Ablation scar in a single pulmonary vein causes proarrhythmic mechanical destabilization in healthy sheep atria

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Catharina Hospital, Eindhoven Medtronic (unrestricted research grant)

Background

Ablative pulmonary vein isolation (PVI) prevents AF in 60% of AF patients. The absence of an antiarrhythmic effect of PVI is poorly understood. Atrial and PV stretch is proarrhythmic but the mechanical effect of PV ablation scar on AF arrhythmogenesis is unknown. We hypothesize that single ablation scars are potentially proarrhythmic because they create heterogeneous stretch.

Purpose

To evaluate the mechanical effect of a purposely incomplete PVI ablation scar on left atrial (LA) electrophysiology.

Methods

Functional cardiac MRIs in vivo in sheep (n = 11) before and 3-months after incomplete PVI by radiofrequency in the right PV (RPV) were analyzed with a feature-tracking algorithm to obtain local strain in the LA. The ablated hearts were explanted and perfused with 1:5 blood:Krebs solution in a dual-chamber working-heart set-up. Diagnostic multi-electrode endocardial catheters were positioned in the RPV and left PV (LPV). Premature stimulation was performed in each PV in low (∼12mmHg) and high (∼25mmHg) LA pressure. Twelve control hearts without ablation scar underwent similar ex vivo investigation.

Results

The maximum longitudinal strain of the myocardial wall between the RPV and LPV increased

 from 20.2 ± 6.2% to 33.5 ± 16.0% (before vs. after ablation, respectively; p = 0.032), whereas the maximum radial strain of the LA septum close to the RPV decreased from 45.6 ± 9.7% to 35.8 ± 7.3% (before vs. after ablation, respectively; p = 0.035). Sustained AF (>30s) was more often induced during stimulation in hearts with ablation scar than in control (25.0% and 11.5% of induction attempts (n = 76 and n = 87) in ablated and control hearts, respectively; p = 0.025). In ablated hearts, an increase in LA pressure augmented AF inducibility (12.8% vs. 37.8% of induction attempts (n = 39 vs. n = 37), low vs. high LA pressure, respectively; p = 0.023), whereas this was not the case in control hearts (4.4% vs. 19.0% of induction attempts (n = 45 vs. n = 42), low vs. high LA pressure; p = 0.289). The number of spontaneous premature atrial complexes (PACs) not leading to AF were similar in ablated and control hearts (0 ± 0 vs. 0 ± 2 total PACs within 20ms of refractory period during premature stimulation protocol, respectively; p = 0.411). The diastolic stimulation threshold of RPV was higher in the ablated than in control hearts (90 ± 63 vs. 79 ± 31mA, respectively; p = 0.049). The refractory period was similar in the ablated and control hearts (237 ± 62 vs. 235 ± 55ms, respectively; p = 0.873).

Conclusion

Local ablation scar caused regionally disparate bio-mechanical changes in proximity to ablative energy delivery and increased inducibility of sustained AF especially during increased LA stretch. This was associated with decreased tissue excitability without changes in refractoriness. A single incomplete PVI ablation scar therefore is proarrhythmic. Development of ablation lesion sets that homogenize atrial mechanics and electrophysiology may improve AF ablation success.

[Non small cell lung carcinoma in never-smokers at the Liege University Hospital : a retrospective cohort study, 2017-2018]

Lung cancer is the third most common cancer in Belgium in 2017 and remains the leading cause of cancer death worldwide. There is no longer any doubt that the main cause of lung cancer is smoking. However, the prevalence of lung cancer in never-smokers has been increasing overtime. Moreover, it is now recognized that the lung cancer of non-smoker patients has very distinct characteristics. In this retrospective cohort study (N = 520), we describe the characteristics of non-smoker patients and their non-small cell lung carcinoma and compare them to those of smokers. The patients included in this study were whose with a new diagnostic of lung cancer made at the Liège University Hospital of Liège over 2 years round. Non small cell lung cancer occurring in never-smokers patients is more often seen in young and very old patients, more frequent in female, essentially adenocarcinoma and often associated with mutations. This work confirms that lung cancer in never-smokers shows different features than lung cancer seen in patients with a smoking history.

[Managing of dyspnea in oncology]

The perception of ventilatory effort is common in oncology, especially but not exclusively in the advanced stages of neoplastic disease. Dyspnea is a symptom whose discomfort and anguish it generates in the patient and his/ her entourage require constant management throughout the illness. The first step is to identify and optimize the treatment of comorbidities associated with tumour disease. Relief of respiratory oppression as a symptom requires a multidisciplinary approach. Opiates and benzodiazepines are at the forefront of pharmacological management. The mechanical obstruction that limits ventilatory flow and/or chest ampliation may justify more invasive management, including endoscopic techniques. Oxygen therapy will be considered on a case-by-case basis. Finally, global management includes respiratory revalidation, psychological support and improvement of environmental quality.

[Small cell lung cancer : update of therapy]

Small cell lung cancer is a malignant tumour with a poor prognosis. Standard treatment of metastatic stages has been a platinum doublet since 1980, but the addition of immunotherapy has improved prognosis. For locally advanced stages, the combination of radio-chemotherapy remains the treatment of choice, with no evidence at present of the value of immunotherapy in consolidation, and for localized stages, surgery is the first-line therapy. Unfortunately, in the second line, we have no other molecule than the topotecan despite several studies. Prophylactic brain irradiation remains debated even if it has been validated in localized forms. Finally, there is hope with targeted therapy following the development of subtypes of small cell lung cancer but studies remain difficult to conduct.

[Neuroendocrine neoplasms : a new era to the top of multidisciplinarity !]

Neuroendocrine neoplasms are histologically defined by a common neuroendocrine cellular phenotype. These are still considered as rare tumours even though their incidence is increasing. Heterogeneity is everywhere whether in the localization of the primitive cancer, the clinical presentation, the histological classification, the prognosis, as well as in therapeutic options, which clearly justifies specialized multidisciplinary care. Heterogeneity and scarcity explain the still fragmented nature of knowledge in this domain. Thanks to an increase in incidence, a desire for standardization of classification as well as the arrival of major therapeutic advances, such as vectorized internal radiotherapy, the future of neuroendocrine neoplasia seems more than promising and exciting. In our daily clinical practice at CHU Liège, we hope to bring our stone to the building by listing as many cases as possible in national and/or international databases, by centralizing therapeutic discussions within specific multidisciplinary concertations and by participating in multicenter study protocols.

[Targeted therapies for non-small cell lung cancer : state of the art in 2021]

The majority of non-small cell lung cancers are diagnosed as advanced disease. Subsets of adenocarcinomas and of squamous cell carcinomas in nonsmokers present a molecular aberration leading to tumour survival. Epidermal Growth Factor Receptor (EGFR), Anaplastic Lymphoma Kinase (ALK) and Repressor Of Silencing1 (ROS1) have been identified and targeted with good efficacy for fifteen years. Newer inhibitors brought even greater efficacy with a generally better tolerability. Other molecular aberrations (Kirsten Rat Sarcoma, Rearranged during Transfection, MET, NeuroTrophic Receptor yrosine kinase) are targets for newly developed, more selective drugs. As more and more patients will benefit from targeted therapies, the identification of molecular aberration is more than ever crucial for optimal lung cancer patient care.

[Empyema and subacute invasive aspergillosis following drowning]

Empyema and subacute invasive aspergillosis are rare pathologies that should not be overlooked because of the need for early treatment and a different management of bacterial infections which are more frequent. We report the case of a 75-year-old man with subacute invasive aspergillosis and an empyema following drowning and cardiopulmonary arrest.

Could KL-6 levels in COVID-19 help to predict lung disease?

