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de Haan A, Groen H, van Nes JGH, Kolff MW, van der Toorn PP, Westenberg AH, Werker PMN, Langendijk JA, Steenbakkers RJHM. An economic evaluation of radiotherapy for patients with symptomatic Ledderhose disease. Radiother Oncol 2023; 188:109890. [PMID: 37659664 DOI: 10.1016/j.radonc.2023.109890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/24/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Evidence for effectiveness of radiotherapy for Ledderhose disease was demonstrated in the LedRad-study. However, the health economic impact of Ledderhose disease is unclear. Therefore, an economic evaluation alongside the LedRad-study was planned. METHODS The economic evaluation was performed as a cost-effectiveness and cost-utility analysis from the societal perspective. Primary outcome parameters were pain burden and Quality Adjusted Life Years (QALY), until 12 months after the end of treatment. Secondary analyses were performed with outcomes until 18 months. Incremental cost-effectiveness (ICER) and cost-utility ratios (ICUR) were calculated to express costs per unit improvement in pain burden and costs per QALY gained, for radiotherapy compared to sham-radiotherapy. Bootstrap replication was used to assess uncertainty surrounding the ratios and to construct cost-effectiveness acceptability curves for QALY gain. RESULTS Previous analysis showed a statistically significant improvement in pain- and QoL scores in favour of radiotherapy at 12 and 18 months. At these timepoints and excluding treatment costs, cumulative total costs were considerably lower in the radiotherapy group. The ICER until 12 months after treatment was 4987 euro per unit of pain burden reduction. The ICUR was 14249 euro per QALY gained. Most of the bootstrap replications were in the upper right quadrant, indicating that health gain can be achieved at higher costs. At increasing levels of willingness to pay for a gain in QALY, the probability of cost-utility gradually increased to approximately 85%. CONCLUSIONS In patients with symptomatic Ledderhose disease, radiotherapy, at a moderate threshold for willingness to pay, is cost-effective in terms of QoL gain.
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Affiliation(s)
- Anneke de Haan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands.
| | - Henk Groen
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, the Netherlands
| | | | - M Willemijn Kolff
- Amsterdam University Medical Center, Department of Radiation Oncology, Amsterdam, the Netherlands
| | | | | | - Paul M N Werker
- University of Groningen, University Medical Center Groningen, Department of Plastic Surgery, Groningen, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Roel J H M Steenbakkers
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
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de Haan A, Hijmans JM, van der Vegt AE, van der Laan HP, van Nes JGH, Werker PMN, Langendijk JA, Steenbakkers RJHM. Effect of painful Ledderhose disease on dynamic plantar foot pressure distribution during walking: a case-control study. Foot (Edinb) 2023; 56:101990. [PMID: 36905795 DOI: 10.1016/j.foot.2023.101990] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 03/13/2023]
Abstract
BACKGROUND Plantar pressure distribution during walking in patients with painful Ledderhose disease is unknown. RESEARCH QUESTION Do patients with painful Ledderhose disease have an altered plantar pressure distribution during walking compared to individuals without foot pathologies? It was hypothesized that plantar pressure is shifted away from the painful nodules. METHODS Pedobarography data of 41 patients with painful Ledderhose disease (cases, mean age: 54.2 ± 10.4 years) was collected and compared to pedobarography data from 41 individuals without foot pathologies (controls, mean age: 21.7 ± 2.0 years). Peak Pressure (PP), Maximum Mean Pressure (MMP) and Force-Time Integral (FTI) were calculated for eight regions (heel, medial midfoot, lateral midfoot, medial forefoot, central forefoot, lateral forefoot, hallux and other toes) under the soles of the feet. Differences between cases and controls were calculated and analysed by means of linear (mixed models) regression. RESULTS Proportional differences in PP, MMP and FTI showed increased values for the cases compared to the controls, especially in the heel, hallux and other toes regions, and decreased values in the medial- and lateral midfoot regions. In naïve regression analysis, being a patient was a predictor for increased- and decreased values for PP, MMP and FTI for several regions. When dependencies in the data were taken into account with linear mixed-model regression analysis, the increased- and decreased values for the patients were most prevalent for FTI at the heel, medial midfoot, hallux and other toes regions. SIGNIFICANCE In patients with painful Ledderhose disease, during walking, a shift of pressure was found towards the proximal and distal foot regions, while offloading the midfoot regions.
