Genomic characterisation of hormone receptor-positive breast cancer arising in very young women

BACKGROUND

Very young premenopausal women diagnosed with hormone receptor-positive, human epidermal growth factor receptor 2-negative (HR+HER2-) early breast cancer (EBC) have higher rates of recurrence and death for reasons that remain largely unexplained.

PATIENTS AND METHODS

Genomic sequencing was applied to HR+HER2- tumours from patients enrolled in the Suppression of Ovarian Function Trial (SOFT) to determine genomic drivers that are enriched in young premenopausal women. Genomic alterations were characterised using next-generation sequencing from a subset of 1276 patients (deep targeted sequencing, n = 1258; whole-exome sequencing in a young-age, case-control subsample, n = 82). We defined copy number (CN) subgroups and assessed for features suggestive of homologous recombination deficiency (HRD). Genomic alteration frequencies were compared between young premenopausal women (<40 years) and older premenopausal women (≥40 years), and assessed for associations with distant recurrence-free interval (DRFI) and overall survival (OS).

RESULTS

Younger women (<40 years, n = 359) compared with older women (≥40 years, n = 917) had significantly higher frequencies of mutations in GATA3 (19% versus 16%) and CN amplifications (CNAs) (47% versus 26%), but significantly lower frequencies of mutations in PIK3CA (32% versus 47%), CDH1 (3% versus 9%), and MAP3K1 (7% versus 12%). Additionally, they had significantly higher frequencies of features suggestive of HRD (27% versus 21%) and a higher proportion of PIK3CA mutations with concurrent CNAs (23% versus 11%). Genomic features suggestive of HRD, PIK3CA mutations with CNAs, and CNAs were associated with significantly worse DRFI and OS compared with those without these features. These poor prognostic features were enriched in younger patients: present in 72% of patients aged <35 years, 54% aged 35-39 years, and 40% aged ≥40 years. Poor prognostic features [n = 584 (46%)] versus none [n = 692 (54%)] had an 8-year DRFI of 84% versus 94% and OS of 88% versus 96%. Younger women (<40 years) had the poorest outcomes: 8-year DRFI 74% versus 85% and OS 80% versus 93%, respectively.

CONCLUSION

These results provide insights into genomic alterations that are enriched in young women with HR+HER2- EBC, provide rationale for genomic subgrouping, and highlight priority molecular targets for future clinical trials.

Identifying oncogenic drivers associated with increased risk of late distant recurrence in postmenopausal, estrogen receptor-positive, HER2-negative early breast cancer: results from the BIG 1-98 study

BACKGROUND

In postmenopausal, estrogen receptor-positive, human epidermal growth factor receptor 2 (HER2)-negative early breast cancer, the risk for distant recurrence can extend beyond 5 years of adjuvant endocrine therapy. This study aims to identify genomic driver alterations associated with late distant recurrence.

PATIENTS AND METHODS

Next generation sequencing was used to characterize driver alterations in primary tumors from a subset of 764 postmenopausal estrogen receptor-positive/HER2-negative patients from the BIG 1-98 randomized trial. Late distant recurrence events were defined as ≥5 years from time of randomization). The association of driver alterations with distant recurrence-free interval in early and late time periods was assessed using Cox regression models. Multivariable analyses were carried out to adjust for clinicopathological factors. Weighted analysis methods were used in order to correct for over-sampling of distant recurrences.

RESULTS

A total of 538 of 764 (70%) samples were successfully sequenced including 88 (63%) early and 52 (37%) late distant recurrence events after a median follow up of 8.1 years. In univariable analysis for late distant recurrence, PIK3CA mutations (58.8%) were significantly associated with reduced risk [hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.20-0.82, P = 0.012], whereas amplifications on chromosome 8p11 (10.9%) (HR 4.79, 95% CI 2.30-9.97, P < 0.001) and BRCA2 mutations (2.3%) (HR 5.39, 95% CI 1.51-19.29, P = 0.010) were significantly associated with an increased risk. In multivariable analysis, only amplifications on 8p11 (P = 0.002) and BRCA2 mutations (P = 0.013) remained significant predictors.

CONCLUSIONS

In estrogen receptor-positive/HER2-negative postmenopausal early breast cancer, PIK3CA mutations were associated with reduced risk of late distant recurrence, whereas amplifications on 8p11 and BRCA2 mutations were associated with increased risk of late distant recurrence. The characterization of oncogenic driver alterations may aid in refining treatment choices in the late disease setting, and help identify potential drug targets for testing in future trials.

Abstract PD2-11: Ki-67 (30-9) scoring and differentiation in Luminal A and Luminal B breast cancer subtypes

Introduction

Ki-67 labeling index is a powerful prognostic marker in breast cancer (BC). It is especially useful in assessing the risk of recurrence for estrogen receptor-positive (ER+) BC, where it may be considered a surrogate of the molecular assays for distinguishing Luminal A-like from Luminal B-like BCs. We evaluated the performance of the VENTANA anti Ki-67 (30-9) rabbit monoclonal antibody in assessing the risk of distant relapses for a large series of patients with ER+ BC treated and followed up in a single Institution.

Patients and Methods

The initial cohort (9415 patients) comprised all women operated on for early ER+, HER2-negative (HER2-) BC at the European Institute of Oncology (IEO), who did not receive neo-adjuvant treatment1. We subsequently restricted the cohort to 3986 patients operated on between 1998-2002 and for whom long-term follow-up data was available. A case-cohort was built by randomly selecting 17% of the above cohort (679 patients, including 84 with events). Additional 303 patients who developed an event (metastasis in distant organs or death due to BC as primary events) were added to this cohort.

Ki-67 was evaluated using the anti-Ki-67 (30-9) antibody (Ventana Medical Systems, Inc., Tucson, AZ) using OptiView IHC DAB detection on the BenchMark ULTRA advanced staining platform. The stained slides were evaluated using the scoring method described by the International Ki-67 in BC Working Group.

We considered “Luminal A-like” tumors that were ER+, HER2-, with Ki-67 &lt;14% or with Ki-67 14-19% and PgR ≥20%, and “Luminal B-like” ER+, HER2- tumors with Ki-67 14-19% and PgR &lt;20% or with Ki-67 ≥20%1.

The main outcome was distant disease-free survival (DDFS) and was calculated from the date of surgery to the date of any first event or last contact with the patient.

Cumulative incidence curves were drawn for patients in the sub-cohort and differences between BC subtypes were assessed using the log-rank test. Multivariable Cox regression with inverse sub-cohort sampling probability weighting was used to evaluate the risk of metastasis or death from BC across groups.

Results

In the sub-cohort, 400 (58.9%) patients had “luminal A-like” and 279 (41.1%) “luminal B-like” BC. The 10-year cumulative incidence of distant metastasis (or BC related death as first event) in the two groups were respectively 8.2% and 24.5% (log rank P&lt;0.0001)

In the whole case-cohort, multivariable analysis confirmed statistically significant increased risk of events for women with “Luminal B-Like” BC compared to women with “Luminal A-Like “BC (HR=1.97; 95% CI 1.38-2.79), after adjustment for pT, pN, PVI and menopausal status.

Conclusion

Ki-67 evaluated using the VENTANA anti-Ki67 (30-9) antibody, was able to stratify patients with endocrine responsive BC, maximizing the number of those classified as having 'Luminal A-like' intrinsic subtype for whom the use of cytotoxic drugs could be at large avoided.

Funding source: Ventana Medical Systems, Inc.

References

Maisonneuve P, Disalvatore D, Rotmensz N, et al. (2014) Proposed new clinicopathological surrogate definitions of luminal A and luminal B (HER2-negative) intrinsic breast cancer subtypes. Breast Cancer Res 16:R65

Citation Format: Viale G, Hanlon Newell AE, Walker E, Bai I, Russo L, Dell'Orto P, Maisonneuve P. Ki-67 (30-9) scoring and differentiation in Luminal A and Luminal B breast cancer subtypes [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD2-11.

Plasma Cell Granuloma of the Lung (Inflammatory Pseudotumor)

A case of plasma cell granuloma (PCG) of the lung in a 54-year old man is reported. PCG is a rare benign lesion that usually presents as a solitary nodule in the lung (coin lesion) at routine X-ray examination. Microscopically it consists of a granulomatous tissue where the major components are mature plasma cells. The immunohistochemical demonstration of poly-clonality of plasma cells, excluding the diagnosis of plasmacytoma, confirms the inflammatory pseudotumoral nature of this lesion, although the etiology remains obscure. The presence of lymphocytes, histiocytes, macrophages, blood vessels with prominent endothelial cells and peripheral sclero-hyalinized connective tissue may pose problems in the differential diagnosis, with sclerosing hemangioma, pseudolymphoma, nodular amyloidosis, pulmonary hyalinizing granuloma, chronic abscess and neoplasms of true histiocytic origin. The term inflammatory pseudotumor is preferable in describing this type of lesion.