BACKGROUND

Coronavirus disease COVID-19 has become a public health emergency of international concern. Together with the quest for an effective treatment, the question of the post-infectious evolution of affected patients in healing process remains uncertain. Krebs von den Lungen 6 (KL-6) is a high molecular weight mucin-like glycoprotein produced by type II pneumocytes and bronchial epithelial cells. Its production is raised during epithelial lesions and cellular regeneration. In COVID-19 infection, KL-6 serum levels could therefore be of interest for diagnosis, prognosis and therapeutic response evaluation.

MATERIALS AND METHODS

Our study retrospectively compared KL-6 levels between a cohort of 83 COVID-19 infected patients and two other groups: healthy subjects (n = 70) on one hand, and a heterogenous group of patients suffering from interstitial lung diseases (n = 31; composed of 16 IPF, 4 sarcoidosis, 11 others) on the other hand. Demographical, clinical and laboratory indexes were collected. Our study aims to compare KL-6 levels between a COVID-19 population and healthy subjects or patients suffering from interstitial lung diseases (ILDs). Ultimately, we ought to determine whether KL-6 could be a marker of disease severity and bad prognosis.

RESULTS

Our results showed that serum KL-6 levels in COVID-19 patients were increased compared to healthy subjects, but to a lesser extent than in patients suffering from ILD. Increased levels of KL-6 in COVID-19 patients were associated with a more severe lung disease.

DISCUSSION AND CONCLUSION

Our results suggest that KL-6 could be a good biomarker to assess ILD severity in COVID-19 infection. Concerning the therapeutic response prediction, more studies are necessary.

Orthostatic blood pressure drop and cardiovascular and psychotropic medication dosages in acutely ill geriatric inpatients

OBJECTIVES

. To investigate the dose-response relationship between cardiovascular or psychotropic medication dosages and falling orthostatic blood pressure in geriatric inpatients.

METHODS

. This cross-sectional study included 100 consecutive geriatric inpatients of a Belgian hospital. The end points were the maximum changes of systolic (sBP) and diastolic (dBP) blood pressure in a standing up position at one or three minutes. The dosages of six classes of vascular and five classes of psychotropic medications were expressed in terms of a proportion of defined daily doses (DDD). Bivariate and multivariate linear regression models were used.

RESULTS

. The 100 geriatric patients (85 ± 5 years, 58 % women) received 7.7 ± 4 medications (mean DDD: vascular = 1.0, psychotropic = 0.74) on the day of an orthostatic test (lying sBP: 136 ± 21; dBP: 72 ± 14 mm Hg). In a standing position, sBP and dBP fell by 12 ± 17 and 11 ± 5 mmHg, respectively. At the individual level, BP change was not correlated with vascular DDD (sBP: p = 0.07, r² = 0.04; dBP: p = 0.59; r² = 0.004) nor with psychotropic DDD (sBP: p = 0.14, r² = 0.02; dBP: p = 0.82; r² = 0.0). In multivariate analysis, sBP drop was positively associated with age, diabetes, falls history, and number of medications, but not with the DDD of any of the medication classes, while dBP drop was positively associated with age, diabetes, stroke and anaemia, but again with the DDD of any of the medication classes.

CONCLUSION

. No correlation was found between vascular and psychotropic medication dosages and the orthostatic blood pressure drop expressed as a continuous variable.

[How I manage... Malignant pleural mesothelioma in 2019]

Malignant pleural mesothelioma is a rare disease originating from mesothelial cells of the pleura and is related to asbestos exposure. The tumor is generally extended at the time of diagnosis and the treatment consists of a systemic palliative therapy. Radical approach is limited to very selected patients and is performed in expert centers but without validated schema. Radiotherapy alone is mainly used in palliative intent. Platinum-based chemotherapy in association with pemetrexed is the frontline standard of care and provides a 12-month overall survival. The addition of bevacizumab, an antiangiogenic drug, shows an improvement in median survival. To date, there is no second-line treatment approved for this disease and therefore inclusion in trials is recommended. Currently, various studies are investigating target therapy, immunotherapy and intrapleural perioperative treatment.

[Medical thoracoscopy in respiratory medicine: The Liège University Hospital experience]

INTRODUCTION

The incidence of pleural disease continues to increase worldwide. Medical thoracoscopy remains the standard method for exploration of the pleural cavity.

METHOD

We report the retrospective evaluation, the efficacy and the observed complications in 1024 medical thoracoscopies undertaken in the University Hospital of Liège between 2000 and 2017.

RESULTS

In total, 100 pneumothoraces and 400 benign and 501 malignant pleural diseases were identified. The main indication for thoracoscopy remains the diagnosis of an exudative, lymphocytic pleural effusion of unknown aetiology after thoracocentesis. The diagnostic sensibility of thoracoscopy was 99.2% in distinguishing benign from malignant pleural disease. Talc pleurodesis was performed in 69.5% of the total population and in 66.1% of pleural effusions or thickening. Failure of pleurodesis was observed in 11% of the patients with recurrent pneumothorax and in 7.8% of neoplastic pleural effusion. We report a mortality of 0.6% in the 30 days post procedure, long duration of drainage in 8.3% and serious complications in 4.7%. In 22/1024 (2.1%) thoracoscopic evaluation was not feasible because of dense pleural fibrosis.

CONCLUSION

Medical thoracoscopy is a safe, well-tolerated procedure with high accuracy in the diagnostic and therapeutic management of pleural disease.

Abstract PD7-07: Synergistic targeting of CDK4/6 and BCL-2 pathways in estrogen receptor positive breast cancer

Background: Despite incremental advances in chemotherapy and endocrine therapy, survival outcomes for patients with ER-positive (ER+) metastatic breast cancer (MBC) remain poor. The majority of relapsing tumors exhibit deregulation of the cyclin-dependent kinase 4 and 6 (CDK4/6)/cyclin D1 (CCND1)/Rb signaling pathway. CDK4/6 inhibitors (such as palbociclib) in combination with endocrine therapy have been shown to significantly improve progression free survival in patients who are in 1st or 2nd line relapse, although overall survival benefit has yet to be demonstrated. This may reflect their largely cytostatic mechanism of action, with minimal induction of tumor cell death. Thus, combinatorial strategies that also induce apoptosis could be beneficial. Notably, the pro-survival protein BCL-2 is overexpressed in the majority of ER+ tumors and the potent and specific BCL-2 inhibitor venetoclax (ABT-199) has been found to synergize with endocrine therapy in patient derived xenograft (PDX) models. Promising activity has also been observed in an early phase clinical trial. We therefore investigated dual targeting of the CDK4/6 and BCL-2 pathways in pre-clinical models of ER+ and BCL-2+ breast cancer.

Results: We first examined endocrine sensitive or resistant cell-lines and found that pro-survival BCL-2 proteins were upregulated in resistant cells. BCL-2 family protein levels were also found to be elevated in palbociclib resistant cells, suggesting that BCL-2 could represent a therapeutic target. We next determined whether venetoclax improved response to dual therapy comprising the selective estrogen receptor degrader fulvestrant and palbociclib. In clonogenic assays of endocrine sensitive breast cancer cell lines, triple therapy containing venetoclax significantly reduced the number and size of colonies, when compared to double therapy. The addition of venetoclax to fulvestrant/palbociclib also augmented cell death in tumor organoid models derived from either ER+ BCL-2+ primary tumors or PDX models. Moreover, triple therapy improved tumor response and overall survival in mice bearing ER+ BCL-2+ PDX tumors. Mechanistically, this was accompanied by increased apoptosis and reduced cellular proliferation (as determined by cleaved caspase-3 and Ki67 levels, respectively). As CDK4/6 inhibitors have recently been shown to promote anti-tumor immunity, we evaluated immune modulation using the ER+ 67NR cell line in a syngeneic (BALB/c) mouse mammary tumor model. Similar to the PDX models, triple therapy comprising fulvestrant, palbociclib and venetoclax was more effective than double therapy comprising either fulvestrant/palbociclib or fulvestrant/venetoclax. Flow cytometric analysis of tumors revealed that this was accompanied by a reduced intratumoral FOXP3+:cytotoxic CD8 T-cell ratio.

