation of the antithrombin-binding region. This proposal was corroborated in a similar experiment using a synthetic pentasaccharide with the structure GlcNSO3(6-OSO3)-GlcA-GlcNSO3(6-OSO3)-Id oA (2-OSO3)-GlcNSO3(6-OSO3) as sulfate acceptor. This molecule corresponds to a functional antithrombin-binding region but for the lack of a 3-O-sulfate group at the internal glucosamine unit. The 35S-labeled pentasaccharide recovered after incubation bound with high affinity to antithrombin-Sepharose and contained a 3-O-[35S]sulfate group at the internal glucosamine residue as the only detectable labeled component. The use of this pentasaccharide substrate along with the affinity matrix provides a highly specific assay for the 3-O-sulfotransferase.

[Clinical aspects and prognosis of granulosa cell tumors of the ovary]

Symptoms, tumour morphology and clinical course were reviewed in 26 women treated at the department of obstetrics and gynaecology of the University of Cologne between 1965 and 1986 for granulosa cell tumours of the ovary. At the time of diagnosis 8 women were in a pre- and 18 in a postmenopausal state. The most common symptoms were irregular haemorrhages, in rare cases lower abdominal pain. Effects of raised estrogen stimulation were seen in 80% of patients. In 24 pre-operative patients, a lower abdominal tumour was diagnosed. 20 patients had lesions of stage I, 5 of stage III and one of stage IV. 21 tumours exceeded 5 cm median diameter. Polymorphic tumours were seen in 16 cases. 14 tumours had a high mitotic activity. Hysterectomy and bilateral salpingoovariectomy were performed in most cases, followed by additional irradiation in 9 and by chemotherapy in 4 cases. Only 3 patients were treated by unilateral salpingoovariectomy. To date 14 patients have no evidence of disease, one suffers from tumour progression and 9 died of the tumours. 2 women died for other reasons. The 5-year survival rate is 70%, the 10-year survival rate 64%. Old age, late progression of tumour stage, tumour diameter exceeding 5 cm, polymorphic tumours and high mitotic index correlated to the worsening prognosis. However, a poor result was also seen in monomorphic tumours with low mitotic activity. The nature of granulosa cell tumours can not be predicted by clinical or morphological criteria. Therefore it is suggested, that all granulosa cell tumours should be considered as malignant.

Identification of oversulphated galactosaminoglycans in intestinal-mucosal mast cells of rats infected with the nematode worm Nippostrongylus brasiliensis

The oversulphated galactosaminoglycans synthesized by rat mucosal mast cells were isolated from the small intestine of animals infected with the nematode Nippostrongylus brasiliensis, which causes proliferation of these cells. The 35S-labelled polysaccharides were degraded by digestion with chondroitinase ABC, and the structures of the disaccharide products were determined by cleavage with mercuric acetate followed by electrophoretic characterization of the resultant sulphated monosaccharides. It was concluded that about half of the disulphated disaccharide units in the polysaccharide consisted of chondroitin sulphate E-type structures [GlcA-GalNAc(4,6-di-OSO3)], in which both sulphate groups were located on the N-acetylgalactosamine unit. The remainder consisted of isomeric structures with one sulphate group on the N-acetylgalactosamine residue and one on the hexuronic acid unit and presumably represented the dermatan sulphate-type sequence [IdoA(2-OSO3)-GalNAc(4-OSO3)].

Determination of the range in binding-site densities of rat skin heparin chains with high binding affinities for antithrombin

Rat skin heparin proteoglycans vary markedly in the proportions of their constituent polysaccharide chains that have high binding affinity for antithrombin. As the proportion of such chains in a proteoglycan rises, their degree of affinity for antithrombin also increases [Horner (1987) Biochem. J. 244, 693-698]. The antithrombin-binding-site densities of such chains have now been determined, by measuring heparin-induced enhancement of the intrinsic fluorescence of antithrombin and by chemical analysis for the disaccharide sequence glucuronosyl-N-sulphoglucosaminyl (3,6-di-O-sulphate), which is unique to this site in heparin [Lindahl, Bäckström, Thunberg & Leder (1980) Proc. Natl. Acad. Sci. U.S.A. 77, 6551-6555]. Antithrombin-binding-site density ranged from one to five sites per chain.

[Effect of competitive sports on the menstrual cycle and sexuality--results of a survey of the West German team for the Olympic games in Los Angeles]

The present investigation attempts to analyse exact data on the menstruation cycle, contraception and the sexual behavior of competitive sportswomen. Since the West German participants at the Olympic Games of 1984 in Los Angeles were chosen for this investigation, the patients are unquestionably highly selected. For this reason, the results cannot claim to be representative in all respects. The objective of this study was primarily to register and to analyse the gynecological aspects of women's competitive sport, to reveal interrelationships and if appropriate to point out disadvantageous tendencies. The Olympics participants were subdivided into five different groups on the basis of the type of sport: I. take-off power/speed II. anaerobic endurance III. aerobic endurance IV. technique/dexterity V. team games. A control group was formed of middle-distance and long-distance runners. The data were analysed with regard to competitive sport and age, number of days of training and training minutes per week, menarche, duration and length as well as intensity of menstrual bleeding, menstruation symptoms, influence of menstrual bleeding on sport performance, dependence of peak performance on the menstruation cycle, sexual behavior, contraception behavior.