Abstract PD7-01: Can surrogate pathological subtyping replace molecular subtyping? Outcome results from the MINDACT trial

Background

Molecular subgroups within early breast cancer (EBC), such as Luminal A, Luminal B, HER-2+, Basal-like may help to best to identify patients for specific treatment regimens. Controversy exists as to which methodology is best at identifying these molecular subgroups. Immunohistochemistry (IHC) may be used as a surrogate method to stratify patients. Molecular subtyping gene expression based tests, such as BluePrint, measure a greater number of genes than pathological criteria. ER, PgR, HER-2 and Ki67 are measured individually at the protein level, while BluePrint is designed to capture the functional underlying biologic pathway regulated by these receptors.

Methods

The MINDACT trial is an international, prospective, randomized, phase III trial which has proventhe clinical utility of MammaPrint in selecting EBC patients who can safely avoid chemotherapy. Here we present the results of a preplanned MINDACT sub-study to compare outcome based on molecular subtyping (MS) to surrogate pathological subtyping (PS) as endorsed by 2013 St. Gallen Consensus. MS data were obtained by MammaPrint (MP) and BluePrint classifying patients in the following subtypes: Luminal A (MP Low Risk); Luminal B (MP High Risk); HER2-type; and Basal-type. ER, PgR, HER2 and Ki67 protein status were centrally assessed by IHC/FISH. The primary hypothesis was that among PS Luminal patients, patients with HER-2+ or Basal-type tumors by MS would have a decreased DMFS compared to MS Luminal patients. At α=5% with 220 events, the study has 80% power to demonstrate this for HR=2.44.

Results

The table depicts classification of tumors according to PS versus MS for all patients (n=5,806).

PS versus MSMSPSLum ALum BHER-2+BasalTotalLum A24562708132747Lum B106979422861971HER-2 enriched1189531826557TN14107500531Total365711693556255806

Most pronounced differences: MS classified 54% as Luminal A among the Luminal B by PS. MS classified 38% as Luminal (A and B) and 5% as Basal-type among the HER-2+ by PS. MS classified 5% as Luminal (A and B) among the TN cases by PS.

MS identifies 63% of patients as Luminal A, while PS identifies 47%; 5yr DMFS for both methods was ≥ 96.0%.

PS Luminal cancers that were classified as HER-2+ or Basal-type by MS had a lower 5yr DMFS (88.0% for HER-2+ and 90.2% for Basal), albeit non-significant, than those who were also Luminal by MS (95.9%): HR= 1.40, 95% CI = 0.75-2.60.

In PS TN cancers, MS identified 24 out of 500 patients (5%) as Luminal-type with excellent prognosis (5yr DMFS of 100% versus 71.4% for MS HER-2+ or 90.1% for MS Basal-type).

Among the PS Luminal patients, Ki67 cut at 20% identified patients with ki67 low (69%), with 5yr DMFS ≥ 96.0% (better compared to the 14% cut-off).

Conclusions

1) MS was able to re-stratify 16% of patients to a low risk Luminal A-type group with an excellent outcome. 2) Among TN EBC, 5% were classified as Luminal by MS and had an excellent outcome. 3) Albeit limited by low numbers of patients in each subgroup, this study suggest that MS is better correlated with outcome. 4) The observed subtype discrepancies may have an impact on treatment decision making. 5) Centrally assessed Ki67 labeling index of 20% may be the best cut-off for surrogate differentiation between Luminal A and B.

Citation Format: Cardoso F, Slaets L, de Snoo F, Bogaerts J, van 't Veer LJ, Rutgers EJ, Piccart-Gebhart MJ, Stork-Sloots L, Russo L, Dell'Orto P, Viale G. Can surrogate pathological subtyping replace molecular subtyping? Outcome results from the MINDACT trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD7-01.

Abstract P5-07-02: Systematic analysis and modulation of Ki67 interobserver variance in 9069 patients from three clinical trials – How much pathologist concordance is needed for meaningful biomarker results?

Background: Ki67 has been suggested as a marker for diagnosis of luminal A and B breast carcinomas. Interestingly, on one hand a multitude of studies have described significant results for Ki67 as a prognostic marker, while on the other hand the analytical validation and standardization of this marker has been a challenge. The best parameter for Ki67 interobserver performance is the interclass correlation coefficient (ICC). ICC values between 0.59 and 0.92 have been reported. Recently a minimum ICC of 0.8 has been suggested as a goal for the international ring trial and as a prerequisite for introduction of Ki67 into clinical practice. However, this suggested ICC is not derived from analysis of data, and the amount of pathologist variance that is allowed for meaningful biomarker results is still not defined.

Methods: This study is based on a total of 9069 tumor samples from three large clinical cohorts (IBCSG VIII+IX, BIG1-98, and GeparTrio). In a systematic modeling approach, we introduced different amounts of variance to previously generated central pathology Ki67 datasets by simulation of a total of 1800 different pathologist evaluations for each study cohort. These evaluations were grouped into groups with defined ICCs, ranging from very good concordance (ICC=0.9) to extremely poor concordance (ICC=0.1). For each of the simulated pathologist evaluations, all possible Ki67 cutoffs were systematically evaluated using the web-based software Cutoff Finder (http://molpath.charite.de/cutoff/). As endpoints, we used DFS for all three study cohorts as well as pCR for the neoadjuvant cohort.

Results: For the neoadjuvant GeparTrio study, the different groups with ICCs of 0.8, 0.6 and 0.4 showed a very similar performance resulting in significant analyses for prediction of pCR across a wide range of cutoffs. The odd ratios for pCR were slightly lower with lower ICC. Even with an extremely low ICC of 0.2, 99% of the analyses had one or more significant cutpoints.

The survival endpoint DFS was shown to be very stable despite increased interpathologist variance in all three clinical cohorts. Even with a poor ICC of 0.4, the majority of cutpoints were significant for DFS. For IBCSG VIII+IX 85% of the analyses with an ICC of 0.4 had one or more significant cutpoints for Ki67. In the large BIG 1-98 dataset (n=6090) even an ICC of 0.2 resulted in one or more significant DFS cutpoints in 100% of the analyses. Comparable results were obtained if the analysis was restricted to luminal tumors.

Conclusion: Our results suggest that Ki67 is extremely robust to pathologist variation. Even if less than 40% of the variance is attributable to true Ki67-based proliferation (ICC&lt;0.4), this percentage of information is sufficient to obtain statistically significant differences. This stable performance of Ki67 might provide an explanation for the observation that many Ki67 studies achieve significant results despite the interobserver variance and heterogeneity issues. It might also suggest a relevant clinical utility for Ki67 despite considerable variation introduced in the evaluation. Ongoing efforts to further reduce interobserver variability, however, should be continued.

Citation Format: Denkert C, Budczies J, Regan M, Loibl S, Dell'Orto P, von Minckwitz G, Mastropasqua M, Mehta K, Müller V, Kammler R, Pfitzner BM, Fasching PA, Viale G. Systematic analysis and modulation of Ki67 interobserver variance in 9069 patients from three clinical trials – How much pathologist concordance is needed for meaningful biomarker results?. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-07-02.

Abstract P1-01-16: Performance evaluation of two ready-to-use antibodies under development for the Dako Omnis automated staining platform on breast carcinoma specimens: Anti-estrogen receptor α clone EP1 and anti-progesterone receptor clone PgR 1294

Background: The expression of estrogen receptor alpha (ERα) and progesterone receptor (PR) in breast carcinomas is a strong predictor of the efficacy of hormonal therapy for breast cancer patients as well as providing a degree of prognostic information. Anti-ERα (clone EP1) and anti-PR (clone PgR 1294) configured as FLEX ready-to-use antibodies have been tested on the Dako Omnis automated staining platform. These products are in performance evaluation and are not commercially available. A series of concordance studies were performed to evaluate the performance characteristics of these monoclonal antibodies on breast cancer tissue specimens: anti-ERα clone EP1/Dako Omnis was compared to (a) anti-ERα clone EP1/Autostainer Link 48 (238 specimens) and to (b) anti-ERα clone SP1/Autostainer (116 specimens), and anti-PR clone PgR 1294/Dako Omnis was compared to (a) anti-PR clone PgR 636/Autostainer Link 48 (289 specimens) and to (b) anti-PR clone 16 (Leica Biosystems, Newcastle, UK) (144 specimens). In addition, the specificity of the ER and PR antibodies for Dako Omnis was evaluated on a set of normal tissue specimens.

Methods: Formalin-fixed, paraffin-embedded (FFPE) human breast carcinoma specimens and normal tissues were obtained from commercial providers or local hospitals. The specimens had no associated personal information and were not traceable back to the tissue donors. Tissue pretreatment and immunohistochemical staining were performed using the recommended protocol for each antibody and staining platform. The stained slides were evaluated for nuclear ER or PR expression according to ASCO/CAP guidelines (≥1% cut-off for positive) by pathologists who were blinded from the staining method and specimen ID. The concordance studies included breast cancer specimens covering the clinical range of ER or PR expression with approximately half the specimens in the negative (&lt;1%) category, and at least 10% of the specimens in the weakly positive (≥1 ≤10%) category in each study. Two-sided Wilson Score 95% Confidence Intervals were calculated using JMP software (SAS Institute, USA). For the analytical specificity studies the presence or absence of specific staining in the various normal tissue types was recorded.