Conclusions: The addition of the BCL-2 inhibitor venetoclax to conventional therapy comprising endocrine therapy and a CDK4/6 inhibitor augments tumor response and elicits a favorable intratumoral immune profile. Collectively, these findings support investigation of combination therapy in the clinic for patients with ER+ BCL-2+ MBC.

Citation Format: Whittle JR, Vaillant F, Policheni AN, Liu K, Pal B, Giner G, Fernandez K, Gray DH, Caldon CE, Smyth GK, Visvader JE, Lindeman GJ. Synergistic targeting of CDK4/6 and BCL-2 pathways in estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD7-07.

Abstract PD1-06: A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC)

Background: Venetoclax, a potent and selective inhibitor of the survival protein BCL-2 (recently approved in CLL and in development in other hematopoietic malignancies), has yet to be evaluated in pts with solid tumors. BCL-2 is overexpressed in ˜85% of ER+ breast cancer. Pre-clinical findings using patient-derived xenograft breast tumor models suggest that venetoclax synergizes with endocrine therapy by increasing apoptosis. Here we report mBEP, an investigator-initiated phase 1b study of venetoclax with tamoxifen in 33 pts with ER+ (>1%), BCL-2+ (>10%, 2-3+ intensity) and HER2– MBC.

Methods: We conducted a 3+3 dose escalation study comprising cohorts receiving venetoclax 200, 400, 600 or 800 mg/d with tamoxifen 20 mg/d (continued until progression). The primary endpoint was to determine the maximum tolerated dose (MTD), define dose-limiting toxicities (DLTs) and identify the recommended phase 2 dose (RP2D). In a dose expansion phase (at the RP2D), secondary endpoints including safety and tolerability, response at 24 wks (RECIST v1.1), clinical benefit rate (CBR) and progression-free survival (PFS) were studied.

Results: In the escalation phase (n=15 pts), treatment was well tolerated with no DLTs or high-grade (Gd 3/4) adverse events observed, apart from asymptomatic on-target lymphopenia (Gd 3, 2/15 pts). MTD was not reached. The 800 mg/d dose was selected as the RP2D and the cohort expanded to include 24 pts with ≥24 wks follow up (range 24-105 wks). Fifteen pts had received prior regimens for MBC (median 3, range 1-9) that included tamoxifen in 5/15.

For the RP2D cohort (n=24), overall responses (OR) included 1 CR (4%) and 12 PR (50%), with 5 SD (21%), corresponding to a CBR of 75%. The 9 pts treated in the first line setting experienced a 78% OR (7/9 pts) and 11% SD (1/9 pts), equating to an 89% CBR. The data are immature for determining median PFS for the RP2D cohort (currently 40+ wks).

Treatment responses were pre-empted by metabolic responses (FDG-PET) at 4 wks (seen in 13/16 (81%) pts studied), and correlated with serial changes in circulating tumor DNA (ctDNA). Intriguingly, responses and clinical benefit were observed in pts with plasma-detected ESR1 mutations (4/10 and 7/10, respectively).

The most common treatment-related AEs (CTCAE v4.0) for all pts were lymphopenia in 29/33 (88%; 57% Gd 1-2, 30% Gd 3-4), neutropenia in 24/33 (73%; 67% Gd 1-2, 6% Gd 3), nausea in 22/33 (67%; all ≤Gd 2), anemia in 13/33 (39%; 33% Gd 1-2, 6% G3), thrombocytopenia in 11/33 (33%; all ≤Gd 2), vomiting in 11/33 (33%, all ≤Gd 2), diarrhea in 10/33 (30%; 24% Gd 1-2, 6% Gd 3), infection in 9/33 (27%; 18% Gd 2, 9% Gd 3) and fatigue in 7/33 (21%; all ≤Gd 2). There was one possible treatment-related SAE (infection).

Conclusions: In the first clinical study to evaluate venetoclax in a solid tumor, we demonstrate that combining venetoclax with endocrine therapy has a tolerable safety profile and elicits remarkable activity in ER+ and BCL-2+ MBC. These findings support further investigation of combination therapy for patients with BCL-2-positive breast cancer.

Sponsor: The Royal Melbourne Hospital (ACTRN12615000702516)

Citation Format: Lindeman GJ, Lok SW, Whittle JR, Siow ZR, Bergin AR, Dawson S-J, Desai J, Gray DH, Liew D, Mann GB, Murugasu A, Roberts AW, Rosenthal MA, Shackleton K, Sherman P, Silva MJ, Teh C, Travers A, Vaillant F, Visvader JE. A phase 1b dose-escalation and expansion study of the BCL-2 inhibitor venetoclax combined with tamoxifen in ER and BCL-2–positive metastatic breast cancer (MBC) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-06.

Influence of Venus and Mars in the cognitive sky of schizophrenia. Results from the first-step national FACE-SZ cohort

OBJECTIVES

Sex differences can yield important clues regarding illness pathophysiology and its treatment. Schizophrenia (SZ) has a lower incidence rate, and a better prognosis, in women versus men. The present study investigated the cognitive profiles of both sexes in a large multi-centre sample of community-dwelling SZ patients.

METHOD

544 community-dwelling stable SZ subjects (141 women and 403 men; mean age 34.5±12.1 and 31.6±8.7years, respectively) were tested with a comprehensive battery of neuropsychological tests.

RESULTS

Although community-dwelling SZ men had more risk factors for impaired cognition (including first-generation antipsychotics administration and comorbid addictive disorders), women had lower scores on a wide range of cognitive functions, including current and premorbid intellectual functioning, working memory, semantic memory, non-verbal abstract thinking and aspects of visual exploration. However, women scored higher in tests of processing speed and verbal learning, as well as having a lower verbal learning bias. No sex difference were evident for visuospatial learning abilities, cued verbal recall, sustained attention and tests of executive functions, including cognitive flexibility, verbal abstract thinking, verbal fluency and planning abilities.

CONCLUSION

Sex differences are evident in the cognitive profiles of SZ patients. The impact on daily functioning and prognosis, as well as longitudinal trajectory, should be further investigated in the FACE-SZ follow-up study. Sex differences in cognition have implications for precision-medicine determined therapeutic strategies.

LIMITS

Given the restricted age range of the sample, future research will have to determine cognitive profiles across gender in late onset SZ.

Abstract S2-04: RANK ligand as a target for breast cancer prevention in BRCA1 mutation carriers

Background: BRCA1 mutation carriers commonly undergo prophylactic mastectomy to reduce their risk of breast cancer. The precise role of chemoprevention with tamoxifen, which reduces the incidence of ER-positive breast cancer in the general population, is uncertain for BRCA1 mutation carriers, where uptake has been modest. The identification of an effective and acceptable prevention therapy therefore remains a 'holy grail' for the field. Precancerous BRCA1mut/+ tissue harbors an aberrant population of luminal progenitor cells and deregulated progesterone signaling has been implicated in BRCA1-associated oncogenesis. Since Receptor Activator of Nuclear Factor-kappa B ligand (RANKL) is a key paracrine effector of progesterone signaling, and RANKL and its receptor RANK contribute to mammary tumorigenesis, we investigated a role for this pathway in the preneoplastic phase of BRCA1 mutation carriers.

