Abstract P5-22-12: Oncological safety of nipple-areola sparing mastectomy in comparison with skin sparing and total mastectomy: Results from a NCI-designated comprehensive cancer center

Nipple-areola sparing mastectomy (NSM) may be offered to some women with breast cancer as an alternative to skin sparing (SSM) or total mastectomy (TM) with excellent cosmetic results and acceptable recurrence risk. The aim of this study is to determine the local/regional recurrence rate of NSM in comparison to SSM and TM at our institution and to determine the factors that may be associated with risk of recurrence. Women who underwent NSM (n=148), SSM (n=660) or TM (n=443) at City of Hope National Medical Center between May 2007 and December 2014 for Stage 0-III breast cancer were identified retrospectively. Exclusions were: women with inflammatory breast cancer and those who had mastectomy for recurrent breast cancer. Overall survival (OS) and disease free survival (DFS) were analyzed using Cox regression controlling for age, race/ethnicity, stage, histology, grade, hormone receptor and Her2 receptor status. There were total of 165 NSMs, 704 SSMs and 466 TMs performed for cancer, accounting for the patients with bilateral cancers. The median follow up time was 38, 58 and 55 months for NSM, SSM and TM, respectively. Median (range) age at diagnosis was 49 (23-74) for NSM, 51 (23-90) for SSM and 59 (26-92) for TM. In the NSM group, 76% of patients had invasive ductal cancer (IDC) and 15% had ductal carcinoma in-situ (DCIS); this was comparable to 73% and 13% in the SSM group and 78% and 9% in the TM group, respectively. The majority of patients who underwent NSM had Stage II disease (45%), which was similar to SSM (43%) and TM (44%). Only 3% of NSM patients had Stage III disease compared to 17% of SSM patients and 29% of TM patients. Most of the patients in all 3 surgical groups received adjuvant chemotherapy (NSM 59%; SSM 52%; TM 51%). Of patients who underwent NSM, 20% received neoadjuvant chemotherapy, compared with 29% of SSM patients and 35% of TM patients. The local/regional recurrence rate per breast was 12/165 (7.3%) for NSM, 23/704 (3.3%) for SSM and 11/466 (2.4%) for TM (n=11). Median time to recurrence was 20, 26 and 16 months for NSM, SSM and TM, respectively. Of the NSMs performed only 1 recurrence occurred at the nipple-areolar complex (0.6%), 9 recurrences were at the chest wall (5.5%) and 2 were at the axilla (1.2%). Eight recurrences after NSM had DCIS in addition to IDC at the time of initial diagnosis while 2 had pure DCIS, 1 had pure IDC and 1 had invasive lobular cancer. There were 8 recurrences with estrogen receptor (ER) and progesterone receptor (PR) positivity at the time of initial diagnosis, that converted to ER+, PR-. One third of recurrences after NSM had multifocal disease. There was no significant difference found in adjusted overall survival (p=0.49) and adjusted disease free survival (p=0.10) among NSM, SSM and TM patients. Even though there is higher rate of local/regional recurrence with NSM, there is no difference in overall and disease-free survival at our institution. Presence of DCIS may be an important factor for recurrence. From these data we conclude that NSM is an oncologically acceptable alternative to SSM and TM, with excellent cosmetic results.

Citation Format: Bostanci Z, Wang X, Ottesen R, Nikowitz J, Jones VC, Springer L, Lai L, Taylor L, Vito CA, Paz IB, Niland J, Kruper L, Yim JH. Oncological safety of nipple-areola sparing mastectomy in comparison with skin sparing and total mastectomy: Results from a NCI-designated comprehensive cancer center [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-12.

Role of EP2 and EP4 receptors in airway microvascular leak induced by prostaglandin E2

BACKGROUND AND PURPOSE

Airway microvascular leak (MVL) involves the extravasation of proteins from post-capillary venules into surrounding tissue. MVL is a cardinal sign of inflammation and an important feature of airway inflammatory diseases such as asthma. PGE2, a product of COX-mediated metabolism of arachidonic acid, binds to four receptors, termed EP1–4. PGE2 has a wide variety of effects within the airway, including modulation of inflammation, sensory nerve activation and airway tone. However, the effect of PGE2 on airway MVL and the receptor/s that mediate this have not been described.

EXPERIMENTAL APPROACH

Evans Blue dye was used as a marker of airway MVL, and selective EP receptor agonists and antagonists were used alongside EP receptor-deficient mice to define the receptor subtype involved.

