A prospective cohort study identifying radiologic and tumor related factors of importance for breast conserving surgery after neoadjuvant chemotherapy

INTRODUCTION

Neoadjuvant chemotherapy (NAC) is an established treatment option for early breast cancer, potentially downstaging the tumor and increasing the eligibility for breast-conserving surgery (BCS). The primary aim of this study was to assess the rate of BCS after NAC, and the secondary aim was to identify predictors of application of BCS after NAC.

MATERIALS AND METHODS

This was an observational prospective cohort study of 226 patients in the SCAN-B (Clinical Trials NCT02306096) neoadjuvant cohort during 2014-2019. Eligibility for BCS was assessed at baseline and after NAC. Uni- and multivariable logistic regression analyses were performed using covariates with clinical relevance and/or those associated with outcome (BCS versus mastectomy), including tumor subtype, by gene expression analysis.

RESULTS

The overall BCS rate was 52%, and this rate increased during the study period (from 37% to 52%). Pathological complete response was achieved in 69 patients (30%). Predictors for BCS were smaller tumor size on mammography, visibility on ultrasound, histological subtype other than lobular, benign axillary status, and a diagnosis of triple-negative or HER2-positive subtype, with a similar trend for gene expression subtypes. Mammographic density was negatively related to BCS in a dose-response pattern. In the multivariable logistic regression model, tumor stage at diagnosis and mammographic density showed the strongest association with BCS.

CONCLUSION

The rate of BCS after NAC increased during the study period to 52%. With modern treatment options for NAC the potential for tumor response and BCS eligibility might further increase.

St Gallen 2019 guidelines understage the axilla in lobular breast cancer: a population-based study

BACKGROUND

The St Gallen 2019 guidelines for primary therapy of early breast cancer recommend omission of completion axillary lymph node dissection (cALND), regardless of histological type, in patients with one or two sentinel lymph node (SLN) metastases. Concurrently, adjuvant chemotherapy is endorsed for luminal A-like disease with four or more axillary lymph node (ALN) metastases. The aim of this study was to estimate the proportion of patients with invasive lobular cancer (ILC) versus invasive ductal cancer of no special type (NST) with one or two SLN metastases for whom cALND would have led to a recommendation for adjuvant chemotherapy.

METHODS

Patients with ILC and NST who had surgery between 2014 and 2017 were identified in the National Breast Cancer Register of Sweden. After exclusion of patients with incongruent or missing data, those who fulfilled the St Gallen 2019 criteria for cALND omission were included in the population-based study cohort.

RESULTS

Some 1886 patients in total were included in the study, 329 with ILC and 1507 with NST. Patients with ILC had a higher metastatic nodal burden and were more likely to have a luminal A-like subtype than those with NST. The prevalence of at least four ALN metastases was higher in ILC (31.0 per cent) than NST (14.9 per cent), corresponding to an adjusted odds ratio of 2.26 (95 per cent c.i. 1.59 to 3.21). Luminal A-like breast cancers with four or more ALN metastases were over-represented in ILC compared with NST, 52 of 281 (18.5 per cent) versus 43 of 1299 (3.3 per cent) (P < 0.001).

CONCLUSION

Patients with ILC more often have luminal A-like breast cancer with at least four nodal metastases. Omission of cALND in patients with luminal A-like invasive lobular cancer and one or two SLN metastases warrants future attention as there is a risk of nodal understaging and undertreatment in one-fifth of patients.

Validated prediction model for positive resection margins in breast-conserving surgery based exclusively on preoperative data

Background

Positive margins after breast-conserving surgery (BCS) and subsequent second surgery are associated with increased costs and patient discomfort. The aim of this study was to develop a prediction model for positive margins based on risk factors available before surgery.

Methods

Patients undergoing BCS for in situ or invasive cancer between 2015 and 2016 at site A formed a development cohort; those operated during 2017 in site A and B formed two validation cohorts. MRI was not used routinely. Preoperative radiographic and tumour characteristics and method of operation were collected from patient charts. Multivariable logistic regression was used to develop a prediction model for positive margins including variables with discriminatory capacity identified in a univariable model. The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed.

Results

There were 432 patients in the development cohort, and 190 and 157 in site A and B validation cohorts respectively. Positive margins were identified in 77 patients (17.8 per cent) in the development cohort. A non-linear transformation of mammographic tumour size and six variables (visible on mammography, ductal carcinoma in situ, lobular invasive cancer, distance from nipple–areola complex, calcification, and type of surgery) were included in the final prediction model, which had an area under the curve of 0.80 (95 per cent c.i. 0.75 to 0.85). The discrimination and calibration of the prediction model was assessed in the validation cohorts, and a nomogram developed.

Conclusion

The prediction model showed good ability to predict positive margins after BCS and might, after further validation, be used before surgery in centres without the routine use of preoperative MRI.

Presented in part to the San Antonio Breast Cancer Symposium, San Antonio, Texas, USA, December 2018 and the Swedish Surgical Society Annual Meeting, Helsingborg, Sweden, August 2018.

Validation of the Skåne University Hospital nomogram for the preoperative prediction of a disease-free axilla in patients with breast cancer

BACKGROUND

Axillary staging via sentinel lymph node biopsy (SLNB) is performed for clinically node-negative (N0) breast cancer patients. The Skåne University Hospital (SUS) nomogram was developed to assess the possibility of omitting SLNB for patients with a low risk of nodal metastasis. Area under the receiver operating characteristic curve (AUC) was 0.74. The aim was to validate the SUS nomogram using only routinely collected data from the Swedish National Quality Registry for Breast Cancer at two breast cancer centres during different time periods.

METHOD

This retrospective study included patients with primary breast cancer who were treated at centres in Lund and Malmö during 2008-2013. Clinicopathological predictors in the SUS nomogram were age, mode of detection, tumour size, multifocality, lymphovascular invasion and surrogate molecular subtype. Multiple imputation was used for missing data. Validation performance was assessed using AUC and calibration.

RESULTS

The study included 2939 patients (1318 patients treated in Lund and 1621 treated in Malmö). Node-positive disease was detected in 1008 patients. The overall validation AUC was 0.74 (Lund cohort AUC: 0.75, Malmö cohort AUC: 0.73), and the calibration was satisfactory. Accepting a false-negative rate of 5 per cent for predicting N0, a possible SLNB reduction rate of 15 per cent was obtained in the overall cohort.

CONCLUSION

The SUS nomogram provided acceptable power for predicting a disease-free axilla in the validation cohort. This tool may assist surgeons in identifying and counselling patients with a low risk of nodal metastasis on the omission of SLNB staging.

Cosmetic Outcomes and Symmetry Comparison in Patients Undergoing Bilateral Therapeutic Mammoplasty for Breast Cancer

Background

Breast-reduction techniques are increasingly used in oncoplastic breast surgery. Bilateral therapeutic mammoplasty has the benefit of decreasing breast volume, enabling resection of larger tumors, and the potential to assure good postoperative symmetry. The aims of this study were to objectively asses the cosmetic outcomes of therapeutic mammoplasty in patients with breast cancer, using the breast cancer conservative treatment cosmetic results (BCCT.core) software, to compare this score with the surgeon’s score and the patient’s assessment, and to evaluate if other defined parameters have an impact on cosmetic outcomes. The secondary aim was to compare breast symmetry pre- and postoperatively.

Materials and Methods

We enrolled 146 consecutive patients with primary breast cancer who underwent therapeutic mammoplasty between 2011 and 2018 in Kristianstad Central Hospital, Sweden. We retrospectively collected data from patients’ records. We analyzed the BCCT.core score using postoperative photographs to objectively evaluate cosmetic outcomes on a four-grade scale and compared with preoperative photographs to evaluate symmetry. Cosmetic outcomes were also assessed subjectively by patients and surgeons, using a 10-point Likert scale.

