New Echocardiography Reference Ranges for Aotearoa (NewERA) Study: the application of international echocardiographic reference values to linear measurements of the hearts of healthy, young Māori and Pacific adults may not detect cardiac enlargement

AIMS

To develop ethnic-specific echocardiography reference ranges for Aotearoa, and to investigate the impact of indexation to body surface area (BSA). Current reference international ranges are derived from people of mostly NZ European ethnicity and may not be appropriate for Māori and New Zealanders of Pacific ethnicity, who both experience high rates of cardiovascular disease.

METHODS

Echocardiography was performed in a cross-sectional study of 263 healthy adults (18-50 years): Māori (N=71, 43 female), Pacific (N=53, 28 female), European (N=139, 74 female). Linear measurements of the left heart are reported and indexed to BSA. The upper/lower limit of normal (ULN/LLN) by ethnicity and sex were derived (quantile regression). Ethnic- and sex-specific differences were examined using ANOVA.

RESULTS

The ULN was higher for all un-indexed dimensions in men compared to women, and for most indices the ULN was smallest in NZ Europeans and largest in Māori and Pacific peoples. Indexation reversed these relationships: NZ Europeans had higher ULN for many measurements.

CONCLUSIONS

Indexing to BSA introduced bias that preferences the NZ European ethnicity by creating an upper limit reference threshold that far exceeds this sample's upper range. As a result, this may lead to under-recognition of cardiac enlargement in Māori and Pacific patients, and in particular for women. Unique reference ranges for all ethnic groups and sexes are required to optimally detect and manage cardiovascular diseases (CVD) in Aotearoa.

Associations of loneliness and social isolation with physical and mental health among adolescents and young adults

AIMS

The present study investigates whether loneliness and social isolation are associated with poor physical and mental health among adolescents and young adults, and whether age and gender play a role in the associations of loneliness and social isolation with mental and physical health.

METHODS

This study used cross-sectional self-report data from the 2017 Danish Health and Morbidity Surveys titled 'How are you?' (N = 19,890, M = 22.6 years).

RESULTS

Logistic regression analyses showed that loneliness and social isolation were independently associated with poor physical and mental health. Loneliness was associated with increased odds of asthma, migraine, osteoarthritis, rheumatoid arthritis, hypertension, slipped disc/back pain, tinnitus, long-term mental illness, depressive symptomatology, anxiety symptomatology and alcohol problems. Social isolation was associated with decreased odds of having migraine, osteoarthritis and alcohol problems, and an increased risk of long-term mental illness and depressive symptomatology. Small age and gender differences were detected.

CONCLUSIONS

In adolescents and young adults, loneliness and social isolation were associated with poor mental health and loneliness with poor physical health. These findings highlight the need for targeted prevention and intervention initiatives to alleviate loneliness and social isolation.

Loneliness, social isolation, and chronic disease outcomes

Background

Research suggests that loneliness and social isolation are serious public health concerns. However, our knowledge of the associations of loneliness and social isolation with specific chronic diseases is limited. The present prospective cohort study investigated (a) the longitudinal associations of loneliness and social isolation with four chronic diseases (cardiovascular disease [CVD], chronic obstructive pulmonary disease [COPD], diabetes mellitus Type 2 [T2D], and cancer), (b) the synergistic association of loneliness and social isolation with chronic disease, and (c) baseline psychological and behavioral explanatory factors.

Methods

Self-reported data from the 2013 Danish “How are you?” survey (N = 24,607) were combined with individual-level data from the National Danish Patient Registry on diagnoses in a 5 year follow-up period (2013-2018).

Results

Cox proportional hazard regression analyses showed that loneliness and social isolation were independently associated with CVD (loneliness: adjusted hazard ratio (AHR) = 1.20, 95% confidence interval [CI; 1.03, 1.40]; SI: AHR = 1.23, 95% CI [1.04, 146]) and T2D (loneliness: AHR =1.90, 95% CI [1.42, 2.55]; SI: AHR = 1.59, 95% CI [1.15, 2.21]). No significant associations were found between loneliness or social isolation and COPD and cancer, respectively. Likewise, loneliness and social isolation did not demonstrate a synergistic effect on chronic disease. Multiple mediation analysis indicated that loneliness and social isolation had an indirect effect on CVD and T2D through both baseline psychological and behavioral factors.

