Imaging findings on contrast-enhanced ultrasound, magnetic resonance imaging and hybrid positron emission tomography in Takayasu arteritis: a case report

This case report demonstrates the potential of contrast-enhanced ultrasound (CEUS) in diagnosing active arterial wall inflammation in a symptomatic patient with Takayasu arteritis (TA). To our knowledge, this is the first case which demonstrates pictorial correlation of arterial wall neovascularity on CEUS with mural edema on magnetic resonance imaging and metabolic activity on positron emission tomography - computed tomography in the same patient. As TA is a chronic disease which requires long-term follow-up, CEUS could be the potential imaging modality of choice as it is radiation-free, non-nephrotoxic and easily available.

Magnetic Resonance Imaging Study of the Pericranial Flap and Its Local Effects Following Endoscopic Craniofacial Resection

OBJECTIVES/HYPOTHESIS

To describe the magnetic resonance imaging (MRI) characteristics of the pericranial flap, changes in the pericranial flap thickness over time, presence of frontal sinus opacification, and presence of frontal lobe herniation into the nasal cavity.

STUDY DESIGN

Retrospective case series.

METHODS

Seventeen consecutive endoscopic craniofacial resections with pericranial flap reconstruction performed at a tertiary hospital from 2010 to 2019 were reviewed. Sixty-eight serial MRI scans were evaluated.

RESULTS

All pericranial flaps consistently featured a homogenous appearance on T1-weighted sequence and enhanced with contrast. On T2-weighted sequence, the skull base reconstruction demonstrated four layers of alternating hypo- and hyperintensity, which corresponded with the inlay synthetic graft or neodura (hypointense), loose areolar tissue (hyperintense), fibrous pericranium (hypointense), and nasal mucosa or granulation tissue (hyperintense). The mean pericranial flap thickness was 9.9 mm. In thicker flaps, the loose areolar layer contributed the bulk of the thickness. Of 13 patients who underwent three or more serial MRI scans, 11 flaps (84.6%) were stable and two (15.4%) had >50% reduction in their original thickness over time. Thirteen of 17 (76.5%) patients had frontal sinus opacification on follow-up. None developed frontal sinus mucoceles or frontal lobe herniation.

CONCLUSIONS

The pericranial flap has a distinctive MRI appearance, especially on T2-weighted sequence. The thickness of the flap remains relatively stable over time for most patients even following radiotherapy. It is a sturdy flap that is able to support the frontal lobe. Frontal sinus obstruction is common, although complications from this appear to be rare.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E90-E97, 2021.

Cabergoline-induced fibrosis of prolactinomas: a neurosurgical perspective

Presently, the standard of care for prolactinomas, a type of pituitary adenoma, is dopaminergic agents such as bromocriptine and cabergoline. However, dopaminergic agents may induce fibrosis of cardiac valves leading to valvular insufficiency, necessitating surgical treatment of prolactinoma. Fibrosis of prolactinoma can be induced by prolonged medical treatment with bromocriptine, and this usually occurs after years of treatment. In comparison to bromocriptine, there have been no reports of cabergoline-induced fibrosis of prolactinoma. There is a potential for greater emphasis to be placed on assessing the tumour consistency from preoperative MRI scans, or even preoperative contrast-enhanced 3D Fast Imaging Employing Steady-state Acquisition imaging to allow better planning of the surgery. We report a rare case of fibrosis of prolactinoma after cabergoline treatment resulting in its subsequent difficult surgical removal. This patient had early MRI changes of fibrosis of prolactinoma after a short period of 6 months of cabergoline treatment.

Prognostic significance of cystic lymph nodal metastasis in nasopharyngeal carcinoma

BACKGROUND

The purpose of this study was to determine the prevalence of cystic lymph nodal metastasis (CLNM) and its prognostic value in patients with nasopharyngeal carcinoma (NPC).

METHODS

A retrospective review was conducted on 257 patients with NPC, analyzing the presence of CLNM on MRI or CT scans. Oncologic outcomes were performed using the Kaplan-Meier analysis.

RESULTS

One hundred eleven patients (43.2%) had CLNM at diagnosis. Overall, patients with CLNM had a poorer disease-specific survival (DSS; P < .001) and overall survival (OS; P < .001) compared with patients without CLNM. When analyzed according to nodal status, CLNM was associated with a higher rate of distant metastasis recurrence (P = .007), a poorer DSS (P < .001), and a poorer OS (P < .001) among patients with N2 disease.