KEY RESULTS

PGE2 induced significant airway MVL in mice and guinea pigs. A significant reduction in PGE2-induced MVL was demonstrated in Ptger2−/− and Ptger4−/− mice and in wild-type mice pretreated simultaneously with EP2 (PF-04418948) and EP4 (ER-819762) receptor antagonists. In a model of allergic asthma, an increase in airway levels of PGE2 was associated with a rise in MVL; this change was absent in Ptger2−/− and Ptger4−/− mice.

CONCLUSIONS AND IMPLICATIONS

PGE2 is a key mediator produced by the lung and has widespread effects according to the EP receptor activated. Airway MVL represents a response to injury and under ‘disease’ conditions is a prominent feature of airway inflammation. The data presented highlight a key role for EP2 and EP4 receptors in MVL induced by PGE2.

Impaired adult neurogenesis in the dentate gyrus of a triple transgenic mouse model of Alzheimer's disease

It has become generally accepted that new neurones are added and integrated mainly in two areas of the mammalian CNS, the subventricular zone and the subgranular zone (SGZ) of the dentate gyrus (DG) of the hippocampus, which is of central importance in learning and memory. The newly generated cells display neuronal morphology, are able to generate action potentials and receive functional synaptic inputs, i.e. their properties are similar to those found in mature neurones. Alzheimer's disease (AD) is the primary and widespread cause of dementia and is an age-related, progressive and irreversible neurodegenerative disease that deteriorates cognitive functions. Here, we have used male and female triple transgenic mice (3xTg-AD) harbouring three mutant genes (beta-amyloid precursor protein, presenilin-1 and tau) and their respective non-transgenic (non-Tg) controls at 2, 3, 4, 6, 9 and 12 months of age to establish the link between AD and neurogenesis. Using immunohistochemistry we determined the area density of proliferating cells within the SGZ of the DG, measured by the presence of phosphorylated Histone H3 (HH3), and their possible co-localisation with GFAP to exclude a glial phenotype. Less than 1% of the HH3 labeled cells co-localised with GFAP. Both non-Tg and 3xTg-AD showed an age-dependent decrease in neurogenesis. However, male 3xTg-AD mice demonstrated a further reduction in the production of new neurones from 9 months of age (73% decrease) and a complete depletion at 12 months, when compared to controls. In addition, female 3xTg-AD mice showed an earlier but equivalent decrease in neurogenesis at 4 months (reduction of 63%) with an almost inexistent rate at 12 months (88% decrease) compared to controls. This reduction in neurogenesis was directly associated with the presence of beta-amyloid plaques and an increase in the number of beta-amyloid containing neurones in the hippocampus; which in the case of 3xgTg females was directly correlated. These results suggest that 3xTg-AD mice have an impaired ability to generate new neurones in the DG of the hippocampus, the severity of which increases with age and might be directly associated with the known cognitive impairment observed from 6 months of age onwards . The earlier reduction of neurogenesis in females, from 4 months, is in agreement with the higher prevalence of AD in women than in men. Thus it is conceivable to speculate that a recovery in neurogenesis rates in AD could help to rescue cognitive impairment.

Expression, essentiality, and a microtiter plate assay for mycobacterial GlmU, the bifunctional glucosamine-1-phosphate acetyltransferase and N-acetylglucosamine-1-phosphate uridyltransferase

UDP-N-acetyl-D-glucosamine (UDP-GlcNAc) is an essential precursor of peptidoglycan and the rhamnose-GlcNAc linker region of mycobacterial cell wall. In Mycobacterium tuberculosis H37Rv genome, Rv1018c shows strong homology to the GlmU protein involved in the formation of UDP-GlcNAc from other bacteria. GlmU is a bifunctional enzyme that catalyzes two sequential steps in UDP-GlcNAc biosynthesis. Glucosamine-1-phosphate acetyl transferase catalyzes the formation of N-acetylglucosamine-1-phosphate, and N-acetylglucosamine-1-phosphate uridylyltransferase catalyzes the formation of UDP-GlcNAc. Since inhibition of peptidoglycan synthesis often results in cell lysis, M. tuberculosis GlmU is a potential anti-tuberculosis (TB) drug target. In this study we cloned M. tuberculosis Rv1018c (glmU gene) and expressed soluble GlmU protein in E. coli BL21(DE3). Enzymatic assays showed that M. tuberculosis GlmU protein exhibits both glucosamine-1-phosphate acetyltransferase and N-acetylglucosamine-1-phosphate uridylyltransferase activities. We also investigated the effect on Mycobacterium smegmatis when the activity of GlmU is fully removed or reduced via a genetic approach. The results showed that activity of GlmU is required for growth of M. smegmatis as the bacteria did not grow in the absence of active GlmU enzyme. As the amount of functional GlmU enzyme was gradually reduced in a temperature shift experiment, the M. smegmatis cells became non-viable and their morphology changed from a normal rod shape to stubby-rounded morphology and in some cases they lysed. Finally a microtiter plate based assay for GlmU activity with an OD340 read out was developed. These studies therefore support the further development of M. tuberculosis GlmU enzyme as a target for new anti-tuberculosis drugs.