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Affiliation(s)
- Anneke de Haan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands.
| | - Juha M Hijmans
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Anna E van der Vegt
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Hans Paul van der Laan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | | | - Paul M N Werker
- University of Groningen, University Medical Center Groningen, Department of Plastic Surgery, Groningen, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Roel J H M Steenbakkers
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
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de Haan A, van Nes JGH, Kolff MW, van der Toorn PP, Westenberg AH, van der Vegt AE, Groen H, Overbosch J, van der Laan HP, Werker PMN, Langendijk JA, Steenbakkers RJHM. Radiotherapy for Ledderhose disease: Results of the LedRad-study, a prospective multicentre randomised double-blind phase 3 trial. Radiother Oncol 2023; 185:109718. [PMID: 37211283 DOI: 10.1016/j.radonc.2023.109718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND PURPOSE Radiotherapy is considered a treatment option for Ledderhose disease. However, its benefits have never been confirmed in a randomised controlled trial. Therefore, the LedRad-study was conducted. MATERIALS AND METHODS The LedRad-study is a prospective multicentre randomised double-blind phase three trial. Patients were randomised to sham-radiotherapy (placebo) or radiotherapy. The primary endpoint was pain reduction at 12 months after treatment, measured with the Numeric Rating Scale (NRS). Secondary endpoints were pain reduction at 6 and 18 months after treatment, quality of life (QoL), walking abilities and toxicity. RESULTS A total of 84 patients were enrolled. At 12 and 18 months, patients in the radiotherapy group had a lower mean pain score compared to patients in the sham-radiotherapy group (2.5 versus 3.6 (p = 0.03) and 2.1 versus 3.4 (p = 0.008), respectively). Pain relief at 12 months was 74% in the radiotherapy group and 56% in the sham-radiotherapy group (p = 0.002). Multilevel testing for QoL scores showed higher QoL scores in the radiotherapy group compared to the sham-radiotherapy group (p < 0.001). Moreover, patients in the radiotherapy group had a higher mean walking speed and step rate with barefoot speed walking (p = 0.02). Erythema, skin dryness, burning sensations and increased pain were the most frequently reported side effects. These side effects were generally graded as mild (95%) and the majority (87%) were resolved at 18 months follow-up. CONCLUSION Radiotherapy for symptomatic Ledderhose disease is an effective treatment resulting in a significant pain reduction, improvement of QoL scores and bare feet walking abilities, in comparison to sham-radiotherapy.
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Affiliation(s)
- Anneke de Haan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands.
| | | | - M Willemijn Kolff
- Amsterdam University Medical Center, Department of Radiation Oncology, Amsterdam, the Netherlands
| | | | | | - Annelies E van der Vegt
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Henk Groen
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, the Netherlands
| | - Jelle Overbosch
- University of Groningen, University Medical Center Groningen, Department of Radiology, Groningen, the Netherlands
| | - Hans Paul van der Laan
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Paul M N Werker
- University of Groningen, University Medical Center Groningen, Department of Plastic Surgery, Groningen, the Netherlands
| | - Johannes A Langendijk
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
| | - Roel J H M Steenbakkers
- University of Groningen, University Medical Center Groningen, Department of Radiation Oncology, Groningen, the Netherlands
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Jeene PM, de Vries KC, van Nes JGH, Kwakman JJM, Wester G, Rozema T, Braam PM, Zindler JD, Koper P, Nuyttens JJ, Vos-Westerman HA, Schmeets I, Niël CGHJ, Hutschemaekers S, van der Linden YM, Verhoeff JJC, Stalpers LJA. Survival after whole brain radiotherapy for brain metastases from lung cancer and breast cancer is poor in 6325 Dutch patients treated between 2000 and 2014. Acta Oncol 2018; 57:637-643. [PMID: 29276848 DOI: 10.1080/0284186x.2017.1418534] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Whole brain radiotherapy (WBRT) is considered standard of care for patients with multiple brain metastases or unfit for radical treatment modalities. Recent studies raised discussion about the expected survival after WBRT. Therefore, we analysed survival after WBRT for brain metastases 'in daily practice' in a large nationwide multicentre retrospective cohort. METHODS Between 2000 and 2014, 6325 patients had WBRT (20 Gy in 4 Gy fractions) for