Nasal symptoms, epithelial injury and neurogenic inflammation in elite swimmers

BACKGROUND

A high burden of lower airway symptoms is found in elite swimmers. To what extent elite swimmers suffer from upper airway symptoms and how these associate with nasal inflammation is less clear. We here aimed to evaluate upper airway symptoms and nasal inflammation in elite athletes.

METHODOLOGY

Elite swimmers, indoor athletes and age-matched controls were recruited. Upper airway symptoms were assessed by sino-nasal outcome test (SNOT)-22 questionnaire. Visual Analogue score (VAS) for nasal symptoms as well as neurogenic and inflammatory mediators in nasal fluid were assessed at baseline, immediately and 24-hours after sport-specific training. The effect of hypochlorite on nasal epithelial cells was evaluated in vitro.

RESULTS

Baseline SNOT-22 and VAS for nasal itch and impaired smell were significantly higher in swimmers compared to controls. Nasal substance P and uric acid levels were increased in elite swimmers 24-hours after swimming compared to baseline. In elite swimmers, uric acid levels 24-hours post-exercise correlated with baseline SNOT-22. As increased symptoms and inflammation were found in swimmers but not in indoor athletes, we hypothesized that hypochlorite exposure might be the underlying mechanism. In vitro, the highest dose of hypochlorite decreased nasal epithelial cell integrity and induced release of uric acid.

CONCLUSION

Upper airway symptoms are frequently reported in elite swimmers. Intensive swimming resulted in a delayed increase of epithelial injury and neurogenic inflammation.

A model and scoring system to predict outcome of intrauterine pregnancies of uncertain viability

OBJECTIVES

To define the incidence and outcome of intrauterine pregnancy of uncertain viability (PUV) and to develop and assess the performance of a model and a scoring system to predict ongoing viability.

METHODS

Of 1881 consecutive women undergoing transvaginal ultrasonography, a cohort of 493 women with an empty gestational sac < 20 mm in mean diameter, gestational sac < 25 mm in mean diameter and containing yolk sac only or an embryonic pole < 6 mm in maximum length and without visible heart activity were followed until the end of the first trimester. Women with multiple pregnancies or who underwent termination of pregnancy were excluded. Outcome measures were pregnancy viability at initial 7-14-day follow-up and first-trimester viability at 11-14 weeks. The data were split randomly into two sets (two-thirds and one-third, respectively) in order to first develop and then test a mathematical model and a 'simple' model in the prediction of viability at each outcome point, based on maternal demographics, ultrasound features and symptoms. The performance of each system was assessed by receiver-operating characteristics (ROC) curve analysis and calibration plots on a test dataset.

RESULTS

The incidence of PUV in this population was 29.2% (549/1881). Of the 493 pregnancies with initial (7-14 days) follow-up available, 307 (62.3%) were viable at this time and of the 444 pregnancies with follow-up at the end of the first trimester, 225 (50.7%) were still viable. Initial (7-14-day) viability was predicted by the model with an area under the ROC curve (AUC) of 0.837 (95% CI, 0.791-0.884) in the training dataset and 0.821 (95% CI, 0.756-0.885) in the test dataset. First-trimester (11-14-week) viability was predicted by the model with an AUC of 0.788 (95% CI, 0.734-0.842) in the training dataset and 0.774 (95% CI, 0.701-0.848) in the test dataset. The scoring system performed slightly worse than did the model, but had the advantage of being easily applicable.

CONCLUSIONS

When early pregnancy viability cannot be established immediately with ultrasound, use of either a logistic regression model or a scoring system allows an individualized prediction of first-trimester outcome.

Short-Term Prognostic Index for Breast Cancer: NPI or Lpi

Axillary lymph node involvement is an important prognostic factor for breast cancer survival but is confounded by the number of nodes examined. We compare the performance of the log odds prognostic index (Lpi), using a ratio of the positive versus negative lymph nodes, with the Nottingham Prognostic Index (NPI) for short-term breast cancer specific disease free survival. A total of 1818 operable breast cancer patients treated in the University Hospital of Leuven between 2000 and 2005 were included. The performance of the NPI and Lpi were compared on two levels: calibration and discrimination. The latter was evaluated using the concordance index (cindex), the number of patients in the extreme groups, and difference in event rates between these. The NPI had a significant higher cindex, but a significant lower percentage of patients in the extreme risk groups. After updating both indices, no significant differences between NPI and Lpi were noted.

