Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Performance analysis of an orbital angular momentum multiplexed amplify-and-forward radio relay chain with inter-modal crosstalk

The end-to-end spectral efficiency and bit error rate (BER) of an amplify-and-forward (AF) radio relay chain employing orbital angular momentum (OAM) multiplexing is presented. The inherent divergence of a beam carrying OAM is overcome by means of a lens. Modelled and measured inter-modal crosstalk levels are incorporated into the analysis. The results show that an end-to-end spectral efficiency of up to 8 bits s^-1 Hz^-1 is achievable using four OAM modes to multiplex four parallel data streams over 20 hops, provided that the detrimental effects of inter-modal crosstalk are mitigated. The spectral efficiency is expected to scale further by using more OAM modes. The BER profile along the relay chain is analysed for each of the four OAM modes.

Impaired fetoplacental angiogenesis in growth-restricted fetuses with abnormal umbilical artery doppler velocimetry is mediated by aryl hydrocarbon receptor nuclear translocator (ARNT)

CONTEXT

Fetal growth restriction with abnormal umbilical artery Doppler velocimetry (FGRadv), reflective of elevated fetoplacental vascular resistance, is associated with increased risks of fetal morbidity and mortality even in comparison to those of growth-restricted fetuses with normal placental blood flow. One major cause of this abnormally elevated fetoplacental vascular resistance is the aberrantly formed, thin, elongated villous vessels that are seen in FGRadv placentas.

OBJECTIVE

The purpose of this study was to determine the role of fetoplacental endothelial cells (ECs) in angiogenesis in normal pregnancies and in those complicated by FGRadv.

DESIGN AND PARTICIPANTS

Human placental specimens were obtained from FGRadv and gestational age-matched, appropriately grown control pregnancies for EC isolation/culture and for immunohistochemical studies. Additional mechanistic studies were performed on ECs isolated from subjects with term, uncomplicated pregnancies.

MAIN OUTCOME MEASURES

We evaluated tube formation and differential angiogenic gene expression in FGRadv and control ECs, and we used ECs from uncomplicated pregnancies to further elucidate the molecular mechanisms by which angiogenesis is impaired in FGRadv pregnancies.

RESULTS

Tube formation assays showed that FGRadv ECs demonstrate fewer branch points and total length compared with those from gestational age-matched controls, and this defect was not rescued by exposure to hypoxia. FGRadv ECs also demonstrated lower aryl hydrocarbon receptor nuclear translocator (ARNT) expression. ARNT knockdown resulted in suppression of key angiogenic genes including vascular endothelial growth factor A expression and led to deficient tube formation.

CONCLUSIONS

ARNT expression in the placental vasculature mediates key angiogenic expression and fetoplacental EC angiogenesis, and low ARNT expression in FGRadv ECs appears to be a key factor in deficient angiogenesis. This, in turn, results in malformed thin villous vessels that structurally contribute to the abnormally elevated fetoplacental vascular resistance that is associated with high morbidity and mortality in fetal growth restriction.

Crosstalk between PKCα and Notch-4 in endocrine-resistant breast cancer cells

The Notch pathway is functionally important in breast cancer. Notch-1 has been reported to maintain an estrogen-independent phenotype in estrogen receptor α (ERα)+ breast cancer cells. Notch-4 expression correlates with Ki67. Notch-4 also plays a key role in breast cancer stem-like cells. Estrogen-independent breast cancer cell lines have higher Notch activity than estrogen-dependent lines. Protein kinase Cα (PKCα) overexpression is common in endocrine-resistant breast cancers and promotes tamoxifen (TAM)-resistant growth in breast cancer cell lines. We tested whether PKCα overexpression affects Notch activity and whether Notch signaling contributes to endocrine resistance in PKCα-overexpressing breast cancer cells.Analysis of published microarray data from ERα+ breast carcinomas shows that PKCα expression correlates strongly with Notch-4. Real-time reverse transcription PCR and immunohistochemistry on archival specimens confirmed this finding. In a PKCα-overexpressing, TAM-resistant T47D model, PKCα selectively increases Notch-4, but not Notch-1, expression in vitro and in vivo. This effect is mediated by activator protein-1 (AP-1) occupancy of the Notch-4 promoter. Notch-4 knockdown inhibits estrogen-independent growth of PKCα-overexpressing T47D cells, whereas Notch-4IC expression stimulates it. Gene expression profiling shows that multiple genes and pathways associated with endocrine resistance are induced in Notch-4IC- and PKCα-expressing T47D cells. In PKCα-overexpressing T47D xenografts, an orally active γ-secretase inhibitor at clinically relevant doses significantly decreased estrogen-independent tumor growth, alone and in combination with TAM. In conclusion, PKCα overexpression induces Notch-4 through AP-1. Notch-4 promotes estrogen-independent, TAM-resistant growth and activates multiple pathways connected with endocrine resistance and chemoresistance. Notch inhibitors should be clinically evaluated in PKCα- and Notch-4-overexpressing, endocrine-resistant breast cancers.

Utility of insulin-like growth factor receptor-1 expression in gefitinib-treated patients with non-small cell lung cancer

BACKGROUND

Insulin-like growth factor receptor 1 (IGF1R) is a proposed mechanism of resistance to epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors. Newer agents targeting this pathway make it of clinical interest. This study evaluates the IGF1R expression in regard to outcomes and molecular markers of EGFR activity in lung cancer patients treated with gefitinib.

MATERIALS AND METHODS

Gefitinib-treated patients with sufficient archived tissue were included. The IGF1R activity was measured by immunohistochemistry and the EGFR by immunohistochemistry, fluorescent in situ hybridization, and gene mutation testing. Logistic regression and cox proportional hazards models were used.

