20 Simultaneous development of acute acquired concomitant esotropia in two siblings during the COVID-19 pandemic: a case report

A 5-year-old boy (sibling one) and his 11-year-old sister (sibling two) were presented to the hospital eye service in early 2021, having both developed acute-onset large angle esotropia within three months of each other. Neither had any significant past medical, ophthalmic, or family history. The siblings lived in the same household, and both experienced lifestyle changes as a result of the UK lockdown in response to COVID-19.Sibling one had a moderate right esotropia, initially maintained straight by corneal light reflex. He measured 45/50 prism dioptres (Δ) base out at near and 45Δ base out at distance. Sibling two had esophoria which broke down into a right esotropia immediately on dissociation. The esotropia measured 30Δ base out at near and 20Δ base out at distance. At four month follow up, both siblings demonstrated a constant large angle esotropia (sibling one: 54Δ base out at near and 45Δ base out at distance, sibling two: 45Δ base out at near and 40/45Δ base out at distance).Each sibling was treated with right medial rectus recession (5.5 mm) and right lateral rectus resection (7 mm), and at a three-month follow-up, both were minimally esophoric with restored binocularity.The unusual and abrupt changes in lifestyle imposed by the COVID-19 pandemic highlight the likelihood of an environmental aetiology for some forms of esotropia and raise the possibility that extended screen time may be a contributory factor.

Determining health-related quality of life and health state utility values of recurrent urinary tract infections in women

INTRODUCTION AND HYPOTHESIS

Health state utility values estimate an individual's valuation of their health-related quality of life. Despite prevalence of recurrent urinary tract infections (rUTIs), the health state utility value of rUTIs is unknown. The primary aim was to determine the utility value of rUTIs using the standard gamble (SG). The secondary aim was to compare the SG utility value with that derived from the EuroQol 5 dimensions (EQ-5D) and visual analog scale (VAS). We hypothesized that a utility value would be successfully derived from the SG and would differ from that derived using the EQ-5D and VAS.

METHODS

Nonpregnant, adult English-speaking female patients with a diagnosis of rUTI were recruited and completed the EQ-5D, VAS, and SG (n = 25). Utility values were evaluated using Wilcoxon signed-rank tests and Spearman's rho correlation.

RESULTS

Health state utility values varied depending on the assessment tool used: EQ-5D 0.76 (IQR 0.52), VAS 0.70 (IQR 0.30), and SG 0.85 (IQR 0.25). There were differences between VAS and the other two assessment methods (p<0.001), as well as between EQ-5D and SG (p=0.013). Spearman correlation demonstrated a moderately positive correlation between EQ-5D and VAS values (r(25) = 0.59, p=0.0019).

CONCLUSIONS

Our data suggest that 0.85 reflects the true health state utility value of rUTIs among nonpregnant adult English-speaking women. The utility value for recurrent UTIs is worse (lower) than that previously published for nonrecurrent UTIs, reflecting the ability of the SG to convey the compounding impact of recurrent disease. In this study, neither the EQ-5D nor the VAS produced results consistent with those found using the SG, which suggests limited validity in this population.

Increased expression of RUNX3 inhibits normal human myeloid development

RUNX3 is a transcription factor dysregulated in acute myeloid leukemia (AML). However, its role in normal myeloid development and leukemia is poorly understood. Here we investigate RUNX3 expression in both settings and the impact of its dysregulation on myelopoiesis. We found that RUNX3 mRNA expression was stable during hematopoiesis but decreased with granulocytic differentiation. In AML, RUNX3 mRNA was overexpressed in many disease subtypes, but downregulated in AML with core binding factor abnormalities, such as RUNX1::ETO. Overexpression of RUNX3 in human hematopoietic stem and progenitor cells (HSPC) inhibited myeloid differentiation, particularly of the granulocytic lineage. Proliferation and myeloid colony formation were also inhibited. Conversely, RUNX3 knockdown did not impact the myeloid growth and development of human HSPC. Overexpression of RUNX3 in the context of RUNX1::ETO did not rescue the RUNX1::ETO-mediated block in differentiation. RNA-sequencing showed that RUNX3 overexpression downregulates key developmental genes, such as KIT and RUNX1, while upregulating lymphoid genes, such as KLRB1 and TBX21. Overall, these data show that increased RUNX3 expression observed in AML could contribute to the developmental arrest characteristic of this disease, possibly by driving a competing transcriptional program favoring a lymphoid fate.

Protein Kinase C Epsilon Overexpression Is Associated With Poor Patient Outcomes in AML and Promotes Daunorubicin Resistance Through p-Glycoprotein-Mediated Drug Efflux

The protein kinase C (PKC) family of serine/threonine kinases are pleiotropic signaling regulators and are implicated in hematopoietic signaling and development. Only one isoform however, PKCϵ, has oncogenic properties in solid cancers where it is associated with poor outcomes. Here we show that PKCϵ protein is significantly overexpressed in acute myeloid leukemia (AML; 37% of patients). In addition, PKCϵ expression in AML was associated with a significant reduction in complete remission induction and disease-free survival. Examination of the functional consequences of PKCϵ overexpression in normal human hematopoiesis, showed that PKCϵ promotes myeloid differentiation, particularly of the monocytic lineage, and decreased colony formation, suggesting that PKCϵ does not act as an oncogene in hematopoietic cells. Rather, in AML cell lines, PKCϵ overexpression selectively conferred resistance to the chemotherapeutic agent, daunorubicin, by reducing intracellular concentrations of this agent. Mechanistic analysis showed that PKCϵ promoted the expression of the efflux pump, P-GP (ABCB1), and that drug efflux mediated by this transporter fully accounted for the daunorubicin resistance associated with PKCϵ overexpression. Analysis of AML patient samples also showed a link between PKCϵ and P-GP protein expression suggesting that PKCϵ expression drives treatment resistance in AML by upregulating P-GP expression.