brain metastases from non-small cell lung cancer (NSCLC; 4363 patients) or breast cancer (BC; 1962 patients); patients were treated in 15 out of 21 Dutch radiotherapy centres. Survival was calculated by the Kaplan-Meier method from the first day of WBRT until death as recorded in local hospital data registration or the Dutch Municipal Personal Records Database. FINDINGS The median survival was 2.7 months for NSCLC and 3.7 months for BC patients (p < .001). For NSCLC patients aged <50, 50-60, 60-70 and >70 years, survival was 4.0, 3.0, 2.8 and 2.1 months, respectively (p < .001). For BC patients, survival was 4.5, 3.8, 3.2 and 2.9 months, respectively (p = .047). In multivariable analyses, higher age was related to poorer survival with hazard ratios (HR) for patients aged 50-60, 60-70 and >70 years being 1.05, 1.19 and 1.34, respectively. Primary BC (HR: 0.83) and female sex (HR: 0.85) were related to better survival (p < .001). INTERPRETATION The survival of patients after WBRT for brain metastases from NSCLC treated in Dutch 'common radiotherapy practice' is poor, in breast cancer and younger patients it is disappointingly little better. These results are in line with the results presented in the QUARTZ trial and we advocate a much more restrictive use of WBRT. In patients with a more favourable prognosis the optimal treatment strategy remains to be determined. Prospective randomized trials and individualized prognostic models are needed to identify these patients and to tailor treatment.
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Affiliation(s)
- Paul M. Jeene
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Radiotherapiegroep, Deventer, The Netherlands
| | - Kim C. de Vries
- Department of Radiotherapy, Antoni van Leeuwenhoek ziekenhuis, Netherlands Cancer Institute, Amsterdam, The Netherlands
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Johannes J. M. Kwakman
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Tom Rozema
- Instituut Verbeeten, Tilburg, The Netherlands
| | - Pètra M. Braam
- Department of Radiotherapy, RadboudUMC, Nijmegen, The Netherlands
| | - Jaap D. Zindler
- MAASTRO Clinic Maastricht, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Peter Koper
- Department of Radiotherapy, HaaglandenMC, The Hague, The Netherlands
| | - Joost J. Nuyttens
- Department of Radiotherapy, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Ilona Schmeets
- Department of Radiotherapy, Catharina ziekenhuis, Eindhoven, The Netherlands
| | | | | | | | - Joost J. C. Verhoeff
- Department of Radiotherapy, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lukas J. A. Stalpers
- Department of Radiotherapy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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van Nes JGH, Beex LVAM, Seynaeve C, Putter H, Sramek A, Lardenoije S, Duijm-de Carpentier M, Van Rongen I, Nortier JWR, Zonderland HM, van de Velde CJH. Minimal impact of adjuvant exemestane or tamoxifen treatment on mammographic breast density in postmenopausal breast cancer patients: a Dutch TEAM trial analysis. Acta Oncol 2015; 54:349-60. [PMID: 25383451 DOI: 10.3109/0284186x.2014.964809] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Mammographic breast density is one of the strongest independent risk factors for developing breast cancer. We examined the effect of exemestane and tamoxifen on breast density in Dutch postmenopausal early breast cancer patients participating in the Tamoxifen Exemestane Adjuvant Multinational (TEAM) trial. MATERIAL AND METHODS Analogue mammograms of selected TEAM participants before start, and after one and two (and if available after three) years of adjuvant endocrine therapy were collected centrally and reviewed. Study endpoints were change in breast density over time, and correlations between breast density and locoregional recurrence (LRR), distance recurrence (DR), and contralateral breast cancer (CBC). RESULTS Mammograms of 378 patients (181 tamoxifen, 197 exemestane) were included in the current per protocol analyses. Baseline breast density was low (breast density score<50% in 75% of patients) and not different between patients randomised to exemestane or tamoxifen (coefficient 0.16, standard error 0.17). Breast density did not change during treatment in exemestane (p=0.25) or tamoxifen users (p=0.59). No relation was observed between breast density and the occurrence of a LRR [hazards ratio (HR) 0.87, 95% CI 0.45-1.68, p=0.67], a DR (HR 1.02, 95% CI 0.77-1.35, p=0.90), or CBC (HR 1.31, 95% CI 0.63-2.72, p=0.48). CONCLUSION The in general low breast density score in early postmenopausal breast cancer patients did not substantially change over time, and this pattern was not different between tamoxifen and exemestane users. Breast density was not a predictive marker for efficacy of adjuvant endocrine therapy.