Conclusions

Loneliness and social isolation were independently associated with a diagnosis of CVD and T2D within a 5 year follow-up period. The associations of loneliness and social isolation with CVD and T2D were fully explained by baseline psychological and behavioral factors.

Key messages

Individuals exposed to loneliness and social isolation constitute vulnerable groups in risk of chronic disease. Psychological and behavioural factors explain the associations with chronic disease.

Loneliness, social isolation and healthcare utilisation in the general population

Background

The present prospective cohort study investigated the association of loneliness and social isolation with healthcare utilisation in the general population over time. We also investigated the synergistic effect of loneliness and social isolation on healthcare utilisation.

Methods

Data from the 2013 Danish “How are you?' survey (n = 29,472) were combined with individual-level register data from the National Danish Patient Registry and the Danish National Health Service Registry in a 6-year follow-up period (2013-2018). Negative binomial regression analyses were performed while adjusting for baseline demographics, chronic disease, and healthcare utilisation during the follow-up period.

Results

Loneliness was significantly associated with number of GP visits (incident-rate ratio (IRR) = 1.06, 95% confidence interval (CI) [1.01, 1.13]), emergency admissions (IRR = 1.19, 95% CI [1.03, 1.37]) and number of hospital admission days (IRR = 1.32, 95% CI [1.08, 1.62]). No significant associations were found between social isolation and healthcare utilisation with one minor exception, in which social isolation was associated with less planned admissions (IRR = .88, 95% CI [.78, .99]). Finally, loneliness and social isolation demonstrated a synergistic effect on number of visits to the GP (IRR = .87, 95% CI [.78, .98]) and number of hospital admission days (IRR = .67, 95% CI [.45, .98]).

Conclusions

Our findings suggest that loneliness is a risk factor for primary and secondary healthcare utilisation, independently of social isolation, baseline demographics, chronic disease, and healthcare utilisation during the follow-up period.

Key messages

Loneliness is an independent risk factor for healthcare utilisation in the general population. Social isolation is not associated with healthcare utilisation in the general population.

RET fusions in a small subset of advanced colorectal cancers at risk of being neglected

Background

Recognition of rare molecular subgroups is a challenge for precision oncology and may lead to tissue-agnostic approval of targeted agents. Here we aimed to comprehensively characterize the clinical, pathological and molecular landscape of RET rearranged metastatic colorectal cancer (mCRC).

Patients and methods

In this case series, we compared clinical, pathological and molecular characteristics of 24 RET rearranged mCRC patients with those of a control group of 291 patients with RET negative tumors. RET rearranged and RET negative mCRCs were retrieved by systematic literature review and by taking advantage of three screening sources: (i) Ignyta's phase 1/1b study on RXDX-105 (NCT01877811), (ii) cohorts screened at two Italian and one South Korean Institutions and (iii) Foundation Medicine Inc. database. Next-generation sequencing data were analyzed for RET rearranged cases.

Results

RET fusions were more frequent in older patients (median age of 66 versus 60 years, P = 0.052), with ECOG PS 1-2 (90% versus 50%, P = 0.02), right-sided (55% versus 32%, P = 0.013), previously unresected primary tumors (58% versus 21%, P < 0.001), RAS and BRAF wild-type (100% versus 40%, P < 0.001) and MSI-high (48% versus 7%, P < 0.001). Notably, 11 (26%) out of 43 patients with right-sided, RAS and BRAF wild-type tumors harbored a RET rearrangement. At a median follow-up of 45.8 months, patients with RET fusion-positive tumors showed a significantly worse OS when compared with RET-negative ones (median OS 14.0 versus 38.0 months, HR: 4.59; 95% CI, 3.64-32.66; P < 0.001). In the multivariable model, RET rearrangements were still associated with shorter OS (HR: 2.97; 95% CI, 1.25-7.07; P = 0.014), while primary tumor location, RAS and BRAF mutations and MSI status were not.