Lower extremity aneurysmal degeneration of great saphenous venous allograft bypass in an adolescent boy

Chronic limb-threatening ischemia in the pediatric population is a rare phenomenon. When open repair is necessitated, an autogenous conduit is preferred. However, venous grafts are prone to their own long-term complications. We have presented the case of a 10-year-old boy with chronic limb-threatening ischemia due to popliteal artery thrombosis that was treated with an ipsilateral great saphenous vein bypass. Seven years after the initial procedure, the venous graft had developed aneurysmal degeneration with acute thrombosis, necessitating bypass revision. Through the present case, we have discussed the surgical approach and highlighted the importance of long-term postoperative surveillance after open repair in the pediatric population.

RUNX3 overexpression inhibits normal human erythroid development

RUNX proteins belong to a family of transcription factors essential for cellular proliferation, differentiation, and apoptosis with emerging data implicating RUNX3 in haematopoiesis and haematological malignancies. Here we show that RUNX3 plays an important regulatory role in normal human erythropoiesis. The impact of altering RUNX3 expression on erythropoiesis was determined by transducing human CD34⁺ cells with RUNX3 overexpression or shRNA knockdown vectors. Analysis of RUNX3 mRNA expression showed that RUNX3 levels decreased during erythropoiesis. Functionally, RUNX3 overexpression had a modest impact on early erythroid growth and development. However, in late-stage erythroid development, RUNX3 promoted growth and inhibited terminal differentiation with RUNX3 overexpressing cells exhibiting lower expression of glycophorin A, greater cell size and less differentiated morphology. These results suggest that suppression of RUNX3 is required for normal erythropoiesis. Overexpression of RUNX3 increased colony formation in liquid culture whilst, corresponding RUNX3 knockdown suppressed colony formation but otherwise had little impact. This study demonstrates that the downregulation of RUNX3 observed in normal human erythropoiesis is important in promoting the terminal stages of erythroid development and may further our understanding of the role of this transcription factor in haematological malignancies.

The impact of the COVID-19 pandemic on cardiology services

Objective

The COVID-19 pandemic resulted in prioritisation of National Health Service (NHS) resources to cope with the surge in infected patients. However, there have been no studies in the UK looking at the effect of the COVID-19 work pattern on the provision of cardiology services. We aimed to assess the impact of the pandemic on cardiology services and clinical activity.

Methods

We analysed key performance indicators in cardiology services in a single centre in the UK in the periods prior to and during lockdown to assess reduction or changes in service provision.

Results

There has been a greater than 50% drop in the number of patients presenting to cardiology and those diagnosed with myocardial infarction. All areas of cardiology service provision sustained significant reductions, which included outpatient clinics, investigations, procedures and cardiology community services such as heart failure and cardiac rehabilitation.

Conclusions

As ischaemic heart disease continues to be the leading cause of death nationally and globally, cardiology services need to prepare for a significant increase in workload in the recovery phase and develop new pathways to urgently help those adversely affected by the changes in service provision.

Supraclavicular Versus Transaxillary First Rib Resection for Thoracic Outlet Syndrome

Background: Thoracic outlet syndrome (TOS) results from compression of neurovascular structures supplying the upper extremity as they exit the thoracic outlet. Depending on the clinical presentation, surgical decompression may be required. Objectives: Transaxillary (TA) and supraclavicular (SC) approaches are both widely utilized and deemed effective. Our objective was to review the outcomes for both approaches at our institution. Methods: A retrospective review was conducted on patients who underwent thoracic outlet decompression between 2010 and 2015. Data on demographics, comorbidities, presenting symptoms, and type of TOS (neurogenic, venous, or arterial) were collected. Operative times, length of hospital stay, perioperative complications, and outcomes were also studied. Results: A total of 82 thoracic outlet decompression procedures were performed during the study period: 42% neurogenic TOS, 46% venous TOS, and 12% arterial TOS. In total, 49% underwent TA approach and 51% underwent SC approach. Adjunct procedures were performed in 13% of patients. There were no significant differences in average operative time (151.3 ± 54.1 minutes versus 126.1 ± 36.1 minutes, P = .11) or hospital stay (2.3 ± 1.9 days versus 2.4 ± 1.4 days, P = .23) between both groups, respectively. Minor complications were seen in 6% of patients with no significant difference in both groups, whereas 6% had major complications. No perioperative or 30-day mortalities were observed. In total, 49% of patients had complete resolution of symptoms, 46% had partial improvement, and 5% had no improvement. There was no difference in symptom resolution between either group. Conclusions: TA and SC approaches are equally safe and effective for the treatment of TOS. SC decompression allows for adjunct procedures and vascular reconstructions.