CONCLUSION

The prevalence of CLNM was 43.2%. In patients with N2 disease, the presence of CLNM was significantly associated with a poorer DSS, OS, and increased risk of distant metastasis recurrence.

Nongated Cardiac Computed Tomographic Angiograms for Detection of Embolic Sources in Acute Ischemic Stroke

Background and Purpose—

We assessed the feasibility of obtaining diagnostic quality images of the heart and thoracic aorta by extending the z axis coverage of a non–ECG-gated computed tomographic angiogram performed in the primary evaluation of acute stroke without increasing the contrast dose.

Methods—

Twenty consecutive patients with acute ischemic stroke within the 4.5 hours of symptom onset were prospectively recruited. We increased the longitudinal coverage to the domes of the diaphragm to include the heart. Contrast administration (Omnipaque 350) remained unchanged (injected at 3–4 mL/s; total 60–80 mL, triggered by bolus tracking). Images of the heart and aorta, reconstructed at 5 mm slice thickness in 3 orthogonal planes, were read by a radiologist and cardiologist, findings conveyed to the treating neurologist, and correlated with the transthoracic or transesophageal echocardiogram performed within the next 24 hours.

Results—

Of 20 patients studied, 3 (15%) had abnormal findings: a left ventricular thrombus, a Stanford type A aortic dissection, and a thrombus of the left atrial appendage. Both thrombi were confirmed by transesophageal echocardiography, and anticoagulation was started urgently the following day. None of the patients developed contrast-induced nephropathy on follow-up. The radiation dose was slightly increased from a mean of 4.26 mSV (range, 3.88–4.70 mSV) to 5.17 (range, 3.95 to 6.25 mSV).

Conclusions—

Including the heart and ascending aorta in a routine non–ECG-gated computed tomographic angiogram enhances an existing imaging modality, with no increased incidence of contrast-induced nephropathy and minimal increase in radiation dose. This may help in the detection of high-risk cardiac and aortic sources of embolism in acute stroke patients.

Good Intracranial Collaterals Trump Poor ASPECTS (Alberta Stroke Program Early CT Score) for Intravenous Thrombolysis in Anterior Circulation Acute Ischemic Stroke

BACKGROUND AND PURPOSE

In acute ischemic stroke, large early infarct size estimated by the Alberta Stroke Program Early CT Score (ASPECTS) is associated with poorer outcomes and is a relative contraindication for recanalization therapies. The state of the intracranial collateral circulation influences the functional outcome and may be a variable to consider before thrombolysis. We evaluated the prognostic effect of the collateral circulation in patients with thrombolyzed acute ischemic stroke who have large early infarct sizes as indicated by low ASPECTS.

MATERIALS AND METHODS

Patients with anterior circulation acute ischemic stroke who received a computed tomographic angiogram and subsequent treatment with intravenous tissue-type plasminogen activator from 2010 to 2013 were studied. Two independent neuroradiologists determined their ASPECTS. We stratified patients using ASPECTS into 2 groups: large volume infarcts (ASPECTS≤7 points) and small volume infarcts (ASPECTS 8-10). In addition, we evaluated a third group with very large volume infarcts (ASPECTS≤5 points). We then analyzed the 3 subgroups using the Maas, Tan, and ASPECTS-collaterals grading systems of the computed tomographic angiogram intracranial collaterals. Good outcomes were defined by modified Rankin Scale score of 0 to 2 at 3 months.

RESULTS

A total of 300 patients were included in the final analysis. For patients with very large volume infarcts (ASPECTS≤5 points), univariable analysis showed that younger age, male sex, lower National Institute of Health Stroke Scale (NIHSS), lower systolic blood pressure, and good collaterals by Maas, Tan, or ASPECTS-collaterals grading were predictors of good outcomes. On multivariate analysis, younger age (odds ratio, 0.93; 95% confidence interval, 0.89-0.97; P=0.002) and good collaterals by ASPECTS-collaterals system (odds ratio, 1.34; 95% confidence interval, 1.15-1.57; P<0.001) were associated with good outcomes.

CONCLUSIONS

In patients with large and very large volume infarcts, good collaterals as measured by the ASPECTS-collaterals system is associated with improved outcomes and can help select patients for intravenous thrombolysis.

Intravenous Thrombolysis for Acute Ischemic Stroke due to Cervical Internal Carotid Artery Occlusion

BACKGROUND

Internal carotid artery (ICA) occlusions are poorly responsive to intravenous thrombolysis with tissue plasminogen activator (IV-tPA) in acute ischemic stroke (AIS). Most study populations have combined intracranial and extracranial ICA occlusions for analysis; few have studied purely cervical ICA occlusions. We evaluated AIS patients with acute cervical ICA occlusion treated with IV-tPA to identify predictors of outcomes.