Improved performance on high-dimensional survival data by application of Survival-SVM

MOTIVATION

New application areas of survival analysis as for example based on micro-array expression data call for novel tools able to handle high-dimensional data. While classical (semi-) parametric techniques as based on likelihood or partial likelihood functions are omnipresent in clinical studies, they are often inadequate for modelling in case when there are less observations than features in the data. Support vector machines (svms) and extensions are in general found particularly useful for such cases, both conceptually (non-parametric approach), computationally (boiling down to a convex program which can be solved efficiently), theoretically (for its intrinsic relation with learning theory) as well as empirically. This article discusses such an extension of svms which is tuned towards survival data. A particularly useful feature is that this method can incorporate such additional structure as additive models, positivity constraints of the parameters or regression constraints.

RESULTS

Besides discussion of the proposed methods, an empirical case study is conducted on both clinical as well as micro-array gene expression data in the context of cancer studies. Results are expressed based on the logrank statistic, concordance index and the hazard ratio. The reported performances indicate that the present method yields better models for high-dimensional data, while it gives results which are comparable to what classical techniques based on a proportional hazard model give for clinical data.

Prospective external validation of the 'ovarian crescent sign' as a single ultrasound parameter to distinguish between benign and malignant adnexal pathology

OBJECTIVE

To determine the sensitivity and specificity of the 'ovarian crescent sign' (OCS)-a rim of normal ovarian tissue seen adjacent to an ipsilateral adnexal mass-as a sonographic feature to discriminate between benign and malignant adnexal masses.

METHODS

The patients included were a subgroup of patients participating in the International Ovarian Tumor Analysis (IOTA) Phase 2 study, which is an international multicenter study. The subgroup comprised 1938 patients, with an adnexal mass, recruited from 19 ultrasound centers in different countries. All patients were scanned using the same standardized ultrasound protocol. Information on more than 40 demographic and ultrasound variables were collected, but the evaluation of the OCS was optional. Only patients from centers that had evaluated the OCS in > or = 90% of their cases were included. The gold standard was the histological diagnosis of the adnexal mass. The ability of the OCS to discriminate between borderline or invasively malignant vs. benign adnexal masses, as well as between invasively malignant vs. other (benign and borderline) tumors, was determined and compared with the performance of subjective evaluation of ultrasound findings by the ultrasound examiner.

RESULTS

The OCS was evaluated in 1377 adnexal masses from 12 centers, 938 (68%) masses being benign, 86 (6%) borderline, 305 (22%) primary invasive and 48 (3%) metastases. The OCS was present in 398 (42%) of 938 benign masses, in 14 (16%) of 86 borderline tumors, in 18 (6%) of 305 primary invasive tumors (one malignant struma ovarii, one uterine clear cell adenocarcinoma and 16 epithelial carcinomas, i.e. four Stage I and 12 Stage II-IV) and in two (4%) of 48 ovarian metastases. Hence, the sensitivity and specificity for absent OCS to identify a malignancy was 92% and 42%, respectively, and the positive and negative likelihood ratios (LR+ and LR-, respectively) were 1.60 and 0.18. Subjective impression performed significantly better than the OCS. Sensitivity and specificity were 90% and 92%, respectively, LR+ was 11.0 and LR- was 0.10. For discrimination between invasive vs. benign or borderline tumors, the sensitivity for absent OCS was 94%, the specificity was 40%, the LR+ was 1.58 and the LR- was 0.14.

CONCLUSION

This study confirms previous reports that the presence of the OCS decreases the likelihood of invasive malignancy in adnexal masses. However it is a poor discriminator between benign and malignant adnexal masses.