RESULTS

A total of 83 patients were included in the study: 71% were positive for IGF1R expression which was not associated with EGFR parameters or clinical outcomes. Exploratory analyses showed counter-intuitive improved outcomes with co-expression of IGF1R and EGFR.

CONCLUSION

IGF1R expression measured by immunohistochemistry does not appear to be related to gefitinib resistance.

PTEN and PIK3CA gene copy numbers and poor outcomes in non-small cell lung cancer patients with gefitinib therapy

METHODS

Fluorescent in situ hybridisation analyses of PTEN, PIK3CA, EGFR and CEN7 were performed on tumour specimens from patients treated on the expanded access gefitinib trial. Progression-free survival (PFS) and overall survival (OS) were correlated with outcomes in all patients and EGFR wild-type patients.

RESULTS

Progression-free survival (hazard ratio=2.54, P<0.001) and OS (hazard ratio=4.04, P<0.001) were significantly shorter in patients whose tumours had all of the following molecular patterns: CEN7 <4 copies per cell, PTEN loss (<2 copies in at least 20% of cells), and PIK3CA gain (>2 copies in at least 40% of cells) both in all and EGFR wild-type only patients.

CONCLUSION

The combination of low CEN7 copy number, PTEN loss, and PI3KCA gain may be useful for identifying NSCLC patients unlikely to benefit from treatment with EGFR (TKIs), specifically in wild-type EGFR cases.

Estrogen receptor-β and fetoplacental endothelial prostanoid biosynthesis: a link to clinically demonstrated fetal growth restriction

CONTEXT

Fetal growth restriction (FGR) due to placental dysfunction impacts short- and long-term neonatal outcomes. Abnormal umbilical artery Doppler velocimetry indicating elevated fetoplacental vascular resistance has been associated with fetal morbidity and mortality. Estrogen receptors are regulators of vasomotor tone, and fetoplacental endothelium expresses estrogen receptor-β (ESR2) as its sole estrogen receptor.

OBJECTIVE

Our objective was to elucidate the mechanism whereby ESR2 regulates placental villous endothelial cell prostanoid biosynthesis.

DESIGN AND PARTICIPANTS

We conducted immunohistochemical analysis of human placental specimens and studies of primary fetoplacental endothelial cells isolated from subjects with uncomplicated pregnancies.

MAIN OUTCOME MEASURES

We evaluated in vivo levels of ESR2 and cyclooxygenase-2 (PTGS2) in villous endothelial cells from fetuses with or without FGR and/or abnormal umbilical artery Doppler indices and in vitro effects of ESR2 on prostanoid biosynthetic gene expression.

RESULTS

ESR2 and PTGS2 expression were significantly higher within subjects with FGR with abnormal umbilical artery Doppler indices in comparison with controls (P < 0.01). ESR2 knockdown led to decreased cyclooxygenase-1 (PTGS1), PTGS2, prostaglandin F synthase (AKR1C3), and increased prostacyclin synthase (PTGIS), with opposing results found after ESR2 overexpression (P < 0.05). ESR2 mediates prostaglandin H2 substrate availability and, in the setting of differential regulation of AKR1C3 and PTGIS, altered the balance between vasodilatory and vasoconstricting prostanoid production.

CONCLUSIONS

Higher ESR2 expression in the placental vasculature of FGR subjects with abnormal blood flow is associated with an endothelial cell phenotype that preferentially produces vasoconstrictive prostanoids. Endothelial ESR2 appears to be a master regulator of prostanoid biosynthesis and contributes to high-resistance fetoplacental blood flow, thereby increasing morbidity and mortality associated with FGR.

Abstract 3831: Functional and epigenetic regulation of SHP-1 in early stage lung cancer

SHP-1 tyrosine phosphatase potentiates mitogenic signalling cascades in multiple cellular pathways by dephosphorylating inhibitory phospho-tyr sites on kinases. With its central role in regulation of cell proliferation, SHP-1 is a logical candidate biomarker for malignant transformation. SHP-1 dephosphorylates a number of phospho-targets including PI3 kinase, EGFR, src family kinases (SFK), and activated cKit, hence normally has a negative impact on cell proliferation. SHP-1 protein function is highly regulated by phosphorylation with up regulation at tyr536, and down regulated by ser591 phosphorylation. The objectives of the present study are to investigate functional control of SHP- 1 and epigenetic control of expression in non small cell lung cancer (NSCLC). In our previous study, Western blot analyses revealed inhibitory ser591 phosphorylation in two of five NSCLC cell lines that expressed high levels of SHP1. We now observe that si-RNA silencing of the major SFK expressed in the EGFR constitutively activated Calu3 cells results in decreased tyr536 phosphorylation suggesting that SFK are required for SHP-1 activity.

Transcription of the SHP-1 gene is regulated by two different promoters: a 3’ promoter (promoter 2) in lymphocytes and a 5’ promoter (promoter 1) in epithelial tissues. Gene silencing of SHP-1 by aberrant methylation of promoter 2 and loss of heterozygosity have been associated with pathogenesis of leukemias/lymphomas. Altered expression of SHP-1 has been reported in ovarian and breast cancer due to epigenetic changes in the 5’ promoter (promoter 1). Promoter 2 hypermethylation has been proposed as a plasma biomarker for lung cancer. Previous observations are consistent with the involvement of aberrant SHP-1 promoter 2 methylation in recurrent cases of NSCLC. Pyrosequencing analysis of 22 normal leukocytes, 19 normal lung specimens, 112 cases of early stage (Ib, IIa and IIb) NSCLC and 8 cell lines of SHP-1 promoter 1 vs promoter 2 methylation revealed 10.2% vs 5.1% in leukocytes, 32.6% vs 52.9% in normal lung 44.4% vs 58.6% in NSCLC, and 50.6% vs 96.2% in the cell lines. Hypermethylation of SHP-1 promoter 1 and promoter 2 were observed in 40.8% and 60.7% of lung tumors, respectively. Previous results showed an association of hypermethylation of promoter 2 with time to tumor recurrence in early stage patients (p=0.010). Hypermethylation of SHP-1 promoter 1 in the present study with a limited number of samples is marginally associated with shorter time to recurrence (25.5 months vs. median not reached; p=0.219). These results demonstrate tissue-specific epigenetic control of both SHP-1 promoters and suggest dysfunction of both epigenetic and post-translational regulation of signalling in early stage NSCLC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3831. doi:10.1158/1538-7445.AM2011-3831