Results

The majority of patients (89%) had good or excellent BCCT.core scores, which correlated with surgeons’ scores, rs =  − 0.22 (p < 0.001). Overall, patients were more satisfied with the cosmetic outcomes than the surgeons (p < 0.001). Evidence supporting an association between the defined clinicopathological variables, for example, tumor size, and cosmetic outcomes, was weak.

Conclusion

Therapeutic mammoplasty yields a very good cosmetic outcome, evaluated both by subjective and objective measurements. Importantly, symmetry can be improved in patients with asymmetry.

Supplementary information

The online version contains supplementary material available at (10.1007/s00268-020-05941-0).

Risk and management of pre-diabetes

Type 2 diabetes mellitus (T2DM) is associated with a two- to four-fold increased risk of developing cardiovascular disease (CVD) and microvascular complications, which may already be present before diagnosis. It is, therefore, important to detect people with an increased risk of T2DM at an early stage. In order to identify individuals with so-called 'pre-diabetes', comprising impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), current guidelines have developed definitions based on fasting plasma glucose, two-hour glucose concentrations and haemoglobin A1c. Subjects with pre-diabetes are at an increased risk of developing T2DM and CVD. This elevated risk seems similar according to the different criteria used to define pre-diabetes. The risk of progression to T2DM or CVD does, however, depend on other risk factors such as sex, body mass index and ethnicity. Based on the risk factors to develop T2DM, many risk assessment models have been developed to identify those at highest risk. These models perform well to identify those at risk and could be used to initiate preventive interventions. Many studies have shown that lifestyle modification and metformin are effective in preventing the development of T2DM, although lifestyle modification seems to have a more sustainable effect. In addition, lifestyle modification seems more effective in those with IGT than those with IFG. In this review, we will describe the different definitions used to define pre-diabetes, progression from pre-diabetes to T2DM or other vascular complications, risk factors associated with progressions and the management of progression to T2DM, ending with clinical recommendations.

Associations among Periodontitis, Calcified Carotid Artery Atheromas, and Risk of Myocardial Infarction

Cardiovascular disease is a common cause of morbidity and premature mortality. Cardiovascular disease can be prevented when risk factors are identified early. Calcified carotid artery atheromas (CCAAs), detected in panoramic radiographs, and periodontitis have both been associated with increased risk of cardiovascular disease. This case-control study aimed to 1) investigate associations between periodontitis and CCAA detected in panoramic radiographs and 2) determine the risk of future myocardial infarctions due to CCAA combined with periodontitis. We evaluated 1,482 participants (738 cases and 744 controls) with periodontitis and CCAAs recruited from the PAROKRANK study (Periodontitis and Its Relation to Coronary Artery Disease). Participants were examined with panoramic radiographs, including the carotid regions. Associations between myocardial infarction and periodontitis combined with CCAA were evaluated in 696 cases and 696 age-, sex-, and residential area–matched controls. Periodontitis was evaluated radiographically (as degree of bone loss) and with a clinical periodontal disease index score (from clinical and radiographic assessments). We found associations between CCAA and clinical periodontal disease index score among cases (odds ratio [OR], 1.51; 95% CI, 1.09 to 2.10; P = 0.02) and controls (OR, 1.70; 95% CI, 1.22 to 2.38; P < 0.01), although not between CCAA and the degree of bone loss. In a multivariable model, myocardial infarction was associated with CCAA combined with periodontitis, as assessed by degree of bone loss (OR, 1.75; 95% CI, 1.11 to 2.74; P = 0.01). When the cohort was stratified by sex, only men showed a significant association between myocardial infarction and CCAA combined with periodontitis. Participants with clinically diagnosed periodontitis exhibited CCAA in panoramic radiographs more often than those without periodontitis, irrespective of the presence of a recent myocardial infarction. Participants with combined periodontitis and CCAA had a higher risk of having had myocardial infarction as compared with participants with either condition alone. These findings implied that patients in dental care might benefit from dentists assessing panoramic radiographs for CCAA—particularly, patients with periodontitis who have not received any preventive measures for cardiovascular disease.

Atrial fibrillation increases the risk of dementia amongst older adults even in the absence of stroke

BACKGROUND

Atrial fibrillation increases risk of stroke, and thus risk of cognitive impairment and dementia. Emerging evidence suggests an association also in the absence of stroke. We aimed to examine the association between atrial fibrillation and incident dementia, with and without exclusion of individuals with stroke, and if sex and genetic factors modify the possible association.

METHODS

In 2000-2001, a population-based sample of 70-year-olds (N = 561) underwent comprehensive somatic and neuropsychiatric examinations, as part of the Gothenburg H70 Birth Cohort Studies. Participants were followed up at age 75 and 79. Atrial fibrillation at baseline was identified through ECG, proxy-reports and the National Patient Register (NPR). Stroke at baseline and follow-up was identified through self-reports, proxy-reports and the NPR. Dementia at baseline and follow-up was diagnosed according to the DSM-III-R criteria based on neuropsychiatric examinations, proxy-reports and the NPR.

RESULTS

Individuals with atrial fibrillation had an almost threefold increased risk of dementia during 12-year follow-up (HR 2.8; 95% CI 1.3-5.7; P = 0.004), and this risk remained after excluding individuals with stroke at baseline and follow-up. After stratification for sex, the association was only found amongst men (HR 4.6; 95% CI 1.9-11.2; P < 0.001, interaction sex*atrial fibrillation; P = 0.047) and noncarriers of the APOE ε4 allele (HR 4.2; 95% CI 1.8-9.7; P < 0.001, interaction APOE*atrial fibrillation; P = 0.128). Population attributable risk for dementia resulting from atrial fibrillation was 13%.

CONCLUSION

The relevance for atrial fibrillation as an indicator of subclinical brain vascular risk needs to be further explored. In addition, patients with atrial fibrillation should be screened for cognitive symptoms.

A comprehensive approach to rehabilitation interventions following breast cancer treatment - a systematic review of systematic reviews

BACKGROUND

Breast cancer (BC) is the most common type of cancer in women worldwide. Post-treatment, patients suffer from side effects and have various rehabilitation needs, which means that individualization is fundamental for optimal rehabilitation. This systematic review (SR) of SRs aims to evaluate the current evidence on rehabilitation interventions in female patients following BC treatment.

METHODS

Full-text SRs published in English from 2009 were searched in Embase, PubMed, Cinahl Complete, PsycINFO, AMED, SCOPUS, and Cochrane Library.

INCLUSION CRITERIA

SRs of randomized or non-randomized controlled trials investigating the effects of rehabilitation interventions in women following BC treatment. All outcomes were considered. Methodological quality was evaluated using the AMSTAR 2 tool and interrater agreement was evaluated. Out of 1269 citations retrieved, 37 SRs were included.

RESULTS

Five rehabilitation areas were identified: exercise and physical activity (PA), complementary and alternative medicine (CAM), yoga, lymphoedema treatment, and psychosocial interventions. The most solid evidence was found in exercise/PA and yoga. Exercise interventions improved outcomes such as shoulder mobility, lymphoedema, pain, fatigue and quality of life (QoL). Effects of yoga were shown on QoL, anxiety, depression, sleep disturbance, fatigue and gastrointestinal symptoms. The effect of CAM was shown on nausea, pain, fatigue, anger and anxiety but these results need to be interpreted with caution because of low methodological quality in included studies in the SRs. Among the lymphoedema treatments, positive effects were seen for resistance training on volume reduction and muscle strength and psychosocial interventions such as cognitive behavioural therapy had positive effects on QoL, anxiety, depression and mood disturbance.