Eukaryotic UDP-galactopyranose mutase (GLF gene) in microbial and metazoal pathogens

Galactofuranose (Gal(f)) is a novel sugar absent in mammals but present in a variety of pathogenic microbes, often within glycoconjugates that play critical roles in cell surface formation and the infectious cycle. In prokaryotes, Gal(f) is synthesized as the nucleotide sugar UDP-Gal(f) by UDP-galactopyranose mutase (UGM) (gene GLF). Here we used a combinatorial bioinformatics screen to identify a family of candidate eukaryotic GLFs that had previously escaped detection. GLFs from three pathogens, two protozoa (Leishmania major and Trypanosoma cruzi) and one fungus (Cryptococcus neoformans), had UGM activity when expressed in Escherichia coli and assayed in vivo and/or in vitro. Eukaryotic GLFs are closely related to each other but distantly related to prokaryotic GLFs, showing limited conservation of core residues around the substrate-binding site and flavin adenine dinucleotide binding domain. Several eukaryotes not previously investigated for Gal(f) synthesis also showed strong GLF homologs with conservation of key residues. These included other fungi, the alga Chlamydomonas and the algal phleovirus Feldmannia irregularis, parasitic nematodes (Brugia, Onchocerca, and Strongyloides) and Caenorhabditis elegans, and the urochordates Halocynthia and Cionia. The C. elegans open reading frame was shown to encode UGM activity. The GLF phylogenetic distribution suggests that Gal(f) synthesis may occur more broadly in eukaryotes than previously supposed. Overall, GLF/Gal(f) synthesis in eukaryotes appears to occur with a disjunct distribution and often in pathogenic species, similar to what is seen in prokaryotes. Thus, UGM inhibition may provide an attractive drug target in those eukaryotes where Gal(f) plays critical roles in cellular viability and virulence.

Synthesis and evaluation of nitrofuranylamides as novel antituberculosis agents

In an effort to develop new and more potent therapies to treat tuberculosis, a library of compounds was screened for M. tuberculosis UDP-Gal mutase inhibition. Nitrofuranylamide 1 was identified as a hit in this screen, possessing good antituberculosis activity. This paper describes the synthesis and evaluation of an expanded set of nitrofuranylamides. We have discovered a number of nitrofuranylamides with submicromolar M. tuberculosis MIC values and acceptable therapeutic indexes. The MIC activity did not correlate with UDP-Gal mutase inhibition, suggesting an alternative primary cellular target was responsible for the antituberculosis activity. The compounds were only active against mycobacteria of the tuberculosis complex. On the basis of these results, four compounds were selected for in vivo testing in a mouse model of tuberculosis infection, and of these compounds one showed significant antituberculosis activity.

Synthesis and evaluation of nitrofuranylamides as novel antituberculosis agents

In an effort to develop new and more potent therapies to treat tuberculosis, a library of compounds was screened for M. tuberculosis UDP-Gal mutase inhibition. Nitrofuranylamide 1 was identified as a hit in this screen, possessing good antituberculosis activity. This paper describes the synthesis and evaluation of an expanded set of nitrofuranylamides. We have discovered a number of nitrofuranylamides with submicromolar M. tuberculosis MIC values and acceptable therapeutic indexes. The MIC activity did not correlate with UDP-Gal mutase inhibition, suggesting an alternative primary cellular target was responsible for the antituberculosis activity. The compounds were only active against mycobacteria of the tuberculosis complex. On the basis of these results, four compounds were selected for in vivo testing in a mouse model of tuberculosis infection, and of these compounds one showed significant antituberculosis activity.

