Plasma Lipidomic Profiling Using Mass Spectrometry for Multiple Sclerosis Diagnosis and Disease Activity Stratification (LipidMS)

This investigation explores the potential of plasma lipidomic signatures for aiding in the diagnosis of Multiple Sclerosis (MS) and evaluating the clinical course and disease activity of diseased patients. Plasma samples from 60 patients with MS (PwMS) were clinically stratified to either a relapsing-remitting (RRMS) or a chronic progressive MS course and 60 age-matched controls were analyzed using state-of-the-art direct infusion quantitative shotgun lipidomics. To account for potential confounders, data were filtered for age and BMI correlations. The statistical analysis employed supervised and unsupervised multivariate data analysis techniques, including a principal component analysis (PCA), a partial least squares discriminant analysis (oPLS-DA) and a random forest (RF). To determine whether the significant absolute differences in the lipid subspecies have a relevant effect on the overall composition of the respective lipid classes, we introduce a class composition visualization (CCV). We identified 670 lipids across 16 classes. PwMS showed a significant increase in diacylglycerols (DAG), with DAG 16:0;0_18:1;0 being proven to be the lipid with the highest predictive ability for MS as determined by RF. The alterations in the phosphatidylethanolamines (PE) were mainly linked to RRMS while the alterations in the ether-bound PEs (PE O-) were found in chronic progressive MS. The amount of CE species was reduced in the CPMS cohort whereas TAG species were reduced in the RRMS patients, both lipid classes being relevant in lipid storage. Combining the above mentioned data analyses, distinct lipidomic signatures were isolated and shown to be correlated with clinical phenotypes. Our study suggests that specific plasma lipid profiles are not merely associated with the diagnosis of MS but instead point toward distinct clinical features in the individual patient paving the way for personalized therapy and an enhanced understanding of MS pathology.

CFTR modulation with elexacaftor-tezacaftor-ivacaftor in people with cystic fibrosis assessed by the β-adrenergic sweat rate assay

BACKGROUND

The cystic fibrosis (CF) sweat gland is defective in β-adrenergically-stimulated sweat secretion in the coil and chloride reabsorption in the duct. Whereas chloride reabsorption is regularly assessed by quantitative pilocarpine iontophoresis (QPIT), the measurement of β-adrenergic sweat secretion is not yet established in clinical practice.

METHODS

A novel sweat bubble imaging protocol was developed that determines sweat secretion rates by automatic recording, processing and quality control of the kinetics of sweat droplet formation.

RESULTS

Treatment of CF patients with the CFTR modulators elexacaftor, tezacaftor and ivacaftor reduced the sweat chloride concentration measured in QPIT in the majority of patients to values in the intermediate or normal range. In contrast, the β-adrenergically-stimulated sweat secretion rate assayed by the automated bubble sweat test was normalized in only 3 patients, slightly increased in 12 patients and remained undetectable in 8 patients.

CONCLUSIONS

β-adrenergic sweat stimulation in the coil is apparently rather stringent in its requirements for a wild type CFTR conformation whereas chloride reabsorption in the duct tolerates residual structural and functional deficits of native or pharmacologically rescued mutant CFTR in the apical membrane.

Impact of pre-OP independence in patients with limited brain metastases on long-term survival

BACKGROUND

Brain metastasis represents a major complication with a significantly shorter overall survival of many oncological diseases, in particular of lung cancer, breast cancer and malignant melanoma patients. However, despite the poor prognosis, sometimes clinical decision-making, between on the one hand not to harm the patient and on the other hand not withholding a potential therapeutic option, is very challenging. Thus the aim of this retrospective study was to compare various scores, including scores for activities of daily living (ADL) before resection of brain metastases and to analyse their impact on survival.