Additive survival least-squares support vector machines

This work studies a new survival modeling technique based on least-squares support vector machines. We propose the use of a least-squares support vector machine combining ranking and regression. The advantage of this kernel-based model is threefold: (i) the problem formulation is convex and can be solved conveniently by a linear system; (ii) non-linearity is introduced by using kernels, componentwise kernels in particular are useful to obtain interpretable results; and (iii) introduction of ranking constraints makes it possible to handle censored data. In an experimental setup, the model is used as a preprocessing step for the standard Cox proportional hazard regression by estimating the functional forms of the covariates. The proposed model was compared with different survival models from the literature on the clinical German Breast Cancer Study Group data and on the high-dimensional Norway/Stanford Breast Cancer Data set.

Acoustic streaming cannot discriminate reliably between endometriomas and other types of adnexal lesion: a multicenter study of 633 adnexal masses

OBJECTIVE

To determine the ability of acoustic streaming to discriminate between endometriomas and other adnexal masses.

METHODS

We used data from 1938 patients with an adnexal mass included in Phase 2 of the International Ovarian Tumor Analysis (IOTA) study. All patients had been examined by transvaginal gray-scale and Doppler ultrasound following a standardized research protocol. Assessment of acoustic streaming was voluntary and was carried out only in lesions containing echogenic cyst fluid. Acoustic streaming was defined as movement of particles inside the cyst fluid during gray-scale and/or color Doppler examination provided that the probe had been held still for two seconds to ensure that the movement of the particles was not caused by movement of the probe or the patient. Only centers where acoustic streaming had been evaluated in > 90% of cases were included. Sensitivity, specificity, positive and negative likelihood ratios (LR+, LR-), and positive and negative predictive values (PPV and NPV) of acoustic streaming with regard to endometrioma were calculated.

RESULTS

460 (24%) masses were excluded because they were examined in centers where </= 90% of the masses with echogenic cyst fluid had been evaluated for the presence of acoustic streaming. Acoustic streaming was evaluated in 633 of 646 lesions containing echogenic cyst fluid. It was present in 19 (9%) of 209 endometriomas and in 55 (13%) of 424 other lesions. This corresponds to a sensitivity of absent acoustic streaming with regard to endometrioma of 91% (190/209), a specificity of 13% (55/424), LR+ of 1.04, LR- of 0.69, PPV of 34% (190/559) and NPV of 74% (55/74).

CONCLUSIONS

Acoustic streaming cannot discriminate reliably between endometriomas and other adnexal lesions, and the presence of acoustic streaming does not exclude an endometrioma.

Prognostic Significance of Nodal and PgR Status on Early Relapse in Operable HER-2 Positive Breast Cancer from the Pre-Trastuzumab Era

Background: Over the last decade, trastuzumab has become a standard adjuvant treatment option in HER-2 positive breast cancers. However, with a mainly 'on-treatment' effect only, the economic burden and adverse effects incurred from its routine use for 1 year following completion of chemotherapy, there emerges a need to identify a group of HER-2 positive breast cancers at low-risk for relapse. We, therefore, investigated potential prognostic factors in a cohort of HER-2 positive breast cancers in the era before trastuzumab, especially focusing on hormonal status.Methods: We retrospectively reviewed the data of 240 trastuzumab-naïve patients with a HER-2 FISH-positive breast cancer who had primary surgery at University Hospitals Leuven between January 2000 and December 2005. We collected data including age at diagnosis, menopausal status, histologic type, tumor size, grade, lymph node involvement, estrogen receptor (ER) /progesterone receptor (PgR) status, and disease-free survival (DFS) outcome. A multivariate Cox hazard model was used to identify prognostic factors and the cumulative DFS rate was determined using the Kaplan-Meier method.Results: After a median follow-up of 57.5 months there were 50 breast cancer related events meaning that 5-year DFS rate was 78.4% for the entire cohort. Median time to first event was 20 months and ranged from 4 to 96 months. Cox model revealed that only PgR status and lymph node involvement were independent prognostic factors for disease relapse. (p = 0.03 and p &lt; 0.01 respectively). In Kaplan-Meier analysis, patients with PgR+ showed better DFS rate than those with PgR- (figure 1; 83.8% vs. 73.1%, p = 0.02) while ER status didn't reach statistical significance (p = 0.154).Nodal involvement ≥4 was strongly associated with poor DFS rate compared with node negativity. (p = 0.00). Of note, a subgroup of patients with PgR+ and LN-. presented no relapse within the first two years after surgery (figure 2).Conclusions: In this series of HER-2 positive breast cancers, PgR and nodal status were strong prognostic factors for early breast cancer relapse. Patients with a PgR+/LN- phenotype were unlikely to relapse within the first two years of surgery. We propose to evaluate the added benefit of adjuvant trastuzumab to chemotherapy in women with this phenotype as such data are yet not available from the major adjuvant trastuzumab trials.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6046.