Abstract 339: Rational selection of biomarkers to help direct erlotinib treatment for advanced non-small cell lung cancer (NSCLC)

Background: The objective of this study was to identify serum biomarkers capable of identifying which advanced NSCLC patients are likely to receive clinical benefit from erlotinib therapy regardless of EGFR mutational status. Although patients harboring tumors with specific EGFR activating mutations are more likely to respond to erlotinib treatment, randomized clinical trials have shown that 30-40%of patients with wild-type EGFRs may also receive clinical benefit in the form of stable disease. Our general approach uses bioinformatic algorithms on gene expression microarray data to predict which tumor-shed biomarkers to assay for in the circulation.

Methods and materials: Affymetrix U133A gene expression data (.CEL files) from Balko, et al. (BMC Cancer. 2009; 9: 145) were preprocessed in R using RMA and tested for differential expression using the Significance Analysis of Microarray (SAM) package. Pathway analysis was performed on the results based on KEGG and Gene ontogeny (GO) to define gene sets and tested for categorical significance by performing a Fisher Exact test. From these results, a selection of gene products either known or predicted to be secreted into circulation were combined with an assortment of previously investigated cancer biomarkers for further evaluation. Using pre-treatment serum from a total of 155 patients with advanced NSCLC we evaluated 43 biomarkers using the following MILLIPLEX®MAP immunoassay kits: Human Circulating Cancer Biomarker 24-plex, Human Soluble Cytokine Receptor 14-plex, and Human MMP panel 2 5-plex. Overall survival (OS) using the log rank test was the primary outcome for this study.

Result: Preliminary single biomarker statistical analysis revealed a total of 23 prognostic biomarkers correlated (1p&lt;0.01; 2 p&lt;0.001) with OS in advanced NSCLC patients receiving erlotinib (n=72). High concentration of Prolactin1, total PSA1, CA15-31, CA1251, HGF1, sTNFRI2, sTNFRII2, CYFRA 21-12, interleukin-62, and osteopontin2 correlated with lower OS; whereas sEGFR1, Leptin1, TRAIL1 were associated with higher OS. Although the full complement of data has not been processed, similar findings and trends were observed within the patient cohorts treated with platinum-based chemotherapy (n=83) suggesting that this biomarker panel may be primarily prognostic and not predictive for outcome with a specific therapy.

Conclusion: These serum biomarkers could be used to define a contingency-based algorithm that would ultimately be implemented alone or in tandem with a EGFR mutation analysis to provide a comprehensive means to both identify patients not likely to benefit from costly therapy and also allow patients to receive less toxic therapy earlier in their treatment course.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 339. doi:10.1158/1538-7445.AM2011-339

An algorithm for classifying tumors based on genomic aberrations and selecting representative tumor models

Background

Cancer is a heterogeneous disease caused by genomic aberrations and characterized by significant variability in clinical outcomes and response to therapies. Several subtypes of common cancers have been identified based on alterations of individual cancer genes, such as HER2, EGFR, and others. However, cancer is a complex disease driven by the interaction of multiple genes, so the copy number status of individual genes is not sufficient to define cancer subtypes and predict responses to treatments. A classification based on genome-wide copy number patterns would be better suited for this purpose.

Method

To develop a more comprehensive cancer taxonomy based on genome-wide patterns of copy number abnormalities, we designed an unsupervised classification algorithm that identifies genomic subgroups of tumors. This algorithm is based on a modified genomic Non-negative Matrix Factorization (gNMF) algorithm and includes several additional components, namely a pilot hierarchical clustering procedure to determine the number of clusters, a multiple random initiation scheme, a new stop criterion for the core gNMF, as well as a 10-fold cross-validation stability test for quality assessment.

Result

We applied our algorithm to identify genomic subgroups of three major cancer types: non-small cell lung carcinoma (NSCLC), colorectal cancer (CRC), and malignant melanoma. High-density SNP array datasets for patient tumors and established cell lines were used to define genomic subclasses of the diseases and identify cell lines representative of each genomic subtype. The algorithm was compared with several traditional clustering methods and showed improved performance. To validate our genomic taxonomy of NSCLC, we correlated the genomic classification with disease outcomes. Overall survival time and time to recurrence were shown to differ significantly between the genomic subtypes.

Conclusions

We developed an algorithm for cancer classification based on genome-wide patterns of copy number aberrations and demonstrated its superiority to existing clustering methods. The algorithm was applied to define genomic subgroups of three cancer types and identify cell lines representative of these subgroups. Our data enabled the assembly of representative cell line panels for testing drug candidates.