METHODS

We studied 550 consecutive patients with AIS who received IV-tPA and identified 100 with pure acute cervical ICA occlusion. We evaluated the associations of vascular risk factors, National Institutes of Health Stroke Scale (NIHSS) score, and leptomeningeal collateral vessel status via 3 different grading systems, with functional recovery at 90 days, mortality, recanalization of the primary occlusion, and symptomatic intracranial hemorrhage (SICH). Modified Rankin Scale score 0-1 was defined as an excellent outcome.

RESULTS

The 100 patients had mean age of 67.8 (range 32-96) and median NIHSS score of 19 (range 4-33). Excellent outcomes were observed in 27% of the patients, SICH in 8%, and mortality in 21%. Up to 54% of the patients achieved recanalization at 24 hours. On ordinal regression, good collaterals showed a significant shift in favorable outcomes by Maas, Tan, or ASPECTS collateral grading systems. On multivariate analysis, good collaterals also showed reduced mortality (OR .721, 95% CI .588-.888, P = .002) and a trend to less SICH (OR .81, 95% CI .65-1.007, P = .058). Interestingly, faster treatment was also associated with favorable functional recovery (OR 1.028 per minute, 95% CI 1.010-1.047, P = .001).

CONCLUSIONS

Improved outcomes are seen in patients with early acute cervical ICA occlusion and better collateral circulation. This could be a valuable biomarker for decision making.

Abstract 208: Non-gated Cardiac Ct Angiograms for Detection of Embolic Sources in Acute Ischemic Stroke

Background and Purpose: We assessed the diagnostic feasibility of using a 2-phase 64-slice non-gated cardiac computed tomographic angiography (CTA) in acute stroke patients, done in the same sitting as the brain CTA and using the same contrast dose, for the detection of a cardiac source of embolism. We expected to identify additional causes of stroke related to other unexpected pathology of heart or ascending aorta, which might be useful in therapeutic decision making and prognostication.

Methods: We recruited 20 consecutive patients with acute ischemic stroke within the 4.5hours of symptom-onset, activated for intravenous thrombolysis. In addition to our usual CTA protocol that spanned from the arch of aorta to the circle of Willis, we enlarged the field of scanning to include the heart. Radio-contrast load (Omipaque 350) remained unchanged (injected at 3-4ml/sec; total 60-80mls, triggered by bolus tracking). All scans were 0.5cm thick slices and were reviewed by a radiologist and cardiologist and the abnormal findings were conveyed to the treating neurologist. In patients with potential cardiac source of embolism, an urgent trans-thoracic or trans-esophageal echocardiogram was arranged.

Results: Of 20 patients, there were 3 abnormal findings, 1patient had a ventricular thrombus , 1 had a localized dissection in the ascending aorta and the third patient had a thrombus at the atrial appendage. Both were confirmed by trans-esophageal echocardiography and anticoagulation was started urgently the next day. None of our patients developed contrast nephropathy on follow up.

Conclusions: expanding the field of scanning to include the heart and ascending aorta ( a non-gated cardiac CTA) to the routinely performed CTA of cervico-cranial arterial tree is a noninvasive and useful modality for detecting high-risk cardiac and aortic sources of embolism in acute stroke patients.

Abstract TP54: Topographical Aspects Collateral Score is a Useful Prognostic Factor in Thrombolysed Anterior Circulation Acute Ischemic Stroke Patients

Background: the ASPECTS- collateral score on CT-angiograms was shown to be successful in prognosticating functional outcomes and complications during intravenous thrombolysis in acute ischemic stroke (AIS). We studied predetermined topological information to see if any specific region had more prognostic value.

Methods: consecutive patients from 2010-2014 with intracranial internal carotid artery, M1 or M2 middle carotid artery occlusions treated with intravenous thrombolysis were included. The primary outcome measure was good clinical outcome (3-month modified Rankin Scale score 0-1). We scored each region as 0= no collaterals, 1= poor compared to contralateral and 2= good collaterals. Prognostic value of the 6 cortical ASPECTS-collateral regions in predicting outcomes was determined by multivariable logistic regression.