Self-Assembling Proteins as High-Performance Substrates for Embryonic Stem Cell Self-Renewal

The development of extracellular matrix mimetics that imitate niche stem cell microenvironments and support cell growth for technological applications is intensely pursued. Specifically, mimetics are sought that can enact control over the self-renewal and directed differentiation of human pluripotent stem cells (hPSCs) for clinical use. Despite considerable progress in the field, a major impediment to the clinical translation of hPSCs is the difficulty and high cost of large-scale cell production under xeno-free culture conditions using current matrices. Here, a bioactive, recombinant, protein-based polymer, termed ZT^Fn , is presented that closely mimics human plasma fibronectin and serves as an economical, xeno-free, biodegradable, and functionally adaptable cell substrate. The ZT^Fn substrate supports with high performance the propagation and long-term self-renewal of human embryonic stem cells while preserving their pluripotency. The ZT^Fn polymer can, therefore, be proposed as an efficient and affordable replacement for fibronectin in clinical grade cell culturing. Further, it can be postulated that the ZT polymer has significant engineering potential for further orthogonal functionalization in complex cell applications.

A case of incidental endometrial adenocarcinoma diagnosed in early pregnancy and managed conservatively

We report a 29-year old nulliparous woman diagnosed with a grade 1 endometrioid adenocarcinoma of the endometrium arising from an atypical polypoid adenomyoma, while being investigated for a suspected threatened miscarriage at 7 weeks gestation. She presented complaining of vaginal bleeding and a small amount of soft tissue in the cervical os was found and sent for histology. An ultrasound scan was performed, which confirmed an intrauterine ongoing pregnancy. The patient had no further episodes of unscheduled bleeding. After the confirmed histological diagnosis an MRI scan was requested, and there were no evidence of myometrial invasion or distant metastasis. The patient was seen at each trimester, remained asymptomatic throughout the pregnancy and had a normal delivery at term. There was no evidence of any residual endometrioid adenocarcinoma in the post-delivery specimen. Six weeks post-natally an endometrial biopsy was performed, which was normal. She is still in remission over a period of 8 years follow-up. Endometrial adenocarcinoma in young pregnant women is a rare clinical circumstance. This case shows that conservative management in young women is possible including in a case of an incidental diagnosis in pregnancy.

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An example of a successful full term pregnancy in women with early stage endometrial cancer

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Conservative management of endometrial cancer in early pregnancy can be considered in young women wishing to keep fertility.

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Long-term use of progestogen therapy can be safely used to treat early stage endometrial cancer.

Less radical surgery for women with early stage cervical cancer: Our experience on radical vaginal trachelectomy and laparoscopic pelvic lymphadenectomy

We report the use of radical vaginal trachelectomy (RVT) with pelvic laparoscopic lymphadenectomy (LPL) in patients with early stages cervical cancer (FIGO stage IA2-IB1). This is a case series prospectively collected over a 6-year period (2011–2017) at the Ipswich hospital, UK. Cases were compared to a group of women with a similar stage of cervical cancer, but treated with radical hysterectomy (RH) and pelvic lymphadenectomy (PL). A total of 19 patients (group 1) underwent RVT and LPL, and 51 (group 2) had RH and PL. We included: 5/19 (26%) stage IA2 and 14/19 (74%) stage IB1. Among those, we had: 12/19 (63%) cases of squamous cell carcinoma (SCC), 7/19(37%) of adenocarcinoma. Mean hospital stay was 2.7 days (range 2–4) in group 1 versus 4.8 days (range 3–8) group 2 (p-value = 0.173). The complication rate was not statistically different between the two groups 4/19(21%) and 7/51(14%) (p-value 0.169). The mean follow-up period was 47.3 months (range 7–78) in both groups. There were no cases of recurrence in group 1 and 2/51(4%) cases in group 2, but the difference was not significant (p-value = 0.497). In our experience RVT in well-selected patients is a safe treatment option with similar oncological outcomes when compared to patients undergoing more extensive surgery for the same early stage cervical cancer.

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Less radical surgery in women with early cervical cancer is a safe surgical alternative.

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Large trials are warranted to reconsider management of early stages cervical cancer in young women.

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We report similar outcomes between radical hysterectomy and fertility sparing surgery.

Anterior approach white line advancement: technique and long-term outcomes in the correction of blepharoptosis

PurposeAnterior approach white line advancement presents a novel surgical option for correction of blepharoptosis. The technique draws on several advantages of other approaches. The aim of this study was to present outcomes using this technique at a minimum follow-up of 18 months.Patients and methodsParticipants having undergone anterior approach white line advancement ptosis correction at a single institution were retrospectively recruited at a minimum of 18 months' follow-up. A total of 18 independent eyelid measurements were recorded at final review. Outcomes included long-term rate of surgical success, upper eyelid margin-reflex distance (MRD1) at both early and late post-operative follow-up, inter-eyelid asymmetry, complications, re-operation rate, patient satisfaction, and quality-of-life improvement using the Glasgow Benefit Inventory (GBI). Pre- and post-operative MRD1, as well as inter-eyelid asymmetry, were compared using a two-tailed t-test.ResultsIn total, 82 eyelids of 47 participants were included with a mean follow-up of 2.3 years (range 1.5-3.7). Surgical success was achieved in 91.5%, with a final mean MRD1 of 3.5 mm (95% confidence 3.2-3.7). An increase of 2.4 mm (2.1-2.8) in eyelid height was observed between baseline and long-term follow-up (P<0.0001). No significant change was observed between early and late post-operative follow-up. Pre-operative asymmetry was reduced from 1.0 mm (0.7-1.3) to 0.4 mm (0.3-0.5; P<0.0001). Patient satisfaction was 95.7% with a mean GBI score of +21.8 (13.2-30.3).ConclusionsAnterior approach white line advancement presents an excellent option for patients undergoing ptosis correction with favourable long-term results. Comparisons are made with other techniques with respect to anatomical, functional, and surgical factors.