Results: High concordance rates were observed with both anti-ERα clone EP1/Dako Omnis and anti-PR clone PgR 1294/Dako Omnis compared to the other ER/PR antibodies, with overall agreement rates exceeding 95% in all of the comparative studies. On a set of normal tissues, specific positive nuclear staining was observed only in tissue types known to express ERα or PR.

Conclusions: Monoclonal antibodies anti-ERα clone EP1 and anti-PR clone PgR 1294 configured as FLEX ready-to-use on Dako Omnis are sensitive and specific assays for detecting estrogen receptor and progesterone receptor in FFPE tissues. In comparison testing for assessment of hormonal receptor status on breast carcinoma specimens, anti-ERα clone EP1/Dako Omnis and anti-PR clone PgR 1294/Dako Omnis were highly concordant with commercially-available ER or PR antibodies.

Citation Format: Viale G, Dell'Orto P, Falzon M, Fält A, Hicks D, Hoff K, Jakobsen K, Jensen LB, Levy YY, McMahon L, Miller K, Russo L. Performance evaluation of two ready-to-use antibodies under development for the Dako Omnis automated staining platform on breast carcinoma specimens: Anti-estrogen receptor α clone EP1 and anti-progesterone receptor clone PgR 1294. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-01-16.

Abstract S4-06: HER2 status as predictive marker for AI vs Tam benefit: A TRANS-AIOG meta-analysis of 12129 patients from ATAC, BIG 1-98 and TEAM with centrally determined HER2

There is now significant evidence emerging from the pivotal trials of AIs versus Tamoxifen (AIOG) demonstrating the value of meta-analysis of key clinical questions. The "Trans-AIOG" group has been tasked with the exploration of key molecular/biomarker questions that are pertinent to meta-analyses of biomarkers (past/present/future) in AIOG trials. HER2 has been long proposed as a marker of endocrine "resistance". Data from three trials, before the era of HER-directed therapy, suggest a potential role for HER2 to select patients for treatment with upfront AIs. However the individual trials lack power to test treatment-by-HER2 interaction due to sample size and low HER2+ve rates. A meta-analysis of the predictive value of HER2 status, specifically within the first 3 years of endocrine therapy, has the potential to inform patient selection for upfront or sequential strategies with AIs. The pre-existing standardization of methodology for HER2 (IHC/FISH) facilitates analysis of existing data from BIG-1-98, TEAM and ATAC for this key marker.

Analysis plan: Following a prospectively-designed analysis plan, patient-level data from 3 randomized phase III trials (ATAC, BIG 1-98, TEAM) comparing AIs to tamoxifen during the first 2-3 years of adjuvant treatment were collected at the CRCTU (Birmingham UK), accounting for both the established time-dependency of relapse in HER2+ve, anti-endocrine treated patients and to address the clinical question of "upfront" vs "sequential" strategies for AIs. For each trial, covariate-adjusted Cox models estimated HER2-by-treatment (AI vs Tam) interaction on distant recurrence-free interval-censored at 2-2.75 years follow-up. A meta-analysis of the HER2-by-treatment interaction terms and of treatment effects according to HER2 status was performed.

Results: 12129 patients with centrally-confirmed ER and HER2 status, 1092 (9%) HER2+ve, with 473 (4%; 111 among HER2+ve) distant recurrences were analyzed. The meta-analysis estimated a pooled HER2-by-treatment interaction of 1.61 (95% CI 1.01,2.57), reflecting treatment effect hazard ratio(AI/Tam) of HR=1.13 (0.75,1.71) among HER2+ve and HR=0.70 (0.56,0.87) among HER2-ve. There was heterogeneity among interaction terms (I-squared=59%, p=.09) that resulted from treatment effect heterogeneity among HER2+ve subgroup (I2=71%, p=.03), not the HER2-ve subgroup (I2=0%). The results for disease-free survival were similar.

Conclusion: An individual patient data meta-analysis across 3 trials (ATAC, BIG 1-98, TEAM) conducted prior to standard use of HER2-directed adjuvant therapy demonstrated a marginally-significant interaction between HER2 status and treatment with AIs vs Tamoxifen in the 2-2.75 years prior to potential "switching" between Tamoxifen and AIs. Patients with HER2-ve cancers experienced improved outcomes when treated with AIs vs Tamoxifen whilst patients with HER+ve cancers fared no better, or slightly worse, during AI treatment. However, the small number of HER2+ve cancers and events even in this meta-analysis may explain a large degree of heterogeneity in the treatment effects within the HER2+ve subgroups across the 3 trials. Other causes, perhaps related to subtle differences between AIs, cannot be excluded.

Citation Format: Bartlett JMS, Ahmed I, Regan MM, Sestak I, Mallon EA, Dell'Orto P, Thürlimann BJK, Seynaeve C, Putter H, Brookes CL, Forbes JF, Colleoni MA, Bayani J, van de Velde CJH, Viale G, Cuzick J, Dowsett M, Rea DW, On Behalf of the Translational Aromatase Inhibitor Overview Group (Trans-AIOG). HER2 status as predictive marker for AI vs Tam benefit: A TRANS-AIOG meta-analysis of 12129 patients from ATAC, BIG 1-98 and TEAM with centrally determined HER2. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr S4-06.

High concordance of protein (by IHC), gene (by FISH; HER2 only), and microarray readout (by TargetPrint) of ER, PgR, and HER2: results from the EORTC 10041/BIG 03-04 MINDACT trial

BACKGROUND

To investigate the correlation of TargetPrint with local and central immunohistochemistry/fluorescence in situ hybridization assessment of estrogen (ER), progesterone (PgR), and human epidermal growth factor receptor 2 (HER2) in the first 800 patients enrolled in the MINDACT trial.

PATIENTS AND METHODS

Data from local (N = 800) and central (N = 626) assessments of receptor status were collected and compared with TargetPrint results.

RESULTS

For ER, the positive agreement (the percentage of central pathology positive assessments that were also TargetPrint/local laboratory positive) for TargetPrint in comparison to centralized assessment was 98% with a negative agreement (the percentage of central pathology negative assessments that were also TargetPrint/local laboratory negative) of 96%. For PgR, the positive agreement was 83% with a negative agreement of 92%. For HER2, the positive agreement was 75% with a negative agreement of 99%. Even though the local assessment showed higher positive agreement for PgR (89%) and higher positive agreement for HER2 (85%), the range of discordant local versus central assessments were as high as 6.7% for ER, 12.9% for PgR, and 4.3% for HER2.

CONCLUSION

TargetPrint and local assessment of ER, PgR, and HER2 show high concordance with central assessment in the first 800 MINDACT patients. However, there are concerns about the higher discordance rates for some local sites. TargetPrint can improve the reliability of hormone receptor and HER2 testing for those centers with a lower rate of concordance with the reference laboratory, with the limitation of a positive agreement of 75% for HER2. TargetPrint consequently has important implications for treatment decisions in clinical practice and is a reliable alternative to local assessment for ER.

CLINICAL TRIALS NUMBER

NCT00433589.

Abstract P3-05-02: Pathological assessment of discordant cases for molecular (BluePrint and MammaPrint) versus clinical subtypes for breast cancer among 621 patients from the EORTC 10041/BIG 3–04 (MINDACT) trial

Background: Biology has become the main driver of breast cancer therapy. Intrinsic biological subtypes by gene expression profiling have been identified. Pathology can be used to define surrogates of these subtypes but these are not always concordant, which may lead to different treatment plans. We investigated the concordance between BluePrint and MammaPrint (microarray-based) breast cancer subtypes and pathological surrogates (based on ER, PR, HER2 & Ki67).

Methods: Using available data (centrally assessed pathology and genomics) from the MINDACT pilot phase [Rutgers et al. EJC 2011] 621 tumors were analyzed. Patients were classified according to 4-category based pathology (ER, PR, HER2 and Ki67); additionally, classification was performed adhering to the recent St. Gallen recommendations [Goldhirsch et al. 2011], which recognizes an additional category (Luminal B HER2+). Based on BluePrint and MammaPrint 4 subtypes are formed: Luminal A (Luminal-type/MammaPrint Low Risk); Luminal B (Luminal-type/MammaPrint High Risk); HER2-type; and Basal-type. This study is an analysis of discordant patient groups (i.e. clinical HER2+/BluePrint Luminal-type; clinical Hormone Receptor (HR)-positive/BluePrint Basal-type) providing comparison of centrally assessed tumor heterogeneity as well as comparison of quantified ER, PR and HER2 results.