Results: 310 patients were included (Median age, 66.1±14.5 years; median National Institutes of Health Stroke Scale (NIHSS)- 18 points (range 3-36). Inter-rater reliability for ASPECTS-collaterals was good (κ=0.78). There was no Statistical collinearity among ASPECTS-collateral regions. Using multivariable logistic regression, only the M5 region (odds ratio, 2.72, 95%CI 1.52-4.84, p =0.001), age (OR 0.957 per yr 95%CI 0.936-0.978, p <0.001), Diabetes (OR 0.367, 95%CI 0.193- 0.700, p =0.002) and NIHSSS (OR 0.878 per point, 95%CI 0.836-0.922, p=0.001) were significantly associated with good outcomes. When compared with NIHSS, the receiver operating characteristic curves for NIHSS+M5 (area under the curve, 0.749) correlated well with clinical severity scores. Addition of M5 collateral score showed a statistically significant additive effect to the NIHSS score for predicting good outcomes (Z score: -1.684, p=0.045).

Conclusions: Involvement of the parietal region (M5) regions is a reliable predictor of clinical outcome in anterior circulation large artery occlusion. This simple radiological marker can strengthen the clinical NIHSS score and may be considered during prognostication

How temporal evolution of intracranial collaterals in acute stroke affects clinical outcomes

OBJECTIVE

We compared intracranial collaterals on pretreatment and day 2 brain CT angiograms (CTA) to assess their evolution and relationship with functional outcomes in acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA).

METHODS

Consecutive AIS patients who underwent pretreatment and day 2 CTA and received IV tPA during 2010-2013 were included. Collaterals were evaluated by 2 independent neuroradiologists using 3 predefined criteria: the Miteff system, the Maas system, and 20-point collateral scale by the Alberta Stroke Program Early CT Score methodology. We stratified our cohort by baseline pre-tPA state of their collaterals and by recanalization status of the primary vessel for analysis. Good outcomes at 3 months were defined by a modified Rankin Scale score of 0-1.

RESULTS

This study included 209 patients. Delayed collateral recruitment by any grading system was not associated with good outcomes. All 3 scoring systems showed that collateral recruitment on the follow-up CTA from a baseline poor collateral state was significantly associated with poor outcome and increased bleeding risk. When the primary vessel remained persistently occluded, collateral recruitment was significantly associated with worse outcomes. Interestingly, collateral recruitment was significantly associated with increased mortality in 2 of the 3 grading systems.

CONCLUSIONS

Not all collateral recruitment is beneficial; delayed collateral recruitment may be different from early recruitment and can result in worse outcomes and higher mortality. Prethrombolysis collateral status and recanalization are determinants of how intracranial collateral evolution affects functional outcomes.

Assessment of intracranial collaterals on CT angiography in anterior circulation acute ischemic stroke

BACKGROUND AND PURPOSE

Intracranial collaterals influence the prognosis of patients treated with intravenous tissue plasminogen activator in acute anterior circulation ischemic stroke. We compared the methods of scoring collaterals on pre-tPA brain CT angiography for predicting functional outcomes in acute anterior circulation ischemic stroke.

MATERIALS AND METHODS

Two hundred consecutive patients with acute anterior circulation ischemic stroke treated with IV-tPA during 2010-2012 were included. Two independent neuroradiologists evaluated intracranial collaterals by using the Miteff system, Maas system, the modified Tan scale, and the Alberta Stroke Program Early CT Score 20-point methodology. Good and extremely poor outcomes at 3 months were defined by modified Rankin Scale scores of 0-1 and 5-6 points, respectively.

RESULTS

Factors associated with good outcome on univariable analysis were younger age, female sex, hypertension, diabetes mellitus, atrial fibrillation, small infarct core (ASPECTS ≥8), vessel recanalization, lower pre-tPA NIHSS scores, and good collaterals according to Tan methodology, ASPECTS methodology, and Miteff methodology. On multivariable logistic regression, only lower NIHSS scores (OR, 1.186 per point; 95% CI, 1.079-1.302; P = .001), recanalization (OR, 5.599; 95% CI, 1.560-20.010; P = .008), and good collaterals by the Miteff method (OR, 3.341; 95% CI, 1.203-5.099; P = .014) were independent predictors of good outcome. Poor collaterals by the Miteff system (OR, 2.592; 95% CI, 1.113-6.038; P = .027), Maas system (OR, 2.580; 95% CI, 1.075-6.187; P = .034), and ASPECTS method ≤5 points (OR, 2.685; 95% CI, 1.156-6.237; P = .022) were independent predictors of extremely poor outcomes.

CONCLUSIONS

Only the Miteff scoring system for intracranial collaterals is reliable for predicting favorable outcome in thrombolyzed acute anterior circulation ischemic stroke. However, poor outcomes can be predicted by most of the existing methods of scoring intracranial collaterals.