Endovascular Treatment of a Traumatic Thoracic Aortic Injury in an Eight-Year Old Patient: Case Report and Review of Literature

Traumatic aortic injuries in children and adolescents are rare. Although endovascular repair has become the preferred approach for such injuries in adults, open repair has endured as the gold standard in children owing mainly to the smaller aortic and access vessel diameter and the scarcity of long-term follow-up data. We report a successful endovascular repair of a traumatic thoracic aortic injury in an 8-year-old girl using a Zenith Alpha thoracic endograft (Cook Medical, Bloomington, IN). We also review the literature on endovascular treatment of traumatic aortic injuries in the pediatric population.

Farming on the edge: farmer attitudes to bovine tuberculosis in newly endemic areas

Defra's recent strategy to eradicate bovine tuberculosis (bTB) establishes three spatial zones: high-risk areas (HRAs) and low-risk areas, and an area referred to as 'the edge', which marks the areas where infection is spreading outwards from the HRA. Little is known about farmers in the edge area, their attitudes towards bTB and their farming practices. This paper examines farmers' practices and attitudes towards bTB in standardised epidemiologically defined areas. A survey was developed to collect data on farmer attitudes, behaviours, practices and environmental conditions as part of an interdisciplinary analysis of bTB risk factors. Survey items were developed from a literature review and focus groups with vets and farmers in different locations within the edge area. A case-control sampling framework was adopted with farms sampled from areas identified as recently endemic for bTB. 347 farmers participated in the survey including 117 with bTB, representing a 70per cent response rate. Results show that farmers believe they are unable to do anything about bTB but are keen for the government intervention to help control the spread of bTB.

A novel approach to mapping and calculating the rate of spread of endemic bovine tuberculosis in England and Wales

A mathematical method for estimating the endemic status of bovine tuberculosis (bTB) in cattle in England and Wales has been developed. 6.25km(2) hexagonal cells were used as the base resolution. Maps were produced for overlapping two-year periods spanning 2001/03 to 2009/11. Distance from a farm to the ten nearest 'Officially Tuberculosis Free status - Withdrawn' incidents within the same time period was measured. Endemic areas were defined as those hexagons containing farms where the 3rd nearest incident occurred within 7km. Temporal spread of endemic bTB was estimated by creating a contour map displaying the spread of endemic bTB over the two-year periods, and using boundary displacement to calculate the rate of spread across each hexagon. A rate was obtained for ∼2300 cells and varied between 0.04km and 15.9km per year (median=3.3km per year). This work will enable further analysis of the factors associated with this expansion.

Method transfer, partial validation, and cross validation: recommendations for best practices and harmonization from the global bioanalysis consortium harmonization team

This paper presents the recommendations of the Global Bioanalytical Consortium Harmonization Team on method transfer, partial validation, and cross validation. These aspects of bioanalytical method validation, while important, have received little detailed attention in recent years. The team has attempted to define, separate, and describe these related activities, and present practical guidance in how to apply these techniques.

Review of laboratory submissions from New World camelids in England and Wales (2000-2011)

Sample submissions to the Animal Health and Veterinary Laboratories Agency's (AHVLA's) diagnostic laboratory network in England and Wales were reviewed for diseases affecting New World camelids (NWCs). In the years 2000-2011, 6757 submissions were analysed, including 5154/6757 (76.3%) for diagnosing a disease problem and 1603/6757 (23.7%) for monitoring (no clinical disease). Wasting (weight loss, ill-thrift) was the most commonly reported clinical sign across all age groups. A diagnosis was reached for 1765/5154 (34.2%) diagnostic submissions. The proportion of submissions with diagnoses was higher for carcasses than non-carcass samples and multiple diagnoses were more likely to be reached from carcasses. Parasitic diseases were collectively the most common problem, including parasitic gastroenteritis (319/1765, 18.2%), coccidiosis (187/1765, 10.6%), fascioliasis (151/1765, 8.6%), ectoparasitic infestations (86/1765, 4.9%) and cryptosporidiosis (24/1765, 1.4%). The most frequently diagnosed non-parasitic problems included nutritional diseases (182/1765, 10.3%), septicaemia (104/1765, 5.9%, including 45 cases of colisepticaemia), gastric ulceration (79/1765, 4.5%), tumours/neoplastic diseases (65/1765, 3.7%), tuberculosis (57/1765, 3.2%), clostridial diseases (44/1765, 2.5%), congenital anomalies (41/1765, 2.3%), peritonitis (39/1765, 2.2%) and Johne's disease (20/1765, 1.1%).

Abstract P1-06-12: The therapeutic sensitivity of ER+/Her2+ breast cancer cells is attenuated in 3D matrix culture and involves switching from AKT to MAPK pathways

Increasing evidence points to interplay between a tumour and components of its microenvironment as a significant determinant of therapeutic sensitivity and response. Thus, a better understanding of this phenomenon is crucial for the development of more effective treatment strategies. Around half of HER2+ breast cancers express the ER. Despite the effectiveness of endocrine and HER2-targeted therapies for such tumours in pre-clinical, two-dimensional models, response can be variable clinically. Here we have investigated the impact of 3D culture within an extracellular matrix on the signaling pathway activity and therapeutic response to trastuzumab and endocrine (tamoxifen and fulvestrant) treatment of ER+/Her2+ breast cancer cell models.