Novel inhibitors of an emerging target in Mycobacterium tuberculosis; substituted thiazolidinones as inhibitors of dTDP-rhamnose synthesis

The emergence of multi-drug resistant tuberculosis, coupled with the increasing overlap of the AIDS and tuberculosis pandemics has brought tuberculosis to the forefront as a major worldwide health concern. In an attempt to find new inhibitors of the enzymes in the essential rhamnose biosynthetic pathway, a virtual library of 2,3,5 trisubstituted-4-thiazolidinones was created. These compounds were then docked into the active site cavity of 6'hydroxyl; dTDP-6-deoxy-D-xylo-4-hexulose 3,5-epimerase (RmlC) from Mycobacterium tuberculosis. The resulting docked conformations were consensus scored and the top 5% were slated for synthesis. Thus far, 94 compounds have been successfully synthesized and initially tested. Of those, 30 (32%) have > or =50% inhibitory activity (at 20 microM) in the coupled rhamnose synthetic assay with seven of the 30 also having modest activity against whole-cell M. tuberculosis.

Farmers’ Perceptions and Concerns: The Risks of Driving Farm Vehicles on Rural Roadways in North Carolina

This study focuses on farmers' perceptions of roadway safety and reviews specific and pertinent North Carolina rural road crash data to evaluate their perceptions and concerns. A survey was mailed to 1,357 prospective participants throughout North Carolina. Of these, 656 (48.3%) North Carolina farmers completed and returned the survey. The study revealed that while the majority of respondents took a number of specific safety measures to ensure their safety while driving their tractor on rural roads, most believed that driving their tractor on rural roads was more dangerous than it was five years ago. Few respondents believed that laws governing tractors on rural roads are well known by urban residents. While a majority of the respondents would support a law to mandate the use of a slow-moving vehicle (SMV) emblem on the back of slow-moving farm equipment, a majority also believed that a more effective way to mitigate potential crashes would be to ensure that all farm vehicles had blinking or flashing lights, that diamond-shaped caution signs depicting a tractor were posted on roadways with frequent tractor traffic, and that roadway shoulders were created or widened on roads with heavy farm traffic so that tractors could move off the roadway. Only 22% of respondents felt safe driving their tractor on rural roadways in North Carolina. Most respondents felt that the biggest problem with roadway safety was the lack of respect and increased speed of other drivers. Recent data indicate that in crashes involving farm vehicles, citations were issued to 34% of the non-farm vehicle operators and 24% to farm vehicle operators. For those driving non-farm vehicle who were deemed at fault, 66% were cited for failure to reduce speed. For those driving farm vehicles, the most frequent citation involved the lack of safe movement.

Quantification of third body damage to the tibial counterface in mobile bearing knees

Fourteen pairs of explanted low contact stress (LCS) tibial interface components: six rotating platform (RP), six meniscal (MN) and two anterior-posterior (AP) glide designs, have been analysed with particular attention paid to the condition of the tibial counterfaces. The average surface roughness, Ra, for the tibial trays ranged from 0.01 to 0.087 micron, significantly greater than the unworn control measurement of 0.008 micron. The scratch geometry analysis showed that the scratch peaks were found to be consistently of a lower aspect ratio than the scratch valleys and under 1 micron in height (average asperity height Rp = 0.52 micron, aspect ratio delta p = 0.01, average asperity depth Rv = 1.10 microns, delta v = 0.05). The largest scratches were 3-4 microns in both Rp and Rv. In vitro tests have shown that ultra-high molecular weight polyethylene (UHMWPE) wear increases in the presence of counterface scratches perpendicular to the direction of motion. In these explants, the unidirectional motion produced scratches parallel to the direction of sliding which is predicted to produce a smaller increase in UHMWPE wear. Other designs in mobile bearing knees have less constrained motion at the tibial counterface and this has been shown to accelerate wear; it may also lead to a further increase in wear in the presence of third body scratches. It may be possible in future knee designs to reduce this type of wear damage by introducing alternative materials or coatings which are more resistant to scratching and surface roughening.

Drug targeting Mycobacterium tuberculosis cell wall synthesis: genetics of dTDP-rhamnose synthetic enzymes and development of a microtiter plate-based screen for inhibitors of conversion of dTDP-glucose to dTDP-rhamnose