Results: Ki67 is often used as biomarker to distinguish Luminal A from Luminal B subgroups. The concordance between MammaPrint and centrally assessed Ki67 in Luminal-type patients is 71%, with a κ score of 0.35 (95% CI 0.26–0.45) indicating that Ki67 and MammaPrint cannot reliably substitute for each other. There is a relatively large group of clinical HER2+ cases that are BluePrint Luminal-type (29 out of 76; 38%) indicating that tumor expression of the Luminal profile is dominant compared with expression of the HER2 profile. These patients have high IHC ER results and fall into the group that St Gallen separately defines as Luminal B HER2-type. These patients may have lower response to trastuzumab [von Minckwitz et al. JCO 2012]. 12 out of 76 BluePrint Basal-type patients are clinical HR+. These patients have low centrally assessed IHC ER and PR expression (≥1% and &lt;10%).

Conclusions: Marked differences are observed between BluePrint and MammaPrint (microarray based) breast cancer subtypes and centrally re-assessed pathological surrogates (based on ER, PR, HER2 & Ki67). The greatest discordance is seen in the sub-stratification of Luminal patients, and in the HR+/HER2+ patients. The observed subtype discrepancies may have an important impact on treatment decision making.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-05-02.

Abstract P6-07-14: Mutational and transcriptomic characterization of breast cancer (BC) arising in young patients (pts) and during pregnancy and their associations with long-term outcome

Background: BC arising in young age is biologically distinct. Whether diagnosis during pregnancy has an impact on prognosis and tumor biology remains to be elucidated. We report for the first time mutational and transcriptomic profiling of BC arising in young pts and the impact of diagnosis during pregnancy. We also correlate these findings with clinical outcome.

Methods: 65 pts with BC during pregnancy diagnosed at the European Institute of Oncology in the period 1999–2009 were matched to 130 BC pts who were diagnosed and treated at the same period/institute. We screened for 84 somatic hotspot mutations on 17 cancer-related genes using mass spectroscopy-based sequencing (Sequenom). We evaluated the pattern of mutations in the two cohorts and according to BC subtype defined using central immunohistochemistry as follows: Luminal A (ER+, HER2−, Ki67 &lt;14%), Luminal-B (ER+, HER2−, Ki67 &gt;14%), HER2+ (HER2+ irrespective of ER), and triple negative (ER−, PgR−, HER2−). Survival endpoints included distant relapse free survival (DRFS) and overall survival (OS).

Results: Median age at diagnosis was 36 years (range: 28–47). At a median follow-up of 74 months (IQR: 42–96), 44 (23%) and 29 (15%) pts developed a DRFS and OS event respectively. Pts diagnosed during pregnancy had inferior DRFS (HR: 3.2 [1.5–6.7]) and OS (HR: 2.9 [1.1–7.9]) after adjusting for pT, pN, grade, BC subtype, and therapy. Mutational profiling was successful in 97% of pts. A total of 57 hotspot mutations (30%) were detected in 51 pts (15 [23%] pregnant and 36 [28%] controls). The differences in mutations between the two groups are summarized in the table.

Abstract PD03-01: EFFECT OF METFORMIN ON APOPTOSIS IN A PRESURGICAL TRIAL IN NON-DIABETIC PATIENTS WITH BREAST CANCER

BACKGROUND: metformin has been associated with antitumor activity in epidemiological and clinical studies. This effect has been related to different mechanisms of actions, including a reduction of the proliferative activity and an increase of apoptosis. We have recently shown that a 4 week pre-surgical treatment with metformin did not affect Ki-67 LI overall but reduced tumor proliferation Ki67 LI in breast cancer (BC) patients with insulin resistance (IR) (HOMA, fasting blood glucose (mmol/L)*insulin (mU/L)/22.5&gt;2.8) or BMI&gt;27 (Bonanni et al. JCO epub May 7, 2012). The objective of the current analysis was to determine whether metformin induced a modulation of apoptosis (TUNEL) overall and by HOMA index.

TRIAL DESIGN: After tumor biopsy we randomly allocated 200 non-diabetic women with operable breast cancer to either metformin (850 mg/bid) or placebo for 4 weeks prior to surgery. The primary outcome measure was the difference between arms in Ki-67 after 4 weeks of treatment. Here we analyzed the apoptotic cell nuclei in 88 consecutive core biopsies and their paired surgical samples from the initial 100 randomized subjects.

RESULTS: Median TUNEL levels at surgery (Metformin = 10%, IQR, 4–20, Placebo = 8%, IQR, 3–15) were significantly higher as compared with baseline (Metformin = 4%, IQR, 2–7, Placebo = 3%, IQR, 2–6, p &lt; 0.0001), but no difference between arms was noted (p = 0.2, adjusted for age, BMI, TUNEL and Ki67 at baseline). Interestingly, Ki67 and TUNEL levels were highly and positively correlated both at baseline and at surgery (Spearman r=0.51, p &lt; 0.0001). Furthermore, we found a trend to a different metformin effect by the HOMA index (p = 0.1). In the 59 women with HOMA &lt;2.8 there was a higher level of TUNEL at surgery on metformin versus placebo (p = 0.05), while an opposite trend was found in the 28 women with HOMA&gt;2.8 (p = 0.6).

CONCLUSIONS: The levels of TUNEL are significantly higher in the surgical specimens compared with baseline biopsy and are directly correlated with those of Ki-67 (TUNEL is high when Ki-67 is high). We found no significant modulation of TUNEL by metformin but a trend to a different effect according to the IR state, with a similar pattern to Ki-67: decrease by metformin in IR women and increase in non-IR women. Our findings confirm the notion that metformin has dual effects on breast cancer according to IR state. As expected, cancer apoptosis and proliferation are directly related. Our results strengthen the importance of placebo control arms in biomarker trials.

ACKNOWLEDGEMENTS: 2 Grants by AIRC and Italian Ministry of Health.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD03-01.

P1-07-06: High Concordance of Protein (by IHC), Gene (by FISH; HER-2 Only) and Microarray Readout (by TargetPrint) of ER/PR/HER2: Results from the MINDACT Trial

Background

Previously, the micro-array readout of ER, PR and HER2 by TargetPrint was shown to be strongly correlated with high quality immunohistochemistry (IHC)/FISH assessment, especially for ER and HER2. Concordance rates were 93% (k=0.79) for ER; 83% (k=0.65) for PR and 96% for HER2 (k=0.88) in 636 patients (Roepman et al., Clin Cancer Res, 2009).

This study analysis was undertaken to further determine the correlation of microarray readout with IHC/FISH assessment both locally and centrally determined in the 1st 800 pts enrolled in the MINDACT trial. This work is essential to determine the quality of biological data in the two risk assessment methods used in MINDACT based upon which adjuvant chemotherapy decision is made, in order to exclude bias.

Methods: ER/PR/HER2 IHC assessment was performed on the 1st 800 primary breast cancers (BC) of pts enrolled in the MINDACT study. The assessment was performed locally at each center (n=800) and by central review at the laboratory of the European Institute of Oncology (n=626). A tumor was classified positive for ER and PR when 1% of tumor cells showed positive staining. HER2 IHC status was scored as 0, 1+, 2+ or 3+; a score of 3+ was considered positive. In 2+ cases FISH was performed to assess final HER2 status. Gene expression data for ER, PR and HER2 were obtained by TargetPrint stratified as receptor positive or negative using previously determined and validated thresholds for ER, PR and HER2 mRNA levels (n=800).

Results: Comparison of local assessment (IHC & FISH for HER2) with central review indicated highly similar results for receptor readout with a concordance of 98% (k=0.90) for ER; and 96% for HER2 (k=0.80) and slightly lower for PR (90% (k=0.72)).

Comparison of central assessment (IHC & FISH for HER2) with micro array readout by TargetPrint indicated highly similar results for receptor readout with a concordance of 97% (k=0.88) for ER and 95% for HER2 (k=0.76). For PR the concordance was lower but still quite acceptable (85% (k=0.62)).

Conclusion: Local and centrally assessed ER, PR and HER2 status in the first 800 MINDACT patient samples indicate a high level of quality for pathology in the local participating hospitals. These results exclude any bias induced by a lower quality of “traditional” pathology results as compared to the centrally assessed MammaPrint, both used for risk assessment and adjuvant chemotherapy decision in the MINDACT trial. The microarray-based assessment of ER, PR and HER2 gives results comparable to IHC & FISH and provides an objective and quantitative assessment of tumor receptor status. These results indicate that TargetPrint can serve as a second pathology assessment for locally assessed parameters, especially since TargetPrint is part of a multi-profile platform for breast cancer treatment management. This work was funded by the Breast Cancer Research Foundation and the EU Framework Program VI.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-07-06.

Which patients benefit most from adjuvant aromatase inhibitors? Results using a composite measure of prognostic risk in the BIG 1-98 randomized trial

BACKGROUND

On average, aromatase inhibitors are better than tamoxifen when used as initial or sequential therapy for postmenopausal women with endocrine-responsive early breast cancer. Because there may be contraindications to their use based on side-effects or cost, we investigated subgroups in which aromatase inhibitors may be more or less important.