ER+/Her2+ BT474 and MDAMB361 cells were grown as 2D monolayers or as 3D cultures in Matrigel and their proliferative response to trastuzumab (0-100nM) and endocrine (tamoxifen or fulvestrant, 0-100nM) mono- and combination therapy assessed using coulter counting and immunocytochemical staining of the proliferation antigen, Ki67. A comparison of signaling pathway activation in 2D versus 3D culture, and in response to treatment in these contexts, was investigated using Western blotting.

Whilst culture of both cell lines in 3D matrices did not significantly affect their endogenous growth rate, 3D culture resulted in a significant loss of PI3K/AKT pathway activity in both cell lines and augmented (BT474) MAPK signaling. The growth inhibitory effects of both trastuzumab and endocrine treatment, either as single agents or in combination, were significantly attenuated in 3D cultures when compared with 2D cultures (% growth inhibition ± sem: 65%±3.8 (3D) vs. 82%±1.3 (2D), p&lt;0.01 [BT474+trastuzumab], 34%±6.4 (3D) vs. 56%±2.2 (2D), p&lt;0.02 [BT474+tamoxifen], and 51%±0.88 (3D) vs. 70%±0.48 (2D), p&lt;0.0001 [MDAMB361+tamoxifen], 53%±7.2 (3D) vs. 77%±0.60 (2D), p&lt;0.02 [MDAMB361+fulvestrant]). Similar effects were observed in Ki67 levels, with a greater suppression of Ki67 in 2D versus 3D culture in response to treatments. Trastuzumab and endocrine treatments, either as monotherapies or in combination, suppressed MAPK signaling in 2D monolayers in contrast to 3D culture, where MAPK activity was maintained (BT474) or augmented (MDAMB361). Consequently, inhibition of MAPK signaling using U0126 in 3D cultures significantly improved trastuzumab and endocrine response in these cells.

These data demonstrate that ER+/Her2+ breast cancer cells significantly alter their signaling pathway activity when cultured in a 3D, matrix-enriched environment, which may in turn act to limit response to a range of endocrine and targeted therapies. Targeting of such adaptive pathways that maintain growth in 3D culture may represent an effective strategy to improve therapeutic response clinically.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-06-12.

Possible Genetic Component to the Etiology of Perigraft Hygromas

Perigraft hygroma is a known complication of prosthetic graft implantation. The specific etiology of perigraft hygromas is still unknown. We report 2 brothers who underwent open abdominal aortic aneurysm repairs with polytetrafluoroethylene grafts that developed progressively enlarging perigraft hygromas. This is the first case report of 2 brothers developing sac hygromas after open abdominal aortic aneurysm repair. This case demonstrates that there could be a genetic component associated with the development of perigraft hygromas and further investigation of genetic etiologies should be considered.

ONCOPOOL - a European database for 16,944 cases of breast cancer

ONCOPOOL is a retrospectively compiled database of primary operable invasive breast cancers treated in the 1990s in 10 European breast cancer Units. Sixteen thousand and nine hundred and forty four cases were entered, with tumours less than 5 cm diameter in women aged 70 or less (mean age 55).

DATA

Data were date of birth, mode of diagnosis, pathology (size, lymph node status, grade, type, lympho-vascular invasion and hormone receptor) and therapies and outcome measures: first local, regional or distant recurrences, contralateral primary, date and cause of death.

TUMOUR CHARACTERISTICS

Mean diameter 1.8 cm, 66% lymph node negative, 24% 1-3 lymph nodes involved and 10% had 4 or more involved. Grade 1, 29%; Grade 2, 41%; and Grade 3, 30%. Polynomial relationships were established between grade, stage and size. Seventy-five percent were oestrogen receptor (ER) positive. ER closely related to grade.

OUTCOMES

Overall Survival was 89% at 5 years from diagnosis, 80% 10 years and 73% 15 years; Breast Cancer-Specific survivals were 91%, 84% and 79%. Survival strongly related to the Nottingham Prognostic Index (NPI). Cases detected at screening had 84% 10-year survival, those presenting symptomatically 76%. ER positive cases treated with adjuvant hormone therapy had a reduction in risk of death of 13% over those not receiving adjuvant therapy (p=0.000). ER negative cases treated with chemotherapy showed a risk reduction of 23% over those not receiving chemotherapy (p=0.000).

CD44-Activated HER-2 Signalling in Tamoxifen Resistant Breast Cancer Cells Promotes a Migratory Phenotype

Background: Acquired endocrine resistance in breast cancer cells is accompanied by altered growth factor receptor signalling. In tamoxifen-resistant ('TamR') MCF7 cells, our microarray analysis has demonstrated elevated levels of CD44, a transmembrane glycoprotein known to interact with, and modulate the function of, a number of growth factor receptors including members of the erbB family and plays a major role in tumor metastasis. Here, we have explored the role of CD44 as a modulator of erbB activity in TamR cells.Methods: Western blotting and immunocytochemistry were used to investigate expression of CD44 together with the activity of erbB signalling pathways following stimulation of CD44 by its ligand, hyaluronan (HA), or stimulation with erbB ligands (heregulin β1) after knockdown of CD44 expression using siRNA. Immunofluorescence microscopy was used to determine association between CD44 and erbB family members. Cell migration was assessed by seeding cells onto fibronectin-coated microporous inserts for 24 hours and also by performing scratch wound assays. Cell proliferation was determined by WST assay in response to trastuzumab (0-100nM) ± HAResults: CD44 was found to be over-expressed in TamR cells where it co-localized with HER-2. Whilst stimulation of HER-2 with heregulin beta-1 promoted an increase in cell migration, heregulin action was significantly attenuated in the absence of CD44 using siRNA. Moreover, treatment of TamR cells with the natural CD44 ligand, HA, promoted HER-2 signalling through MAPK and an increase in cell migration. Furthermore, whilst TamR cells were sensitive to the growth-inhibitory effects of trastuzumab, these effects were diminished in the presence of HA.Conclusions: Overexpression of CD44 sensitizes tamoxifen-resistant cells to heregulin and HA, factors commonly found within the stromal environment, with a resultant increase in migratory behaviour. Interestingly, activation of CD44 by HA appears to suppress the effects of trastuzumab on cell proliferation. Thus, CD44 may prove a valuable therapeutic target in breast cancer that expresses HER-2 and CD44.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5137.