Methods: We explored a role for the RANK/RANKL pathway during the preneoplastic phase in freshly isolated (histologically normal) patient specimens from BRCA1 mutation carriers using several approaches. RANK and RANKL expression in breast cancer was evaluated in formalin fixed paraffin embedded (FFPE) archival sections by IHC from the kConFab and the Amgen Tissue Banks. All samples were obtained with patient consent and relevant IRB approval. A role for RANKL inhibition in attenuating tumor onset was studied using the MMTV-cre/Brca1fl/fl/p53+/– mouse model that recapitulates human basal-like breast cancer.

Results: We identified two subsets of luminal progenitors (RANK+ and RANK–) in histologically normal tissue of BRCA1 mutation carriers and found that RANK+ cells are highly proliferative, exhibit grossly aberrant DNA repair and bear a molecular signature similar to that of basal-like breast cancer. Moreover, high levels of RANK expression prevailed in established BRCA1-associated tumors. These data suggest that RANK+ and not RANK– progenitors are a key target population in these women. Notably, inhibition of RANKL signaling by denosumab in 3D breast organoids derived from pre-neoplastic BRCA1mut/+ tissue attenuated progesterone-induced proliferation. Furthermore, inhibition of RANKL with either the RANKL inhibitor OPG-Fc or a RANKL monoclonal antibody in a Brca1-deficient mouse model significantly curtailed mammary tumorigenesis, when compared to controls (p<0.001).

Conclusions: Together these findings identify a targetable pathway in a putative cell of origin population in BRCA1 mutation carriers and implicate RANKL blockade as a promising breast cancer prevention strategy.

Citation Format: Lindeman GJ, Nolan E, Vaillant F, Branstetter D, Pal B, Giner G, Whitehead L, Lok SW, Mann GB, kConFab Consortium, Rohrbach K, Huang L-Y, Soriano R, Smyth GK, Dougall WC, Visvader JE. RANK ligand as a target for breast cancer prevention in BRCA1 mutation carriers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr S2-04.

Abstract P3-11-05: RANK ligand is a target for breast cancer prevention in BRCA1 mutation carriers

Background: BRCA1 mutation carriers often undergo prophylactic mastectomy to minimize their risk of breast cancer. The value of targeting ovarian hormones to prevent breast tumorigenesis remains contentious and the identification of an effective and acceptable chemoprevention strategy remains a 'holy grail' for the field. Recently, luminal progenitor cells have been identified as the likely cell-of-origin for BRCA1-associated breast tumors1. In addition, deregulated progesterone signaling has been implicated as a potential mechanism underlying tumor development in Brca1-deficient mammary glands2, although its role in luminal progenitor activation in BRCA1 mutation carriers is unknown. RANKL (Receptor Activator of Nuclear Factor-kappa B Ligand) has been identified as a key paracrine effector of progesterone-induced mammary epithelial proliferation in both mouse and human tissue3-5. Notably, RANKL and its receptor RANK play a critical role in the development of breast cancer, with inhibition of RANKL resulting in attenuation of tumorigenesis in mouse models of hormone-driven mammary carcinogenesis6,7.

Methods: We explored a role for the RANK/RANKL pathway during the preneoplastic phase in freshly isolated, histologically normal specimens from BRCA1 mutation carriers using a combination of strategies. RANK and RANKL expression in breast cancer was also evaluated in formalin fixed paraffin embedded (FFPE) archival sections by IHC. All samples were obtained with relevant IRB approval. A role for RANKL inhibition in attenuating tumor onset was studied using models that recapitulate human basal-like cancer.

Results: A RANK+ subset of luminal progenitor cells was identified in histologically normal breast tissue from BRCA1-mutation carriers. The RANK+ luminal progenitors exhibited higher proliferative activity compared to RANK- progenitors. RNA profiling revealed a distinctive molecular signature, consistent with the RANK+ subset being a possible target for neoplastic transformation. In established BRCA1-associated breast tumors, a four-fold higher incidence of RANK expression was observed, compared to tumors from non-carriers. In ongoing work, histologically normal pre-neoplastic BRCA1mut/+ tissue is being studied using ex vivo breast organoid assays to determine whether RANKL inhibition can attenuate breast epithelial proliferation.

Conclusions: Our data raise the possibility that RANK signaling is implicated in the initiation of tumorigenesis in BRCA1 mutation carriers (and possibly other high risk women) and that RANKL is a promising chemoprevention target. The findings are of sufficient interest to have led to a clinical trial, BRCA-D (Registered as ACTRN12614000694617). A finalized abstract will be submitted in early September, during the Late-Breaking Abstract submission period.

References:

1. Lim et al Nature Med 2009: 15, 907-13.

2. Poole et al Science 2006: 314, 1467-70.

3. Asselin-Labat et al Nature 2010: 465, 798-802.

4. Joshi et al Nature 2010: 465, 803-7.

5. Tanos et al Sci Transl Med 2013: 5, 182ra55.

6. Schramek et al Nature 2010: 468, 98-102.

7. Gonzales-Suarez et al Nature 2010: 468, 103-7.

Citation Format: Lindeman GJ, Nolan E, Pal B, Vaillant F, Giner G, Whitehead L, Mann GB, Lok SW, Shackleton K, Kathleen Cuningham Foundation Consortium (kConFab), Smyth GK, Visvader JE. RANK ligand is a target for breast cancer prevention in BRCA1 mutation carriers. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-11-05.

Akathisia: prevalence and risk factors in a community-dwelling sample of patients with schizophrenia. Results from the FACE-SZ dataset

The main objective of this study was to determine the prevalence of akathisia in a community-dwelling sample of patients with schizophrenia, and to determine the effects of treatments and the clinical variables associated with akathisia. 372 patients with schizophrenia or schizoaffective disorder were systematically included in the network of FondaMental Expert Center for Schizophrenia and assessed with validated scales. Akathisia was measured with the Barnes Akathisia Scale (BAS). Ongoing psychotropic treatment was recorded. The global prevalence of akathisia (as defined by a score of 2 or more on the global akathisia subscale of the BAS) in our sample was 18.5%. Patients who received antipsychotic polytherapy were at higher risk of akathisia and this result remained significant (adjusted odd ratio=2.04, p=.025) after controlling the influence of age, gender, level of education, level of psychotic symptoms, substance use comorbidities, current administration of antidepressant, anticholinergic drugs, benzodiazepines, and daily-administered antipsychotic dose. The combination of second-generation antipsychotics was associated with a 3-fold risk of akathisia compared to second-generation antipsychotics used in monotherapy. Our results indicate that antipsychotic polytherapy should be at best avoided and suggest that monotherapy should be recommended in cases of akathisia. Long-term administration of benzodiazepines or anticholinergic drugs does not seem to be advisable in cases of akathisia, given the potential side effects of these medications.

Metabolic syndrome, abdominal obesity and hyperuricemia in schizophrenia: Results from the FACE-SZ cohort

OBJECTIVE

Abdominal obesity was suggested to be a better predictor than Metabolic Syndrome (MetS) for cardiovascular mortality, however this is has not been extensively studied in schizophrenia. Hyperuricemia (HU) was also suggested to be both an independent risk factor for greater somatic comorbidity and a global metabolic stress marker in patients with schizophrenia. The aim of this study was to estimate the prevalence of MetS, abdominal obesity and HU, to examine the association between metabolic parameters with HU in a cohort of French patients with schizophrenia or schizo-affective disorder (SZ), and to estimate the prevalence rates of treatment of cardio-vascular risk factors.

METHOD

240 SZ patients (age=31.4years, male gender 74.3%) were systematically included. Metabolic syndrome was defined according to the International Diabetes Federation and HU if serum uric acid level was above 360μmol/L.