CONCLUSIONS

This SR of SRs show solid positive effects of exercise/PA and yoga for women following BC treatment, and provides extended knowledge of the effects of CAM, yoga, lymphoedema treatment and psychosocial interventions. It is evident that more than one intervention could have positive effects on a specific symptom and that the effects depend not only on intervention type but also on how and when the intervention is provided. The results can be used as a foundation for individualized rehabilitation and aid health care professionals in meeting patients' individual needs and preferences.

TRIAL REGISTRATION

PROSPERO ( CRD42017060912 ).

Epidemiology of suicidal feelings in an ageing Swedish population: from old to very old age in the Gothenburg H70 Birth Cohort Studies

AIMS

The first aim of this study was to provide prevalence suicidal feelings over time (past week, past month, past year and lifetime) in a population-based sample of old to very old adults without dementia. Does prevalence change with rising age? The second aim was to examine the fluctuation of suicidal feelings over time. How does this coincide with depression status?

METHODS

Data were derived from the Gothenburg H70 Birth Cohort Studies (the H70 studies) which are multidisciplinary longitudinal studies on ageing. A representative sample of adults in Gothenburg, Sweden with birth years 1901-1944 were invited to take part in a longitudinal health study on ageing and participated at one or more occasions during 1986-2014. The sample consisted of 6668 observations originating from 3972 participants without dementia between the ages of 70 and 108, including 1604 participants with multiple examination times. Suicidal feelings were examined during a psychiatric interview using the Paykel questions (life not worth living, death wishes, thoughts of taking own life, seriously considered taking life, attempted suicide).

RESULTS

Prevalence figures for suicidal feelings of any severity were as follows: past week 4.8%, past month 6.7%, past year 11.2% and lifetime 25.2%. Prevalence rates increased with age in the total group and in women but not in men. Suicidal feelings were common in participants with concurrent major or minor depression, but over a third of the participants who reported suicidal feelings did not fulfil criteria for these diagnoses nor did they present elevated mean depressive symptom scores. The majority of participants consistently reported no experience of suicidal feelings over multiple examination times, but fluctuation was more common in women compared with men.

CONCLUSION

Suicidal feelings in late-life are uncommon in individuals without depression indicating that such behaviour is not a widespread, normative phenomenon. However, such feelings may occur outside the context of depression.

Clinical implications of cardiovascular outcome trials in type 2 diabetes

Cardiovascular disease (CVD) is the main reason for premature death in patients with type 2 diabetes. Hyperglycemia, the hallmark of diabetes, has long been considered the link between diabetes and CVD, and many trials focused on preventing CVD manifestations by means of tight glucose control. However, diabetes is a multifactorial disease in which, e. g., insulin resistance, endothelial dysfunction, and factors such as hypertension and dyslipidemia contribute. Thus, treatment needs to be multifactorial and take cardiovascular aspects into account. Newer classes of drugs, originally launched for glucose lowering, among them dipeptidyl-peptidase (DPP)-4 inhibitors, sodium-glucose cotransporter (SGLT)-2 inhibitors, and glucagon-like peptide (GLP)-1 receptor agonists, have been studied in large cardiovascular outcome trials (CVOT). Several SGLT-2 inhibitors and GLP-1 receptor agonists are associated with a reduction of cardiovascular events (cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke). Although the mechanisms behind the effects are not fully understood, an important reason for the benefits of SGLT-2 inhibitors seems be a reduction in heart failure, while GLP-1 receptor agonists may retard the development of the atherosclerotic vascular disease or may be effective by stabilizing plaques. The outcomes of these studies have been taken into account in recently issued guidelines and an important task for diabetologists, cardiologists, and general practitioners is to incorporate the findings of these trials into clinical practice.

Abstract P4-14-10: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Ekholm M, Bendahl P-O, Fernö M, Nordenskjöld B, Stål O, Rydén L. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-14-10.

Abstract GS5-07: International pooled analysis of the prognostic impact of disseminated tumor cells from the bone marrow in early breast cancer: Results from the PADDY study

Introduction

As early breast cancer might relapse even after complete removal of breast and lymphnodes, the disease must persist in secondary sites. The detection of disseminated tumor cells (DTC) in the bone marrow (BM) has been described as a surrogate of residual disease. Various trials showed an impaired prognosis of DTC positive early breast cancer (EBC) patients. The PADDY (Pooled Analysis of DTC Detection in Early Breast Cancer) study is a large international pooled analysis that aimed to assess the prognostic impact of DTC detection in patients with EBC.

Methods

A pre-specified protocol was followed, and centers known to practice BM sampling for DTC detection were contacted for individual patient data. Patients with EBC, with available follow-up data and BM sampling before any anti-cancer treatment were eligible. BM aspirates were collected at the time of primary surgery. DTC were identified by antibody (A45-B/B3, AE1/AE3, 2E11 and E29) staining against cytokeratin. The DTC status was compared to other prognostic factors using the chi-squared test. Univariate log-rank test and multivariate cox regression were used to compare survival of DTC positive versus DTC negative patients.

Results

Individual data from 10,320 patients (11 centers from Europe and USA) were included with a median follow-up of 91 months. Of all patients, 2,823 (27.4 %) were DTC positive. DTC detection was associated with higher tumor grade, higher T stage, nodal positivity, ER and PR negativity, and HER2 positivity (all p&lt;0.001). In univariate analyses, overall, breast cancer specific, disease-free and distant disease-free survival (OS, BCSS, DFS, DDFS) were significantly shorter in DTC positive patients with p-values of &lt;0.001. Multivariate analyses showed the DTC status to be an independent prognostic marker for OS, BCSS, DFS and DDFS with hazard ratios (HR) and 95%-confidence intervals (CI) of 1.23 (95%-CI: 1.06-1.42, p=0.007), 1.38 (95%-CI: 1.11-1.72, p=0.004), 1.29 (95%-CI: 1.10-1.50, p=0.001) and 1.32 (95%-CI: 1.10-1.58, p=0.003), respectively.

Conclusions

Detection of DTC in the bone marrow is an independent prognostic marker in patients with non-metastatic breast cancer. Further studies should investigate the impact of DTC on metastatic cancer progression and their role for clinical decision making.

Citation Format: Hartkopf AD, Brucker SY, Taran F-A, Harbeck N, von Au A, Naume B, Pierga J-Y, Hoffmann O, Beckmann MW, Rydén L, Fehm T, Aft R, Montserrat S, Walter V, Rack B, Schuetz F, Borgen E, Ta M-H, Bittner A-K, Fasching P, Fernö M, Krawczyk N, Weilbaecher K, Margelí M, Hahn M, Jueckstock J, Domschke C, Bidard F-C, Kasimir-Bauer S, Schoenfisch B, Kurt AG, Wallwiener M, Gebauer G, Wallwiener D, Janni W, Pantel K. International pooled analysis of the prognostic impact of disseminated tumor cells from the bone marrow in early breast cancer: Results from the PADDY study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr GS5-07.

Abstract P3-13-03: Risk factors for reoperation following breast-conserving surgery integrated into pre- and postoperative models with high accuracy

Purpose:

Breast-conserving surgery (BCS) is today applied in 60-70% of patients with invasive and in situ cancer and tumor size of 3 cm or less. However, a significant fraction of patients (10-40%) who undergo BCS require a reoperation due to incomplete excision of the tumor despite the evolvement of oncoplastic surgical techniques. We aimed to define risk factors for non-radical BCS due to positive margins in patients with in situ and invasive breast cancer operated with BCS. A specific focus was to identify preoperatively available characteristics which could be informative for the surgeon and patients when planning the primary choice of breast surgery.