PATIENTS AND METHODS

Breast International Group 1-98 trial randomized 6182 women among four groups comparing letrozole and tamoxifen with sequences of each agent; 5177 (84%) had centrally confirmed estrogen receptor (ER) positivity. We assessed whether centrally determined ER, progesterone receptor (PgR), human epidermal growth factor receptor 2, and Ki-67 labeling index, alone or in combination with other prognostic features, predicted the magnitude of letrozole effectiveness compared with either sequence or tamoxifen monotherapy.

RESULTS

Individually, none of the markers significantly predicted differential treatment effects. Subpopulation treatment effect pattern plot analysis of a composite measure of prognostic risk revealed three patterns. Estimated 5-year disease-free survival for letrozole monotherapy, letrozole→tamoxifen, tamoxifen→letrozole, and tamoxifen monotherapy were 96%, 94%, 93%, and 94%, respectively, for patients at lowest risk; 90%, 91%, 93%, and 86%, respectively, for patients at intermediate risk; and 80%, 76%, 74%, and 69%, respectively, for patients at highest risk.

CONCLUSION

A composite measure of risk informs treatment selection better than individual biomarkers and supports the choice of 5 years of letrozole for patients at highest risk for recurrence.

Abstract P3-02-13: Is HER2 Evaluation with the CellSearch System a Method Reliable for Detecting HER2 Overexpression?

Background. Circulating tumor cells (CTCs) detected in patients with both localized and metastatic breast cancer are significantly associated with a worse outcome. In addition to enumeration, an exciting area of CTC research involves the phenotyping and expression profiling of CTCs. In this regard, in patients with metastatic breast cancer, the evaluation of CTCs could be considered as a “real-time” biopsy allowing the detection of possible changes in tumor phenotype, such as a shift in patients HER2- negative on the primary tumor to HER2-positive CTCs. This could be of relevance as these patients may become suitable to targeted anti-HER2 therapy. Currently, there is no standardized and widely accepted method available for the determination of HER2 status on CTC. Aims. Objectives of this study were: 1. verifying the feasibility and reliability of HER2 determination on cells from scraping of breast cancer tissue by FISH analysis, 2. evaluating the concordance of HER2 status determined on primary breast tumor by immunohistochemistry (IHC) and on scraped cells, obtained from the same breast tumor and spiked in blood from healthy subjects, using the CellSearch System, and finally 3. evaluating the concordance of HER2 expression determinated by FISH analysis and by CellSearch on the same scraped cells. Methods. Cells from scraping of fresh breast cancer tissues with different level of HER2 expression were spiked in 18 healthy subjects blood samples. The determination of the HER2 expression on these cells was performed with the CellSearch System (Veridex, USA) by the addition of a fluorescein conjugated monoclonal antibody to be used in conjunction with the CellSearch™ Epithelial Cell Kit to phenotype CTCs for the presence of HER-2/neu. The HER2 characterisation of the primary breast tumors was performed by IHC by FISH analysis according to standard procedures. FISH was also performed on cells from scraping of fresh breast cancer tissues after CellSearch enumeration and characterization, by removing them from the “MagNest” cartridge. Tumors with a score of 3+ were considered positive.

Results. The results of the FISH analysis performed on the cells aspirated from the cartridge demonstrated a 100% concordance with the FISH performed on fresh tissue (9 not amplified and 9 amplified). The evaluation of HER2 expression on scraped cells by CellSearch System and by IHC on the corresponding tumor showed that the CellSearch method is reliable in identifying HER2 overexpression, as in all the 3+ tumors it was possible to detect variable percentage of scraped cells overexpressing HER2. Finally, different number of HER2+ scraped cells were found in 16 out of the 18 samples: the only 2 negative samples were both IHC negative and FISH not amplified. On the contrary 2 of the 4 remaining negative/1+ IHC samples, showed some scraped cells HER2+ which resulted FISH amplified. Conclusion. This study demonstrates that FISH analysis is feasible and the results are reliable when performed on cells after CellSearch procedure. Moreover HER2 expression may be evaluated with the CellSearch System and it may be used as a preliminary method to indicate possibly HER2 positive samples which may be confirmed by FISH analysis.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-02-13.

Epidermal growth factor receptor serum (sEGFR) level may predict response in patients with EGFR-positive advanced colorectal cancer treated with gefitinib?

PURPOSE

Epidermal growth factor receptor-overexpression reported in colorectal cancer, justifies therapeutic use of EGFR-inhibitors. We have recently conducted a phase II study in 57 patients with EGFR-positive advanced colorectal cancer (ACC) who received gefitinib-FOLFOX6 followed by gefitinib-single agent as maintenance. Main biological objective was to assess sEGFR as surrogate marker of tyrosine kinase inhibition and as predictor of response.

METHODS

sEGFR, evaluated by quantitative ELISA, was investigated as predictive factor both taking into account the basal value only, and its whole pattern over time. sEGFR was collected at baseline and at every 2-months assessment in 42 cases. Thirty-three patients reported CR/PR as best objective response (BOR), while nine showed SD/PD.

RESULTS

Retrospectively, on average, the sEGFR values reported by both responders (CR/PR) and not responders (SD/PD) were already different at baseline (49.4 +/- 6.2 and 42.4 +/- 8.4 ng/ml respectively). This difference was statistically significant (p = 0.042). Although sEGFR trend over time confirmed the basal difference (p = 0.032), this result should be taken with caution, due to the small number of patients reporting EGFR values besides the basal one.

CONCLUSIONS

Higher sEGFR at baseline was associated to BOR and may be considered a significant predictor of outcome in patients with ACC.

Restoration of Posterior Aspect of Rhabdosphincter Shortens Continence Time After Radical Retropubic Prostatectomy

PURPOSE

Prolonged postoperative incontinence is a major drawback of RRP. Age, scars in the rhabdosphincter, nonnerve sparing surgery and postoperative sphincter insufficiency can cause temporary or definitive urinary incontinence. We believe that sphincter deficiency is the main cause of early incontinence. Urinary leakage results from the shortening of anatomical and functional sphincter length due to caudal retraction of the urethral sphincteric complex and disruption of the median posterior fibrous raphe. We describe a modification of the Walsh RRP that overcomes caudal retraction, reconstructs the posterior fibrous raphe and decreases time to continence. The primary study end point was early continence rate assessment. Long-term continence (1 year) and erectile function assessment were secondary end points.

MATERIALS AND METHODS

To avoid caudal retraction of the urethrosphincteric complex, before completing the vesicourethral anastomosis the posterior semicircumference of the sphincter is joined to the residuum of Denonvilliers' fascia and fixed to the posterior bladder wall 1 to 2 cm cranial and dorsal to the new bladder neck. Vesicourethral anastomosis is subsequently performed with care taken not to involve the neurovascular bundles. A total of 161 patients with clinically confined disease underwent modified RRP (group 1). They were compared with a historical series of 50 patients who underwent standard RRP (group 2). Early continence was defined as no pad use but patients using 1 diaper were also considered continent. Continence, assessed prospectively as the number of pads daily, was evaluated 3, 30 and 90 days, and 1 year after catheter removal. The continence state was assessed by a multivariate logistic model. Erectile function was evaluated using the International Index of Erectile Function questionnaire preoperatively and after 18 months in patients younger than 65 years who underwent nerve sparing surgery.

RESULTS

In group 1, 116 (72%), 127 (78.8%) and 139 patients (86.3%) were continent 3, 30 and 90 days after catheter removal compared with 7 (14%), 15 (30%) and 23 (46%), respectively, in group 2. One-year continence rates were 96% and 90%, respectively. Erectile function was similar in groups 1 and 2 (46% and 42%, respectively). Multivariate analysis showed that continence was significantly influenced by operation type, stage and patient age.

CONCLUSIONS

Careful reconstruction of the posterior aspect of the rhabdosphincter markedly shortens time to continence.

Reverse transcription-polymerase chain reaction assay for multiple mRNA markers in the detection of breast cancer metastases in sentinel lymph nodes

The identification of specific tumor mRNA markers by reverse transcription-polymerase chain reaction might be a valuable diagnostic adjunct for the detection of breast cancer metastases in axillary sentinel lymph nodes (SLNs). In this study we have compared the diagnostic accuracy of an extensive histopathologic examination of 146 SLNs from 123 breast carcinoma patients with that of the evaluation of 5 mRNA markers. When analyzed individually, none of the different markers attained a sensitivity higher than 77.8%, and the general concordance with the histopathologic findings ranged from 78.8 to 83.6%. In a multiple-marker assay, taking into account the expression of at least 1 of the 5 tumor markers, the sensitivity of the test rose to 95.6%, with a specificity of 66.3% and a general concordance with the histopathologic status of 75.3%. Finally, when at least 2 of 3 markers (maspin, cytokeratin 19 and mammaglobin 1) were expressed, the concordance with either SLN or axillary lymph node status was highest (88.4% and 84.6%, respectively). The high prevalence of positive reverse transcription-polymerase chain reaction assays in histologically uninvolved SLNs, however, may hamper extensive application of these techniques in the clinical setting.