Abstract 4120: SHP-1 tyrosine phosphatase in early stage lung cancer

SHP-1 tyrosine phosphatase potentiates mitogenic signalling cascades in multiple cellular pathways, by dephosphorylating inhibitory phospho-tyr sites on kinases. The SHP-1 gene is highly expressed from a 3′ promoter (promoter 2) in lymphocytes, but not in lymphomas or leukemic cells. Gene silencing of SHP-1 by aberrant methylation and loss of heterozygosity has been associated with the pathogenesis of leukemias/lymphomas. With its central role in regulation of cell proliferation, SHP-1 is a logical candidate biomarker for malignant transformation, however, its role in solid tissues is unclear. SHP-1 dephosphorylates a number of phospho-targets including PI3 kinase, EFGR, src family kinases, and activated cKit, the stem cell factor receptor. Dephosphorylation of inhibitory phospho-tyr sites in these kinases results in increased signaling and gene expression. In the present study, western blot analyses of protein expression in two of four NSCLC cell lines which reportedly have silenced SHP-1 but had elevated levels of SHP-1 protein revealed inhibitory ser591 phosphorylation suggesting that this phosphatase was not activated in those cells. Altered expression of SHP-1 in leukemias and lymphomas was recently shown to be associated with clinical stage and pathogenesis with decreased levels evident in residual disease. Furthermore, altered expression of SHP-1 in epithelial tumors has been reported in ovarian and breast cancer, due to changes in the 5′ promoter (promoter 1) methylation. Previous observations by ourselves and others are consistent with the involvement of aberrant tumor suppressor gene promoter methylation in non-small cell lung cancer (NSCLC) particularly in recurrent cases. To investigate the role of epigenetic regulation of SHP-1 promoter 2 methylation in NSCLC, we used pyrosequencing to quantify methylation in 22 normal blood leukocytes, 19 normal lung specimens, 112 cases of early stage (Ib, IIa and IIb) NSCLC and 8 cell lines. Average SHP-1 promoter 2 methylation was 5.1% in leukocytes, 52.9% in normal lung 58.6% in NSCLC, and 96.2% in the cell lines. Promoter hypermethylation of SHP-1 (defined as more than 55% methylated) was observed in 68/112 of lung tumors. When compared to those tumors with methylation less than 55%, hypermethylation of SHP-1 at position −449 (+6025) was associated with shorter time to recurrence (51.4 months vs. 112 months; p=0.010) and marginally associated with five year survival (92.0 months vs. 125 months; p=0.073). These results demonstrate tissue-specific epigenetic control of SHP-1 promoter 2 and suggest a role for promoter 2-regulated signalling in early stage NSCLC. Furthermore, considering the relative low levels of SHP1 protein expression detected in the lung cancer cell lines, SHP-1 promoter 1 methylation in NSCLC is currently under investigation.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4120.

Abstract 823: Identification of FISH biomarkers to detect chromosome abnormalities associated with prostate adenocarcinoma in tumor and field effect environment

Introduction. The focal nature of prostate cancer (CA) contributes to needle biopsy sampling error with false negative rates of 15-30%. Here we used fluorescence in situ hybridization (FISH) analysis to assess molecular abnormalities in prostate specimens as an aid to CA diagnosis. We also evaluated the feasibility of combined immunofluorescence and FISH to facilitate assessment of chromosomal abnormalities.

Experimental Procedure. 33 radical prostatectomy (RP) specimens from patients with adenocarcinoma of the prostate were evaluated by FISH with MYC, LPL, PTEN and centromere 8 probes. For each specimen, a tissue section was scribed by a pathologist to mark the tumor region(s). For 17 of the RP cases, a second section was available with only histologically benign tissue. FISH signals were enumerated in 50-100 cells per section. 26 hyperplasia (BPH) specimens, served as controls. Immunofluorescence (IF) with AMACR antibody was also used in the same assay with FISH.

Results. Chromosomal copy number abnormalities were observed in most RP specimens, both within tumor regions and extending beyond histologically evident tumor, while few abnormalities were observed in the BPH specimens, using a cut-off value for FISH positivity based on the mean +/- 2 SD of cells with less than or greater than 2 signals in BPH specimens. A combination of MYC gain, LPL loss, PTEN loss or chromosome 8 aneusomy within the scribed tumor regions identified adenocarcinoma in 82% (27/33) of RP specimens, with a specificity of 81% relative to BPH (χ2 p&lt;0.001). When detected in regions of normal histology, these abnormalities correlated with adenocarcinoma in 47% (8/17 RP specimens, χ2 p=0.05 relative to BPH). IF combined with FISH facilitated selection of the abnormal regions of interest for molecular assessment in the heterogeneous prostate specimens. The IF-staining closely correlated with morphological assessment of tumor by a trained pathologist.

Conclusions. This study identified FISH probes for detection of chromosomal abnormalities associated with prostate CA that could potentially serve as a diagnostic aid in biopsy specimens. This study also indicates that chromosome abnormalities are present in RP specimens within regions of normal histology, indicating a substantial tumor field effect. Therefore, a molecular test based on FISH to measure abnormal MYC, LPL, PTEN and centromere 8 copy numbers may allow detection of cancer otherwise missed by histopathological examination and thus improve diagnosis of prostate cancer by reducing sampling error of needle biopsies.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 823.

PTEN, RASSF1 and DAPK site-specific hypermethylation and outcome in surgically treated stage I and II nonsmall cell lung cancer patients

The primary objective of this study is to identify prognostic site-specific epigenetic changes in surgically treated Stage I and II nonsmall cell lung cancer (NSCLC) patients by quantifying methylation levels at multiple CpG sites within each gene promoter. Paraffin-embedded tumors from stage Ib, IIa and IIb in training and validation groups of 75 and 57 surgically treated NSCLC patients, respectively, were analyzed for p16, MGMT, RASSF1, RASSF5, CDH1, LET7, DAPK and PTEN promoter hypermethylation. Hypermethylation status was quantified individually at multiple CpG sites within each promoter by pyrosequencing. Molecular and clinical characteristics with time to recurrence (TTR) and overall survival (OS) were evaluated. Overall average promoter methylation levels of MGMT and RASSF1 were significantly higher in smokers than in nonsmokers (p = 0.006 and p = 0.029, respectively). Methylation levels of the p16 promoter were significantly higher in squamous cell carcinoma than in adenocarcinoma (p = 0.020). In univariate analysis, hypermethylation of RASSF1 at CpG sites -53 and -48 and PTEN at CpG site -1310 were the significantly associated with shorter TTR (p = 0.002 and p < 0.000, respectively). Hypermethylation of PTEN at -1310 and DAPK at -1482 were most significantly associated with outcome in multivariate analysis. These results show that methylation of specific promoter CpG sites in PTEN, RASSF1 and DAPK is associated with outcome in early stage surgically treated NSCLC.