Conclusions

Though very rare, RET rearrangements define a new subtype of mCRC that shows poor prognosis with conventional treatments and is therefore worth of a specific management.

Educational renewal of physician training in Australia and New Zealand: Multiple educational innovations in a complex environment

AIM

The Royal Australasian College of Physicians is renewing its specialty training programs and shifting towards competency-based medical education. Our aim is to improve the quality and rigor of training and graduate outcomes, and promote high standards of physician practice to serve the health of patients, families, and communities in a changing healthcare environment.

METHODS

We are progressing holistic change and multiple educational innovations in a complex environment. Numerous stakeholders, a disparate training landscape and a largely volunteer supervisor workforce pose challenges in supporting effective implementation. This paper describes our progress and experience with three key components of our education renewal program: curricular renewal, a new selection process and faculty development. It offers reflections on the practical challenges, lessons learned and factors critical for success.

CONCLUSIONS

Our experience highlights opportunities for training organizations to maximize their influence over workplace training experiences and outcomes by taking a systems approach to the design, delivery and evaluation of the components of education renewal. We found that design, development and delivery of our multiple educational innovations have benefited from co-design approaches, progressive and concurrent development, continual exploration of new strategies, and implementation as soon as viable with a commitment to iterative improvements over time.

Place of Abdominoperineal Excision in Rectal Cancer

In an attempt to elucidate if and when there is a place for abdominoperineal excision in rectal cancer, we have evaluated survival, risk of local recurrence and functional results of alternative procedures. There seems to be no difference in survival rate after intended curative surgery for rectal cancer between rectal excision and sphincter-saving resection. This is also true with respect to risk of local recurrence, except in patients with poorly differentiated Dukes’ C tumours, where the risk of significant distal intramural spread is increased.

Functional results are satisfactory after low anterior resection with colorectal anastomosis, whereas coloanal anastomosis is followed by less satisfactory results especially in elderly patients. In these patients rectal excision with a permanent colostomy is probably preferable.

Quality control for the first large areas of triple-GEM chambers for the CMS endcaps

The CMS Collaboration plans to equip the very forward muon system with triple-GEM detectors that can withstand the environment of the High-Luminosity LHC. This project is at the final stages of R&D and moving to production. An unprecedented large area of several 100 m2 are to be instrumented with GEM detectors which will be produced in six different sites around the world. A common construction and quality control procedure is required to ensure the performance of each detector. The quality control steps will include optical inspection, cleaning and baking of all materials and parts used to build the detector, leakage current tests of the GEM foils, high voltage tests, gas leak tests of the chambers and monitoring pressure drop vs. time, gain calibration to know the optimal operation region of the detector, gain uniformity tests, and studying the efficiency, noise and tracking performance of the detectors in a cosmic stand using scintillators.

A novel application of Fiber Bragg Grating (FBG) sensors in MPGD

We present a novel application of Fiber Bragg Grating (FBG) sensors in the construction and characterisation of Micro Pattern Gaseous Detector (MPGD), with particular attention to the realisation of the largest triple (Gas electron Multiplier) GEM chambers so far operated, the GE1/1 chambers of the CMS experiment at LHC. The GE1/1 CMS project consists of 144 GEM chambers of about 0.5 m2 active area each, employing three GEM foils per chamber, to be installed in the forward region of the CMS endcap during the long shutdown of LHC in 2108-2019. The large active area of each GE1/1 chamber consists of GEM foils that are mechanically stretched in order to secure their flatness and the consequent uniform performance of the GE1/1 chamber across its whole active surface. So far FBGs have been used in high energy physics mainly as high precision positioning and re-positioning sensors and as low cost, easy to mount, low space consuming temperature sensors. FBGs are also commonly used for very precise strain measurements in material studies. In this work we present a novel use of FBGs as flatness and mechanical tensioning sensors applied to the wide GEM foils of the GE1/1 chambers. A network of FBG sensors have been used to determine the optimal mechanical tension applied and to characterise the mechanical tension that should be applied to the foils. We discuss the results of the test done on a full-sized GE1/1 final prototype, the studies done to fully characterise the GEM material, how this information was used to define a standard assembly procedure and possible future developments.