RESULTS

MetS, abdominal obesity and HU were found respectively in 24.2%, 21.3% and 19.6% of patients. In terms of risk factors, multiple logistic regression showed that after taking into account the potential confounders, the risk for HU was higher in males (OR=5.9, IC95 [1.7-21.4]) and in subjects with high waist circumference (OR=3.1, IC95 [1.1-8.3]) or hypertriglyceridemia (OR=4.9, IC95 [1.9-13]). No association with hypertension, low HDL cholesterol or high fasting glucose was observed. Only 10% of patients with hypertension received a specific treatment, 18% for high fasting glucose and 8% for dyslipidemia.

CONCLUSIONS

The prevalence of MetS, abdominal obesity and hyperuricemia is elevated in French patients with schizophrenia, all of which are considerably under-diagnosed and undertreated. HU is strongly associated with abdominal obesity but not with psychiatric symptomatology.

Orthostatic hypotension and associated conditions in geriatric inpatients

Screening of orthostatic hypotension (OH) was performed in 285 patients aged 75  years. Current drugs, reasons for admission, geriatric syndromes, and confounding medical conditions were collected. Patients with OH (n = 116, 41%) as compared to those without OH (n = 169) more frequently (P < 0.01) presented falls in the last 6  months (62 vs. 40%, P < 0.001), a fall as the reason for the current admission (49 vs. 26%, P < 0.001), feeling of fainting (20 vs. 6%, P = 0.002), syncope (29 vs. 4%, P < 0.001) or functional decline (71 vs. 47%, P = 0.012). No difference was observed between the two groups in terms of age (85  ±  5 vs. 84  ±  4  years), gender (59 vs. 50% female), common geriatric conditions (e.g. malnutrition 46 vs. 58%, dementia 22 vs. 26%), comorbidity or confounding conditions (dehydration 28 vs. 30%, sepsis 2 vs. 6%). No difference was detected in the use of drugs with psychotropic cardiovascular or diuretic effect, or in their associations. Orthostatic hypotension is frequent upon hospital admission and should be screened, particularly in geriatric fallers. This absence of relation between OH and drugs use suggests that non-pharmacological interventions should be first attempted in older inpatients with OH before deciding to reduce or withdraw useful drugs.

Abstract P5-03-02: Expression of RANK and RANK ligand (RANKL) in breast carcinoma and distinct breast epithelial cells from BRCA1 mutation carriers

Background: Breast tumors in BRCA1 mutation carriers likely arise from luminal progenitor (LP) cells, previously shown to exhibit aberrant growth properties. Oophorectomy, and possibly tamoxifen, reduce breast cancer risk in BRCA1 carriers, potentially via inhibition of paracrine mediated signaling to stem/progenitor cells. RANKL is a major paracrine effector of progesterone's mitogenic action in mammary epithelium via its receptor RANK, and has a role in ovarian hormone-dependent activation of stem cells. Here we assessed RANK and RANKL expression in breast tumors and normal breast epithelial subtypes from women with mutations of BRCA1 (mBRCA1) or BRCA2 (mBRCA2).

Methods: RANK and RANKL expression in breast cancer or normal breast tissue samples with mBRCA1, mBRCA2 or wildtype (WT) BRCA1/2 were analyzed in formalin fixed paraffin embedded (FFPE) sections by IHC. kConFab and The Royal Melbourne Hospital Tissue Bank provided the samples used in this analysis; these samples were obtained with relevant IRB approval. RANK expression on normal breast epithelial cells was measured by flow cytometry. Antibodies against human RANK (N-1H8, N-2B10; Amgen) and RANKL (M366; Amgen) were used in both assays. Incidence of IHC staining was scored as a positive IHC signal of any intensity. The overall expression was generated using the H scoring method which is calculated as the staining intensity of the tumor (0-3) multiplied by the percentage of positively staining cells.

Results: Breast tumors from women with mBRCA1 had a higher incidence of RANK expression (68/162; 42%) compared with mBRCA2 (17/113; 15%) or WT (34/314; 11%) and higher overall H score (21.3) compared with mBRCA2 (8.0) or WT (3.4); RANKL expression did not vary greatly between groups: mBRCA1 (13/135; 10%), mBRCA2 (5/114; 4%), WT (23/212; 11%). In normal breast tissue, LP (Lin−EpCAM+CD49f+) and basal/stem cells (Lin−EpCAM−CD49fhi) expressed RANK on their surface. Similar expression patterns were seen in these epithelial subtypes from each BRCA1/2 genotype. Stromal cells (Lin−EpCAM−CD49f−) had minimal RANK expression.

Conclusions: RANK expression intensity and incidence scores are both enriched approximately 4-fold in breast tumors from BRCA1 carriers compared with other genotypes. Also, RANK is normally expressed in breast LP cells as well as the basal/stem cell containing population. Ongoing studies will assess functional regulation of LP or mammary stem cell activity by RANKL and determine if the RANKL/RANK signaling pathway affects the aberrant growth characteristics of these cells from BRCA1 mutation carriers.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-03-02.

Abstract P2-09-01: Targeting BCL-2 with the BH3 mimetic ABT-199 in ER-positive breast cancer

Background: Impairment of apoptosis is a hallmark of cancer and can result in resistance to therapy. Over-expression of the pro-survival protein BCL-2 is common in breast cancer, with elevated levels found in approximately 85% of luminal tumors. Although BCL-2 has been shown to be an important prognostic marker, its role as a therapeutic target has yet to be fully explored. Small molecule inhibitors termed ‘BH3 mimetics’ that mimic the action of pro-apoptotic BH3-only proteins have recently been developed. These bind and neutralize BCL-2 pro-survival proteins. We have previously shown that the BH3 mimetic ABT-737 (which neutralizes BCL-2, BCL-XL and BCL-W) synergizes with docetaxel in BCL-2-positive patient-derived xenograft (PDX) models. Recently, a potent BCL-2-specific inhibitor, ABT-199, has been developed that is showing considerable promise in early phase studies of lymphoid malignancies. Since BCL-2 expression is prominent in the luminal B tumors, we sought to determine whether it might be feasible to target luminal B tumors with combination therapy comprising endocrine therapy (tamoxifen) and a BH3 mimetic (ABT-737 or ABT-199), using novel PDX models of luminal B breast cancer.

Methods and Results: A panel of 36 primary breast tumor xenografts (including 15 luminal tumors) was generated in immunocompromised (NOG) mice. Three BCL-2-positive luminal B models (23T, 315T, 50T), as determined by Ki-67 immunostaining and gene expression profiling, and a control BCL-2-positive, ER-negative model (838T) were selected for further study. Cohorts of mice bearing tumor xenografts were treated with either ABT-737 (50 mg/kg i.p. d1-10), tamoxifen or both agents in q21d cycles. Tumor response and overall survival were significantly improved by combination therapy in all three ER-positive xenograft models, when compared to tamoxifen alone (p&lt;0.005). Despite abundant BCL-XL expression in tumors, similar efficacy was observed with the selective BCL-2 inhibitor ABT-199 (50 mg/kg o.g. d1-5 and 8-12 q21d) and tamoxifen (p&lt;0.005), revealing that BCL-2 is a crucial target. Unexpectedly, both BH3 mimetics were found to counteract the side effect of tamoxifen-induced endometrial hyperplasia. In addition, we observed that BH3 mimetics synergized with dual PI3K/mTOR inhibitors in the induction of apoptosis. In the 315T model, where AKT was found to be activated, triple therapy with ABT-737, a PI3K/mTOR inhibitor (PKI-587) and tamoxifen further augmented tumor response in vivo, when compared to ABT-737 and tamoxifen (p&lt;0.004).

Discussion: Patient derived xenograft models of luminal B breast cancer have been derived that recapitulate the phenotype of the primary tumor. Here we have demonstrated that concomitant targeting of BCL-2 confers marked benefit above tamoxifen alone. Moreover, synergy between BH3 mimetics and PI3K/mTOR inhibitors could be exploited by targeting of both survival pathways, a strategy that appeared both safe and effective. Collectively, our findings provide a rationale for clinical evaluation of BH3 mimetics in early phase studies in breast cancer. Here, BCL-2 protein or mRNA expression (as determined by immunohistochemistry or RT-PCR, respectively) could provide a suitable companion biomarker for patient selection.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-09-01.