N-cadherin, E-cadherin, ERCC1, and c-kit expression in small cell lung cancer (SCLC) and potential for new therapeutic targets

e22157

Background: Minimal advances have been made in the treatment of SCLC. Molecular markers may allow us to better stratify patients (pts) for new treatment options and drug combinations. The objective of our study was to determine the frequency and potential prognostic significance of N-cadherin (N-cad), E-cadherin (E-cad), ERCC1, and c-kit (CD117) expression in SCLC. Methods: Tissue from 132 pts with SCLC was retrospectively stained for N-cad, E-cad, ERCC1, and c-kit. Frequency of expression (% of tumor cells staining positive) was measured on a scale of 0–4 (freq 0=no expression (<1%), freq 1=1–10%, freq 2=11–35%, freq 3=36–70%, freq 4=71–100%). Charts were reviewed for stage, performance status, date of diagnosis/death, survival, and treatment (type, dates, response). The frequency of molecular markers was correlated with clinical data and overall survival. Results: Age range 42 to 97 years, 65 male:67 female, and 64 had limited and 68 had extensive stage. Of the 132 pts, 75% had tumors that expressed (frequency ≥ 1) N-cad, 58% E-cad, 70% ERCC1, and 55% c-kit. Comparing tumor marker expression with survival using either the Log-Rank Test or the Wilcoxon Test, there was no significant association for N-cad, E-cad, or ERCC1. However, tumors that expressed c-kit with frequency ≥ 3 had a trend toward superior survival compared with frequency < 3. Median survival for c-kit frequency ≥ 3 was 496 days compared to 312 days for frequency < 3 (p = 0.09, Log-Rank Test). Conclusions: In our retrospective study of 132 SCLC pts, we found that all 4 markers were expressed in greater than 50% of specimens, and that higher c-kit expression was associated with marginally significant increase in overall survival. Though previous experience with imatinib alone or with chemotherapy showed limited clinical activity in unselected SCLC pts, given preclinical synergy with cisplatin, it seems reasonable to consider combination therapy with cisplatin/etoposide and imatinib in pts selected for high c-kit expression.

[Table: see text]

No significant financial relationships to disclose.

Tumor survivin expression in locally advanced non-small cell lung cancer (NSCLC) patients treated with platinum-based chemoradiation followed by surgical resection

7595

Background: Recently tumor molecular markers have shown promise as prognostic and predictive indicators for survival in early and advanced stage NSCLC patients (pts.) treated with chemotherapy. The objective of this study was to correlate immunohistochemistry (IHC) markers of pre-treatment biopsies in locally advanced NSCLC patients treated with concurrent platinum based chemoradiation followed by surgical resection. Methods: This is a retrospective study that included stage III NSCLC pts who had adequate pre-treatment tumor specimens and were treated with platinum based chemotherapy regimens and concurrent thoracic radiation (40 Gy). Thirty three pts had sufficient pre-treatment tissue for IHC and were identified from a surgical database. Cells were stained by IHC for frequency (0–4) and intensity (0–4) of ERCC1, PTEN, and survivin and analyzed by log-rank and multivariate Cox PH regression for potential relationships to pathologic complete response (pCR), time to recurrence (TTR), and overall survival (OS). Results: Characteristics of 33 pts: 15 females; median age 61; 17 adenocarcinoma, 10 squamous(sq), 5 undifferentiated, 1 adeno-sq. Median OS was 23 months (mo) (5.9–140), and median TTR was 14.7 mo (3.5–121). Following chemoradiation, 9 patients had pCR. pCR was associated with improved TTR, p < .027. ERCC1 and PTEN were not significantly related to OS, TTR, or pCR. High nuclear survivin frequency (>2) was associated with worse OS, HR 0.4, p< .045 and lower nuclear survivin intensity (<4) was marginally associated with pCR, p< .10. Conclusions: In this exploratory analysis, higher survivin expression was associated with worse prognosis in locally advanced NSCLC patients treated with chemoradiation followed by surgery. These results suggest that additional studies of survivin are warranted in NSCLC and that adding survivin inhibitors to chemoradiation is a reasonable strategy for locally advanced NSCLC with high survivin expression.

No significant financial relationships to disclose.

Selecting Patients for Treatment with Epidermal Growth Factor Tyrosine Kinase Inhibitors

Identification of objective tumor regressions with epidermal growth factor receptor tyrosine kinases (EGFR TKI) in non-small cell lung cancer (NSCLC) patients has resulted in intense, worldwide clinical and basic research directed toward finding the optimal use of EGFR TKIs in NSCLC. EGFR TKI clinical trials have shown that higher response rates and longer survival are associated with specific patient characteristics and that using conventional chemotherapy simultaneously with EGFR TKIs in unselected patients does not increase survival. Molecular studies have revealed that EGFR-activating mutations and high EGFR gene copy number are frequently found in patients who have the best outcomes with EGFR TKIs. More recent studies suggest that KRAS mutations may identify the subset of patients who have the worst outcome with the EGFR TKI treatment. Currently, investigators are trying to determine the optimal approach to selecting patients for treatment with EGFR TKIs. Studies that have evaluated the potential predictive value of clinical features and/or molecular profiles in EGFR TKI-treated NSCLC patients are discussed in this review.