An L-rhamnosyl residue plays an essential structural role in the cell wall of Mycobacterium tuberculosis. Therefore, the four enzymes (RmlA to RmlD) that form dTDP-rhamnose from dTTP and glucose-1-phosphate are important targets for the development of new tuberculosis therapeutics. M. tuberculosis genes encoding RmlA, RmlC, and RmlD have been identified and expressed in Escherichia coli. It is shown here that genes for only one isotype each of RmlA to RmlD are present in the M. tuberculosis genome. The gene for RmlB is Rv3464. Rv3264c was shown to encode ManB, not a second isotype of RmlA. Using recombinant RmlB, -C, and -D enzymes, a microtiter plate assay was developed to screen for inhibitors of the formation of dTDP-rhamnose. The three enzymes were incubated with dTDP-glucose and NADPH to form dTDP-rhamnose and NADP(+) with a concomitant decrease in optical density at 340 nm (OD(340)). Inhibitor candidates were monitored for their ability to lower the rate of OD(340) change. To test the robustness and practicality of the assay, a chemical library of 8,000 compounds was screened. Eleven inhibitors active at 10 microM were identified; four of these showed activities against whole M. tuberculosis cells, with MICs from 128 to 16 microg/ml. A rhodanine structural motif was present in three of the enzyme inhibitors, and two of these showed activity against whole M. tuberculosis cells. The enzyme assay was used to screen 60 Peruvian plant extracts known to inhibit the growth of M. tuberculosis in culture; two extracts were active inhibitors in the enzyme assay at concentrations of less than 2 microg/ml.

Simulation of tibial counterface wear in mobile bearing knees with uncoated and ADLC coated surfaces

A multidirectional pin-on-plate reciprocating machine was used to compare the wear performance of UHMWPE sliding against cast cobalt chrome (CoCr) plates that were either untreated or coated with Amorphous Diamond Like Carbon (ADLC). The test conditions were based on a 1/5 scale model representative of in vivo motion at the tibial counterfaces of unconstrained mobile bearing knees. The average +/- STERR wear rates were 13.78+/-1.06 mm3/Mcycles for the ADLC counterfaces and 0.504+/-0.12 mm3/Mcycles for the control CoCr counterfaces. All of the pins run on the ADLC counterfaces exhibited the same patterns of blistering along the central axis, and severe abrasion elsewhere to the extent that all of the original machining marks were removed after just one week of testing. The average value of friction coefficient was 0.24 for the ADLC counterfaces and 0.073 for the control CoCr counterfaces. The factor of 3.5 increase was statistically significant at p < 0.05. In the tribological evaluation of ADLC coatings for tibial trays in mobile bearing knees, this study shows that this specific Physical Vapour Deposition (PVD) ADLC showed significantly poorer frictional and wear performance than uncoated surfaces which was sufficient to negate any potential benefits of improved resistance to third body damage.

An experimental model of tibial counterface polyethylene wear in mobile bearing knees: the influence of design and kinematics

Current designs of mobile bearing knees have different kinematics at the tibial counterface articulation; unidirectional represented by linear tracks and rotating platform designs, and multidirectional represented by reduced constraint designs with motion of the tibial surface in A-P and M-L directions simultaneously. One fifth scale experimental models of the tibial counterface articulation have been developed with mean contact stresses of 0.6 MPa. The unidirectional model had a linear reciprocating motion with a 10 mm stroke, the multidirectional model had a reciprocating motion with a 10 mm stroke and simultaneous rotation of +/- 7.5 degrees. Six specimens of GUR415 polyethylene were tested for each model, sliding on polished cobalt chrome counterfaces with Ra < 0.01 micron in 25% bovine serum lubricant. The mean +/- STERR wear rates were: unidirectional 0.045 +/- 0.015 mm3/million cycles and multidirectional 0.44 +/- 0.15 mm3/million cycles. Applying the scaling factor of 5, the predicted wear rates in actual knee prostheses were: unidirectional 0.23 mm3/million cycles and multidirectional 2.2 mm3/million cycles. The order of magnitude increase in wear rate was statistically significant (p = 0.05).

Determining transthoracic impedance, delivered energy, and peak current during defibrillation episodes

A simplified method has been developed to determine peak current, transthoracic impedance, and delivered energy during a damped sinusoidal defibrillation pulse. The discharge waveform information is generated from sampling the peak discharge current through a current transformer and measuring the voltage stored on the energy storage capacitor. For a given defibrillator circuit a unique relationship exists between the peak discharge current IM and the unknown external impedance Rext presented to the defibrillator by the patient; hence, measurement of IM allows calculation of Rext. A microprocessor-controlled algorithm provides delivered energy information using known internal resistance, capacitance, and inductance parameters. The benefit of this method of delivered energy calculation is that the current and voltage waveforms need not be digitized and then integrated to provide the desired information. This method also keeps defibrillation circuitry ground isolated and simplifies operation through the high electromagnetic fields generated during the discharge. The delivered energy information, along with time, date, and other patient parameters, is documented automatically with an annotation strip-chart recorder.