Reverse transcription-polymerase chain reaction assay for multiple mRNA markers in the detection of breast cancer metastases in sentinel lymph nodes

The identification of specific tumor mRNA markers by reverse transcription-polymerase chain reaction might be a valuable diagnostic adjunct for the detection of breast cancer metastases in axillary sentinel lymph nodes (SLNs). In this study we have compared the diagnostic accuracy of an extensive histopathologic examination of 146 SLNs from 123 breast carcinoma patients with that of the evaluation of 5 mRNA markers. When analyzed individually, none of the different markers attained a sensitivity higher than 77.8%, and the general concordance with the histopathologic findings ranged from 78.8 to 83.6%. In a multiple-marker assay, taking into account the expression of at least 1 of the 5 tumor markers, the sensitivity of the test rose to 95.6%, with a specificity of 66.3% and a general concordance with the histopathologic status of 75.3%. Finally, when at least 2 of 3 markers (maspin, cytokeratin 19 and mammaglobin 1) were expressed, the concordance with either SLN or axillary lymph node status was highest (88.4% and 84.6%, respectively). The high prevalence of positive reverse transcription-polymerase chain reaction assays in histologically uninvolved SLNs, however, may hamper extensive application of these techniques in the clinical setting.

[Physiology of the urethral sphincteric vesico-prostatic complex]

We propose a review of the literature about innervation and physiology of the urethral sphincteric complex. Parasympathetic innervation of the pelvic viscera comes from ventral branches of the sacral nerves (S2-S4). The orthosympathetic component derives from superior hypogastric plexus and runs down the hypogastric nerves to form the right and left pelvic plexus together with the parasympathetic component. The pelvic plexus is situated inferolaterally with respect to the rectum and runs on the surface of the levator ani muscle down to the prostatic apex. The pelvic plexus gives innervation to the rectum, the bladder, the prostate and the urethral sphincteric complex. The pelvic muscular floor is innervated by the somatic component (pudendal nerve) derived from the sacral branches (S2-S4). Bladder neck and smooth muscle urethral sphincter innervation is given mostly by the orthosympathetic component. The rhabdosphincter innervation comes from the pudendal nerve and from the pelvic plexus; its role in the continence mechanism is probably to give steady tonic urethral compression. Levator ani muscle takes part in the sphincteric complex with its anteromedial pubococcygeal portion. It plays its role strengthening the sphincteric tone during increase of the abdominal pressure or during active quick stop cessation of the urinary stream.

[Personal research: reconstruction of the urethral striated sphincter]

OBJECTIVE

Incontinence is one of the drawbacks of radical prostatectomy. The causes of post-operative incontinence are sphincter deficiency (SD) and bladder dysfunction (BD). SD seems to be the main cause of incontinence and long time to continence. We present a surgical modification of the anatomical radical retropubic prostatectomy consisting in the reconstruction of the posterior aspect of the striated urethral sphincter in order to obtain a quick recovery of continence postoperatively.

MATERIALS AND METHODS

Caudal retraction of the urethro-sphincteric complex after apical dissection of the prostate often occurs. Furthermore posterior fibrous raphe interruption can cause shortening of anatomical and functional urethral length and affect continence. In order to avoid caudal retraction of the sphincteric complex, after completing vesico-urethral anastomosis, the posterior emicircumference of the striated sphincter is fixed to the posterior aspect of the bladder one centimeter cranially and posteriorly to the urethro-vesical anastomosis. The rabdosphincter is sutured separately from the urethro-vesical suturing. This technical modification makes it possible to obtain an anatomical length of the urethra of about a centimeter more than with the standard technique, replacing it in a more anatomical position. Furthermore, this technique provides the new posterior platform for the urethro-sphincteric complex. Twenty-four patients with clinical organ confined disease and age range 54-74 years (mean 64 years) underwent Walsh's anatomical radical retropubic prostatectomy with reconstruction of the rabdosphincter (group A). Catheter was removed 7 to 11 days postoperatively. Early continence was assessed objectively with the number of pads per day as follows: 0-1 mini pad = continent; 1-2 pads per day = mild incontinence; 2 or more pads per day = severe incontinence. Continence was evaluated at 3 days and one month after catheter removal. Group A compared to 21 patients (group B) who underwent standard anatomical RPP (historical control group).

RESULTS

In group A 16/24 patients (66.7%) and 19/24 patients (79.2%) were continent respectively at three days after removal of the catheter and after one month; mild incontinence (1-2 pads/day) was present in 6/24 patients (25%) and 3/24 (12.5%) respectively, 2/24 patients (8.3%) suffered from severe incontinence after 3 days and one month. In group B 7/21 patients (33%) were continent at hospital discharge, 11/21 (52%) after one month.

CONCLUSIONS

Careful reconstruction of the posterior aspects of the rabdosphincter shortens time to continence after RRP.

Immunoreactivity for latent membrane protein 1 of Epstein-Barr virus in nevi and melanomas is not related to the viral infection

Epstein-Barr virus (EBV) is a human herpes virus with oncogenic potential, associated with several malignancies. The EBV-encoded latent membrane protein 1 (LMP1) is one of nine proteins regularly expressed in virally infected and immortalised B lymphocytes. We now document the consistent immunoreactivity for LMP1 in 90% of 65 nevi and melanomas, using the monoclonal antibody cocktail CS1-4. The immunocytochemical findings, however, were not confirmed using reverse-transcription polymerase chain reaction (RT-PCR) experiments, which failed to demonstrate any actual expression of LMP1 mRNA. In situ hybridisation for EBV-encoded RNAs (EBERs 1 and 2) and PCR amplification of EBV genomic sequences also failed to document any viral infection. Several normal and neoplastic human tissues have also been immunostained for LMP1, without any positive staining, with the exception of a minor percentage of skin melanocytes and of normal blasts of the myeloid and erythroid lineages. We conclude that the vast majority of nevi and melanomas express a still uncharacterised molecule, cross-reacting with anti-LMP1 (CS1-4) antibodies, which may be considered a consistent marker of melanocytic proliferations. The immunoreactivity of normal and neoplastic human tissues for the anti-LMP1 reagent should not be taken as evidence of EBV infection.

Down-regulation of beta(1C) integrin in breast carcinomas correlates with high proliferative fraction, high histological grade, and larger size

beta(1C) integrin is an unspliced form of the integrin beta(1) subfamily, which has been shown to inhibit cell proliferation in vitro. Using an affinity-purified rabbit antibody, we have investigated 283 previously untreated breast carcinomas, with the aim of ascertaining the actual prevalence of beta(1C) expression in these tumors and of defining its pathological correlates. Immunoblotting and reverse transcriptase-polymerase chain reaction experiments have also been performed in selected cases, to confirm the immunocytochemical findings. Overall, beta(1C) immunoreactivity was down-regulated (ie, expressed in < 50% of the neoplastic cells) in 114 cases (40.3%). Down-regulation of beta(1C) expression in breast carcinomas correlated significantly with the tumor grade, the proliferative fraction (as evaluated by Ki-67 immunostaining with the MIB-1 monoclonal antibody), the estrogen and progesterone receptor status, and the tumor size (pT classification) and marginally with the node status. In a multivariate analysis with all available measures fitted simultaneously, tumor grade (P = 0.004), Ki-67 immunolabeling (P = 0.01), and pT categories (P = 0.04) were significantly associated with beta(1C) immunoreactivity. Although the short follow-up time (2-3 years) of the current series of patients does not allow the performance of survival analyses, the correlation of beta(1C) expression with tumor size, grade, and proliferative fraction and its alleged role as an upstream regulator of p27(kip1) make this integrin variant a likely novel prognostic parameter for invasive carcinomas of the breast.

Original Digital Technique to Isolate Santorini'S Plexus and Membranous Urethra during Radical Retropubic Prostatectomy and Radical Cystectomy

The authors give the results obtained with their digital technique for isolating Santorini's plexus during radical retropubic cystectomy or radical prostatectomy. Objectives: to reduce bleeding during surgery; to respect anatomic structures; greater safety during resection of the urethra; to respect the neurovascular erectile bundles; to assess post-operative erection. This technique was used in 46 operations (32 cystectomies and 14 radical prostatectomies) between January 1997 and February 1998. Blood loss from the plexus was 150 ml max. Operating time was reduced by about 15 minutes. Although the number of cases is still small, this digital isolation technique can be considered safe, almost bloodless and should preserve erection in a higher percentage of patients compared to the “classic” nerve-sparing technique.

RANTES is more prevalent in bacterial than in nonbacterial maxillary sinusitis: and P-selectin is preferentially up-regulated in diseased mucosae

OBJECTIVE

To investigate the relationship of the clinical appearance, histological characteristics, bacterial culturing, and messenger RNA (mRNA) expression of RANTES, interleukin 6, and interleukin 12, as well as the occurrence of endothelial adhesion molecules, in inflammatory diseased maxillary sinus mucosa in critically ill patients.