Clinical and molecular characteristics of advanced non-small cell lung cancer (NSCLC) patients (pts) with rapid progressive disease (RPD) on gefitinib therapy (G)

7592

Background: Prognostic factors associated with better outcomes (EGFR mutations (mut), high EGFR gene copy number, never smoking) can be used to select pts for EGFR tyrosine kinase inhibitor (TKI) combination trials, but would exclude the majority of NSCLC pts. Excluding pts with the worst likely outcomes is another strategy that may result in more pts who could benefit from the combination of a TKI with other agents. Our objective was to identify clinical and molecular characteristics associated with RPD (=70 days) and shorter progression-free survival (PFS) in previously treated NSCLC pts receiving G. Methods: Consecutive Expanded Access Trial pts with >1 week G were included for analysis. Tissue from 87 pts was evaluated for EGFR, pAKT and PTEN protein expression by immunohistochemistry; 58 tumors were analyzed for mut and sum of CA dinucliotide repeats (ΣCA rpts) by SSCP, PCR and sequencing. Results: There were 150 pts; 77 female, median (md) age 67. Md follow-up was 5.8 months (mo). Objective response was 8% (2CR, 10PR, 56 SD, 82 RPD). Md Kaplan-Meier PFS and survival were 2.0 and 5.8 mo, respectively. See table for univariate results. Smoking, Mut-PTEN-, EGFR-PTEN- and EGFR-pAKT- tumors were associated with shorter PFS. Separate clinical and molecular multivariate models were developed. In logistic regressions, non-adenocarcinoma histology (N- A), p=0.004, =12 mo from diagnosis to G (dx-G =12 mo), p=0.0009, lack of mut (p=0.0298) and ΣCA rpts <34 (p=0.0622) were associated with RPD. In Cox regressions, N-A (p=0.0256), dx-G =12 mo (p=0.0166) and lack of mut (p=0.0298) were associated with shorter PFS. Conclusions: N-A, dx-G =12 mo and lack of mut were associated with RPD and shorter PFS in univariate and multivariate analyses. ΣCA rpts <34 and double-negative molecular combinations were also related to worse outcome. These clinical and molecular characteristics may warrant further study as exclusion criteria for TKI combination clinical trials.

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EGFR mutations (muts), IHC and FISH status, and chromosome 7 gene copy number combined with pAkt expression as potential predictors of survival in non-small cell lung cancer (NSCLC) patients (pts) treated with gefitinib (GEF)

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Background: EGFR and pAkt expression by immunohistochemistry (IHC), muts, and FISH status have been identified as possible molecular predictors for GEF efficacy in NSCLC (Cappuzzo, et. al, JNCI, 2005). The goal of this study was to independently evaluate these findings regarding survival (surv), and to assess the predictive value of mean chromosome 7 copy number/cell (C7). Methods: 150 consecutive Expanded Access Trial pts with >1 week GEF therapy were included for analysis. IHC (present vs not detected) was performed for 87 pts, and 58 pts were analyzed for muts by SSCP, mut-specific PCR, and sequencing. Tissue from 81 pts was evaluated for EGFR and C7 gene copy numbers by fluorescence in situ hybridization (FISH). Results: 150 pts (77 female, 73 male; median (md) age 67; 85 adenocarcinoma) received GEF; md follow-up was 5.8 months (mo). Overall response was 8% (2 CR, 10 PR); 56 pts had stable disease. Md Kaplan-Meier surv was 5.9 mo. IHC revealed that 47/87 pts (54%) had EGFR+, and 36/75 pts (48%) had pAkt + tumors. pAkt+ pts had significantly (sig) longer surv than pAkt− pts (11.4 vs 5.8 mo, p < .05). High polysomy was seen in 36/81 pts (44%) who were designated FISH+; 45 pts were FISH−. EGFR IHC and FISH positivity were not sig associated with surv. C7 was defined as low (<3.6, 63 pts) or high (≥3.6, 18 pts); md surv was 6.6 and 17.1 mo, respectively, p < .01. Muts were found in 17/58 tumors (29%). Md surv for pts with and without muts was 23.8 and 7.9 mo, respectively, p < .07. EGFR IHC− pAkt− pts (18 pts) had sig shorter surv than 57 pts with any pos value (4.7 vs 8.8 mo, p < .02). Double-positive pts had sig longer surv than pts with any neg value. Conclusions: These findings resemble but do not duplicate those reported by Cappuzzo, et al. Additionally, high C7, alone or combined with pAKT, may be an important predictor for GEF efficacy in NSCLC. Further studies of C7, a technically simple and reproducible FISH assay, are warranted.