ECG-derived spatial QRS-T angle is associated with ICD implantation, mortality and heart failure admissions in patients with LV systolic dysfunction

Background

Increased spatial QRS-T angle has been shown to predict appropriate implantable cardioverter defibrilIator (ICD) therapy in patients with left ventricular systolic dysfunction (LVSD). We performed a retrospective cohort study in patients with left ventricular ejection fraction (LVEF) 31–40% to assess the relationship between the spatial QRS-T angle and other advanced ECG (A-ECG) as well as echocardiographic metadata, with all-cause mortality or ICD implantation for secondary prevention.

Methods

534 patients ≤75 years of age with LVEF 31–40% were identified through an echocardiography reporting database. Digital 12-lead ECGs were retrospectively matched to 295 of these patients, for whom echocardiographic and A-ECG metadata were then generated. Data mining was applied to discover novel ECG and echocardiographic markers of risk. Machine learning was used to develop a model to predict possible outcomes.

Results

49 patients (17%) had events, defined as either mortality (n = 16) or ICD implantation for secondary prevention (n = 33). 72 parameters (58 A-ECG, 14 echocardiographic) were univariately different (p<0.05) in those with vs. without events. After adjustment for multiplicity, 24 A-ECG parameters and 3 echocardiographic parameters remained different (p<2x10^-3). These included the posterior-to-leftward QRS loop ratio from the derived vectorcardiographic horizontal plane (previously associated with pulmonary artery pressure, p = 2x10^-6); spatial mean QRS-T angle (134 vs. 112°, p = 1.6x10^-4); various repolarisation vectors; and a previously described 5-parameter A-ECG score for LVSD (p = 4x10^-6) that also correlated with echocardiographic global longitudinal strain (R² = - 0.51, P < 0.0001). A spatial QRS-T angle >110° had an adjusted HR of 3.4 (95% CI 1.6 to 7.4) for secondary ICD implantation or all-cause death and adjusted HR of 4.1 (95% CI 1.2 to 13.9) for future heart failure admission. There was a loss of complexity between A-ECG and echocardiographic variables with an increasing degree of disease.

Conclusion

Spatial QRS-T angle >110° was strongly associated with arrhythmic events and all-cause death. Deep analysis of global ECG and echocardiographic metadata revealed underlying relationships, which otherwise would not have been appreciated. Delivered at scale such techniques may prove useful in clinical decision making in the future.

Invasive pneumococcal disease in Greenland

INTRODUCTION

The purpose of the present study was to evaluate the incidence and outcome of pneumococcal infections in Greenland with special reference to serotypes.

STUDY DESIGN

Retrospective study of invasive pneumococcal infections in Greenland in the period 1996-2002.

METHODS

Cases were defined as patients with positive cultures of Streptococcus pneumoniae from blood and/or CSF received at the microbiological laboratory of Dronning Ingrids Hospital in Nuuk. Cultures were sent to Statens Serum Institut in Copenhagen for serotyping. Medical charts were reviewed.

RESULTS

Fifty-one cases were identified. Incidence among Inuit was 54 and among non-Inuit 17 per 100,000 per year. Twenty-one patients were in the age group 35-49 years and 20 in the age group 50-64 years. Twenty patients had meningitis (incidence 6 per 100,000). Seventeen patients died (33%). Most common serotypes were 1 (6 cases) and 12F (8 cases). Mortality rate was significantly higher among patients with 12F than among others (p<0.01). No patients wit serotype 1 died.

CONCLUSION

Like in Canada and Alaska, the incidence of invasive pneumococcal disease, especially meningitis, is high among the Inuit in Greenland. Young and middle-aged adults were most frequently affected. Serotype seems to be an important determinant of the outcome of invasive pneumococcal disease.