DESIGN

Prospective case series.

SETTING

General intensive care unit and neurosurgical intensive care unit of a tertiary care hospital.

SUBJECTS

Seven critically ill patients, nasotracheally intubated or tracheotomized, who received ventilator treatment for more than 7 days and treatment with antibiotics.

INTERVENTIONS

Bilateral biopsy specimens of antral mucosa were obtained at sinoscopy. Reverse transcriptase-polymerase chain reaction was used to detect the cytokine mRNAs in situ on paraformaldehyde-fixed tissue, and intercellular adhesion molecule 1, vascular cell adhesion molecule 1, E-selectin, and P-selectin were analyzed by immunochemistry on frozen sections. Sampling of secretion and tissue from the antra was performed for bacterial culturing.

RESULTS

Macroscopic and histological appearance varied and showed moderate to pronounced inflammation in 6 antra. All 4 bacterially infected antra showed mRNA RANTES (P=.005). No correlation was found for interleukin 6 and interleukin 12. Up-regulation of P-selectin in all cases and sparse expression of vascular cell adhesion molecule 1 indicate that the inflammation is chronic but nonallergic in type.

CONCLUSION

We find an indication that RANTES is more prevalent in bacterial sinusitis.

Bcl-2 immunoreactivity in salivary gland neoplasms is unrelated to the expression of mRNA for natural killer cell stimulatory cytokines interleukin (IL)-2 and IL-12

Certain cytokines are involved in the generation of natural killer (NK) cells and participate in the regulation of the proto-oncogene bcl-2. We aimed to study the mRNA expression of interleukin (IL)-2, IL-4 and IL-5, the composition of the tumour infiltrating lymphocytes (TIL), and the expression of bcl-2 in 14 benign and malignant human parotid tumours. T IL were predominantly composed of T lymphocytes and NK cells. We found evidence for the homing of T cells, and for generation of NK cells in the vicinity of the tumours. mRNA for IL-2 and IL-12, were identified but IL-4 mRNA was not found. The cytokine profiles and the composition of TIL of the two tumour categories were indistinguishable, suggesting that these host-response variables do not explain the differences in biological behaviour of these particular tumours. The results support a shift towards Th 1 (T helper 1) cells and interferon-gamma production, and that IL-12 also in vivo may play an important role in the regulatory interaction between innate resistance and adaptive immunity in tumour diseases. Most infiltrating lymphocytes showed strong expression of bcl-2; an interesting observation with regard to lymphocytic apoptosis in neoplastic diseases. The immunoreactivity for the bcl-2 protein varied considerably between and within tumours, and almost all benign tumours showed strong bcl-2 positively whereas several of the malignant tumours showed weak or absent staining. The variable expression of bcl-2 protein suggests a different susceptibility of tumour cells to apoptosis. The results also indicate that bcl-2 cannot pla a major role as protective agent in the specific apoptotic pathway induced by NK cells.

Positive identification in situ of mRNA expression of IL-6, and IL-12, and the chemotactic cytokine RANTES in patients with chronic sinusitis and polypoid disease. Clinical relevance and relation to allergy

Interleukins 6 (IL-6) and 12 (IL-12), and the chemoattractant chemokine RANTES were studied in ethmoidal mucosa, using reverse transcriptase polymerase chain reaction. The 49 patients had chronic sinusitis or nasal/paranasal polyposis, and some also allergy. To the best of our knowledge, this is the first study that demonstrates RANTES and IL-12 on mRNA level in human sinonasal mucosa in situ. mRNA for IL-6, IL-12 and RANTES were detected in 2, 8 and 6 patients with chronic sinusitis, respectively, and in mucosa from patients with polyposis a positive expression was observed in 4, 14 and 10 cases. There were no statistically significant differences. Analysing the entire group of 49 patients, disregarding type of mucosal disease, the number of patients with positive RANTES was significantly higher than that for IL-6. Similarly, IL-12 positivity was more frequently expressed than IL-6. mRNA for IL-6 was expressed in only 2 of the allergic patients. The cytokine production studied thus seems to be unrelated to the clinically defined entities. There is thus a local production in human diseased sinonasal mucosa of RANTES, as well as of IL-6 and IL-12. The local production of RANTES is an important prerequisite for recruitment and migration of inflammatory cells into the tissue. IL-12 is a co-stimulator of antigen-specific responses of established T helper 1 (Th1) clones, and regulates the responsiveness of the clones to a number of T cell growth factors. The study supports a shift towards Th1 cells in these disease entities.

[pT1G3 bladder carcinoma: parameters of a correct therapy]

Between 13.8% and 27% of all superficial bladder cancers are represented by pT1G3 neoplasm. In the Department of Urology of Policlinico S. Marco-Zingonia, between February 1988 and June 1994, we treated 22 patients suffering for pT1G3 bladder tumor. TUR-B has demonstrated to be a good approach for treatment of superficial bladder cancer, with low morbility; on the opposite side, we have to underline the high rate of recurrence and of progression of the urothelium disease. Now a day our best approach for the treatment of pT1G3 bladder tumor is represented by radical cystectomy supplied by chemotherapy.

[pT1G3 bladder carcinoma: our experience]

Approximately 6 to 23% of the patients with transitional cell carcinoma confined to the superficial mucosa of the bladder suffer for a pT1G3 tumor. Between 1984 and 1994, 12 patients were treated for high grade stage T1 tumores. Trans-urethral resection of the bladder cancer was performed in 8 patients, supported in two cases by immunotherapy with B.C.G. and in one case by endovesical chemotherapy. Radical cystectomy was carried out in 4 patients. Our results are similar to what reported by other Authors, but we didn't have any progression in all 8 patients treated with conservative therapy.

[Etiopathogenesis of benign prostatic hypertrophy]

The pathogenesis of benign prostatic hyperplasia (BPH) remains largely unresolved. The natural history of the disease involves two distinct phases, a pathological and a clinical one, whose pathogenesis is different. The pathologic phase is composed of two stages microscopic and macroscopic neither of which produces clinical dysuria. Nearly all men develop microscopic BPH if they live long enough but only in 50% of men microscopic BPH grows to produce a macroscopic enlargement of the gland and the evolvement happens in a period between 5 and 7 years. So different etiologies for the microscopic and macroscopic evolution of prostate can be argued. The clinical phase of BPH involves the progression of pathologic BPH to the clinical form in which the patients develop symptomatic dysuria. Again only about 50% of the men with macroscopic BPH progress to the clinical form: although macroscopic enlargement of the prostate is necessary for the development of clinical BPH it is not sufficient by itself for the progression to clinical phase and additional factors are required such as phlogosis, vascular infarct, enanchement of alpha adrenergic tone. These remarks on natural history suggest a multiple approach to BPH not addressed to treat the pathologic phase but the clinical one.(ABSTRACT TRUNCATED AT 250 WORDS)

[PSA values before and after finasteride treatment in patients with benign prostatic hypertrophy]

A total of 21 patients with benign prostatic hyperplasia was treated with finasteride to evaluate the variation of prostatic volumes and PSA values. After 6 months prostatic volumes showed a decrease of 16% while PSA values of 27%. No variations of PSA density were observed.

Experimental and clinical urinary diversion

In order to achieve an appropriate technical experience and explore clinical feasibility of laparoscopic urinary diversion, the authors planned a laboratory experiment. In ten male pigs weighing about 25 kilograms cystoprostatectomy was performed. Ureterocutaneostomy or ureterosigmoidostomy were carried out next. For ureterocutaneostomy a channel was bluntly dissected through the abdominal wall. The ureter was grasped by a clamp passed through the stroma, drawn outside and anstomosed to the skin. Operative time was about 30 minutes. For ureterosigmoidostomy a longitudinal incision of approximately 1 cm was made through the wall of the sigmoid colon in order to reach the mucosa. A very small opening in the angle of the incision was made. A suture was placed in the ureteral tip and secured to the colon wall. Finally, the ureter was covered in its bed with antireflux technique. Operative time was about 180 minutes. Laparoscopic ureterocutaneostomy was also successfully applied in a compromised patient to resolve a particular clinical situation.

[Cavernosography]

Dynamic cavernosography remains today an important step in diagnosis of veno-occlusive impotence, as support to cavernosometry: cavernosometry facilitate the diagnosis and the evaluation of venous-defect, but a contemporary show-timed cavernosography takes many informations about the site of venous-escape; these date allow to perform a correct selective vein ligation or percutaneous procedures, recently introduced in the clinical practice as an alternative or in association with vein ligation. Static cavernous-spongiosography, instead, has many indications in neoplasms and severe malformations.