METHODS

Our single institution retrospective patient cohort (N = 100) with a median age of 63.6 years, which had all undergone resection of one or more brain metastases, was categorized using the original patient files. The cohort includes 52 patients with lung cancer, 27 patients with breast cancer, 8 patients with colorectal carcinoma and 13 patients with kidney cancer. To categorize, we used different score systems which were capable to evaluate the patient in relation to self-sufficiency, activity and self-determination as part of ADL. The retrospective analysis includes the ECOG-Status, Karnofsky-Index, Barthel-Index, ASA-Classification and Katz-Index. Pre-processing and the analysis of the data was implemented using KNIME, where we used the R-plugin nodes to perform the final statistical tests with R.

RESULTS

Our analysis reveals that most of the ADL scores we tested are able to give a reliable prediction on overall survival after brain metastasis surgery. The survival rates decrease significantly with a lower score in all tested score systems, with the exception of the ASA-Risk score. In particular, the Katz Index < 6 was identified to have a significant correlation with a lower cancer specific survival (CSS) (HR 3.33, 95%-CI [2.17-5.00]; p-Value = 9.6*10^- 9), which is easy to use and has reproducible measurements.

CONCLUSIONS

Pre-operative independence assessment by indices of ADL represents a predictor for overall survival after resection of brain metastases. Especially the easily, objectively and rapidly applicable Katz-Score is a very helpful tool to assess the pre-operative status, which could be additionally included in clinical decision making in daily practice.

KRAS mutation status concordance between the primary tumor and the corresponding metastasis in patients with rectal cancer

INTRODUCTION

Oncogenic mutation within the KRAS gene represents a negative predictor for treatment response to anti-epidermal growth factor receptor (EGFR) in patients with colorectal cancer. Recently, we have shown no relevant heterogeneity for KRAS mutation status within and between pre- and posttherapeutic samples from the primary tumor in patients with locally advanced rectal cancer. The aim of this study was to evaluate the intertumoral heterogeneity of KRAS mutation status between the primary tumor and the corresponding metastasis or local recurrence in the similar cohort and to evaluate the ideal representative tissue for KRAS mutation testing.

MATERIALS AND METHODS

KRAS mutation status was analyzed from 47 patients with locally advanced rectal cancer, which were enrolled in the CAO/ARO/AIO-94 or CAO/ARO/AIO-04 trial. Mutations in KRAS codons 12, 13, and 61 were analyzed by using the KRAS RGQ PCR Kit (therascreen® KRAS test). Six patients needed to be excluded due to incomplete follow up data. 11 patients showed a relapse of the disease during the follow up presented by distant metastases or local recurrence. DNA from representative areas of metastatic tissue was obtained from formalin-fixed paraffin-embedded specimens.

RESULTS

The mean patient age was 64.13 ± 10.64 years. In total, 19 patients showed a KRAS mutation (46.34%) in the primary tumor. Of the eleven patients with a metastatic disease or local recurrence, five patients showed a KRAS mutation whereas six patients had a KRAS wildtype status. Metastatic localizations included the liver (n = 2), lung (n = 4), local recurrence (n = 1), liver + lung (n = 3), lung + local recurrence (n = 1). For these eleven patients with paired data available for the primary tumor and metastatic tissue, a significant KRAS mutation status concordance was detected in 81.18% (9/11) of the patients (p = 0.03271). Only two patients showed intertumoral heterogeneity, which harbored in one patient a KRAS G12C mutation status in the primary tumor, but a G12V KRAS mutation status in the corresponding lung lesion, and in the other patient a G12A mutation in the primary lesion and a WT in the lung metastasis.

CONCLUSIONS

We show a significant concordance of the KRAS mutation status between tumor samples obtained from the primary tumor and the corresponding metastasis and/ or local recurrence in patients with rectal cancer indicating no relevant intertumoral heterogeneity. Our data suggest that sampling either the primary (pre- or posttherapeutical tumor tissue) or metastatic lesion may be valid for the initial evaluation of KRAS mutation status predicting the response to anti-EGFR treatment and guiding clinical decisions.