Trimetazidine demonstrated cardioprotective effects through mitochondrial pathway in a model of acute coronary ischemia

Myocardial ischemia affects mitochondrial function leading to ionic imbalance and susceptibility to ventricular fibrillation. Trimetazidine (TMZ), a metabolic agent, is clinically used as an anti-anginal therapy. This study was conducted to compare the effect of TMZ 20 mg immediate release (IR) and TMZ 35 mg modified release (MR), two bioequivalent marketed formulations of TMZ, on cardioprotection during acute ischemia in pigs. A 4-day oral treatment with TMZ 20 mg IR (800 mg, tid) or TMZ 35 mg MR (1,400 mg, bid) had no effect on ventricular fibrillation threshold (VFT) prior to ischemia but significantly prevented the decrease in VFT observed in placebo-treated groups after a 1-min left anterior descending coronary artery occlusion. This effect occurred without modifying cardiac hemodynamic and conduction parameters. In both TMZ-treated groups, a significant reduction of the ischemic area as well as a protection of cardiomyocytes were observed. Cardiac enzymatic activity (phosphorylase, succinate dehydrogenase, ATPase) was increased in TMZ-treated groups. Both formulations preserved mitochondrial structure and improved mitochondrial function as demonstrated by a twofold increase of oxidative phosphorylation, by a reduction of reactive oxygen species (ROS) production (>30 %) and by a trend to increase the mitochondrial calcium retention capacity. In this model of ischemia, both TMZ formulations, leading to equivalent TMZ plasma exposures, demonstrated similar cardioprotective effects. This protection could be attributed to a preservation of mitochondrial structure and function, which plays a central role in ATP and ROS production and consequently could be considered as a target of cardioprotection.

PD08-02: Targeting BCL-2 Expressing Breast Tumors with BH3-Mimetics – A New Class of Drugs in Breast Cancer?

Background: Impairment of apoptosis is a hallmark of cancer and can result in resistance to chemotherapy. Tumor resistance to apoptosis is frequently acquired through deregulated expression of BCL-2 family members or inactivation of the p53 tumor suppressor pathway. Over-expression of the pro-survival protein BCL-2 is common in breast cancer (where it is readily detected by immunostaining), and has been shown to be an important prognostic marker. A potential role for BCL-2 as a therapeutic target in breast cancer, however, has not been explored. Recently, small molecules termed ‘BH3-mimetics’ have been developed that mimic the action of pro-apoptotic BH3-only proteins. These bind and neutralize pro-survival proteins including BCL-2. Here we have derived a panel of primary breast tumor xenografts (that include basal-like breast tumors) to study the efficacy of the BH3-mimetic ABT-737 combined with docetaxel in targeting BCL-2-positive breast cancer.

Methods and Results: We first studied the expression of BCL-2, pro-survival family members BCL-XL and MCL-1, and the pro-apoptotic protein BIM in tissue microarrays of 197 primary breast tumors, which were subtyped on the basis of ER, PR, HER2, CK5/6 and EGFR expression. BCL-2 was overexpressed in luminal (83.3%), HER2−positive (50.0%), basal-like (18.5%) and ‘marker-null’ (41.4%) breast cancers. BCL-2-positive tumors generally co-expressed BCL-XL (96.2%), MCL-1 (94.7%) and BIM (93.5%). To determine whether the BH3-mimetic ABT-737 (which neutralizes BCL-2, BCL-XL and BCL-W) was effective in targeting BCL-2-expressing breast tumors, we generated a panel of 28 primary breast tumor xenografts in immunocompromised NOG mice. Five xenograft lines (838T, 24T, 315T, 13T and 806T) were selected for further analysis. Four were basal-like, and one (315T) was a luminal B tumor, as determined by gene profiling. Mice bearing tumor xenografts were treated with ABT-737 (50 mg/kg i.p. d1-10), docetaxel (10 mg/kg i.p. d1) or a combination in q21d cycles. Tumor response and overall survival were significantly improved by combination therapy, but only for tumors that expressed elevated levels of BCL-2. Treatment with ABT-737 alone was ineffective, suggesting that ABT-737 sensitized tumors to docetaxel. Combination therapy was accompanied by a marked increase in apoptosis and dissociation of BIM from BCL-2, indicating that a perturbation of BIM complexes may contribute to the activation of the apoptotic cascade. Notably, ABT-737 appeared effective in targeting BCL-2-expressing basal-like tumor xenografts (838T and 24T) harboring p53 mutations.

Discussion: Primary breast tumor xenograft models that recapitulate the phenotype of the primary tumor have been developed as useful ‘proof-of-principle', pre-clinical models. Here we provide the first in vivo evidence that BH3-mimetics can be used to sensitize primary BCL-2-expressing breast tumors to taxane chemotherapy. Our results suggest that elevated BCL-2 expression constitutes a predictive response marker in breast cancer. These findings provide a rationale for the development of clinical protocols using the oral analogue ABT-263 (navitoclax) as an adjunct to taxane chemotherapy in BCL-2-expressing basal-like and luminal breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD08-02.

Abstract S5-6: Steroid Hormone Regulation of Mammary Stem Cell Function

Background: The ovarian hormones estrogen and progesterone profoundly influence breast cancer risk, underpinning the benefit of endocrine therapies in the treatment of breast cancer. Modulation of their effects through ovarian ablation or chemoprevention strategies also significantly decreases breast cancer incidence. Conversely, there is an increased risk of breast cancer associated with pregnancy in the short-term. The cellular mechanisms underlying these observations, however, are poorly defined. We and others recently isolated mammary epithelial populations enriched for mammary stem cells (MaSCs), committed luminal progenitor and mature luminal cells from both mouse and human mammary glands. Unexpectedly, MaSCs exhibited a receptor-negative phenotype for ERα , PR and ErbB2. Given the central important of estrogen and progesterone signaling to mammary gland development and cancer, we sought to determine whether these hormones could indirectly modulate MaSC function. Methods and Results: We utilized mouse models to directly study the effects of steroid hormones on the in vivo repopulating ability of MaSCs. Ovariectomy markedly diminished MaSC number and the extent of ductal outgrowth in vivo. The relative contribution of estrogen and progesterone to the regulation of MaSC activity was next examined using hormone pellets or antagonists. MaSC activity increased in animals treated with both estrogen and progesterone. Remarkably, even three weeks of treatment with the aromatase inhibitor letrozole was sufficient to reduce the MaSC pool. The outgrowth potential of these cells was again affected, suggesting that MaSCs retain a ‘memory’ of estrogen deprivation, perhaps through perturbation of their cycling status. Indeed, cell cycle analysis revealed an increase in the percentage of MaSC-enriched cells in G0/G1 in ovariectomized glands compared to controls. This was accompanied by a profound reduction in the expression of cell cycle genes including Cyclin D1.

We further evaluated the effect of the hormonal environment on MaSC function during pregnancy, where progesterone (and prolactin) have prominent roles. Pregnancy led to a transient 11-fold increase in MaSC numbers. This was accompanied by marked elevation in the expression of the progesterone target gene RANK ligand in luminal cells, together with its receptor RANK in the MaSC-containing population. To determine whether MaSC activity is in part mediated through paracrine signals from RANK ligand, inhibitors of RANK signaling were evaluated. Treatment of virgin or pregnant mice with an anti-RANK ligand monoclonal antibody in vivo significantly impaired the clonogenic activity of the MaSC-enriched but not luminal subpopulation.