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Affiliation(s)
- Johanna G H van Nes
- Department of Surgery, Leiden University Medical Centre , Leiden , The Netherlands
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6
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van Hoesel AQ, van de Velde CJH, Kuppen PJK, Liefers GJ, Putter H, Sato Y, Elashoff DA, Turner RR, Shamonki JM, de Kruijf EM, van Nes JGH, Giuliano AE, Hoon DSB. Hypomethylation of LINE-1 in primary tumor has poor prognosis in young breast cancer patients: a retrospective cohort study. Breast Cancer Res Treat 2012; 134:1103-14. [PMID: 22476853 DOI: 10.1007/s10549-012-2038-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 03/15/2012] [Indexed: 10/28/2022]
Abstract
Long interspersed element 1 (LINE-1), a non-coding genomic repeat sequence, methylation status can influence tumor progression. In this study, the clinical significance of LINE-1 methylation status was assessed in primary breast cancer in young versus old breast cancer patients. LINE-1 methylation index (MI) was assessed by absolute quantitative assessment of methylated alleles (AQAMA) PCR assay. Initially, LINE-1 MI was assessed in a preliminary study of 235 tissues representing different stages of ductal breast cancer development. Next, an independent cohort of 379 primary ductal breast cancer patients (median follow-up 18.9 years) was studied. LINE-1 hypomethylation was shown to occur in DCIS and invasive breast cancer. In primary breast cancer it was associated with pathological tumor stage (p = 0.026), lymph node metastasis (p = 0.022), and higher age at diagnosis (>55, p < 0.001). In multivariate analysis, LINE-1 hypomethylation was associated with decreased OS (HR 2.19, 95 % CI 1.17-4.09, log-rank p = 0.014), DFS (HR 2.05, 95 % CI 1.14-3.67, log-rank p = 0.016) and increased DR (HR 2.83, 95 % CI 1.53-5.21, log-rank p = 0.001) in younger (≤55 years), but not older patients (>55 years). LINE-1 analysis of primary breast cancer demonstrated cancer-related age-dependent hypomethylation. In patients ≤55 years, LINE-1 hypomethylation portends a high-risk of DR.