Urological laparoscopy: our preliminary results

From the beginning of urological applications of laparoscopy, this technique has found many clinical indications. In our center, after an experimental training in animals, we performed 48 operations using laparoscopy: 18 pelvic lymphadenectomies (15 for prostate cancer, 2 for bladder tumor and 1 for penis carcinoma), 11 ligatures of the spermatic vein (3 bilateral), 4 orchidopexies, 10 excisions of renal cysts, 4 nephrectomies and 1 adrenalectomy. For cryptorchidism, laparoscopy is a less invasive alternative to surgical exploration; in case of prostate cancer, laparoscopic pelvic node dissection has a lower incidence of complications and requires few days of hospitalisation. The excision of renal cysts by laparoscopy, in case of large symptomatic pathology, is an efficacious operation with low morbidity. In case of nephrectomy for small wrinkled kidneys or severe hydronephrosis, long execution time makes cost/benefit ratio somewhat debatable; adrenalectomy, instead, is easier than nephrectomy and offers many advantages in comparison with traditional surgical approach. All indications will be better evaluated at a later date, with the indispensable learning period and the continuous progress of technical equipment.

[Laparoscopic cystectomy: an experimental model of urinary diversion]

During our experimental trial we achieved laparoscopic cistectomies with urinary diversion to prove our manual capability with the reconstructive surgery. We executed, on male pigs, 10 cistectomies with urinary diversion using laparoscopic technique. We performed 5 ureterocutaneostomies on 5 pigs and, in the other ones, 5 ureterosigmoidostomies. During UCS the pigs laid in lateral position, and during USS in supine position. The average time of the operation is going to reduce in consideration of the overcoming of the initial techno-instrumental difficulties and is 60 minutes for cistectomy, 30 minutes for ureterocutaneostomy and 120 minutes for ureterosigmoidostomy.

[Laparoscopic nephrectomy]

Laparoscopic nephrectomy is a new procedure in which the entire kidney is removed introducing it in an Endopouch and, after morcellation pulled out through a 12 mm port. After an initial experimental experience, in our Institute we have performed one laparoscopic nephrectomy for left pyelonephritic kidney and ureteral reflux. The operation required the positioning of 5 trocars and 4 hours for its execution. The discharge of the patient was possible four days after.

[Section of the spermatic vein]

Surgical treatment of varicocele can be carried out using different techniques. The laparoscopic approach [1-2] represent a new trend that we used to ligate and dissect the spermatic vein in 10 patients, 8 with monolateral left varicocele and 2 with bilateral varicocele. The average time for laparoscopic surgery has been 45 minutes for monolateral varicocele and 65 minutes in the bilateral one. The absence of important complications during and after the operation has allowed to dismiss all patients 48 hours after the surgical treatment. The preferential direction of laparoscopic approach to varicocele is represented by the bilateral form.

[Renal cysts resection]

Six patients with inferior and middle polar renal cysts of 8-15 centimeters of diameter, underwent the resection of the cyst by laparoscopic technique. The operation required an average time of execution of two hours and the positioning of four trochars to consent an adequate access. The absence of important complications during and after the operation has allowed a quick dismission of the patients. The laparoscopic treatment of renal cysts represent a valid choice to traditional surgery and percutaneous needle aspiration.

[Laparoscopic lymphadenectomy]

7 patients, suffering by prostatic adenocarcinoma in clinical stage B, were undergone to laparoscopic pelvic lymphadenectomy, to obtain a complete staging. The average time of execution of the operation was 180 minutes. The absence of important complications during and after surgical time, within low surgical trauma, has allowed the dismission of patients 48 hours after the operation. The low morbility demonstrated for this technique has allowed the dissection of a number of lymph node to consent an adequate staging.

[Orchiopexy]

The Authors illustrate their experience in the treatment of a case of left criptorchidism using laparoscopic technique associated with traditional surgery (Fowler-Stephens technique) without important complications during and after the procedure. The non palpable testis was located in the peritoneal cavity. The first step consists in a laparoscopic clip ligation of the spermatic vessels with the intent of improve the vasal collateral blood flow. After a 6 months interval, the patient underwent laparoscopic orchidopexy.

Round Table: “Urinary diversion” - Prevention of complications

— The Authors take into consideration the different techniques of urinary diversion; in the light of their findings, they reviewed the most important complications following urinary diversion and the possibilities of their prevention.

Non-radioactive nucleic acid probes: labelling and detection procedures

A comprehensive overview is given concerning the in situ hybridization techniques using non-radioactively labelled probes. Details are given on the preparation of the probes with different reporter molecules and on the corresponding revealing assays. The development of non-isotopic labelling methods for nucleic acid probes has facilitated the diffusion of the in situ hybridization techniques to the research as well as to the clinical pathology laboratory. Non-radioactive probes have several advantages over the radiolabelled ones, including cost, shelf-life, safety and, last but not least, resolution of the signal.

Laboratory laparoscopy: Nephroureterectomy, pelvic lymphadenectomy and orchiectomy

Recent developments in technology have resulted in the application of laparoscopy in several areas of urology. To develop the technique different procedures were performed in 22 male pigs weighing 25–30 kilograms. The types of procedure included: pelvic lymphadenectomy, nephroureterectomy, orchiectomy of cryptorchid testicle.

Glial fibrillary acidic protein immunoreactivity in normal and diseased human breast

Immunostaining for glial fibrillary acidic protein (GFAP) identifies a minor subpopulation of immunoreactive myoepithelial cells in the normal resting human breast. The GFAP-immunoreactive cells also express a panel of myoepithelial cell markers, including cytokeratin 14 (CK 14), vimentin, smooth-muscle-specific actin isoforms, nerve growth factor receptor (NGFR) and common acute lymphoblastic leukaemia antigen (CALLA). The percentage of GFAP-immunoreactive myoepithelial cells is greatly increased in various neoplastic and non-neoplastic diseases of the breast, being highest in adenomyoepitheliomas. Furthermore, in all the instances of fibroadenoma, phyllodes tumour, epitheliosis and gynaecomastia, a variable number of epithelial cells also acquires immunoreactivity for GFAP, vimentin, CK 14, NGFR and, to a lesser extent, for CALLA. Conversely, GFAP immunoreactivity has never been encountered in the malignant cells of the different types of breast carcinoma. These findings suggest that the expression of GFAP might be a (possibly transient) feature of proliferating epithelial and myoepithelial cells in breast diseases other than carcinomas.

Cytokeratin-immunoreactive cells of human lymph nodes and spleen in normal and pathological conditions. An immunocytochemical study

The occurrence and the distribution of cytokeratin (CK)-immunoreactive reticulum cells in a series of normal and pathological human lymph nodes and spleens are documented. The immunoreactive cells exhibit morphological and immunophenotypic features of so-called fibroblastic reticulum cells, with or without myoid differentiation. They invariably co-express vimentin and, to a lesser extent, desmin and muscle-specific actin isoforms. These CK-immunoreactive cells are apparently a normal subpopulation of reticulum cells, being detectable from the early stages of spleen and lymph node development. They are distributed mainly in the paracortical and medullary regions of the lymph nodes and at the periphery of the white pulp in the spleen. Their number and distribution are highly variable in different neoplastic and non-neoplastic pathological conditions but the changes are not disease specific. CK-immunoreactive reticulum cells are easily identifiable in both frozen and fixed lymphoid tissue and in cytological smears of fine-needle aspirates, provided that monoclonal antibodies whose spectrum of reactivity includes cytokeratins 8 and 18 are used. The awareness of the occurrence of CK-immunoreactive cells in normal lymphoid tissues is of particular relevance in the search for micrometastatic foci using anti-CK antibodies.

Differences in the organization and chromosomal allocation of satellite DNA between the European long tailed house mice Mus domesticus and Mus musculus

We compared the organization of satellite DNA (stDNA) and its chromosomal allocation in Mus domesticus and in Mus musculus. The two stDNAs show similar restriction fragment profiles after digestion (probed with M. domesticus stDNA) with some endonucleases of which restriction sequences are present in the 230-240 bp repetitive unit of the M. domesticus stDNA. In contrast, EcoRI digestion reveals that M. musculus stDNA lacks most of the GAATTC restriction sites, particularly at the level of the half-monomer. The chromosome distribution of stDNA (revealed by an M. domesticus stDNA probe) shows different patterns in the M. domesticus and M. musculus karyotypes, with about 60% of M. domesticus stDNA retained in the M. musculus genome. It is particularly noteworthy that the pericentromeric regions of M. musculus chromosomes 1 and X are totally devoid of M. domesticus stDNA sequences. In both groups, the differences in energy transfer between the stDNA-bound fluorochromes Hoechst 33258 and propidium iodide suggest that AT-rich repeated sequences have a much more clustered array in the M. domesticus stDNA, as if they are organized in tandem repeats longer than those of M. musculus. Considering the data as a whole, it seems likely that the evolutionary paths of the two stDNAs diverged after the generation of the ancestral 230-240 bp stDNA repetitive unit through the amplification, in the M. domesticus genome, of a family repeat which included the EcoRI GAATTC restriction sequence.