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Gastrointestinal hemorrhage in advanced non-small cell lung cancer (NSCLC) patients treated with erlotinib and celecoxib

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Background: Erlotinib (E) was associated with superior survival in a phase III trial of previously treated advanced NSCLC patients (pts). Celecoxib (C) has been shown to potentiate the apoptotic and growth inhibitory effects of E in pre-clinical models. Methods: This was a phase II trial of E plus C in advanced NSCLC pts that failed one prior chemotherapy regimen. Primary endpoint: efficacy; secondary endpoint: toxicity. Pts received C (400mg b.i.d.) and E (150mg daily) until disease progression. Planned accrual: 40 pts. Results: 26 pts with stage IIIB/IV NSCLC were enrolled. Patient (pt) characteristics: male 65%; median age 66; ECOG performance status 0/1- 96%. Eighteen pts had tissue available for FISH and EGFR mutation analysis: 50% had chromosome 7 polysomy (> 4 copies per cell); none had EGFR gains (>2 EGFR/chromosome 7). Two pts had an EGFR gene mutation (1 exon 19, 1 exon 21). Response results: partial response- 2 pts (1 with exon 19 mutation), stable disease- 8 pts, and progressive disease- 16 pts (1 with exon 21 mutation). Median progression free survival (PFS) and overall survival (OS): 1.9 and 10.2 months, respectively. Grade 3/4 upper gastrointestinal bleeding (GIB) occurred in 4 pts prompting study closure. One pt was on therapeutic dalteparin and two pts receiving warfarin developed marked INR prolongation (INR >10). The fourth pt had a history of peptic ulcer disease. Platelet counts at time of GIB: 142 - 559. Three pts had endoscopy and gastric or duodenal ulcers were found in all three cases. No pts were taking anti-acid medication at the time of GIB. No other pts were on therapeutic anticoagulation. Three pts without upper GIB were taking low-dose aspirin. Other toxicities: 85% grade 1/2 rash; 65% grade 1/2 diarrhea, 30% grade 1/2 nausea, 30% grade 1/2 fatigue (one grade 3 fatigue); one grade 3 pneumonitis, one grade 3 esophageal stricture. Conclusions: These observations suggest that C plus E may be associated with increased incidence of gastrointestinal ulceration and GIB and that the regimen should not be given to pts with a previous history of peptic ulcer disease or to pts requiring therapeutic anticoagulation. Based on response rate, PFS, and OS in this group of pts, it appears that results with E and C are similar to those reported for E alone.

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Safety and efficacy of a continuous infusion, patient controlled anti-emetic pump to facilitate outpatient administration of high-dose chemotherapy

We evaluated the combination of diphenhydramine, lorazepam, and dexamethasone delivered as a continuous i.v. infusion via an ambulatory infusion pump with patient-activated intermittent dosing (BAD pump) for prevention of acute and delayed nausea/vomiting in patients receiving high-dose chemotherapy (HDC) for peripheral blood progenitor cell (PBPC) mobilization (MOB) or prior to autologous PBPC rescue. The BAD pump was titrated to patient response and tolerance, and continued until the patient could tolerate oral anti-emetics. Forty-four patients utilized the BAD pump during 66 chemotherapy courses, 34 (52%) for MOB and 32 (48%) for HDC with autologous PBPC rescue. The median number of days on the BAD pump during MOB and HDC was 3 (1-6) and 9 (2-19) days, respectively. Complete overall or complete emesis control occurred on 94% of MOB and 89% of HDC treatment days during chemotherapy administration and 72% and 43%, respectively, following chemotherapy administration. Eighty-three percent of MOB and 55% of HDC treatment days were associated with no nausea. While on the BAD pump, no patient experienced severe toxicity or required hospitalization for management of nausea/vomiting. The BAD pump was safe and effective in minimizing nausea and vomiting associated with HDC, and thus, eliminated the need for hospitalization for management of chemotherapy-induced nausea and vomiting.

Assessment of apoptosis in relation to proliferation and mutational status of p53 gene in head and neck cancers

The present studies were undertaken to determine the incidence of apoptosis in plastic embedded head and neck (HN) tumor biopsies (n=31) using in situ end labeling (ISEL) of fragmented DNA. The extent of spontaneous apoptosis in untreated tumors was correlated with histological grade, percent S-phase cells (Labeling Index, LI) and with the mutational status of p53 gene in these tumors. Additionally, the in vivo effects of chemo- and/or radiotherapy on apoptosis were evaluated in seven patients. In the majority of tumors studied (25/31) spontaneous apoptosis was virtually undetectable or was very low (1-15% positively labeled cells). Only 6 tumors showed intermediate to high apoptosis (>15% positively labeled cells). High apoptosis was more frequent in poorly differentiated tumors (similar to 50%), as compared to well and moderately differentiated tumors. The median LI for 31 tumors studied was 20.2%. The mean LI for moderately differentiated tumors (23.7+/-1.7%) was significantly higher than that in well differentiated (15.1+/-2.1%, p=0.005) and was comparable in poorly differentiated tumors (24.5%). Cytotoxic therapy significantly increased the degree of apoptosis in 5/7 specimens studied (p=0.03). Double labeling of 5 of these tumors before and after the therapy, combining ISEL with detection of IUdR/BrdU, showed compartmentalized apoptosis and proliferation with virtually no double labeled cells in any specimen. Interestingly, tumors with a mutated p53 gene (n=6) showed intermediate to high degree of pretherapy, baseline apoptosis in contrast to low or undetectable levels of apoptosis in tumors bearing wild-type p53 (n=13, p=0.034). It appears that low levels of apoptosis and high proliferation may be characteristic of HN tumors. The spontaneous apoptosis in HN tumors seems unrelated to mutations in the p53 gene. Moreover, our data also show that despite overall increase in apoptosis induced by cytotoxic therapy, some proliferating tumor cells escaped the effects of therapy, which may contribute to the tumor relapse.