Methods:

Patients with final diagnosis of in situ or invasive cancer who underwent BCS 2015-2016 at Skåne University Hospital in Malmö were included in the study. Patients undergoing neoadjuvant therapy were excluded. Data was extracted from mammography/ultrasound files, type of surgery from clinical files and pre-and postoperative pathological diagnosis and radicality from pathological files according to a prespecified protocol. The definition of radicality was according to international consensus (ie no tumor on ink for invasive cancer and 2 mm for in situ cancer).Uni- and multivariable logistic regression analysis were executed separately for pre- and postoperatively available parameters in the SPSS software to calculate odds ratios (OR) for predictors of non-radicality. Separate models for pre- and postoperative characteristics were defined based on data derived in 2015, 2016 was used as a validation set. Accuracy of the models were presented as AUC-values. P-values of ≤0.05 were considered significant.

Results:

202 patients diagnosed in 2015 were included of which 43 (21.3%) patients were considered non-radically operated, whereas 231 patients diagnosed in 2016 were eligible and had a reoperation rate of 14.3%. Multivariable analysis included determinants from the univariate analysis and clinically relevant variables with the following results for the preoperative model: mammographic size per mm: OR 1.06 (95% CI:1.01-1.11), p=0.014 , invasive lobular cancer on core needle biopsy vs not: OR 7.3 (95% CI: 1.8-29.4), P=0.005, DCIS diagnosis on core needle biopsy vs not OR 3.60 (95% CI: 1.00-13.02) p=0.051, benign core needle biopsy vs not OR 6.3 (95% CI: 0.9-46.7), p=0.070, oncoplastic surgery and presence of calcifications had p-values &gt; 0.1. In the postoperative model pure DCIS in the specimen and total extent were significant predictive factors in the multivariate analysis. The preoperative model predicting non-radicality had an AUC of 0.81 and the postoperative model had an AUC of 0.86 in the test set (year 2015), the AUC in the validation set (year 2016) was 0.80 for the preoperative model and 0.81 for the postoperative model.

Conclusion:

Important preoperative prediction factors for non-radicality following BCS derived from core needle biopsies and mammograms have shown promising results and may be helpful when planning the primary choice of breast surgery. An extended study with larger cohort size is desirable.

Citation Format: Ellrant J, Plassgård E, Bendahl P-O, Rydén L. Risk factors for reoperation following breast-conserving surgery integrated into pre- and postoperative models with high accuracy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-03.

Effects of adjuvant tamoxifen over three decades on breast cancer-free and distant recurrence-free interval among premenopausal women with oestrogen receptor-positive breast cancer randomised in the Swedish SBII:2pre trial

AIMS

The primary aim was to compare 2 years of adjuvant tamoxifen versus no systemic treatment in premenopausal patients with oestrogen receptor (ER)-positive tumours, regarding breast cancer-free interval (BCFi) and distant recurrence-free interval (D-RFi), with 30 years of follow-up and for specified intervals. Moreover, we aimed to investigate the effects of adjuvant tamoxifen on the incidence of secondary malignancies and survival after distant recurrence.

METHODS

Premenopausal patients with primary breast cancer were randomised to 2 years of tamoxifen (n = 277) or no systemic treatment (n = 287), irrespective of ER status. Information regarding events was collected by a review of medical records and from national registers.

RESULTS

The median follow-up for all patients without events was 28 years, and only four of the patients alive had a follow-up of <20 years. With 30 years of follow-up, tamoxifen prolonged BCFi in the intention-to-treat population (hazard ratio [HR] = 0.76, 95% confidence interval (CI) 0.61-0.94, p = 0.011) compared with no treatment. In patients with ER-positive tumours (n = 362), tamoxifen prolonged BCFi (HR = 0.62, 95% CI 0.47-0.82, p = 0.001) and D-RFi (HR = 0.73, 95% CI 0.54-0.99, p = 0.043). The positive effect on BCFi was significant also for the interval >15-30 years (HR = 0.53, 95% CI 0.28-0.98, p = 0.042). For patients with ER-positive tumours who were diagnosed with distant recurrence (n = 165), survival after distant recurrence was shorter among tamoxifen-treated patients (median, 29 months versus 43 months). The incidence of contralateral breast cancer was 42% lower in the tamoxifen group (HR = 0.58, 95% CI 0.35-0.96, p = 0.035), whereas no differences were observed regarding other secondary malignancies.

CONCLUSIONS

With three decades of follow-up, 2 years of adjuvant tamoxifen reduced the incidence of breast cancer-related events and distant recurrence, and the carryover effect seems to extend beyond 15 years. Moreover, adjuvant tamoxifen seems to be associated with shorter survival after diagnosis of distant recurrence.

Minimizing inequality in access to precision medicine in breast cancer by real-time population-based molecular analysis in the SCAN-B initiative

BACKGROUND

Selection of systemic therapy for primary breast cancer is currently based on clinical biomarkers along with stage. Novel genomic tests are continuously being introduced as more precise tools for guidance of therapy, although they are often developed for specific patient subgroups. The Sweden Cancerome Analysis Network - Breast (SCAN-B) initiative aims to include all patients with breast cancer for tumour genomic analysis, and to deliver molecular subtype and mutational data back to the treating physician.

METHODS

An infrastructure for collection of blood and fresh tumour tissue from all patients newly diagnosed with breast cancer was set up in 2010, initially including seven hospitals within the southern Sweden regional catchment area, which has 1.8 million inhabitants. Inclusion of patients was implemented into routine clinical care, with collection of tumour tissue at local pathology departments for transport to the central laboratory, where routines for rapid sample processing, RNA sequencing and biomarker reporting were developed.

RESULTS

More than 10 000 patients from nine hospitals have currently consented to inclusion in SCAN-B with high (90 per cent) inclusion rates from both university and secondary hospitals. Tumour samples and successful RNA sequencing are being obtained from more than 70 per cent of patients, showing excellent representation compared with the national quality registry as a truly population-based cohort. Molecular biomarker reports can be delivered to multidisciplinary conferences within 1 week.

CONCLUSION

Population-based collection of fresh tumour tissue is feasible given a decisive joint effort between academia and collaborative healthcare groups, and with governmental support. An infrastructure for genomic analysis and prompt data output paves the way for novel systemic therapy for patients from all hospitals, irrespective of size and location.

Severe Periodontitis Is Associated with Myocardial Infarction in Females

The aim of the present study was to test the hypothesis that there is a sex difference in the association between periodontitis (PD) and a first myocardial infarction (MI). The analysis in the case-control study was based on 785 patients (147 females and 638 males) with a first MI and 792 matched controls (147 females and 645 males), screened for cardiovascular risk factors and subjected to a panoramic dental X-ray. Periodontal status was defined by alveolar bone loss and diagnosed as no PD (≥80% remaining alveolar bone), mild to moderate PD (66% to 79%), or severe PD (<66%). Logistic regression was used when analyzing PD as a risk factor for MI, adjusting for age, smoking, diabetes, education, and marital status. The mean age was 64 ± 7 y for females and 62 ± 8 y for males. Severe PD was more common in female patients than female controls (14 vs. 4%, P = 0.005), with an increased risk for severe PD among female patients with a first MI (odds ratio [OR] = 3.92, 95% confidence interval [CI] =1.53 to 10.00, P = 0.005), which remained (OR = 3.72, 95% CI = 1.24 to 11.16, P = 0.005) after adjustments. Male patients had more severe PD (7% vs. 4%; P = 0.005) than male controls and an increased risk for severe PD (OR = 1.88, 95% CI = 1.14 to 3.11, P = 0.005), but this association did not remain following adjustment (OR = 1.67, 95% CI = 0.97 to 2.84, NS). Severe PD was associated with MI in both females and males. After adjustments for relevant confounders, this association did, however, remain only in females. These data underline the importance of considering poor dental health when evaluating cardiovascular risk, especially in females.