[Obstetric management in severe fetal growth retardation. Report of experiences based on 278 newborn infants with severe dystrophy 1970-1985]

The article discusses and reviews the obstetrical modalities in confirmed severe growth retardation and the effects exercised by marked dystrophy of newborn (less than or equal to 3rd percentile of weight) at the Department of Gynaecology of the University of Cologne between 1970 and 1985 on perinatal mortality, rate of asphyxiation and neonatal complications. In view of the optimal diagnostic possibilities available during the past decade, the examinations were subdivided into two groups (1970-1975 and 1976-1985). In severe foetal growth retardation-mainly confirmed sonographically-the proportion of primary Caesarean sections increased from 10% to 38%, whereas indication for inducing labour clearly dropped from 25% to 6%. The desired slight reduction in incidence of prenatally severely dystrophic newborn from 1.6% to 1.2% is regarded as the beginning of the effect of ultrasound screening during pregnancy. The higher perinatal mortality of the severely dystrophic newborn of the years 1976-1985 is explained by the increased incidence of dystrophic newborn who are considerably underweight (less than 1000 g) from 1.3% (1970-1985) to 10.4% (1976-1985). If perinatal mortality rate is corrected accordingly, perinatal mortality for both groups is about equal, namely, 3.3% and 3.2% respectively. Among the severely dystrophic newborn there were distinct differences on comparing the two groups in respect of the degree of maturity depending on the pregnancy period, and of the weight at birth. In 1970-75 85% of the dystrophic children were born after the 37th pregnancy week, i.e. mature-dystrophic, and only 15% showed in addition the signs of immaturity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Physical performance in pregnancy]

To evaluate their physical efficiency, 14 healthy untrained women were examined during pregnancy weeks 16-20, 25-29 and 34-38 and 5 to 10 weeks post partum, by spiroergometry at various exercise levels on the bicycle ergometer. Besides the spiroergometric values, circulatory parameters were measured and serum analyses were carried out. The physical efficiency of the subjects was by no means reduced in the stages of pregnancy investigated. Indeed, several factors indicated an improvement of performance. Thus common features were found regarding the physiological effects of pregnancy and endurance training: increase of the maximum oxygen uptake, lower lactate production when the aerobic/anaerobic threshold was exceeded at high exercise intensity, as well as a relatively lower pulse under exercise. The increased metabolic fat utilisation for energy production in physical work is likewise similar to the effect of endurance training. Many pregnant women occasionally feel that they have reduced physical efficiency. Pregnant subjects were subjected to a standardised exercise test to appraise these complaints objectively. The study carried out was intended to answer the question as to whether the specific processes of adaptation of the cardiopulmonary system in pregnancy would lead to an impairment of physical efficiency. Furthermore, the question was to be answered as to whether the altered metabolic conditions of pregnant women under exercise will influence energy production from carbohydrate and fat metabolism.

The importance of antepartum cardiotocography

The significance of antepartum cardiotocography was examined on patients at the University of Cologne in the years 1982 and 1983. We analyzed 13,310 cardiotocograms of 1,463 women and correlated their pregnancies and deliveries with the status of their newborns. There were only 66 suspect/prepathologic fetal heart rate recordings in 50 patients. All these patients had severe complications during their pregnancies. Impending prematurity, toxemia, first and second trimester bleeding as well as placental insufficiency and polyhydramnios were the leading complications. The analysis of the cardiotocograms using Hammacher's criteria demonstrated that the CTG characteristics "floating line" and "oscillation type" together accounted for the largest proportion (43.9%) to the total score and thus constituted the most important parameters. Fetuses with abnormal CTGs had a birthweight of less than 1500 grams in 30% of the cases. This group also had poorer Apgar scores and umbilical artery pH values than neonates with normal antepartum cardiotocograms. After excluding non-viable malformations the perinatal mortality was 80 per 1000, i.e. it was nine times higher for newborns with abnormal antepartum heart rate patterns. The study demonstrated that abnormal antepartum CTGs in non-selected patients are rare and are always associated with severe complications of pregnancy. Thus, the method is not suitable as a general screening method but should be used for specific indications in high risk pregnancies and for the evaluation of any tocolytic treatment. The recognition of abnormal CTG characteristics requires technically adequate recording and accurate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Glycosaminoglycans in rat mucosal mast cells

Rats were infected with the nematode Nippostrongylus brasiliensis, resulting in an approx. 5-fold increase in the number of mucosal mast cells and the histamine content of the intestinal (jejunum) wall. After injection of the infected animals with inorganic [35S]sulphate, a similar increase in the yield of labelled intestinal glycosaminoglycans was observed, compared with uninfected control rats. Autoradiography showed a highly selective labelling of the numerous mucosal mast cells and of the few connective-tissue mast cells in the subserosal region of the bowel. Analysis of the labelled polysaccharide from the infected animals showed that almost 60% of this material consisted of oversulphated galactosaminoglycan, whereas heparin-related polysaccharides accounted for only 13%. The galactosaminoglycan contained 4-monosulphated and 4,6-disulphated N-acetylgalactosamine residues in approx. 5:1 molar ratio, both being linked to D-glucuronic acid residues; the occurrence of L-iduronic acid units could not be excluded. No significant difference in structure was found between this polysaccharide and the corresponding component isolated from uninfected rats. It is concluded that the major polysaccharide produced by rat mucosal mast cells in vivo is an oversulphated galactosaminoglycan rather than heparin.

[Clinical aspects and therapy of trophoblastic tumors]

Over a period of ten years 14 women with trophoblast tumours (rarely seen in Europe) underwent diagnosis, treatment and follow-up, appropriate for the time. The high specificity of human beta-chorionic gonadotropin as marker in the recognition and follow-up of this tumour contributed to the good prognosis, as well as the cytostatic treatment, varied according to risk factors. Twelve of the 14 women are either cured or free of recurrences for a long time.