Correlation of colony-forming cells, long-term culture initiating cells and CD34+ cells in apheresis products from patients mobilized for peripheral blood progenitors with different regimens

Peripheral blood progenitor cell (PBPC) populations used for transplantation were analyzed for the presence of CD34+ cells, colony-forming cells (initial CFC), and long-term culture initiating cells (LTC-IC) cultured on irradiated stroma for 5 weeks. Thirty-eight leukapheresis products were studied from 11 patients with breast cancer, 2 with non-Hodgkin's lymphoma and 1 with ovarian cancer harvested during recovery from either cyclophosphamide (CY) chemotherapy or cyclophosphamide-VP16 with G-CSF (CY-VP-G). CY-VP-G products had a threefold higher median number of mononuclear cells collected, a fivefold higher median concentration of CD34 and LTC-IC and a threefold higher concentration of initial-CFC when compared with CY products. CY-VP-G products had a significantly higher ratio of CFU-GM to BFU-E than the CY-mobilized products. Significant correlations of r = 0.89 and r = 0.68 were observed when comparing CD34 and CFC in products from CY or CY-VP-G patients, respectively. Analysis of the regression lines indicated that slopes of these regression lines were significantly different with a ratio of CD34 to initial CFC of 15:1 in the CY-VP-G products versus 5.2:1 with the CY products. These data indicate a higher cloning efficiency of the CD34+ population in the products from CY-mobilized patients. Significant correlations of r = 0.9 (CY) and r = 0.53 (CY-VP-G) were observed when the initial CD34 concentration and the LTC-IC were compared. Comparison of initial CFC with LTC-IC also showed significant correlations (r = 0.94, CY; r = 0.58, CY-VP-G) in samples from both patient groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of a C-reactive protein neoantigen (neo-CRP) in inflamed rabbit liver and muscle

We have reported that human C-reactive protein (huCRP) can exist in two antigenically distinct forms which are observed as the native, pentameric, phosphorylcholine (PC)-binding CRP ("native-huCRP antigen"), and as a conformationally and physicochemically distinct free huCRP subunit ("neo-huCRP antigen"), respectively. We have demonstrated that forms of huCRP which preferentially express neo-huCRP antigenicity are naturally present on the surface of both normal human peripheral blood B lymphocytes and lymphocytes with natural killer cell activity. We have also reported that forms of huCRP expressing the neo-huCRP antigen have potent in vitro activities in platelet, polymorphonuclear leukocyte, and monocyte assays. In this study, we demonstrate a rabbit-CRP (raCRP) neoantigen can be expressed when isolated PC-binding raCRP is modified in analogy to huCRP. This "neo-raCRP" is cross-reactive with the neo-huCRP antigen and occurs naturally in acute phase but not normal rabbit liver and muscle. The relative distribution and localization of both antigens were comparable in tissue sections taken at 24 and 48 hr postinflammation elicited with typhoid vaccine. These data support the concept that CRP molecules expressing a structure and antigenicity which are distinct from native, pentagonal CRP do occur in vivo, and that such molecules accumulate at tissue sites of inflammation and necrosis.

Properties of Conjugated Protein Immunogens Which Selectively Stimulate Delayed-Type Hypersensitivity

If bovine serum albumin (BSA) is covalently conjugated with dodecanoic acid, its ability to stimulate delayed-type hypersensitivity (DTH) is enhanced whereas its ability to stimulate antibody production is suppressed. Conjugates of BSA prepared with negatively charged succinyl groups and positively charged amidine groups were unable to stimulate any detectable DTH to BSA even though their ability to bind anti-BSA antibody in a radioimmunoassay was similar to that of dodecanoyl-BSA which stimulated strong, sustained DTH. By analyzing a series of conjugates of BSA with fatty acids of varying chain length, we found that the enhancement of the ability of a preparation to stimulate DTH to BSA could be separated from the suppression of its ability to stimulate antibody formation. The ability of a preparation to stimulate DTH correlated with the covalent conjugation of a large number of hydrophobic groups whereas the suppression of the ability to stimulate antibody formation correlated with covering of antibody-combining sites as measured in a radioimmunoassay.

Properties of conjugated protein immunogens which selectively stimulate delayed-type hypersensitivity

If bovine serum albumin (BSA) is covalently conjugated with dodecanoic acid, its ability to stimulate delayed-type hypersensitivity (DTH) is enhanced whereas its ability to stimulate antibody production is suppressed. Conjugates of BSA prepared with negatively charged succinyl groups and positively charged amidine groups were unable to stimulate any detectable DTH to BSA even though their ability to bind anti-BSA antibody in a radioimmunoassay was similar to that of dodecanoyl-BSA which stimulated strong, sustained DTH. By analyzing a series of conjugates of BSA with fatty acids of varying chain length, we found that enhancement of the ability of a preparation to stimulate DTH to BSA could be separated from the suppression of its ability to stimulate antibody formation. The ability of a preparation to stimulate DTH correlated with the covalent conjugation of a large number of hydrophobic groups whereas the suppression of the ability to stimulate antibody formation correlated with covering of antibody-combining sites as measured in a radioimmunoassay.

Selective Induction of Delayed Hypersensitivity by a Lipid Conjugated Protein Antigen Which Is Localized in Thymus Dependent Lymphoid Tissue

Multiple injections of bovine serum albumin (BSA) without adjuvant stimulate production of large amounts of antibody but no detectable delayed type hypersensitivity (DTH) in guinea pigs. In contrast, single or multiple injections of BSA heavily conjugated with a lipid, dodecanoic acid, without adjuvant, stimulated sustained DTH but no detectable antibody production. The DTH produced was specific for native BSA and no detectable immune response was produced against the fatty acid groups. This change in the type of immune response produced was associated with a change in the area of antigen localization in popliteal lymph nodes. Native BSA labeled with 125I was localized in germinal centers in the bone marrow derived cell area but was not detectable in the thymic dependent or thymus derived (T) cell area of the lymph nodes. In contrast, lipid conjugated BSA labeled with 125I was prominently localized in the thymic dependent area of the lymph nodes but was not found in the germinal centers of animals producing pure DTH reactions. These results suggest that the well known ability of lipids to enhance the production of DTH may be in part due to a lipid-mediated localization of antigen within the thymic dependent area of lymph nodes where it is in close association with many T type lymphocytes.