Intravenous contrast ultrasound examination using contrast-tuned imaging (CnTI) and the contrast medium SonoVue for discrimination between benign and malignant adnexal masses with solid components

OBJECTIVE

To determine whether intravenous contrast ultrasound examination is superior to gray-scale or power Doppler ultrasound for discrimination between benign and malignant adnexal masses with complex ultrasound morphology.

METHODS

In an international multicenter study, 134 patients with an ovarian mass with solid components or a multilocular cyst with more than 10 cyst locules, underwent a standardized transvaginal ultrasound examination followed by contrast examination using the contrast-tuned imaging technique and intravenous injection of the contrast medium SonoVue(R). Time intensity curves were constructed, and peak intensity, area under the intensity curve, time to peak, sharpness and half wash-out time were calculated. The sensitivity and specificity with regard to malignancy were calculated and receiver-operating characteristics (ROC) curves were drawn for gray-scale, power Doppler and contrast variables and for pattern recognition (subjective assignment of a certainly benign, probably benign, uncertain or malignant diagnosis, using gray-scale and power Doppler ultrasound findings). The gold standard was the histological diagnosis of the surgically removed tumors.

RESULTS

After exclusions (surgical removal of the mass > 3 months after the ultrasound examination, technical problems), 72 adnexal masses with solid components were used in our statistical analyses. The values for peak contrast signal intensity and area under the contrast signal intensity curve in malignant tumors were significantly higher than those in borderline tumors and benign tumors, while those for the benign and borderline tumors were similar. The area under the ROC curve of the best contrast variable with regard to diagnosing borderline or invasive malignancy (0.84) was larger than that of the best gray-scale (0.75) and power Doppler ultrasound variable (0.79) but smaller than that of pattern recognition (0.93).

CONCLUSION

Findings on ultrasound contrast examination differed between benign and malignant tumors but there was a substantial overlap in contrast findings between benign and borderline tumors. It appears that ultrasound contrast examination is not superior to conventional ultrasound techniques, which also have difficulty in distinguishing between benign and borderline tumors, but can easily differentiate invasive malignancies from other tumors.

Triple negative breast cancer: a study from the point of view of basal CK5/6 and HER-1

AIM

Basal-like breast tumours, as defined by microarrays, carry a poor prognosis and therapeutic options are limited to date. Often, these tumours are defined as oestrogen receptor (ER) negative/progesterone receptor (PR) negative/human epidermal growth factor receptor 2 (HER-2) negative (triple negative) by immunohistochemistry (IHC), but a more complete definition should include expression of basal cytokeratins (CK5/6, CK14 or CK17) and/or human epidermal growth factor receptor 1 (HER-1). The aim of this study was to investigate to what extent CK5/6 and HER-1 characterise the group of triple negative breast cancers.

METHODS

Expression of CK5/6 and HER-1 was studied by IHC in 25 triple negative breast carcinomas and 32 grade-matched, non-triple-negative controls. All 57 cases were further subjected to fluorescence in situ hybridisation to investigate HER-1 gene copy number.