Prognostic and Predictive Impact of Expression of the Angiogenic Markers CD105 and CD31 Expression in Patients with High Risk Breast Cancer (HRBC)

Purpose: Several angiogenic factors have been reported to influence prognosis of breast cancer and spread to regional lymph nodes. CD105 (Endoglin) is expressed by human vascular endothelial cells and plays a major role in angiogenesis. Similarly, CD31 is a platelet endothelial cell adhesion molecule involved in normal and pathologic vessel function. In the prospective randomized WSG-AM-01 trial HRBC patients with more than 9 positive lymph nodes derived particular benefit from tandem high-dose (HD) rather than dose-dense (DD) chemotherapy with regard to both event-free (EFS) and overall survival (OS), particularly among tumors carrying a basal-like or HER2 molecular phenotype. The goal of the present study was to examine the interaction between angiogenic factors and efficacy of different dose intensification strategies in the WSG-AM-01 trial among both unselected patients as well as among distinct molecular disease subtypes.Methods: Immunohistochemical staining for CD31 (n=128) and CD105 (n=130) was performed to assess vascular surface area (VSA) separately for both factors using the Chalkley count method.Expression of estrogen (ER) and progesterone receptor (PR), HER2, Ki67, and epidermal growth factor receptor (EGFR) was analyzed immunohistochemically using tissue microarrays, allowing for stratification into molecular breast cancer subclasses (k-clustering k=5 by expression of 24 proteins). Correlation analysis between CD31 and CD105 expression and molecular subtypes was carried out using Pearson correlations. Univariate survival estimates were determined by Kaplan-Meier analysis and tested for significance by log rank statistics. Multivariate survival modeling was performed by a generalized Cox model, with linear proportional hazards terms in the first block and time-varying interactions in the second block.Results: Both VSA/CD 31 and VSA/CD105 showed significantly higher expression among HER-2 and basal-like breast cancer subtypes (p=0.007), as well as among cases wit increased Ki67 (p=0.005).Increased VSA/CD105 (above a median of 1.295) was associated with significantly decreases in both EFS (p=0.01) and OS (p=0.02). In multivariate analysis (including therapy, tumor size, age and grade as well as expression of ER, PR, HER-2 and Ki-67) increased VSA/CD 105 was an independent prognostic factor for decreased EFS (HR=1.68, p=0.05). Dose intensification showed significantly increased efficacy (for OS and EFS) only among patients with low VSA/CD105 tumors.Discussion: Expression of angiogenic markers may mirror/confer resistance to chemotherapy among patients with breast cancer, particularly in the context of dose intensified chemotherapy and may explain differences observed among distinct molecular breast cancer phenotypes. The correlation observed between angiogenic markers and distinct molecular subtypes may serve as a rationale for exploring antiangiogenic treatment options in patients carrying these tumors.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2154.

Role of complement C5a in mechanical inflammatory hypernociception: potential use of C5a receptor antagonists to control inflammatory pain

BACKGROUND AND PURPOSE

C5a, a complement activation product, exhibits a broad spectrum of inflammatory activities particularly neutrophil chemoattraction. Herein, the role of C5a in the genesis of inflammatory hypernociception was investigated in rats and mice using the specific C5a receptor antagonist PMX53 (AcF-[OP(D-Cha)WR]).

EXPERIMENTAL APPROACH

Mechanical hypernociception was evaluated with a modification of the Randall-Selitto test in rats and electronic pressure meter paw test in mice. Cytokines were measured by ELISA and neutrophil migration was determined by myeloperoxidase activity.

KEY RESULTS

Local pretreatment of rats with PMX53 (60-180 microg per paw) inhibited zymosan-, carrageenan-, lipopolysaccharide (LPS)- and antigen-induced hypernociception. These effects were associated with C5a receptor blockade since PMX53 also inhibited the hypernociception induced by zymosan-activated serum and C5a but not by the direct-acting hypernociceptive mediators, prostaglandin E(2) and dopamine. Underlying the C5a hypernociceptive mechanisms, PMX53 did not alter the cytokine release induced by inflammatory stimuli. However, PMX53 inhibited cytokine-induced hypernociception. PMX53 also inhibited the recruitment of neutrophils induced by zymosan but not by carrageenan or LPS, indicating an involvement of neutrophils in the hypernociceptive effect of C5a. Furthermore, the C5a-induced hypernociception was reduced in neutrophil-depleted rats. Extending these findings in rats, blocking C5a receptors also reduced zymosan-induced joint hypernociception in mice.