Discussion: Despite lacking the steroid hormone receptors ERα and PR, MaSCs appear to be exquisitely sensitive to hormone signaling, presumably via paracrine signaling that includes the RANK signaling pathway. The augmented MaSC pool during pregnancy suggests a cellular basis for the short-term increase in breast cancer incidence following pregnancy. Our findings further indicate that breast cancer chemoprevention may in part be achieved through suppression of MaSC function. We speculate that inhibitors of RANK and other stem cell signaling pathways could represent potential chemoprevention agents.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr S5-6.

Abstract P4-04-03: Transcriptome Analyses of Mouse and Human Mammary Cell Subpopulations Reveals Multiple Conserved Genes and Pathways

INTRODUCTION: Molecular characterization of the normal epithelial cell types that reside in the mammary gland is an important step toward understanding pathways that regulate self-renewal, lineage commitment, and differentiation along the hierarchy. We previously reported distinct stages in human mammary epithelial cell development and linked them to breast tumor subtypes previously defined by gene expression profiling. Here we determined the gene expression signatures of four distinct subpopulations isolated from the mouse mammary gland. The epithelial cell signatures were used to interrogate mouse models of mammary tumorigenesis and to compare with their normal human counterpart subsets to identify conserved genes and networks.

METHODS: RNA was prepared from freshly sorted mouse mammary cell subpopulations (mammary stem cell (MaSC)-enriched, committed luminal progenitor, mature luminal and stromal cell) and used for gene expression profiling analysis on the Illumina platform. Gene signatures were derived and compared with those previously reported for the analogous normal human mammary cell subpopulations. The mouse and human epithelial subset signatures were then subjected to Ingenuity Pathway Analysis (IPA) to identify conserved pathways.

RESULTS: The four mouse mammary cell subpopulations exhibited distinct gene signatures. Comparison of these signatures with the molecular profiles of different mouse models of mammary tumorigenesis revealed that tumors arising in MMTV-Wnt-1 and p53-/- mice were enriched for MaSC-subset genes, whereas the gene profiles of MMTV-Neu and MMTV-PyMT tumors were most concordant with the luminal progenitor cell signature. Comparison of the mouse mammary epithelial cell signatures with their human counterparts revealed substantial conservation of genes, whereas IPA highlighted a number of conserved pathways in the three epithelial subsets.

CONCLUSIONS: The conservation of genes and pathways across species further validates the use of the mouse as a model to study mammary gland development and highlights pathways that are likely to govern cell-fate decisions and differentiation. It is noteworthy that many of the conserved genes in the MaSC population have been considered as epithelialmesenchymal transition (EMT) signature genes. Therefore, the expression of these genes in tumor cells may reflect basal epithelial cell characteristics and not necessarily cells that have undergone an EMT. Comparative analyses of normal mouse epithelial subsets with murine tumor models have implicated distinct cell types in contributing to tumorigenesis in the different models.

Figures available in online version.

Protective role of selenium supplementation against cardiac lesions induced by the combination of levomepromazine and risperidone in the rabbit

Neuroleptics are a suspected cause of sudden death in psychiatric patients, especially in those with pre-existing cardiac lesions. As these lesions were previously shown to be associated with selenium (Se) deficiency, the aim of the present study was to evidence the possible protective effect of Se supplementation against cardiac lesions induced by the combination of the neuroleptic drugs levomepromazine and risperidone in the rabbit. Two groups of 6 rabbits were treated with 3 mg/kg of levomepromazine daily intramuscularly combined with 1 mg/kg of risperidone intramuscularly every other week for 3 consecutive months, and one group additionally received a solution of sodium selenite (2 μg/kg/day) intramuscularly during the whole treatment period. Furthermore, one group of six untreated animals was given the Se supplementation and another group of six control animals received saline daily. Blood samples were drawn before and at the end of the treatment period for the measurement of serum Se levels. At the end of the study, all animals were sacrificed and their hearts were removed for the measurement of tissue Se concentrations. In addition, the hearts were prepared for histopathological examination. A variety of cardiac lesions was found in the neuroleptics-treated animals without supplementation and to a lesser extent in the control and Se-supplemented untreated animals. Importantly, only rare cardiac lesions were observed in neuroleptics-Se-treated animals. The most striking differences in Se concentrations were noted in the myocardium: as compared to controls, there was a 43% reduction in neuroleptics-treated, but non-Se-supplemented animals (p < .01), at the end of the treatment period, whereas only a 14% reduction (p < .05) was noted in the neuroleptics-Se-treated animals. These results confirm that neuroleptics induce cardiac lesions associated with Se deficiency. Selenium supplementation markedly decreased the incidence and severity of neuroleptics-induced cardiac lesions and these findings may serve as a basis for further evaluation of the protective role of Se supplementation in neuroleptics-treated patients. However, Se supplementation in normal animals without Se deficiency was also shown to be cardiotoxic.

Investigation of human mammary stem and progenitor subpopulations from BRCA1 mutation carriers and noncarriers

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Background: We have previously isolated discrete populations of mouse mammary epithelial cells (MECs) and defined a population that expresses ‘basal’ markers and is highly enriched for mammary stem cells. This subset was ‘triple negative’ for ER, PR and ErbB2 expression and is reminiscent of the basal subtype of breast cancer, suggesting that the mammary stem cell may be the ‘cell of origin’ for this poor prognosis group. Since tumors arising in BRCA1 mutation carriers often exhibit a ‘basal’ phenotype, we hypothesized that the mammary stem cell pool is aberrant in these women. Our objective was to define the human MEC hierarchy and evaluate the functional characteristics of MECs from BRCA1± and normal breast tissue. Methods: Single cell suspensions prepared from fresh human BRCA1± and normal breast tissue were sorted by flow cytometry. Hematopoietic (CD45+, CD235a+) and endothelial (CD31+) cells were removed, and the remaining viable ‘lineage minus’ (Lin-) MECs fractionated based on cell surface markers. These subpopulations were evaluated by immunostaining, RNA profiling, in vitro culture in Matrigel and in vivo xenotransplantation into ‘humanised’ mammary fat pads of immunocompromised mice. Results: Lin- cells fractionated with α6-integrin (CD49f) and epithelial cell adhesion molecule (EpCAM) revealed three discrete MEC subpopulations. A stem/progenitor population that preferentially yields breast outgrowths in vivo has been identified. These subpopulations gave rise in vitro to colonies that were either large and heterogenous or small and homogenous. Only the latter differentiated into milk-producing cells when exposed to lactogenic stimuli. Immunostaining confirmed their origins from myoepithelial and luminal progenitor cells respectively. Intriguingly, BRCA1± MECs exhibited perturbed in vitro growth properties when compared to normal controls. Conclusions: Our studies provide evidence for a human MEC hierarchy, a model to interrogate the perturbation noted in pre-neoplastic tissue derived from BRCA1 mutation carriers and the identification of the cell of transformation in BRCA1 associated breast cancer. These findings may have implications on developing prevention strategies for hereditary breast cancer.

No significant financial relationships to disclose.

Delineating the epithelial hierarchy in the mouse mammary gland

Reconstitution assays have shown that mouse mammary stem cells reside within the mature mammary gland in vivo. Single cells could be prospectively isolated and shown to regenerate an entire mammary gland that exhibited full developmental capacity. The more recent identification of luminal progenitor populations has indicated that the mammary epithelium is organized in a hierarchical manner. Further definition of epithelial cell types in both mouse and human mammary glands will provide insight into the "cells of origin" in the different subtypes of breast cancer, as well as the nature of cancer-propagating cells. Here, we review the known characteristics of mammary stem and progenitor cells, their steroid receptor status, and the pathways that have thus far been implicated in regulating their self-renewal and differentiation.