RESULTS

CK5/6 and HER-1 expression was most frequent in triple negative tumours: 22 out of 25 cases (88.0%) expressed at least one of these markers (60.0% CK5/6 positive and 52.0% HER-1 positive). In the control group, CK5/6 and HER-1 expression was found in ER-negative but not in ER-positive tumours (ER negative/PR negative/HER-2 positive tumours: 20.0% CK5/6 positive and 46.7% HER-1 positive). HER-1 gene amplification was found in five cases only: four triple negative (16.0%) and one ER-negative control (ER negative/PR negative/HER-2 positive, 6.7%). Of interest, all five HER-1 amplified cases showed a remarkably homogeneous HER-1 expression pattern.

CONCLUSION

Expression of CK5/6 and HER-1 is frequent in ER-negative breast cancers, in triple negative and in non-triple negative tumours. In a minority of cases, HER-1 overexpression may be caused by HER-1 gene amplification. Further studies are needed to investigate whether such cases might benefit from anti-HER-1 therapy.

Improving NPI for breast cancer prognosis by including PR and HER-2 expression: own data and external validation set

Abstract #1080

The Nottingham Prognostic Index (NPI) classifies primary operable breast cancer patients into good (NPI ≤ 3.4) , intermediate (NPI 3.4-5.4) and poor (NPI ≥ 5.4) prognostic risk groups [Br J Cancer 1987; 56: 489–92]. Studies indicate a significant short term prognostic role for estrogen (ER), progesterone (PR) and HER-2 receptor on disease free survival (DFS). We proposed at SABCS 2007 to add PR and HER-2 expression to the NPI called improved NPI (iNPI) defined as (NPI) + (HER-2) – (PR), with HER-2 and PR '1' in case of amplified HER-2 and any PR-expression and '0' otherwise.&#x2028; Internal validation of the iNPI was performed on 1928 breast cancer patients, primary operated between Jan 2000 and June 2005 at Univ Hospital Leuven. All patients were classified into any of the three NPI or iNPI risk group. Mean follow-up was 3.5 yrs and DFS was defined as previously stated [Breast Cancer Research and Treatment 2007; 106: S247-S247]. Out of the 601 patients classified as NPI low risk, 59 shifted towards the intermediate iNPI group. Comparison of DFS for the 59 shifted with the non-shifted patients from the low NPI class did not reveal a significant difference (p=0.129, log-rank test). 57 patients out of 935 and 136 out of 392 respectively classified as intermediate and high NPI group became high and intermediate risk according to the iNPI. In both cases, DFS of the shifted patients differed significantly from DFS of the non-shifted patients (p=&lt;.001 en p=0.029). DFS of the shifted patients with the iNPI group they where shifted to was not/marginally significant (p=0.856, p=0.462 and p=0.047 for low, intermediate and high NPI respectively).&#x2028; For external validation a dataset from the Breast Cancer Micrometastasis group in Oslo with 677 patients and known NPI, PR and HER-2 was used. Figure 1 confirms a significant difference between DFS of the shifted and the non-shifted patients within the highest NPI risk group (p=0.021). The difference in DFS between shifted and non-shifted patients was marginally non-significant (p=0.068) in the intermediate and non-significant in the low NPI group (p=0.116). The non-significant difference between DFS of the shifted groups with the DFS of the group they were shifted to was confirmed, with exception of the low NPI group (difference in systemic treatment) (p=0.040, p=0.621 and p=0.076 for low, intermediate and high NPI respectively).&#x2028; We confirm the results from an internal study at the Univ Hospital in Leuven on an external dataset. Inclusion of the PR and HER-2 status into the NPI results in more homogenate risk groups concerning DFS.&#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1080.