Abstract P3-02-02: Concordance between immunohistochemical and gene-expression based subtyping of early breast cancer using core needle biopsies and surgical specimens - experices from SCAN-B

Introduction: Preoperative chemotherapy in early breast cancer increases the rate of breast preservation and provides prognostic information. Treatment decisions in these cases rely on biomarker assessments and subtyping from tissue acquired through core needle biopsies. Tumor heterogeneity and representativity are pit-falls when limited tissue is available. Biomarker expression may change considerably as a result of preoperative chemotherapy, and in a subset of cases a complete pathological response at time of surgery may even preclude any further assessment. Therefore, the reliability and reproducibility of biomarkers in base-line core biopsies are of utmost importance for patients treated with preoperative chemotherapy.

Material and Methods: In an ongoing population-based study of early breast cancer, the SCAN-B (NCT02306096), patients were identified for whom an ultra-sound guided core needle biopsy was analyzed for biomarkers during primary clinical work-up and the patient was offered primary surgery as initial treatment. Clinical biomarker profiles including immunohistochemical (IHC) determinations of ER, PgR, HER2 and Ki67 were translated to subtypes according to modified St Gallen criteria (2013) and compared with paired samples from surgical specimens. In addition, tumor specimens for biomolecule extraction and RNA sequencing were collected fresh in RNAlater.

Results: IHC data was available from 51 paired samples. The subtype distribution in core needle biopsies was DCIS in 1 case (2 %), LCIS in 1 case (2 %) Luminal A-like in 16 cases (31 %), Luminal B-like (HER2 negative) in 26 cases (51 %), Luminal B-HER2-like (HER2 positive) in 4 cases (8 %), HER2-positive (non-luminal) in 1 case (2 %) and triple negative (ductal) breast cancer in 2 cases (4 %). The subtype distribution in surgical specimens was DCIS in 0 case (0 %), LCIS in 1 case (2 %) Luminal A-like in 18 cases (35 %), Luminal B-like (HER2negative) in 23 cases (45 %), Luminal B--like (HER2 positive) in 6 cases (12 %), HER2-positive (non-luminal) in 1 case (2 %) and triple negative (ductal) breast cancer in 2 cases (4 %). Notably, 5/16 cases classified as Luminal A-like in the core needle biopsy were reclassified as Luminal B-like (HER2-negative) in the surgical specimen, whereas 9/26 cases classified as Luminal B-like (HER2-negative) in the core needle biopsy were reclassified as either Luminal A-like (7 cases) or Luminal B-like (HER2 positive) (2 cases) in the surgical specimen. In all instances, except one, transition between Luminal A-like and Luminal B-like was due to recorded Ki67 expression. One case that was classified as a DCIS in the core needle was reclassified as Luminal B-like (HER2 negative) at time of surgery.

Discussion: In this limited material, discordance between evaluations regarding Luminal A-like and Luminal B-like was considerable. Especially the misclassification of primary HER2-positive breast cancer needs further evaluation. These findings may be caused by tumor heterogeneity, and highlight the risk of both over- and under-treatment upon biomarker assessment from core needle biopsies. Data from gene expression based subtype classifications will be presented during the meeting.

Citation Format: Morgan G, Larsson C, Tahin B, Vallon-Christersson J, Häkkinen J, Ehinger A, Malmberg M, Hegardt C, Borg Å, Rydén L, Saal LH, Hedenfalk I, Loman N. Concordance between immunohistochemical and gene-expression based subtyping of early breast cancer using core needle biopsies and surgical specimens - experices from SCAN-B [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-02-02.

Abstract P1-07-05: AIB1 is a new putative prognostic biomarker in the luminal A and B-like (HER2-negative) classification of invasive lobular carcinoma

Background: Estrogen receptor (ER) positive HER2-negative breast cancer comprises 75–80% of all breast cancer. This fraction is even higher (&gt;90%) in invasive lobular carcinoma (ILC). According to the St Gallen surrogate definitions of the intrinsic subtypes, Ki67 and progesterone receptor (PgR) are used to classify these tumors as luminal A- and luminal B-like (HER2-negative). These guidelines are based on information derived from patient materials with mixed histological types, where the vast majority of the patients have invasive ductal carcinoma. The `luminal-like classification´ together with histological grade, tumor size and lymph node status is widely used in the clinic for prognostication. The aim of the present study was to investigate if the same markers are applicable for ILC, and furthermore, if additional biomarkers involved in the endocrine signaling system, e.g. Amplified in breast cancer 1 (AIB1) and the putative G protein-coupled estrogen receptor (GPER), might provide complementary prognostic information.

Patients: Two hundred and thirty-three (N = 233) well-characterized patients with primary ILC, diagnosed between 1980 and 1991 were included. Forty-two percent of the patients received adjuvant endocrine treatment and 2 % received adjuvant chemotherapy. All biomarkers were analyzed immunohistochemically on tissue microarray, whereas histological grade was evaluated on whole sections according to Elston and Ellis (NHG). The primary endpoint was breast cancer mortality (BCM).

Results: In univariable analyses with 10-year follow-up, Ki67 (high vs. low), NHG (3 vs. 1+2) and AIB1 (high vs. low) were significantly associated to BCM (Hazard Ratio: 4.7, 95% CI: 2.1–10.4, p &lt;0.001; HR: 3.1, 95% CI: 1.5–6.4, p = 0.003; HR: 3.2, 95% CI: 1.4–7.2, p = 0.005 respectively), whereas PgR (&lt;1% vs ≥1%) and GPER (linear 0-4) were not (p = 0.25; p = 0.31 respectively). Essentially the same effect was seen after multivariable adjustment for lymph node status (+ vs. -), tumor size (&gt;20 mm vs. &lt;20 mm), adjuvant treatment and age (continuous). Subgrouping the tumors into luminal A- and B-like (HER2-negative) according to St Gallen surrogate definitions did not show significant prognostic differences between the two groups (p = 0.12). Patients with &lt;20 mm, lymph node negative breast cancer and favorable tumor characteristics (low Ki67, NHG 1+2, and low AIB1) had a 10-year BCM of 4.2% (95% CI: 1.4–12%). This group constituted 34% of the patients included in the present study.

Conclusions: In contrast to other previous studies, where breast cancers of mixed histological types were included, PgR was not significantly associated to prognosis in the ER-positive HER2-negative subgroup in the present study, consisting only of ILC. The prognostic role of PgR and the clinical usefulness of the luminal A and B-like (HER2-negative) classification (using only Ki67 and PgR) in ILC is still to be further investigated. The prognostic importance of Ki67 and NHG in this subgroup was, however, confirmed also in ILC, and AIB1 might be a new putative prognostic factor. By combining Ki67, NHG, and AIB1, together with lymph node status and tumor size, a group of patients with an excellent prognosis could be identified.

Citation Format: Narbe U, Forsare C, Bendahl P-O, Lövgren K, Alkner S, Sjöström M, Rydén L, Leeb-Lundberg F, Ingvar C, Fernö M. AIB1 is a new putative prognostic biomarker in the luminal A and B-like (HER2-negative) classification of invasive lobular carcinoma [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-05.

Abstract P3-08-13: Serum thymidine kinase activity is an independent prognostic factor for progression-free and overall survival in women with metastatic breast cancer

Introduction:

Although prognosis and treatment of metastatic breast cancer (MBC) have improved over the last years, there is still an unmet clinical need for more precise prognostic and treatment monitoring tools. Liquid-based markers are preferred since they reflect real-time tumor progression and are not dependent on repeated invasive tissue biopsies. Thymidine kinase 1 (TK1) is an enzyme involved in nucleotide metabolism and has a fundamental role in the DNA synthesis. It can be used as a marker of cell proliferation rate and the TK1 activity has demonstrated correlations to prognosis and usefulness for treatment monitoring in different malignancies. The aim of this study was to determine serum TK1 activity (sTK1) levels measured with the DiviTum assay (Biovica, Sweden), in women with MBC scheduled for 1st line systemic therapy and to evaluate its potential for prediction of outcome and treatment monitoring.