Role of selenium in heart lesions produced by neuroleptics in the rabbit

Organic and/or functional heart lesions sometimes resulting in sudden death have been described in psychiatric patients treated with neuroleptics. As selenium has been suggested previously to play a role in the development of such lesions, the present study was undertaken to determine whether a correlation could be found between heart lesions induced by neuroleptics and changes in blood selenium as well as myocardial tissue concentrations in the rabbit. Twelve NZW adult rabbits were treated intramuscularly with both levomepromazine (3 mg kg(-1) day(-1)) and risperidone (1 mg kg(-1) once every other week) for 3 months, and compared with 12 saline-treated controls. Blood samples were drawn before and at the end of the study. Tissue samples from the heart, liver and kidneys were obtained at the end of treatment, and the hearts were examined histologically. Heart lesions including disorganization of cardiac fibers, myolysis, interstitial and endocardial fibrosis, and necrosis were noted in treated animals, but not in controls. There was a 20% decrease in selenium blood levels and a 50% decrease in selenium myocardial tissue levels in treated animals compared with controls (P < 0.001). In contrast, no differences in selenium levels in liver and kidneys were found across the experimental groups. These results suggest a possible correlation between selenium depletion and neuroleptics-induced heart lesions.

Mitochondrial cytochrome c release is caspase-dependent and does not involve mitochondrial permeability transition in didemnin B-induced apoptosis

Permeability transition, and a subsequent drop in mitochondrial membrane potential (DeltaPsi(m)), have been suggested to be mechanisms by which cytochrome c is released from the mitochondria into the cytosol during apoptosis. Furthermore, a drop in DeltaPsi(m) has been suggested to be an obligate early step in the apoptotic pathway. Didemnin B, a branched cyclic peptolide described to have immunosuppressive, anti-tumour, and anti-viral properties, induces rapid apoptosis in a range of mammalian cell lines. Induction of apoptosis by didemnin B in cultured human pro-myeloid HL-60 cells is the fastest and most complete ever described with all cells being apoptotic after 3 h of treatment. By utilizing the system of didemnin B-induced apoptosis in HL-60 cells, and the potent inhibitors of mitochondrial permeability transition, cyclosporin A and bongkrekic acid, we show that permeability transition as determined by changes in DeltaPsi(m) and mitochondrial Ca2+ fluxing, is not a requirement for apoptosis or cytochrome c release. In this system, changes in mitochondrial membrane potential and cytochrome c release are shown to be dependent on caspase activation, and to occur concurrently with the release of caspase-9 from mitochondria, genomic DNA fragmentation and apoptotic body formation.

Runx2: a novel oncogenic effector revealed by in vivo complementation and retroviral tagging

The Runx2 (Cbfa1, Pebp2alphaA, Aml3) gene was previously identified as a frequent target for transcriptional activation by proviral insertion in T-cell lymphomas of CD2-MYC transgenic mice. We have recently shown that over-expression of the full-length, most highly expressed Runx2 isoform in the thymus perturbs T-cell development, leads to development of spontaneous lymphomas at low frequency and is strongly synergistic with Myc. To gain further insight into the relationship of Runx2 to other lymphomagenic pathways, we tested the effect of combining the CD2-Runx2 transgene either with a Pim1 transgene (E(mu)-Pim1) or with the p53 null genotype, as each of these displays independent synergy with Myc. In both cases we observed synergistic tumour development. However, Runx2 appeared to have a dominant effect on the tumour phenotype in each case, with most tumours conforming to the CD3(+), CD8(+), CD4(+/-) phenotype seen in CD2-Runx2 mice. Neonatal infection of CD2-Runx2 mice with Moloney murine leukaemia virus (Moloney MLV) also led to a dramatic acceleration of tumour onset. Analysis of known Moloney MLV target genes in these lymphomas showed a high frequency of rearrangement at c-Myc or N-Myc (82%), and a significant number at Pim1 or Pim2 (23%), and at Pal1/Gfi1 (18%). These results indicate that Runx2 makes a distinct contribution to T-cell lymphoma development which does not coincide with any of the oncogene complementation groups previously identified by retroviral tagging.

A full-length Cbfa1 gene product perturbs T-cell development and promotes lymphomagenesis in synergy with myc

The Cbfa1/PEBP2 alpha A/AML3 gene plays an essential role in osteogenesis but is also expressed in the T-cell lineage where it has been implicated in lymphoma development as a target for retroviral insertional mutagenesis. As lymphoma cells with til-1 insertion express at least five distinct Cbfa1 isoforms, it is important to establish which, if any, have intrinsic oncogenic potential. We have generated transgenic mice in which the most abundant lymphoma isoform (G1/p57) is expressed under the control of the CD2 locus control region. Co-precipitation analysis of transgenic thymus revealed high levels of Cbfa1 protein in an abundant complex containing the binding cofactor Cbfb. CD2-Cbfa1-G1 mice displayed abnormal T-cell development, with a pronounced skew towards CD8 SP cells in the thymus and developed a low incidence of spontaneous lymphomas (6% at 12 months) with cells of similar phenotype. Strongly synergistic tumour development was seen when CD2-Cbfa1-G1 mice were crossed with lines carrying myc transgenes (CD2-myc or tamoxifen-regulatable CD2-mycER) and Cbfa1 was found to rescue expression of the CD2-myc transgene in pre-leukaemic mice. However, synergy did not appear to be due to a dominant block of myc-induced apoptosis by Cbfa1 as explanted primary tumours and cell lines from CD2-Cbfa1-G1/CD2-mycER mice showed accelerated death on induction with tamoxifen at similar rates to CD2-mycER controls. Moreover, thymocytes from preleukaemic CD2-Cbfa1-G1 mice showed reduced survival in vitro and increased sensitivity to the inhibitory effects of TGF-beta. This study demonstrates that a full-length Cbf alpha-chain gene can act as an oncogene without fusion to a heterologous protein.

Effectors of the mammalian plasma membrane NADH-oxidoreductase system. Short-chain ubiquinone analogues as potent stimulators

In the presence of effectors variations in the two recognized activities of the plasma membrane NADH-oxidoreductase system were studied in separate, specific in vitro assays. We report here that ubiquinone analogues that contain a short, less hydrophobic side chain than coenzyme Q-10 dramatically stimulate the NADH-oxidase activity of isolated rat liver plasma membranes whereas they show no effect on the reductase activity of isolated membranes. If measured in assays of the NADH:ferricyanide reductase of living cultured cells these compounds have only a limited effect; the oxidase activity of whole cells is not measurable in our hands. We have furthermore identified selective inhibitors of both enzyme activities. In particular, the NADH-oxidase activity can be significantly inhibited by structural analogues of ubiquinone, such as capsaicin and resiniferatoxin. The NADH:ferricyanide reductase, on the other hand, is particularly sensitive to pCMBS, indicating the presence of a sulfhydryl group of groups at its active site. The identification of these specific effectors of the different enzyme activities of the PMOR yields further insights into the function of this system.

Protein tyrosine kinase inhibitors prevent didemnin B-induced apoptosis in HL-60 cells

Didemnin B induces rapid apoptosis in human promyeloid HL-60 cells with an optimal concentration of 1 microM (Grubb et al. (1995) Biochem. Biophys. Res. Commum. 215, 1130-1136), but little is known about how it does so. In order to determine whether protein tyrosine phosphorylation is involved in this rapid induction of apoptosis, HL-60 cells were pre-treated with tyrosine kinase inhibitors for 1 h before didemnin B treatment. Genistein, 2,5-dihydroxycinnamic acid methyl ester, and a range of tyrphostins inhibit didemnin B-induced apoptotic morphology in a concentration-dependent manner. DNA fragmentation induced by didemnin B is also inhibited by genistein, 2,5-dihydroxycinnamic acid methyl ester, and tyrphostins.