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Affiliation(s)
- Anneke Q van Hoesel
- Department of Molecular Oncology, John Wayne Cancer Institute (JWCI) at St. John's Health Center, 2200 Santa Monica Blvd., Santa Monica, CA 90404, USA
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7
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de Kruijf EM, Sajet A, van Nes JGH, Putter H, Smit VTHBM, Eagle RA, Jafferji I, Trowsdale J, Liefers GJ, van de Velde CJH, Kuppen PJK. NKG2D ligand tumor expression and association with clinical outcome in early breast cancer patients: an observational study. BMC Cancer 2012; 12:24. [PMID: 22257486 PMCID: PMC3292504 DOI: 10.1186/1471-2407-12-24] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 01/18/2012] [Indexed: 02/06/2023] Open
Abstract
Background Cell surface NKG2D ligands (NKG2DL) bind to the activating NKG2D receptor present on NK cells and subsets of T cells, thus playing a role in initiating an immune response. We examined tumor expression and prognostic effect of NKG2DL in breast cancer patients. Methods Our study population (n = 677) consisted of all breast cancer patients primarily treated with surgery in our center between 1985 and 1994. Formalin-fixed paraffin-embedded tumor tissue was immunohistochemically stained with antibodies directed against MIC-A/MIC-B (MIC-AB), ULBP-1, ULBP-2, ULBP-3, ULBP-4, and ULBP-5. Results NKG2DL were frequently expressed by tumors (MIC-AB, 50% of the cases; ULBP-1, 90%; ULBP-2, 99%; ULBP-3, 100%; ULBP-4, 26%; ULBP-5, 90%) and often showed co-expression: MIC-AB and ULBP-4 (p = 0.043), ULBP-1 and ULBP-5 (p = 0.006), ULBP-4 and ULBP-5 (p < 0.001). MIC-AB (p = 0.001) and ULBP-2 (p = 0.006) expression resulted in a statistically significant longer relapse free period (RFP). Combined expression of these ligands showed to be an independent prognostic parameter for RFP (p < 0.001, HR 0.41). Combined expression of all ligands showed no associations with clinical outcome. Conclusions We demonstrated for the first time that NKG2DL are frequently expressed and often co-expressed in breast cancer. Expression of MIC-AB and ULBP-2 resulted in a statistically significant beneficial outcome concerning RFP with high discriminative power. Combination of all NKG2DL showed no additive or interactive effect of ligands on each other, suggesting that similar and co-operative functioning of all NKG2DL can not be assumed. Our observations suggest that among driving forces in breast cancer outcome are immune activation on one site and tumor immune escape on the other site.
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Affiliation(s)
- Esther M de Kruijf
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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8
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van Hoesel AQ, van de Velde CJH, Kuppen PJK, Putter H, de Kruijf EM, van Nes JGH, Giuliano AE, Hoon DSB. Primary tumor classification according to methylation pattern is prognostic in patients with early stage ER-negative breast cancer. Breast Cancer Res Treat 2011; 131:859-69. [PMID: 21479925 DOI: 10.1007/s10549-011-1485-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Accepted: 03/25/2011] [Indexed: 11/26/2022]
Abstract
Breast cancer patients with similar clinical stage may experience different disease outcomes. Aberrant DNA methylation of primary breast tumors can have impact on the clinical outcome. This study aimed to assess clinical utility of tumor-specific methylated sequences (MINT17, 31) and tumor-related gene (RARβ2) methylation classification in primary breast tumors. Absolute quantitative assessment of methylated alleles (AQAMA) was used to determine the methylation index (MI) of MINT17, MINT31, and RARß2 in 242 primary tumors of early stage breast cancer patients. Patients were classified into three methylation groups: meth-N, with normal methylation levels of all biomarkers; meth-L, with one biomarker hypermethylation; and meth-H, with hypermethylation of >1 biomarker. Disease outcome of methylation groups was compared during follow-up. MI of all biomarkers was successfully obtained in 237 tumors of which 79 (33%) were classified as meth-N, 86 (36%) as meth-L, and 72 (30%) as meth-H. Meth-H status was a risk factor for distant recurrence (DR) (log-rank P = 0.007) and shorter disease-free survival (DFS) (log-rank P = 0.039). Methylation classification had strongest prognostic value for patients with ER-negative tumors. In multivariate analysis (n = 222), ER-negative meth-H patients had a 4.1-fold increased risk of DR (95% CI 1.80-9.59; meth-N HR 1.0, P = 0.001), a 4.2-fold increased risk of overall recurrence (OR) (95% CI 1.88-9.47; meth-N HR 1.0, P = 0.001), and a 3.1-fold shorter DFS (95% CI 1.57-5.98; meth-N HR 1.0, P = 0.003). Methylation classification of primary breast cancer is an independent prognostic factor for disease outcome in patients with ER-negative tumors. The study's findings will have to be confirmed in an independent dataset.