[Incidence and Predictive Factors for Bilaterality in Patients with Papillary Thyroid Carcinoma]

BACKGROUND

The optimal extent of thyroidectomy for papillary thyroid cancer (PTC) ≥ 10 mm und < 10 mm is still controversial. Therefore, the purpose of this study was to investigate factors predictive for bilaterality in patients with papillary thyroid carcinoma (PTC).

MATERIAL AND METHODS

We retrospectively reviewed 123 PTC patients in a single centre study who underwent either completion or total thyroidectomy and analysed the predictive value of tumour size, histological parameters, multifocality, and lymph node metastases with primary tumour size of ≥ 10 mm and < 10 mm as well as for ≥ 7 mm and < 7 mm.

RESULTS

Out of 123 patients, 26 exhibited bilateral PTC. This was significantly more frequent in patients with a primary tumour size of ≥ 10 mm (77%) compared to a tumour size of < 10 mm (23%) (p = 0.004). Multifocality was found to be an independent predictive factor for bilaterality (p = 5.022e-18). Metachronous lymph node metastases showed a trend for bilateral PTCs (p = 0.0691). These findings were reproducible for the comparison between the ≥ 7 mm and < 7 mm group.

CONCLUSION

The presence of bilateral PTC appears to be related to the size of the primary tumour ≥ 10 mm. Multifocality is a positive predictor for bilaterality. When multifocality, even with a primary tumour size of < 10 mm, is observed in patients with PTC, total thyroidectomy or completion thyroidectomy may be considered. If lobectomy is performed in patients with PTC, meticulous follow-up is needed to detect hidden malignancies in the contralateral lobe.

The utilization of multidisciplinary tumor boards (MDT) in clinical routine: results of a health care research study focusing on patients with metastasized colorectal cancer

PURPOSE

Multidisciplinary tumor boards (MDT) have been advocated as standard of care in modern oncology. German guidelines for metastasized colorectal cancer (mCRC) recommend MDT discussion of colon cancer patients after completion of primary tumor therapy but stage IV colon cancer as well as rectal cancer patients prior to any therapy. In this health care research study, we evaluated application and decisional consequences of this approach in clinical routine.

METHODS

All major institutions providing oncological care in southern Lower Saxony and Northern Hesse (N = 11) were invited. Patients with mCRC diagnosed between 01/2011 and 12/2013 were eligible. Data were collected using a standardized patient report form and stored in a GCP-conform EDC-system (secuTrial®).

RESULTS

A university medical center, four teaching hospitals, one communal hospital, and three oncological focus practices participated in the study. In total, 470 patients with a median age of 70 years were enrolled. Guideline conform MDT discussion was performed in 63% of operated colon cancer patients, 38% of stage IV colon cancer patients and 47% of rectal cancer patients, respectively. Resection of metastases was performed in 41% of cases. Patients ≥70 years (n = 250) received significantly more often treatment following MDT discussion (86 versus 64%, p = 0.0002). Not the resection rate (48 versus 57%, p = 0.1574) but indication for preoperative chemotherapy (57 versus 33%, p = 0.0056) significantly differed when patients with single organ metastases experienced MDT discussion.

CONCLUSIONS

MDT discussion is not as established as advocated by national guidelines. Treatment decisions differ especially in older patients and those with single organ metastases.

The Prognostic Value of Tyrosine Kinase SRC Expression in Locally Advanced Rectal Cancer

The cellular sarcoma gene (SRC) is a proto-oncogene encoding for a tyrosine kinase. SRC expression was determined in locally advanced rectal adenocarcinoma tissue from pretreatment biopsies and resection specimens. The expression level was correlated with clinicopathological parameters to evaluate the predictive and prognostic capacity.