Comparison of Methods for Detection of Fulvestrant-Induced Changes in Breast Tumor Estrogen and Progesterone Receptor Expression in a Neoadjuvant Trial (NEWEST)

Background: Fulvestrant downregulates breast tumor estrogen and progesterone receptor (ER and PgR) levels in a dose-dependent manner. Using an Automated Cellular Imaging System (ACIS), NEWEST (NCT00093002) reported that 4-wks' treatment with fulvestrant high-dose (HD, 500mg/month+500mg on Day 14 of Month 1) significantly reduced ER levels in primary breast tumors v approved-dose (AD, 250mg/month). However, no significant difference was detected between the two doses on PgR levels. To allow comparison with previous studies, a non-automated H-score assessment was performed and compared with ACIS.Methods: ER and PgR H-scores were derived by manual assessment of % tumor cells in each of 5 staining categories (negative, very weak, weak, moderate, strong) in the same sections scored by ACIS. This microscopic assessment was performed by 2 experienced observers blind to ACIS and clinical data. Mean % changes in H-scores were then calculated (table).Results: Both scoring methods showed a greater effect for fulvestrant HD v AD on ER expression at Wk 4, but H-score provided better dose discrimination. ACIS showed no difference between fulvestrant HD v AD on PgR expression at Wk 4, however, a significantly greater reduction in PgR expression was detected with fulvestrant HD using H-score.Wk 4Mean % change from baseline ACISH-score HDADHDADER-25.0%-13.5%-50.3%-13.7% n=60(n=63)(n=58)(n=60) p=0.0002 p&lt;0.0001 PgR-22.7%-17.6%-80.5%-46.3% (n=43)(n=45)(n=31)(n=34) NS p=0.0018 Baseline mean H-score for HD and AD: 151.6 and 157.7 for ER; 103.8 and 122.9 for PgR.Conclusion: The choice of scoring method for determining ER and PgR expression in pharmacodynamic studies such as NEWEST is critical. Compared with H-scores, ACIS has a narrower dynamic range and reduced ability to discriminate fulvestrant HD v AD, particularly on PgR expression.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1087.

Tamoxifen Resistance in Estrogen Receptor Positive (ER+) Breast Cancer Is Driven by Estrogen Receptor Negative (ER-) Cancer Stem-Like Cells

Introduction: Intrinsic and acquired resistance to endocrine therapy significantly reduces survival rates of women with ER+ breast cancer. In the normal breast, multipotent stem cells are ER-. We hypothesised that tumourigenic breast cancer stem-like cells (CSCs) are ER- and therefore function independently of estrogen, representing a novel mechanism of resistance to endocrine therapy.Methods: Three ER+ cell lines, MCF-7, T47D and BT474 were assessed for ER expression by immunocytochemistry (ICC) in monolayer and after CSC enrichment. Putative CSC number was assessed by the non-adherent mammosphere (MS) assay, in the presence and absence of tamoxifen, and by Fluorescence Activated Cell Sorting (FACS) for the markers CD44+/CD24-/low/epithelial specific antigen(ESA)+. The effect of acquired Tamoxifen resistance on the CSC population of two independent Tamoxifen-resistant (TAM-R) MCF-7 variants, from Cardiff (TAM-RCARD) and Copenhagen (TAM-RCOP) was compared to parental, tamoxifen sensitive (TAM-S) controls. In the MS assay both the number and size of colonies were assessed.Results: A small sub-population of ER_ cells were demonstrated in MCF7 (6.1 ± 1.4%), T47D (6.8± 0.5) and BT474 (3.7±1.3) cells by ICC. However, the majority of putative breast CSCs (CD44+/CD24-/low/ESA-) in MCF7 cells were ER_ (73.2 ± 4.6 % p= 0.0007). There was a significant increase in the proportion of ER- cells in TAM-R cell lines (TAM-RCARD 11.6 ± 1.4% p=0.01 and TAM-RCOP 22 ± 4.8% p=0.02 respectively) compared to the parental TAM-S controls. Both TAM-R cell lines demonstrated increased mammosphere forming efficiency (MFE) compared to TAM-S cells (TAM-RCARD 4% vs. 2.5% p=0.03, and TAM-RCOP 8% vs. 3% p=0.007). The putative CSC population (CD44+/CD24-/low/ESA+) was enriched more than 2.5 fold in TAM-R compared to TAM-S parental controls. Compared with controls, the absolute MFE was not affected by Tamoxifen treatment, although mammospheres formed were significantly smaller.Conclusions: The majority of the putative CSC populations in ER+ breast cancer do not express ER. There is an increase in the proportion of putative ER- CSCs in TAM-R MCF7 cell lines. The reduction in MS size suggests that Tamoxifen targets transit amplifying cells but does not reduce the absolute number of CSC in ER+ breast cancers. These findings demonstrate a novel mechanism of endocrine resistance in ER+ breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5125.