Methods:

142 women with MBC scheduled for 1st line systemic treatment and included in a prospective monitoring trial (CTC-MBC, NCT01322893) were evaluated for sTK1 at baseline (BL) and during treatment at 1, 3 and 6 months. 132 patients had at least one follow-up sample. sTK1 activity levels were measured and correlations to important clinicopathological variables and prognosis (PFS and OS) at BL and during treatment were evaluated.

Results:

The median sTK1 level at BL was 391 u/L (range 10-35520 u/L). When comparing patients with high (above median) versus low (below median) sTK1 levels at BL, high sTK1 levels were found to be associated to worse performance status (p=0.001) and high number of metastatic sites (p=0.03). There was also a statistically significant association between high sTK1 levels and high Ki67 expression in biopsies from metastatic lesions (p=0.038). In univariable analyses high sTK1 levels correlated to worse PFS and OS (HRPFS-BL 2.32, p&lt;0.001; HROS-BL 2.54, p&lt;0.001) at BL. In multivariable analysis adjusted for clinically used prognostic factors, sTK1 was an independent prognostic factor for PFS and OS (HRPFS-BL 2.4, p&lt;0.001; HROS-BL 2.0, p=0.01). During treatment, sTK1 was significantly associated with OS from each of the four time points and onwards (BL, 1, 3, 6 months) (HROS-1m 1.93, p=0.01; HROS-3m 2.35, p=0.02; HROS-6m 2.78, p=0.002) in univariable analysis. High sTK1 levels were also associated with impaired PFS (HRPFS-1m 1.48, p=0.06; HRPFS-3m 1.52, p=0.07; HRPFS-6m 2.03, p=0.009) and these associations were significant at BL and 6 months.

Discussion:

sTK1 activity level is an independent prognostic factor for PFS and OS in patients with MBC scheduled for 1st line systemic therapy. During treatment, sTK1 is prognostic for OS evaluated from all time-points up to 6 months. The sTK1 effects observed for PFS are slightly weaker, but still propose potential usefulness for treatment monitoring. Further, sTK1 levels correlate to Ki67 expression in metastatic lesions suggesting that it can be useful as a liquid-based real-time proliferation marker. In conclusion, these results are clinically relevant for prognostication and treatment monitoring in patients with MBC. Future studies of sTK1 are justified to further elucidate in what settings this marker is most useful.

Citation Format: Larsson A-M, Jansson S, Bendahl P-O, Baker S, Bergqvist M, Aaltonen K, Rydén L. Serum thymidine kinase activity is an independent prognostic factor for progression-free and overall survival in women with metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-13.

Abstract PD2-08: Predictors of axillary nodal metastasis based on gene expression and clinicopathological characteristics: Data from a population-based prospective study, the Sweden Cancerome Analysis Network – Breast (SCAN-B)

Background

Gene expression patterns show promise in estimating prognosis and directing adjuvant therapy, but its significance in guiding axillary treatment is sparsely evaluated. We aimed to identify predictors for nodal status based on gene expression patterns alongside clinicopathological characteristics, and to validate the performances as well as the prognostic importance of the predictors in a population-based context.

Material and Methods

The study assigned consecutive patients with primary breast cancer enrolled in the SCAN-B study (ClinicalTrials.gov ID: NCT02306096)in South Sweden between September 2010-March 2015. Exclusion criteria were: prior breast cancer, neoadjuvant therapy or unknown nodal status after surgical staging. Data on age, tumour size, multifocality, vascular invasion, NHG and ER/PR/HER2 status were retrieved. 3026 patients were successfully profiled by RNA sequencing (RNA-seq) forming the study analysis cohort. Patients enrolled during 2011 (n=1206) were excluded from predictor training/test sets and kept as an independent validation set. Seven machine-based learning algorithms were evaluated for all samples and for each of the molecular subtypes based on routine analysis: ER+/HER2-, HER2+ and TNBC. Primary outcome was discrimination (AUC) for N0/N+ based on either clinicopathological parameters, RNA-seq data or mixed data. Secondary outcome was to evaluate the prognostic value of the predictors. Kaplan-Meier estimates were used to portray univariate survival data in subgroups stratified by nodal status.

Results

The Swedish National Quality Registry for Breast Cancer revealed 5235 patients eligible for study inclusion, of which 89% were enrolled in the SCAN-B study. Distribution of clinicopathological characteristics for the 3026 RNA-sequenced patients reflected features in the catchment region, and were similar for the training/test sets (n = 1820) as well as the validation set (n = 1206). Mean AUCs from 10 iterative assessments in the training/test sets identified Generalized Boosted Regression Models having the highest performance. AUCs for clinicopathological predictors in the validation set were 0.73, 0.75, 0.71 and 0.66 for all samples, ER+/HER2-, HER2+ and TNBC, respectively. Corresponding AUCs for gene expression predictors were 0.66, 0.66, 0.62 and 0.57, respectively, while the best predictive performances were achieved with mixed predictors, revealing AUCs 0.75, 0.75, 0.78 and 0.68, respectively. Preliminary results indicated prognostic value of the predictors; patients with stated N0 but predicted N+ by the models had worse survival rates. On the contrary, a trend towards better survival was observed for those with stated N+ but predicted N0 by the models.

Conclusions

Subgroup-specific predictors for nodal status based on gene expression data alongside traditional clinicopathological characteristics were developed, and independently validated regarding performance and prognostic value, in a population-based breast cancer cohort. Integrating gene expression data in the preoperative setting may improve decision-making on the required extent of axillary surgery and systemic therapy needed.

Citation Format: Dihge L, Staaf J, Vallon-Christersson J, Hegardt C, Häkkinen J, Borg Å, Rydén L. Predictors of axillary nodal metastasis based on gene expression and clinicopathological characteristics: Data from a population-based prospective study, the Sweden Cancerome Analysis Network – Breast (SCAN-B) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-08.

Abstract P2-02-09: Breast cancer subtype distribution and circulating tumor DNA in response to neoadjuvant chemotherapy: Experiences from a preoperative cohort within SCAN-B

Introduction: Preoperative chemotherapy in early breast cancer increases the rate of breast preservation and provides prognostic information. In the case of residual disease, a change in subtypes may be observed. Sensitive and reproducible biomarkers predicting treatment response early during the treatment course are needed in order to better exploit the potential benefit of an individualized preoperative treatment.

Material and Methods: In an ongoing prospective study within the population-based SCAN-B project (NCT02306096), patients undergoing preoperative chemotherapy for early or locally recurrent breast cancer have been treated with iv Epirubicin and Cyclophosphamide q3w x 3 in sequence with either Docetaxel q3w x 3 or Paclitaxel q1w x 9 with a preoperative intent. HER2-positive cases also received HER2-directed treatment. At baseline, patients were staged using sentinel node biopsy for clinically node-negative patients and CT scan for cytologically confirmed node-positive cases. A clinical core needle biopsy as well as tissue from the surgical specimen was collected for determination of conventional biomarkers including ER, PgR, HER2 and Ki67. Tumor biopsies for biomolecule-extraction and RNA-sequencing were taken using ultrasound guidance and collected fresh in RNAlater at baseline, after 2 treatment cycles, as well as at surgery. Blood plasma samples were collected at baseline, after one-, three-, and six- 3w treatment cycles, and post-surgery. Using RNA-sequencing data, somatic mutations were identified in the tumor biopsies and personalized analyses for circulating tumor DNA (ctDNA) were performed. A pathological complete remission (pCR) was defined as the complete disappearance of invasive breast cancer in the breast and axilla at time of definitive surgery. Subtyping was performed using modified St Gallen criteria (2013).