For this monocentric analysis 186 patients with locally advanced rectal cancer (median: 63.7 years; 130 men (69.9%), 56 women (30.1%)) were included. Patients with a carcinoma of the upper third of the rectum were treated with primary tumor resection (n=27; 14.5%). All other patients received a preoperative chemoradiotherapy (CRT) with 50.4 Gy and concomitant 5-fluorouracil (5-FU) or 5-FU+oxaliplatin followed by postoperative chemotherapy with 5-FU or 5-FU+oxaliplatin. SRC expression was determined with immunohistochemical staining from pretreatment biopsies (n=152) and residual tumor tissue from the resection specimens (n=163). The results were correlated with clinicopathological parameters and long-term follow-up.

The expression of SRC was determined in pretherapeutic biopsies (mean H-Score: 229) and resection specimens (mean H-Score: 254). High SRC expression in pretherapeutic tumor samples significantly correlated with a negative postoperative nodal status (p=0.005). Furthermore an increased protein expression in residual tumor tissue was associated with fewer distant metastases (p=0.04). The overexpression of SRC in pretreatment tumor biopsies showed also a trend for a longer cancer-specific survival (CSS; p=0.05) and fewer local relapses (p=0.06) during long-term follow-up.

High SRC expression in rectal cancer seems to be associated with a better long-term outcome. This finding could help in the future to stratify patients for a recurrence risk adapted postoperative treatment.

The utilization of multidiciplinary tumor boards (MDT) in clinical routine: Results of a health care research study focusing on patients with metastatic colorectal cancer

805

Background: Multidisciplinary Tumor Boards (MDT) have been advocated as standard of care in modern oncology. German cancer guidelines for metastasized colorectal cancer (mCRC) recommend discussing every patient (pt) with colon cancer (CC) after primary surgery and every pt with clinical stage IV CC as well as every rectal cancer (RC) pt prior to any therapy in a MDT. In this study we evaluated how extensive this approach has been implemented in clinical routine and how MDT discussion influences treatment decisions within a representative region with established access to MDTs for all actors. Methods: All major institutions treating oncological pts in southern Lower Saxony and Northern Hesse (N = 11) were invited to participate in the study. Pts with mCRC and diagnosis of the first metastasis between 01/2011 and 12/2013 were eligible. A standardized pt report form was developed and data were collected in a GCP-conform EDC-system named secuTrial. Results: A university medical center, 4 teaching hospitals, 1 communal hospital and 3 oncological focus practices participated in the study. In total, 470 pts (CC n = 278, RC n = 192) with a median age of 70 (range 22-92) years were enrolled. 286 (60.9%) pts had synchronous and 184 (39.1%) pts had metachronous metastases. Discussion within an MDT was performed in 141 (62.9%) of 224 CC pts after primary surgery and in 70 (38.3%) of 183 pts with clinical stage IV CC prior to any therapy. In RC pts, MDT discussion prior to any therapy happened in 91 (47.4%) pts. Curative resection of metastases was performed in 193 (41.1%) cases. Pts > 70 years (n = 250) received significantly more often chemotherapy ± surgery when presented in an MDT (85.8% versus 64.4%, p = 0.0002). In pts with single organ metastases the resection rate was not significantly different (48.4% versus 56.9%, p = 0.1574) but preoperative chemotherapy was more often indicated (56.7% versus 33.3%, p = 0.0056) when pts were discussed in a MDT. Conclusions: In clinical routine MDT discussion is not as established as advocated by national guidelines. Treatment decisions differ depending on MDT discussion especially in older pts and those with single organ metastases.

HER-2 and HER-3 expression in liver metastases of patients with colorectal cancer

OBJECTIVE

In this study, we evaluate the frequency of HER-2 and HER-3 expression in liver metastases from patients with colorectal cancer (CRLM). We analyzed the potential of HER-2 and HER-3 as therapeutic targets and evaluated their prognostic value.