Comparison of methods for detection of fulvestrant-induced changes in breast tumor estrogen and progesterone receptor expression in a neoadjuvant trial (NEWEST)

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Background: Fulvestrant downregulates breast tumor estrogen and progesterone receptor (ER and PgR) levels in a dose-dependent manner. Using an Automated Cellular Imaging System (ACIS), NEWEST reported that 4-wks’ treatment with fulvestrant high-dose (HD, 500mg/month+500mg on Day 14 of Month 1) significantly reduced ER levels in primary breast tumors v approved-dose (AD, 250mg/month). However, no significant difference was detected between the two doses on PgR levels. To allow comparison with previous studies, a non-automated H-score assessment was performed and compared with ACIS. Methods: ER and PgR H-scores were derived by manual assessment of % tumor cells in each of 5 staining categories (negative, very weak, weak, moderate, strong) in the same sections scored by ACIS. This microscopic assessment was performed by 2 experienced observers blind to ACIS and clinical data. Mean % changes in H-scores were then calculated (table). Results: Both scoring methods showed a greater effect for fulvestrant HD v AD on ER expression at Wk 4, but H-score provided better dose discrimination. ACIS showed no difference between fulvestrant HD v AD on PgR expression at Wk 4, however, a significantly greater reduction in PgR expression was detected with fulvestrant HD using H-score. Conclusions: The choice of scoring method for determining ER and PgR expression in pharmacodynamic studies such as NEWEST is critical. Compared with H-scores, ACIS has a narrower dynamic range and reduced ability to discriminate fulvestrant HD v AD, particularly on PgR expression.

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ASCO Conflict of Interest Policy and Exceptions

In compliance with the guidelines established by the ASCO Conflict of Interest Policy (J Clin Oncol. 2006 Jan 20;24[3]:519–521) and the Accreditation Council for Continuing Medical Education (ACCME), ASCO strives to promote balance, independence, objectivity, and scientific rigor through disclosure of financial and other interests, and identification and management of potential conflicts. According to the ASCO Conflict of Interest Policy, the following financial and other relationships must be disclosed: employment or leadership position, consultant or advisory role, stock ownership, honoraria, research funding, expert testimony, and other remuneration (J Clin Oncol. 2006 Jan 20;24[3]:520). The ASCO Conflict of Interest Policy disclosure requirements apply to all authors who submit abstracts to the Annual Meeting.

For clinical trials that began accrual on or after April 29, 2004, ASCO's Policy places some restrictions on the financial relationships of principal investigators (J Clin Oncol. 2006 Jan 20;24[3]:521). If a principal investigator holds any restricted relationships, his or her abstract will be ineligible for placement in the 2009 Annual Meeting unless the ASCO Ethics Committee grants an exception. Among the circumstances that might justify an exception are that the principal investigator (1) is a widely acknowledged expert in a particular therapeutic area; (2) is the inventor of a unique technology or treatment being evaluated in the clinical trial; or (3) is involved in international clinical oncology research and has acted consistently with recognized international standards of ethics in the conduct of clinical research. NIH-sponsored trials are exempt from the Policy restrictions. Abstracts for which authors requested and have been granted an exception in accordance with ASCO's Policy are designated with a caret symbol (^) in the Annual Meeting Proceedings.

For more information about the ASCO Conflict of Interest Policy and the exceptions process, please visit www.asco.org/conflictofinterest .

Akt-dependent phosphorylation on AIB1 serine 967 contributes to breast cancer tamoxifen resistance

Abstract #3021

AIB1, a coactivator for nuclear receptors and other transcription factors, is involved in breast cancer development and progression. Overexpression of both AIB1 and HER2/neu (HER2) results in tamoxifen (Tam) resistance in clinical and experimental breast cancer. We hypothesized that HER2 signaling, via its downstream kinase Akt, leads to phosphorylation and activation of AIB1, which may then contribute to development of Tam resistance by reducing its antagonist activity.&#x2028; We have previously shown that Akt synergizes with AIB1 to enhance estrogen- and Tam-induced estrogen receptor (ER)-dependent transcriptional activity. This synergy is mainly mediated by Akt phosphorylation of AIB1 on serine 967, which is located between the nuclear receptor and the CBP/p300 interacting domains. We showed that this serine residue was phosphorylated specifically by Akt both in vitro and in vivo, including in both acquired and de novo Tam-resistant xenograft models that are associated with increased Akt signaling. More recent data showed that serine 967 of AIB1 is phosphorylated in Tam-resistant MCF7 tumors, and that this phosphorylation is stable in the resistant cells. By using immunoprecipitation and Western blot analysis, in ER positive breast tumors from patients, 90% of tumors were positive for total AIB, while AIB1 phosphorylation was detectable in 60% of tumors. Phosphorylated AIB1 was positively correlated with total and phosphorylated HER2 (Tyrosine 1248) (p=0.004 and p=0.0008 respectively, Fisher's exact test), implying that phophorylation of serine 967 of AIB1 may be stimulated by HER2 in these AIB1 positive tumors. Serine 967 of AIB1 was also phosphorylated in breast cancer cell lines, including both basal (HCC1954, BT20 and SUM190PT) and luminal (T47D, ZR7530, MDAMB361, and UACC812) subtypes, in which HER2 (except BT20) and Akt were activated .&#x2028; Taken together, Akt phosphorylation of AIB1 serine 967 appears important for AIB1 to function as an ER coactivator and regulator of breast cancer proliferation, and for Tam agonistic activity. Thus phosphorylation at serine 967 of AIB1 may be an essential factor required for Tam resistance as well as for tumor growth independent of ER. Additional regulatory roles of serine 967 in AIB1 function are currently under investigation.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3021.