The value of CT cardiac angiography and CT calcium score testing in a modern cardiology service in New Zealand: a report of a single centre eight-year experience from 5,237 outpatient procedures

BACKGROUND

Computed tomographic (CT) cardiac angiography is of increasing value in several areas of patient management in cardiology. We assessed the ability of CT cardiac angiography to effectively 'rule out' severe coronary stenoses in patients presenting with 'atypical' symptoms and/or an equivocal stress test, which offers a new approach to the management of coronary artery disease. We also examined the use of the CT calcium score test in cardiovascular (CVS) risk assessment.

METHODS

From a large single centre (Mercy Hospital) in Auckland, using a prospectively acquired, comprehensive database, we audited the entire eight-year experience of 5,169 patients (7/8/06 to 31/1/14) who underwent 5,237 64-slice computed tomographic (CT) cardiac angiogram or CT calcium score tests (GE Lightspeed scanner).

RESULTS

From 5,169 patients there were 5,237 CT procedures. The mean patient age was 57 (SD 10) years; 42% patients were female. Of the 3,603 (69%) full CT cardiac angiogram scans, 3,509 (67%) included a calcium score test. One thousand four hundred and eighty-three (28%) of scans were a calcium score test only. Of the 3,603 (69%) full CT cardiac angiogram scans, it was possible to 'rule out' significant coronary atheroma (stenosis ≥50%) in 2,947 (82%) of these procedures. Of the 4,903 (94%) patients who had a CT calcium score test, in whom we could calculate the NZ Framingham-based CVS risk, it was possible to reassign 532 (22%) of these patients who were previously thought to be at 'low risk' to be at a higher CVS risk.

CONCLUSION

CT cardiac angiography has become established in the modern management of cardiology patients. It has particular value as a tool to 'rule out' severe coronary stenoses, and as a tool to give a more accurate assessment of CVS risk. It adds significant value to the care of many patients within an established cardiology practice.

Anal Sphincter Size Measured by Endosonography in Healthy Volunteers

The anal sphincter muscles consist of the circular internal and external sphincters together with the sling-shaped associated puborectalis muscle. Ten men, 10 women with no vaginal deliveries, and 10 women with one or more vaginal deliveries were studied with anal endosonography using a 7 MHz multiplanar endoprobe. The thickness of the internal sphincter and the thickness, length, and cross-sectional area of the external sphincter were measured and related to age, sex, and parity. Reproducibility was assessed by similar measurements on different days in 10 volunteers. Anal sphincter size was the same in men and women and was not affected by the number of child births. Internal sphincter muscle thickness increased with age. Anal manometry and electromyography with an anal sponge were performed in all volunteers but the results did not correlate to any of the anal sphincter dimensions. Our conclusion is that although there are some limitations, endosonography can be used to determine the size of the anal sphincter muscles.

Videodefaecography Combined with Measurement of the Anorectal Angle and of Perineal Descent

Cineradiographic defaecography combined with measurement of the anorectal angle and descent of the pelvic floor is proposed. The method used in 73 women gave valuable information in 48 patients who complained of anal incompetence, rectal tenesmus, and chronic constipation. In these patients, high and low rectal intussusception, rectocele, and pathologic movement of the pelvic floor were detected. Some of these phenomena could only be diagnosed by the radiologic method here described. Quantitations of the anorectal angle and descent of the pelvic floor placed the group with constipation halfway between normal individuals and those with anal incompetence. The value of this finding is discussed. Recent improvements in anorectal surgery often make videodefaecography decisive for the choice of the optimal operative method. Therefore, videodefaecography together with measurement of the anorectal angle and pelvic floor descent is recommended whenever anorectal surgery for correction of functional disturbances is contemplated.

Anal Endosonographic Findings in Patients with Obstructed Defecation

Anal endosonography, including measurements of anal sphincter size, was performed in 16 patients with obstructed defecation. The findings were compared with those at defecography and anal manometry. Patients with rectocele and intussusception had a normal endosonographic appearance. One patient with puborectalic spasm had normal sonography. There was no correlation between sphincter size and anal manometry. The external sphincter muscle was thicker and the cross-sectional area larger in patients with obstructed defecation than in healthy controls (p < 0.05). Two patients with sphincter spasm and impaired rectal emptying at defecography had clearly thickened internal sphincters which may be the cause of their defecatory disorder. Three patients with previous anal dilatation or hemorrhoidectomy had sphincteric defects. Anal endosonography may be considered in patients with obstructed defecation to identify patients with internal sphincter hypertrophy.