Results: Thus far, 45 patients aged 24-74 years have been included, of which 34 (76 %) were clinical stage 2 and 11 (24%) were stage 3. The subtype distribution at baseline was five Luminal A-like (11 %), 21 Luminal B-like (HER2 negative) (47 %), 8 HER2-positive (18 %) and 11 Triple-negative (ductal) (24 %). The rates of pCR in 38 operated cases to date were 0/3 Luminal A-like, 3/19 Luminal B-like (HER2 negative), 2/8 HER2-positive, and 4/7 Triple-negative (overall 24 % pCR rate). One patient did not undergo surgery due to clinically progressive disease. In 25 cases with evaluable residual disease at surgery, there was a shift in the subtype in 13 (52 %), the majority of which represented a transition from Luminal B to Luminal A. No Triple-negative cases underwent a change in subtype during treatment. Results of the ctDNA analyses will be presented at the meeting.

Discussion: We have established an infrastructure allowing for an extensive evaluation of preoperative chemotherapy in early breast cancer. The goal is to develop methods to refine response-guided treatment in early breast cancer using molecular responses in the tumor as well as in the blood circulation. The patients continue to be prospectively monitored with iterative ctDNA analyses during follow-up.

Citation Format: Loman N, Chen Y, Aaltonen K, Brueffer C, George AM, Zander L, Vallon-Christersson J, Häkkinen J, Förnvik D, Rigo R, Ehinger A, Malmberg M, Larsson C, Hegardt C, Borg Å, Rydén L, Saal LH. Breast cancer subtype distribution and circulating tumor DNA in response to neoadjuvant chemotherapy: Experiences from a preoperative cohort within SCAN-B [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-02-09.

Abstract P2-01-03: Improved prognostic information by serial monitoring of CTC enumeration and CTC-clusters from baseline to six months in patients with metastatic breast cancer scheduled for 1st line systemic therapy

Background: Detection and enumeration of circulating tumor cells (CTCs) allows real time monitoring of disease evolvement. In women with metastatic breast cancer (MBC), a CTC count of ≥5 CTCs is associated with decreased progression-free survival (PFS) and overall survival (OS). Serial sampling after therapy initiation has indicated that longitudinal CTC enumeration adds prognostic information, but data from long time sampling is sparse. The aim of this study was to evaluate if prospective longitudinal detection of CTC count and CTC clusters in women with newly diagnosed MBC can improve prognostication and monitoring of patients in the clinical setting.

Methods: Longitudinal blood samples were collected at baseline (BL) and after 1, 3 and 6 months in 156 women with MBC scheduled for 1st line systemic therapy. CTC enumeration and cluster detection were performed by the CellSearch® system in a prospective monitoring trial (NCT01322893). 115 patients had evaluable samples at all time-points. Primary endpoint was PFS and secondary endpoint was OS at BL in relation to CTC count and as landmark analyses during treatment. In addition, change in CTC count during therapy was compared to progressive disease (PD) versus non-PD. Structured clinical and radiological evaluation for PD was performed every 3rd month.

Results: Seventy-nine (52%) of 152 evaluable patients had ≥5 CTC and 14/79 patients had CTC-clusters (33 clustered CTC) at BL. Median follow-up time was 25 (7-69) months. Patients with ≥5 CTCs had inferior PFS and OS in uni-(data not shown) and multivariable analysis (HRPFS 1.91 (1.26-2.91), P=0.003) (HROS 3.57 (2.02-6.31), P&lt;0.001) at BL. Presence of clusters at BL was prognostic for OS (HROS 2.37 (1.25-4.51), P=0.008). Longitudinal landmark analysis of number of CTCs and presence of CTC clusters showed a time-dependent increase in HR during treatment for CTCs and CTC-clusters and predicted worse PFS and OS at all time-points. Stratifying patients based on CTC count and presence of clusters revealed four risk groups (0, 1-4, ≥5 CTC, ≥5 CTC + clusters) where patients with clusters had inferior PFS and OS at all time points. Change in CTC count from BL to 1 and 3 months, and from 3 to 6 months was significantly related to evaluation at 3 and 6 months (PD vs non-PD, P=0.013 (3 months), P=0.016 (6 months)) and change in CTC count from BL to 1, 3 and 6 months was also significantly predictive of both PFS and OS. Notably, survival was significantly inferior for patients with persistent CTC ≥5 during treatment.

Discussion: CTC is an independent prognostic factor for MBC patients scheduled for 1st line systemic therapy. By longitudinal monitoring during treatment, the prognostic information by presence of ≥5 CTC and clusters increases over time and supports long time monitoring of patients. Importantly, detection of CTC-clusters identifies a subgroup of patients with dismal prognosis at all time-points indicating that CTC-clusters renders important clinical information. Change in CTC count during systemic therapy is related to outcome of evaluation and prognosis at all time-points.

Citation Format: Larsson A-M, Jansson S, Bendahl P-O, Baker S, Graffman C, Lundgren C, Loman N, Aaltonen KE, Rydén L. Improved prognostic information by serial monitoring of CTC enumeration and CTC-clusters from baseline to six months in patients with metastatic breast cancer scheduled for 1st line systemic therapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-01-03.

Nomograms for preoperative prediction of axillary nodal status in breast cancer

Background

Axillary staging in patients with breast cancer and clinically node‐negative disease is performed by sentinel node biopsy (SLNB). The aim of this study was to integrate feasible preoperative variables into nomograms to guide clinicians in stratifying treatment options into no axillary staging for patients with non‐metastatic disease (N0), SLNB for those with one or two metastases, and axillary lymph node dissection (ALND) for patients with three or more metastases.

Methods

Patients presenting to Skåne University Hospital, Lund, with breast cancer were included in a prospectively maintained registry between January 2009 and December 2012. Those with a preoperative diagnosis of nodal metastases were excluded. Patients with data on hormone receptor status, human epidermal growth factor receptor 2 and Ki‐67 expression were included to allow grouping into surrogate molecular subtypes. Based on logistic regression analyses, nomograms summarizing the strength of the associations between the predictors and each nodal status endpoint were developed. Predictive performance was assessed using the area under the receiver operating characteristic (ROC) curve. Bootstrap resampling was performed for internal validation.

Results

Of the 692 patients eligible for analysis, 248 were diagnosed with node‐positive disease. Molecular subtype, age, mode of detection, tumour size, multifocality and vascular invasion were identified as predictors of any nodal disease. Nomograms that included these predictors demonstrated good predictive abilities, and comparable performances in the internal validation; the area under the ROC curve was 0·74 for N0versus any lymph node metastasis, 0·70 for one or two involved nodes versusN0, and 0·81 for at least three nodes versus two or fewer metastatic nodes.

Conclusion

The nomograms presented facilitate preoperative decision‐making regarding the extent of axillary surgery.

Defines need for staging?

Abstract P6-09-43: Bcl2 as a long-term prognostic factor in invasive lobular carcinoma of the breast

Background: B-cell lymphoma 2 (Bcl2) is an anti-apoptotic protein with known tumor suppressor effect in breast cancer. Multiple studies have shown that high Bcl2-expression is associated with a better prognosis in breast cancer, but its clinical usefulness as a prognostic factor is still not fully elucidated. Invasive lobular carcinoma (ILC) of the breast is the second most common histologic subtype and comprises 5 to 15 % of all breast cancers. ILC has distinct clinico-pathological features and a specific pattern of recurrence, but treatment strategies are often similar as for the whole group of breast cancers. ILC´s are typically estrogen receptor positive (ER+), progesterone receptor positive (PgR+), HER2 negative, low proliferative and histological grade 2. According to the St Gallen surrogate definitions of the intrinsic subtypes of breast cancer most ILC´s are classified as 'luminal disease' and predominantly as low-risk 'luminal A-like'. Patients with 'luminal disease' in general and 'luminal A-like' in particular falls into prognostic categories where uncertainty about optimal treatment strategy often arises, as clinicians seek to avoid both over- and under-treatment. Additional prognostic factors are needed in order to further improve risk stratification. The use of multigene assays to better predict recurrence is increasing, but the availability is still limited and the cost is high. Measurement of apoptosis-related factors, such as Bcl2 gene expression is included as a prognosticator in a majority of these tests. The aim of this retrospective study was to evaluate the long-term prognostic effect of Bcl2 in a subset of patients with ILC.