Effectiveness of the dual specific Src/Abl kinase inhibitor AZD0530 in combination with tamoxifen in preventing acquired anti-estrogen resistance in breast cancer cells

14054

Background: AZD0530 is a novel, orally potent, once-daily, highly selective and dual-specific Src/Abl kinase inhibitor with potential for activity in a wide range of tumors. In the context of breast cancer, where tamoxifen resistance presents a major problem, Src inhibition may be a particularly valuable therapeutic strategy since we have previously observed that elevated Src kinase activity accompanies anti-estrogen resistance in vitro, promoting an aggressive cell phenotype. Here, we have explored the potential therapeutic effects of Src inhibition with AZD0530, alone and in combination with tamoxifen, on the acquisition of endocrine resistance in breast cancer cells. Methods: MCF7 and T47D breast cancer cells were exposed to tamoxifen (10–7 M), AZD0530 (1 μM), or both agents in combination for a minimum of 10 months with passaging as necessary, or until total cell death occurred. Cells were assayed at monthly intervals for intracellular signaling pathway activity (Western Blotting) and in vitro invasive capacity (Matrigel invasion assays). Apoptosis and proliferation were assessed by ELISA and Ki67 staining, respectively. Changes in c-Myc and cyclin-D1 were measured with RT-PCR. Results: Treatment of cells with tamoxifen alone ultimately resulted in acquired resistance, elevated Src kinase activity, and a Src- dependent increase in invasive capacity. Chronic exposure to AZD0530 alone resulted in outgrowth of AZD0530 resistant cells, in which Src kinase activity remained suppressed as did their in vitro invasiveness. Treatment of MCF7 and T47D cells with AZD0530 and tamoxifen combined resulted in a reduction of Src, FAK, and Akt activity, inhibition of c-Myc gene expression, and complete abrogation of their in vitro invasive behavior. Furthermore, combination treatment completely prevented cell proliferation and the subsequent emergence of a resistant phenotype, with a total loss of cells by 12 weeks. Conclusions: Inhibition of Src kinase with AZD0530, when used in conjunction with anti-estrogen therapies, effectively prevents acquired resistance in breast cancer cells in vitro suggesting a potential novel therapeutic benefit of Src kinase inhibitors clinically.

No significant financial relationships to disclose.

Noradrenergic receptor mRNA expression in adult rat superficial dorsal horn and dorsal root ganglion neurons

Noradrenaline (NAdr) has well documented analgesic actions at the level of the spinal cord. Released from bulbospinal projections onto superficial dorsal horn (SDH) neurons, NAdr modulates the excitability of these neurons through the activation of alpha1, alpha2 or beta adrenoceptors. This study utilised in situ hybridisation to determine the specific expression of adrenoceptors within adult rat lumbar SDH and dorsal root ganglion (DRG) neurons, and reports the presence of alpha1A, alpha1B, alpha2B, beta1 and beta2 adrenoceptor mRNA within SDH neurons, and the presence of alpha1A, alpha1B and alpha2C adrenoceptor mRNA within DRG neurons. The present study provides an insight into the modulation of sensory processing at the level of the spinal cord following adrenoceptor activation.

Kawasaki disease with severe cardiac sequelae: lessons from recent New Zealand experience

OBJECTIVES

To review recent cases of Kawasaki disease (KD) with significant cardiac sequelae in New Zealand. It is known that intravenous immunoglobulin (IVIG) reduces the risk of coronary artery aneurysm formation if given within 8-10 days of onset of KD.

METHODS

Retrospective review of medical course, criteria for KD, laboratory and cardiac findings for six children identified with KD and significant coronary artery sequelae.

RESULTS

There was delay in diagnosis of KD in three of the six children. Three cases were atypical by extremes of age (2 months, 10 years, 14 years). By definition all six children had significant coronary artery involvement. One patient had a thrombus detected in a coronary aneurysm 3 weeks after KD. One patient underwent coronary artery bypass grafting for unstable angina 2 years after KD. One patient developed coronary artery aneurysms after an initial 'toxic shock' type illness evolving to KD. Three patients died, one due to rupture of a coronary artery aneurysm, two from rapid early coronary artery obstruction occurring at three and 4 months after initial KD.

CONCLUSIONS

Kawasaki disease remains an important cause of mortality and morbidity for children. Diagnostic delay beyond 8 days reduces the chances of successful IVIG therapy in KD. Current studies supported by the Paediatric Surveillance Unit should establish the epidemiology of KD in New Zealand.

Serotonin receptor mRNA expression in rat dorsal root ganglion neurons

In the present study, we have used in situ hybridization to examine the distribution of serotonin (5-HT) receptors in rat dorsal root ganglion (DRG) neurons. Within DRG neurons, mRNAs for 5-HT1B, 5-HT1D, 5-HT2A, 5-HT2B, 5-HT3B and 5-HT4 receptors were readily detected in small (<25 microm), medium (25-45 microm) and large (>45 microm) diameter neurons. In contrast mRNAs for 5-HT1A, 5-HT1E, 5-HT2C, 5-HT5A, 5-HT5B, 5-HT6 and 5-HT7 receptors were undetectable in these neurons. The present study provides an insight into the molecular profile of 5-HT receptor subtypes in neurons responsible for modulating sensory information.