CONCLUSIONS AND IMPLICATIONS

These results suggest that C5a is an important inflammatory hypernociceptive mediator, acting by a mechanism independent of hypernociceptive cytokine release, but dependent on the presence of neutrophils. Therefore, we suggest that inhibiting the action of C5a has therapeutic potential in the control of inflammatory pain.

YB-1 expression and effectiveness of different dose-intensification strategies in high-risk breast cancer: Five-year follow-up results of prospective randomized WSG-AM-01 trial

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Background: Y-box binding protein (YB-1), known as oncogenic transcription factor, is associated with up-regulation of MDR1, alters p53 function, and induces growth of an aggressive phenotype. In high-risk breast cancer, the prospective randomized WSG-AM-01 trial has reported significantly better event-free (EFS) and overall survival (OS) for tandem high-dose (HD) vs. dose-dense (DD) chemotherapy, especially in basal-like und HER2 subgroups. The present study examines the interaction of a drug resistant phenotype induced by YB-1 within the WSG-AM-01 collective at 5-year follow-up. Methods: 236 tumors (116 HD/120 DD) of 403 randomized patients (60%) were available for construction of tissue microarrays and determination of molecular classification by k-clustering of expression of 34 protein markers. Immunostaining of YB-1 by specific peptide antibody was scored semiquatitatively by intensity. Associations of YB-1 staining with other protein expression factors were studied by Pearson correlations. Univariate survival was estimated by Kaplan-Meier analysis and tested by log rank statistics. Multivariate survival modeling was performed by a generalized Cox model, with linear proportional hazards terms in the first block and time-varying interactions in the second block. Results: At a median follow-up of 61.7 months, the WSG-AM-01 confirms a significant EFS and OS benefit for HD in HRBC. In 60% of tumors, there was strong YB-1 expression. YB-1 was significantly associated with several proliferation and drug resistance markers, such as p53, EGFR, S6 and with basal-like/Her2 subtypes.YB-1 expression was highly predictive for response to HD: both EFS (HR=0.29, p=0.001) and OS (HR=0.16, p=0.0001) were significantly improved by HD compared to DD for YB-1 positive tumors; these favorable time-varying hazard ratios signify decreases in early (≤3 years) relapses and deaths, respectively. Conclusions: Among all investigated markers, only YB-1 expression was significantly associated by time- varying interaction analysis with efficacy of HD. The results suggest YB-1 as a potential stratification criterion for future trials as well as a target for treatment of drug resistant HRBC.

No significant financial relationships to disclose.

[Prognostic and predictive impact of protein expression profiling in high risk breast cancer patients treated with high-dose chemotherapy]

The prognostic and predictive impact of protein expression profiles was analyzed in high-risk breast cancer patients who had previously been shown to benefit from high-dose chemotherapy (HDCT) in comparison to dose-dense chemotherapy (DDCT). Using tissue microarrays, the expression of 34 protein markers was evaluated in 236 patients who had received either HDCT or DDCT (in the WSG AM01 trial). 1) 24 protein markers of the initial panel of 34 markers were sufficient to identify five profile clusters by K-means clustering: luminal A (27%), luminal B (12%), HER-2 (21%), basal-like (13%) cluster and a so called 'multiple marker negative'=MMN cluster (27%) characterized by the absence of specifying markers. 2) After DDCT, HER-2 and basal-like groups had significantly worse event-free survival (EFS) (HR 3.6 (95% CI, 1.65-8.18; p = 0.001) and HR 3.7 (95% CI, 1.68-8.48); p < 0.0001), respectively) when compared to both luminal groups. 3) After HDCT, the hazard ratio was 1.5 (95% CI, 0.76-3.05) for EFS in the HER-2 subgroups and 1.1 (95% CI, 0.37-3.32) in the basal-like subgroups which indicates a better outcome for patients in the HER-2 and basal-like subgroups who received HDCT. Protein expression profiling in high-risk breast cancers identified 5 subtypes, which differed with respect to survival and response to chemotherapy: In contrast to luminal A and B subtypes, HER-2 and basal-like subgroups had a significant predictive benefit from HDCT when compared to DDCT.