Biology and prognosis by age of primary operable breast cancer

Abstract #2082

Introduction Breast cancer (BC) biology and prognosis are age dependent. We studied the effect of age on BC biology, treatment and prognosis.&#x2028; Methods Data from 2059 consecutive patients, primary operated for invasive BC in UZ Leuven (01/01/00–01/06/05), were used. Patients with ≥ 3.5 yrs follow-up were included (n=1064) to study relapse in relation to age (logistic regression).&#x2028; Results Early relapse in BC is age-related, decreasing 3.2% each yr for patients &lt; 60 yrs at diagnosis (p=0.0132, 95% CI OR: 0.943-0.993). This relation is reversed &gt;60 yrs: early relapse increases 5.5% each yr (p=0.0007, 95% CI OR: 1.021-1.082). The positive lymph node status is decreasing 3.5% each yr &lt;65 yrs (p&lt;0.0001, 95% CI OR: 0.950-0.980) and increasing 3.8% each yr ≥65 yrs (p=0.0259, 95% CI OR: 1.004-1.072) (Fig 1). The chance on a positive estrogen receptor (ER) increases with increasing age until 60 yrs (p=0.0071, 95% CI OR=1.009-1.059) with no significant effect &gt;60 years. For the progesterone receptor (PR), this depends quadratically on the age at diagnosis (p=0.0108, 95% CI OR=0.999-1.000), decreasing &lt;50 years and increasing above. With increasing age, the chance on HER-2 positivity decreased (p=0.0414, 95% CI OR: 0.970-0.999). Grade 3 tumors dropped significantly until 50 yrs (p&lt;0.0001 CI OR=0.900 (0.869-0.933) whereafter we observed a non significant upward trend (Fig 2). The chance to receive any adjuvant therapy decreased with age (p=0.0023, 95% CI OR: 0.958-0.991). Above 70 yrs, systemic adjuvant therapy was absent in 12.95% of non-relapsing -, but in 28.95% of relapsing patients. Radiotherapy was not taken into account.&#x2028; Conclusion Early relapse was higher with increasing/decreasing age, starting from age 60. This goes in parallel with the U-shape curve of lymph node involvement (Fig1). Increased relapse and lymph node positivity in elderly might partially be a reflection of the fact that BC is diagnosed in a later stage in elderly patients but might also be related to different biological behavior or to decreased use of adjuvant systemic treatment. HER-2 overexpression decreases with age and age related differences in ER and PR expression as well as tumor grading are observed (Fig 2).&#x2028; &#x2028; &#x2028; &#x2028;

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2082.

Age interacts with the expression of steroid and HER-2 receptors in operable invasive breast cancer

BACKGROUND

The negative association between the oestrogen receptor (ER) and the human epidermal growth factor receptor 2 (HER-2) in breast cancer travels in both directions. ER+ tumours are less likely HER-2+ and HER-2+ tumours are less likely ER+.

METHODS

We studied the age-related immunohistochemical (IHC) expression of ER, progesterone receptor (PR) and HER-2 in 2,227 tumours using age as a continuous variable. Steroid receptors were considered positive for any nuclear staining of invasive cancer cells and for HER-2, either for strong expression by IHC (score 3+) or gene amplification by fluorescence in situ hybridisation (FISH). Based on nonparametric regression, the age-related association between steroid receptors and HER-2 was presented as likelihood curves.

RESULTS

The association between ER or PR and HER-2 is age-related. The age-related expression of ER and PR is HER-2 dependent. In HER-2(-) cases, the odds ratio (OR) for being ER+ was 2.594 (95% CI = 1.874-3.591) up to age 50 and age-independent thereafter; for PR-expression the OR was 2.687 (95% CI = 1.780-4.057) up to age 45 and 0.847 (95% CI = 0.761-0.942) thereafter. In HER-2+ cases, the OR was 0.806 (95% CI = 0.656-0.991) to be ER+ and 0.722 (95% CI = 0.589-0.886) to be PR+. The age-related OR for breast cancers to be HER-2+ is steroid receptor dependent. Taking together, ER+PR+HER-2+ breast cancers appear on average 5.4 years earlier than breast cancers of any other ER/PR/HER-2 phenotype (95% CI = 3.3-7.5; P < 0.0001).

CONCLUSION

There is a qualitative interaction between age and expression of steroid and HER-2 receptors. Our findings suggest a strong age-related selective growth advantage for breast tumour cells belonging to the ER+PR+HER-2+ subgroup.