PATIENTS AND METHODS

Overall 208 patients with CRLM were enrolled. HER-2 and HER-3 expression were determined in metastatic tissue of diagnostic punch biopsies (n = 29) or resection specimens (n = 179). The results of immunohistochemistry (IHC) scoring and In-situ-hybridization (ISH)-amplification were correlated with clinical parameters and for the 179 resected patients with cancer-specific (CSS) and overall survival (OS). The mean follow-up time was 56.7 months.

RESULTS

Positivity of HER-2 status (IHC score 2+/ISH+ and IHC 3+) was found in 8.2% of CRLM. High expression of HER-3 (IHC score 2+ and IHC 3+) was detected in 75.0% of liver metastases. CSS after liver surgery was determined and was independent from the HER-2 status (p = 0.963); however HER-3 was prognostic with a favorable course for patients showing an overexpression of HER-3 (p = 0.037).

CONCLUSIONS

HER-2 overexpression occurs in only 8% of patients with CRLM but with 75% of cases HER-3 is frequently overexpressed in CRLM. Therefore, HER-2 and particularly HER-3 could serve as novel targets to be addressed within multimodal treatment approaches.

Loads in hip disarticulation prostheses during normal daily use

As a result of deficiency at birth, disease or trauma, there are people who have no limbs from the hip joint downwards. These people have no possibility of locomotion without the use of other devices such as wheelchairs or hip disarticulation prostheses. As these prostheses are used by people of all ages, people who are different in their grade of physical activities and their weights, the prostheses are subject to different stresses related to these different circumstances. The European Level 2 Draft Standard prEN 12523: 1966 "External limb prostheses and external orthoses - requirements and test methods" contains strength requirements for lower limb prostheses. These requirements shall be verified, where appropriate, by the application of the International Standard ISO 10328 "Prosthetics - Structural testing of lower limb prostheses" and ISO/FDIS 15032 "Prosthetics: Structural testing of hip prostheses". In order to allow the prostheses to be tested to the stresses that are experienced in real life, it is necessary to measure the stress that is induced in the prostheses while the patient is in an everyday situation, such as walking on level floor, walking on grass and/or walking on an uneven surface. This work is concerned with the acquisition of loads generated in hip units of hip disarticulation prostheses by amputees during various activities. More than 30 patients were tested in Germany, France, and Belgium. The measurements were carried out with financial support from the European Commission and coordinated by the secretariat of CEN TC 293.

Photometric measurement of color changes in livor mortis as a function of pressure and time. Development of a computer-aided system for measuring pressure-induced blanching of livor mortis to estimate time of death

Until now, blanching of livor mortis in estimating time of death has generally been assessed based on subjective impressions, i.e. on whether blanching is visible after the application of pressure. We have developed a measuring system that uses digital processing to objectify the relationship between the pressure applied and blanching of postmortem lividity. The pressure is electronically registered by a strain gauge. At predefined levels (10, 20, 30, up to 100 N) the software triggers a color measurement by a commercially available tristimulus colorimeter. All parameters are measured in a single procedure and routed to the computer through a data interface. The pressure-induced color changes in the livor mortis are evaluated according to the L*, a*, b* system (CIE-LAB according to DIN 5033, DIN 6174), which closely approximates the physiology of sight. An additional color spacing formula (delta E) allows analysis of color changes irrespective of the basic skin tone. Initial measurements on cadavers showed that application of increasing pressure produced regular courses of color changes in livor mortis.

[Dynamic force measurement in implantation of total endoprostheses of the hip joint]

The forces within the femoral shaft have been studied in preparation for the total hip replacement. The experimental device consisted of a personal computer connected with a digital enhanced measurement system which converted the data, that was received from the strain gauges, mounted on the femur. The bitochanter hip replacement designed by Ecke was used as an example of a press fit endoprosthesis which is anchored cementless. It was implanted in femora of cadavers. The results showed an extension of the femur at first within the intertrochanteric region, and as the rasp was further implanted, it showed at the distal end of the rasp a medial extension and a lateral traction with a delay of 3 ms, proving that it was a result of a medullary extension. The maximum forces applied with the metal hammer were 3500 N. Fractures and fissures were provoked and the result showed that they were mostly due to a misplacement of the rasp.