Retrospective analysis of WSG AM01 tandem high dose chemotherapy trial in high risk primary breast cancer: A hypothesis generating study

665

Background: The WSG AM 01 trial is the first one to report superiority of HDC in terms of DFS and OS in patients with >9 positive axillary lymph nodes. Retrospectively we tried to identify patient subgroups with maximum benefit from HDC. Methods: 403 patients were randomized to tandem HDC or to dose-dense conventional chemotherapy (DD). 236 tumors were available for central pathologic review (117/119). A panel of 34 markers were determined by IHC in TMA. Kaplan-Meier, Log rank and Cox proportional hazard models were used for uni- and multivariate analysis. We choose K-means clustering with K=5 and using Manhattan distance as similarity measure. Results: Pts: n=236 (HDC/DD): mean age 47.3/47.4 yrs, mean tumor sizes 3.5/3.4cm, mean positive lymph nodes 17.2/17.0, HR+ 55%/53%, G3 44%/35%. HDC was superior to DD (p=0.02). Multivariate analysis demonstrated a significant correlation for grading, tumor size, PR+. HR > 2 were reported for the following markers: Her2neu+, p53+, bcl2−, Ck 5/6 and 17+, Ck8−, c-kit+, vimentin+, ETR 1/2, BCRP+. Triple negative tumors (TN) (31%) had a large benefit from HDC (HR DD vs. HD: 3.06, 95%CI:1.41–6.06). Groups identified by K-means clustering could be attributed to luminal-A-(31%), luminal-B-(27%), her2-(11%), basal like-(11%) type and a so far undefined proliferative group (20%) characterized mainly by the absence of specifying markers. Interestingly, the proportion of the above mentioned molecular subtypes within of high risk populations very similar to those reported for less selected populations. Her2, basal-like and the undefined proliferative group had significantly worse outcome when compared to luminal tumors (p<0.01). Very poor prognosis if treated by conventional CT was observed in basal like (HR DD vs HD=2.66 95%CI: 0.9–7.9) und the undefined group (HR=1,72, 95%CI:0.92–3.21), where most of the TN tumors were found. Conclusions: Tandem HDC is superior to DD conventional CT for treatment of HRBC. The largest benefit from high dose chemotherapy was reported for younger patients with TN poor differentiated tumors, >2cm. Negative hormone receptor status, p53+, bcl2−, MIB/p16+ and BCRP+ predicted benefit from dose intensification. Subgroups are small and may help to generate further hypothesises.

No significant financial relationships to disclose.

Biological characteristics in triple negative high risk breast cancer and their clinical implications

20032

Background: Hormone receptor and Her2neu negative breast cancer (triple negative, TN) presents an aggressive biological subtype with decreased survival. Basal-like BC identified by gene expression arrays (Perou CM, et al. Nature 2000) may be associated with TN breast cancer. Several studies defined the origin of TN or BBC breast cancer in a progenitor epithelial cell that is undifferentiated. Other studies investigated the association of TN with EGFR expression or BRCA1 mutations. The aim of our study was to analyze the expression of stem cell or basal markers in TN high risk breast cancer. Methods: We examined 236 patients from central tumour bank from high risk breast cancer patients (>9 positive LN), who were randomized to the WSG AM-01 trial (phase III tandem HDC versus DD CT). The following markers were profiled by IHC in TMA for all patients: ER, PR, Her2neu, MIB-1, EGFR, p53, Ck 5/6, CK17, c-kit, p63, Vimentin, ABCA3, and BCRP. Their correlation with survival was studied. Results: 65 patients (30%) of 218 patients assessable for hormone receptor and Her2neu staining, were identified as TN, surprisingly not indicating any higher incidence of TN tumors in this selected high risk collective, when compared to other more heterogeneous populations. This phenotype was significantly more frequent in premenopausal women, and was significantly associated with G3, MIB1 and EGFR, CK5/6 and 17, c-kit, vimentin, p53 and BCRP expression. No association with p63 and ABCA3 was found. Poor grading, MIB1+, CK5/6 and 17, c-kit, vimentin and BCRP+ strongly correlated with relapse. Patients with TN tumors had significantly worse overall survival (p = 0.002) in comparison to the remaining group. Conclusions: The triple negative BC-type is frequent in patients with multiple positive lymph nodes and has a poor prognosis. Its association with age and basal and progenitor cell molecular markers suggests correlation with BRCA1 mutations as a potential marker for resistance to alkylating agents (Sorlie, PNAS 2003). Modern experimental (chemo)-therapy designs in this subgroup should take into account the higher incidence of EGFR and basal stem cell marker expression, p53 mutations, the poor differentiation, the expression of chemoresistance markers and the high proliferative activity.

No significant financial relationships to disclose.