What hides behind the MASC: clinical response and acquired resistance to entrectinib after ETV6-NTRK3 identification in a mammary analogue secretory carcinoma (MASC)

Here, we describe the dramatic response of a patient with an ETV6-NTRK3-driven mammary analogue secretory carcinoma to treatment with a pan-Trk inhibitor, and the development of acquired resistance linked to a novel NTRK3 mutation that interferes with drug binding. This case emphasizes how molecular profiling can identify therapies for rare diseases and dissect mechanisms of drug resistance.

Background

Mammary analogue secretory carcinoma (MASC) is a recently described pathologic entity. We report the case of a patient with an initial diagnosis of salivary acinic cell carcinoma later reclassified as MASC after next-generation sequencing revealed an ETV6-NTRK3 fusion.

Patients and methods

This alteration was targeted with the pan-Trk inhibitor entrectinib (Ignyta), which possesses potent in vitro activity against cell lines containing various NTRK1/2/3 fusions.

Results

A dramatic and durable response was achieved with entrectinib in this patient, followed by acquired resistance that correlated with the appearance of a novel NTRK3 G623R mutation. Structural modeling predicts that this alteration sterically interferes with drug binding, correlating to decreased sensitivity to drug inhibition observed in cell-based assays.

Conclusions

This first report of clinical activity with TrkC inhibition and the development of acquired resistance in an NTRK3-rearranged cancer emphasize the utility of comprehensive molecular profiling and targeted therapy for rare malignancies (NCT02097810).

GH safety workshop position paper: a critical appraisal of recombinant human GH therapy in children and adults

Recombinant human GH (rhGH) has been in use for 30 years, and over that time its safety and efficacy in children and adults has been subject to considerable scrutiny. In 2001, a statement from the GH Research Society (GRS) concluded that 'for approved indications, GH is safe'; however, the statement highlighted a number of areas for on-going surveillance of long-term safety, including cancer risk, impact on glucose homeostasis, and use of high dose pharmacological rhGH treatment. Over the intervening years, there have been a number of publications addressing the safety of rhGH with regard to mortality, cancer and cardiovascular risk, and the need for long-term surveillance of the increasing number of adults who were treated with rhGH in childhood. Against this backdrop of interest in safety, the European Society of Paediatric Endocrinology (ESPE), the GRS, and the Pediatric Endocrine Society (PES) convened a meeting to reappraise the safety of rhGH. The ouput of the meeting is a concise position statement.

Abstract PD06-03: Development of a highly reproducible clinical test for Ki67 using AQUA technology

Background: The measurement of Ki67 is showing promise in the management of breast cancer patients. It has shown potential for prognosis and as a chemotherapeutic response predictor, and also has a role in multivariate assessment of residual risk. However, the advancement in clinical testing has been arduous due to a lack of clinically validated scoring and/or cutpoints to guide clinicians. Standardization of Ki67 scoring is hindered by inter-laboratory variability in analysis of Ki67 in clinically relevant whole tissue sections, which are complicated not only by the subjective measurement required for IHC but also by heterogeneous expression due to biological variation and inconsistent fixation. In our diagnostic laboratory, we observed a significant amount of variability in the assessment of Ki67 using manual IHC scoring for percentage of positively stained nuclei. To attempt to reduce the variations in Ki67 assessment in clinically relevant specimens, our laboratory investigated the use of image analysis methods. Fluorescence immunohistochemistry (FIHC) coupled with the AQUA® technology has been established as a diagnostic test using image analysis and has been shown to eliminate much of the variation introduced in typical visual assessment.

Materials and methods: FIHC, based on the SP6 antibody clone, was used with AQUA technology to assess Ki67 expression as measured by percentage of positively stained nuclei. Results were compared to manually scored IHC results generated using the commonly used anti-Ki67 MIB1 antibody. IHC interpretation was performed by three pathologists on the same slides.