[Effect of form elasticity of the prosthesis shaft in response to stress of the proximal femur]

Uncemented hip prostheses are characterized by a variable design of the stem. In these investigations, nine different prostheses were studied according to the model of a standard bone (Kunststoffnormfemur). After preparation of the cavity of the prostheses with original instruments and after its implantation, strain gauges were placed at 16 certain points. Measurements were carried out in steps of 200 N until reaching the maximal force of 2kN. Prostheses that are characterized by an anatomical design of the stem resemble the physiological nature of normal bone, in contrast to the models with a rectangular cross-section or with a stretched lateral shape of the stem.

[Bone stress. A hitherto neglected factor in hip endoprosthesis design]

Growing interest in hip endoprostheses is giving rise to new ideas on form and materials, although it is not precisely known what forces the proximal femur is subject to. To find out more about these forces, we made computerized analyses of the stresses on some different types of prostheses in an artificial standardized femur. The E-module amounts to about 14,000 N/mm. Following measurements in tension-optic trials, we inserted Student gages (EA-13-060LZ-120) at 16 points around the proximal femur; these transmitted the pressure, tensile and torsion stresses to a multipoint measuring instrument (UPM 60) and on-line to a computer. The quality of implantation was monitored by X-ray. With loads varying from 0 to 1.5 kN in 250-N steps we made five readings to reproduce the measurements, without having any material failure. To ensure an absolutely reproducible outcome we used an artificial standardized femur (KNF by Mecron), which without prostheses shows the typical and well-known (Pauwels, Perren) pressure tensions medially and tensile stresses laterally, without crossing the zero line. A distinctly reduced stress profile was seen for pressure and tensile stresses with the ribbed system prosthesis, which might be due to the anchor and collar. Nevertheless, the torsion tensions should be noted. As expected, the shaft systems without anchor and collar show a lesser degree of stiffness. The Mecroblock MR system produces preponderantly pressure stresses, while the CLS (Spotorno) prosthesis sets up more torsion tensions in different directions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Torsion forces of the proximal femur following implantation of a hip prostheses]

Growing interest in hip endoprosthesis is inducing a lot of ideas for formgiving, without having cleared the adequate strength to the proximale femur. To know more about these forces, we made computerized tension-analyses of some different types of prosthesis in a normed artificial femur. Measurement of press- and tensile tensions on one hand and the torsion-tensions on the other hand showed some enhanced forces which might be the reason for slackening of hip endoprosthesis.

[Ultrasonic modelling of bone cement - (reoperation of total hip endoprosthesis) (author's transl)]

In medicine ultrasound is very common in diagnostic and therapeutic applications, in surgery especially as so-called ultrasonic lithotripsy. Up to now experiences in bone surgery are not very successful. Bone cement (PMMA) is a thermoplastic material. Therefore results of ultrasonic lithotripsy cannot be simply transmitted. Investigations show that, because of their thermoplastic quality, the ultrasonic method may be helpful in modelling bone cement, for example in changing endoprosthesis. The preconditions for the use of high frequent oscillating probes are examined experimentally. The necessary visual distinction of bone cement and natural bone may be intensified by fluorochrome labelling of cement.

[Result of a user inquiry for the improvement of hand propelled wheelchairs (author's transl)]

The contribution describes the results of an inquiry of handicapped wheelchair drivers which have been compiled by evaluating 3482 questionnaires with 268,144 informations using an IBM 1130 computer. Divided into "rim" and "lever" propulsion the driving quality, the manoeuvrability, the seat comfort, problems of driving mechanism and the transportation suitability as well as the wear of the vehicles are analysed. Finally some recommendations for the design of future wheelchair models are given on the basis of the observed drawbacks.