C-kit expression in high-risk breast cancer subgroup treated with high-dose or conventional dose-dense chemotherapy

The proto-oncogene c-kit is known to be expressed in poorly differentiated breast cancer. In this study, we retrospectively evaluated the prognostic and predictive impact of c-kit in a high risk subgroup of breast cancer patients (>9 axillary node metastases) who received high-dose (HDCT) or dose-dense (DDCT) conventional chemotherapy and correlated these findings with the expression of the basal-type markers CK5 and CK 17, estrogen (ER) and progesterone (PR) receptor, Her-2/neu and MIB 1. C-kit, CK5, CK17, ER, PR, Her-2/neu and MIBI expression was evaluated immunohistochemically using tissue microarrays containing breast cancer samples from 236 patients who were randomized to the WSG AM01 trial (median follow-up of 60 months). There was a significant overall survival (OS) benefit for patients receiving HDCT compared to DDCT (p = 0.027). C-KIT expression was found in 12 % of all breast cancers and correlated with a poorer OS in multivariate analysis (p = 0.051). Furthermore, c-kit correlated with high grade (p = 0.019), CK5- and CK17-positivity (p <0.0001 and p = 0.001, respectively) and ER- and PR-negativity (p = 0.04 and p = 0.008, respectively). In contrast to CK5 and CK17, patients with c-kit positive breast cancers revealed no benefit from high-dose chemotherapy. These findings underline that c-kit expression represents an independent negative prognostic marker in high-risk breast cancer. Correlation with CK5 +/CK17+ and ER-/PR-suggests that c-kit positive carcinomas are at least partly of basal-type.

Ambient-temperature-stable molecular biology reagents

We have processed biological materials to generate several reagents that are ambient temperature stable and ready to use. Stabilized biomolecules in a glassy matrix of carbohydrate polymers offer water-soluble reagents for complex molecular biology applications. This approach is particularly useful for reagent systems composed of enzymes, nucleotides and other components dispensed in single-use aliquots. Reconstitution of the glassy matrix delivers buffered enzymes and/or nucleotides for restriction, modification, sequencing and/or amplification of nucleic acids. These ambient-temperature-stable reagents allow a high level of reproducibility as they minimize the potential for pipetting errors. They also provide advantages in shipping, storage and subsequent handling. Added convenience includes elimination of setup time, cross contamination and refrigeration. Applications of ambient-temperature-stable biological reagents for routine molecular biology methods are presented.

Occupational exposure to cocaine involving crime lab personnel

The possibility of exposure to cocaine as a result of analyzing it or handling material contaminated by it has been a major concern of laboratory personnel. Several different work environments and simulated situations were examined to assess the likelihood of this type of exposure occurring. Urine specimens were collected and evaluated for cocaine and benzoylecgonine using the Syva ETS System (EMIT). Each specimen was analyzed for the two substances using gas chromatography/mass spectrometry (GC/MS). Urine specimens of laboratory-management personnel not working with drug samples showed no trace of cocaine or benzoylecgonine. A urinary benzoylecgonine level of 227 ng/mL was found in the specimen from one narcotics criminalist who was working on a routine case of 2 kilos of cocaine hydrochloride in the Narcotics Laboratory. A maximal urinary benzoylecgonine concentration of 1570 ng/mL was determined in the urine specimen from one narcotics criminalist who was sampling a case containing 50 kilos of cocaine hydrochloride over a period of 3 h. Decreasing the levels of airborne cocaine dust appears to minimize the amount of cocaine absorbed by the criminalists. Gloves, face masks, and goggles prove to be effective in minimizing exposure.

Antibiotic and steroid therapy of massive systemic bacillus Calmette-Guerin toxicity

Intravesical bacillus Calmette-Guerin (BCG) is the most effective treatment of carcinoma in situ available today and is superior to chemotherapy in the prevention of bladder tumor recurrence. While therapy is generally well tolerated, serious and even life threatening toxicity can occur. Treatment options for serious infection include isoniazid, rifampin, ethambutol, and cycloserine, but shock may also be secondary to hypersensitivity and require the addition of corticosteroids. The morbidity and mortality of systemically BCG-infected mice treated with single and combined antimicrobial and/or corticosteroid therapies was evaluated. BCG immunized mice were unable to survive doses of BCG which were uniformly tolerated in naive mice. The addition of cycloserine increased survival in mice treated with isoniazid and rifampin, but optimal survival was achieved with isoniazid, rifampin, and prednisolone. These experimental results support the previously reported clinical success of isoniazid, rifampin and prednisolone in patients with septic BCG reactions.