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Affiliation(s)
- Anneke Q van Hoesel
- Department of Molecular Oncology, John Wayne Cancer Institute (JWCI) at St. John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, CA, 90404, USA
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9
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de Kruijf EM, Sajet A, van Nes JGH, Natanov R, Putter H, Smit VTHBM, Liefers GJ, van den Elsen PJ, van de Velde CJH, Kuppen PJK. HLA-E and HLA-G expression in classical HLA class I-negative tumors is of prognostic value for clinical outcome of early breast cancer patients. J Immunol 2010; 185:7452-9. [PMID: 21057081 DOI: 10.4049/jimmunol.1002629] [Citation(s) in RCA: 204] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Nonclassical HLAs, HLA-E and HLA-G, are known to affect clinical outcome in various tumor types. We examined the clinical impact of HLA-E and HLA-G expression in early breast cancer patients, and related the results to tumor expression of classical HLA class I. Our study population (n = 677) consisted of all early breast cancer patients primarily treated with surgery in our center between 1985 and 1995. Tissue microarray sections of arrayed tumor and normal control material were immunohistochemically stained for HLA-E and HLA-G. For evaluation of HLA-E and HLA-G and the combined variable, HLA-EG, a binary score was used. Expression of classical HLA class I molecules was determined previously. HLA-E, HLA-G, and HLA-EG on breast tumors were classified as expression in 50, 60, and 23% of patients, respectively. Remarkably, only in patients with loss of classical HLA class I tumor expression, expression of HLA-E (p = 0.027), HLA-G (p = 0.035), or HLA-EG (p = 0.001) resulted in a worse relapse-free period. An interaction was found between classical and nonclassical HLA class I expression (p = 0.002), suggestive for a biological connection. We have demonstrated that, next to expression of classical HLA class I, expression of HLA-E and HLA-G is an important factor in the prediction of outcome of breast cancer patients. These results provide further evidence that breast cancer is immunogenic, but also capable of evading tumor eradication by the host's immune system, by up- or downregulation of HLA class Ia and class Ib loci.
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Affiliation(s)
- Esther M de Kruijf
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
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10
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de Kruijf EM, van Nes JGH, van de Velde CJH, Putter H, Smit VTHBM, Liefers GJ, Kuppen PJK, Tollenaar RAEM, Mesker WE. Tumor-stroma ratio in the primary tumor is a prognostic factor in early breast cancer patients, especially in triple-negative carcinoma patients. Breast Cancer Res Treat 2010; 125:687-96. [PMID: 20361254 DOI: 10.1007/s10549-010-0855-6] [Citation(s) in RCA: 211] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Accepted: 03/16/2010] [Indexed: 02/07/2023]
Abstract
Stroma tissue surrounding cancer cells plays an important role in tumor development and behavior. In colorectal cancer, it has been found that the amount of stroma within the primary tumor is of prognostic value. We therefore have evaluated the prognostic value of this tumor-stroma ratio for breast cancer. A cohort of 574 early breast cancer patients, primarily treated with surgery between 1985 and 1994 was analyzed for the tumor-stroma ratio. The percentage of stroma was visually estimated on Haematoxylin-Eosin (H&E) stained histological sections. Patients with more than 50% intra-tumor stroma were quantified as stroma rich and patients with less than 50% as stroma poor. For the total group of patients, stroma-rich tumors had a shorter relapse-free period (RFP) (P = 0.001) and overall survival (OS) (P = 0.025) compared to stroma-poor tumors. Tumor-stroma ratio was an independent prognostic parameter for the total group of patients (P < 0.001) and also in stratified analysis based on systemic treatment. Importantly, in the triple-negative cancer subpopulation, patients with stroma-rich tumors had a 2.92 times higher risk of relapse (P = 0.006) compared to those with stroma-poor tumors, independently of other clinico-pathological parameters. Five-year RFP-rates for triple-negative cancer patients with stroma-rich compared to stroma-poor tumors were 56 and 81%, respectively. Tumor-stroma ratio has proven to be an independent prognostic factor for RFP in breast cancer patients and especially in the triple-negative cancer subpopulation. Tumor-stroma ratio could be easily implemented in routine daily pathology diagnostics, as it is simple to determine, reproducible, and performed in quick time.