Results: The Ki67 assay using FIHC and AQUA technology was validated for use in a CLIA environment. Inter-reader variability by IHC was first demonstrated on whole tissues (Average difference in percent positive nuclei was 18% and ranged from 0–50%). This was further assessed on tissue microarrays, which mitigate the heterogeneity component of the tissue and resulted in the same high inter-reader variability (average percent difference was 18%). A significant correlation was observed for Ki67 percent positivity between AQUA and IHC in TMAs (Spearman: r = 0.88, p &lt; 0.0001). FIHC staining and scoring for Ki67 positivity by AQUA resulted in a 3-fold reduced variation compared to IHC and manual reads (6% variation). Using clinically relevant whole tissue sections, the accuracy of Ki67 measurement by AQUA was compared to IHC performed by an outside laboratory and resulted in a significant correlation between the two methods (Spearman: r=0.78, p &lt; 0.0001). The inter-instrument scoring variability by FIHC of a subset of the whole tissue specimens was substantially reduced compared to manual reads (Average difference in percentage of positive nuclei was 2%).

Discussion: The use of image analysis has been shown to be of significant value in expression assessment due to increased objectivity and the potential for broader standardization. We have demonstrated that the use of advanced image analysis when coupled with fluorescence immunohistochemistry can produce a system with greatly improved precision over traditional IHC methods in clinically relevant samples. These results indicate that image analysis of Ki67 is advantageous over manual IHC in clinical diagnostic assessment.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD06-03.

Abstract PD02-01: Her2 expression measured by AQUA analysis on BCIRG-005 and BCIRG-006 predicts the benefit of Herceptin therapy

Introduction: There have been disparate results reported in breast cancer testing for HER2 assessment as measured by protein expression or DNA amplification, yet both tests are routinely used to prescribe the drug Herceptin (trastuzumab, Genentech, So San Francisco, CA). Typically, immunohistochemistry (IHC) staining intensity of 3+ or FISH copy ratio of ≥2.0 are used to establish the cutoff between a negative and a positive result. However, it is unclear whether positivity is correlated with differential response to therapy. We used Automated Quantitative Analysis (AQUA) and a fluorescent immunohistochemical assay to measure HER2 expression in cases scored by central laboratory FISH and also receiving Herceptin therapy. The intentions of the study were two-fold: first, to provide further validation of the AQUA technology as applied to the clinical measurement of HER2 expression in breast cancer and second, to examine the potential of drug response stratification within those patients that are considered positive.

Methods: AQUA fluorescence IHC staining was performed on a multi-cohort tissue microarray (TMA) set. The assay was constructed in the Genoptix CLIA laboratory per ASCO/CAP guidelines and with a cutpoint that was validated against IHC (with FISH reflex). The trial specimens tested were from the BCIRG-005/006 studies. BCIRG-005 had n=1544 cases all assessed as FISH- while the 006 cohort had n=1477 cases all assessed as FISH+. Disease free survival (DFS) was used as the variable in subsequent modeling and analysis.

Results: The BCIRG 005 and 006 cohorts, examined in aggregate, allowed for an initial examination of agreement relationships between HER2 levels as assessed by AQUA scoring and HER2 levels as assessed by central lab FISH. Results indicated a 77% negative agreement, a 97% positive agreement and an 87% overall concordance agreement for a total of n=3021 cases. Additional Cox modeling of the patients that were enrolled as FISH+ and stratified for those who did or did not receive Herceptin treatment demonstrated a significant overall hazard ratio (HR = 0.75, CI=0.60,0.93) and when stratified for response to Herceptin, cases determined to be positive by AQUA showed significant benefit from treatment (HR = 0.66, CI = 0.52,0.85) in contrast to those who were scored as negative by AQUA that did demonstrate benefit from therapy (HR = 1.19, CI=0.71,1.97).

Conclusions: Analysis of the cases in this study originally determined to be HER2+ by FISH indicates that AQUA may improve predictions of which patients will benefit from Herceptin therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD02-01.