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Affiliation(s)
- Esther M de Kruijf
- Departments of Surgery, Leiden University Medical Center, P.O Box 9600, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
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de Kruijf EM, van Nes JGH, Sajet A, Tummers QRJG, Putter H, Osanto S, Speetjens FM, Smit VTHBM, Liefers GJ, van de Velde CJH, Kuppen PJK. The predictive value of HLA class I tumor cell expression and presence of intratumoral Tregs for chemotherapy in patients with early breast cancer. Clin Cancer Res 2010; 16:1272-80. [PMID: 20145162 DOI: 10.1158/1078-0432.ccr-09-1844] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We hypothesized that T-cell immune interaction affects tumor development and thus clinical outcome. Therefore, we examined the clinical impact of human leukocyte antigen (HLA) class I tumor cell expression and regulatory T-cell (Treg) infiltration in breast cancer. EXPERIMENTAL DESIGN Our study population (N = 677) is consisted of all early breast cancer patients primarily treated with surgery in our center between 1985 and 1994. Formalin-fixed, paraffin-embedded tumor tissue was immunohistochemically stained using HCA2, HC10, and Foxp3 monoclonal antibodies. RESULTS HLA class I expression was evaluated by combining results from HCA2 and HC10 antibodies and classified into three groups: loss, downregulation, and expression. Remarkably, only in patients who received chemotherapy, both presence of Treg (P = 0.013) and higher HLA class I expression levels (P = 0.002) resulted in less relapses, independently of other variables. Treg and HLA class I were not of influence on clinical outcome in patients who did not receive chemotherapy. CONCLUSIONS We showed that HLA class I and Treg affect prognosis exclusively in chemotherapy-treated patients and are therefore one of the few predictive factors for chemotherapy response in early breast cancer patients. Chemotherapy may selectively eliminate Treg, thus enabling CTLs to kill tumor cells that have retained HLA class I expression. As a consequence, HLA class I and Treg can predict response to chemotherapy with high discriminative power. These markers could be applied in response prediction to chemotherapy in breast cancer patients.
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Affiliation(s)
- Esther M de Kruijf
- Departments of Surgery, Leiden University Medical Center, Leiden, The Netherlands
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van Nes JGH, Hendriks JM, Tseng LNL, van Dijk LC, van Sambeek MRHM. Endoscopic Aneurysm Sac Fenestration as a Treatment Option for Growing Aneurysms Due to Type II Endoleak or Endotension. J Endovasc Ther 2005; 12:430-4. [PMID: 16048374 DOI: 10.1583/05-1541r.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To evaluate endoscopic fenestration as a treatment option for growing aneurysm due to a type II endoleak or endotension after endovascular aneurysm repair (EVAR). METHODS Eight patients (7 men; median age 69 years, range 55-79) who underwent "successful" EVAR were diagnosed with a growing aneurysm due to a type II endoleak (n=4) or endotension (n=4). Surgical intervention consisted of endoscopic fenestration of the sac and removal of all the thrombus material, preceded by clipping of the inferior mesenteric and all lumbar arteries in cases of endoleak. Fluid samples from the fenestrated aneurysm sac were analyzed for the presence of microorganisms and fibrin degradation products (FDP) and/or D-dimers. RESULTS The median duration of operation was 220 minutes (range 111-333). There was no perioperative mortality. In one patient, the endoscopic procedure was converted to an open fenestration procedure. Seven patients had uncomplicated follow-up and a clear decrease in the diameter of the sac; one patient was converted to open repair owing to continued sac growth despite fenestration. Bacterial cultures were negative in all patients, but high levels of FDP and/or D-dimers were found in all available samples, indicating continued fibrinolysis. CONCLUSION Endoscopic fenestration, with or without endoscopic clipping of all side branches, seems to be an effective, reliable and minimally invasive treatment option for patients with a growing aneurysm due to type II endoleak or endotension. The high levels of FDP and/or D-dimers in the aneurysm sac are suggestive of hyperfibrinolysis, which may play an important role in aneurysm growth after EVAR.
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Affiliation(s)
- Johanna G H van Nes
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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