Patients and methods: One hundred and ninety-two well-characterized patients with primary ILC were included in the present study. Bcl2 was evaluated together with ER, PgR, HER2, Ki67, histological grade, tumor size, nodal status and age at diagnosis. Ninety-two percent of the patients were ER and/or PgR positive and 41% were node positive. Forty-one percent of the patients received adjuvant endocrine treatment and 3% received adjuvant chemotherapy. The median follow-up of the 52 patients still alive was 26 years. Bcl2 was analyzed immunohistochemically on whole sections of tumor tissue and Bcl2-positivity (Bcl2+) was defined as more than 10% cells with stained cytoplasma. Eighty-six percent of the patients (165/192) were Bcl2+. The primary endpoint was breast cancer mortality (BCM).

Results: Overall, 32% (61/192) of the patients have died from breast cancer. Bcl2 (positive vs negative) was a significant prognostic factor for BCM in univariable Cox regression analysis (HR 0.44, 95% CI: 0.23-0.85). Essentially the same Bcl2 effect was seen after multivariable adjustment for ER, Ki67, histological grade, tumor size, nodal status, age at diagnosis and adjuvant therapy (HR 0.33, 95% CI: 0.15-0.74).

Conclusions: Bcl2 is an independent long-term prognostic factor in this subset of patients with ILC. Bcl2 might add new prognostic information based on apoptotic tumor features that could be useful in the clinical treatment decision-making.

Citation Format: Narbe U, Forsare C, Bendahl P-O, Rydén L, Ingvar C, Fernö M. Bcl2 as a long-term prognostic factor in invasive lobular carcinoma of the breast [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-43.

Abstract P1-07-17: The SCAN-B study: 5-year summary of a large-scale population-based prospective breast cancer translational genomics platform covering a wide geography of Sweden (NCT02306096)

Background:

Breast cancer exhibits significant molecular, pathological, and clinical heterogeneity. Current clinicopathological evaluation is imperfect for predicting outcome, which results in overtreatment for many patients, and for others, leads to death from recurrent disease. Therefore, additional criteria are needed to better personalize care and maximize treatment effectiveness and survival. To address these challenges, large-scale population-based studies are needed to develop and evaluate new predictive biomarker tests under real-world conditions.

Methods:

In 2010 we initiated the Sweden Cancerome Analysis Network - Breast (SCAN-B) multicenter prospective study (ClinicalTrials.gov identifier NCT02306096) with longsighted aims to 1) analyze breast cancers with next-generation genomic technologies for translational research in a population-based manner and integrated with healthcare; 2) decipher fundamental tumor biology from these analyses; 3) utilize genomic data to develop and validate new clinically-actionable biomarker assays; and 4) establish real-time clinical implementation of molecular diagnostic and treatment-predictive tests. Eligibility criteria are suspicion or confirmed diagnosis of primary breast cancer. Eligibility will be extended to recurrent breast cancer in late 2016. For all patients, tumor biopsy and/or surgical tumor specimen and baseline blood samples are collected, as well as follow-up blood samples at defined intervals, and clinical data are obtained from regional and national databases. From all samples, DNA, RNA, and protein fractions are isolated, and tissue arrays are constructed. In the first phase, we focus on molecular profiling of tumor tissue by next-generation RNA-sequencing.

Results:

From August 2010 through May 2016, we have consented and enrolled 8,669 patients with primary breast cancer at 9 hospital sites in Sweden, representing approximately 85% of eligible patients in the catchment area. Preoperative blood samples have been collected for 8,288 (96%) patients and primary fresh-frozen tumor specimens collected for 6,129 (71%) patients. All tumors have been RNA-sequenced, and newly enrolled cases are analyzed in “real-time” within an average of 7 days after biopsy/surgery. Herein we describe the study infrastructure and protocols and present initial proof of concept results from prospective RNA-sequencing including tumor molecular subtyping, detection of driver gene mutations, and determination of ER, PgR, HER2, Ki67, and tumor grade from RNA-seq data. Prospective patient enrollment is ongoing and pilot clinical reports are being evaluated at multidisciplinary breast cancer conferences.

Conclusions:

We demonstrate that population-based collection and real-time RNA-sequencing analysis of breast cancer is feasible at large-scale. The SCAN-B Study should significantly reduce the time to discovery, validation, and clinical implementation of novel molecular diagnostic and predictive tests. We welcome the participation of additional comprehensive cancer treatment centers.

Citation Format: Saal LH, Hegardt C, Vallon-Christersson J, Häkkinen J, Ehinger A, Manjer J, Larsson C, Loman N, Rydén L, Malmberg M, Borg Å. The SCAN-B study: 5-year summary of a large-scale population-based prospective breast cancer translational genomics platform covering a wide geography of Sweden (NCT02306096) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-07-17.

Abstract P2-01-18: Preoperative prediction of axillary lymph node status based on artificial neural network algorithm model

Background

Axillary lymph node status remains the single most significant prognostic factor for patients with primary breast cancer. Clinical and pathologic data have been used to develop statistical models to predict the axillary nodal status; the diverse accuracy may reflect the complexity of factors related to axillary metastasis.

Artificial neural network (ANN) is a computational method proposed as a supplement to standard statistical models for predicting complex biological phenomena. ANN is composed of artificial neurons and interrelated by synaptic weights, effective in multifactorial analysis and has the ability to explore underlying nonlinear relations of interconnected variables.

The aim of this study was to create an ANN-based preoperative decision tool for prediction of nodal axillary status (N0, N+ with 1-3 positive lymph nodes and N+ with ≥ 4 positive nodes). In the clinical setting, this may contribute to improved selection of patients for no axillary staging for those predicted with disease-free axilla (N0), sentinel node biopsy for patients with predicted 1-3 nodal metastases, and axillary lymph node dissection or neoadjuvant therapy for patients displaying four or more involved axillary lymph nodes.

Methods

The cohort constituted of consecutive patients diagnosed with primary breast malignancy between January 2009 and December 2012 at Skåne University Hospital in Lund, Sweden. The exclusion criteria were palpable axillary nodes or cytology-verified axillary metastasis and neoadjuvant chemotherapy. Data on mode of detection were retrieved. Clinical parameters included age, BMI, menopausal status and the location of the tumor within the breast. A breast pathologist extracted the histopathological variables of the tumor and lymph node. The ANN consisted of 3 layers, an input layer using 1-22 separate variables, one hidden layer, and a single node output layer, with the nodal status N0, macro-metastases N+1-3 and N+≥ 4, respectively as output. The ANN was trained by back-propagation using gradient descent of a cross entropy error, for 2000 epochs. Area under the receiver operating characteristic curve (AUC) was used to assess the performance of the ANN-based predictive models for axillary nodal status. Evaluation was performed in a stratified 5-fold cross validation scheme, repeated 10 times. Sensitivity and specificity are given for a cutoff value corresponding to optimal balanced accuracy.

Results

The cohort consisted of 800 patients, classified into N0 64 % (n=514), N+1-3 positive nodes 29% (n=232) and N+≥ 4 positive nodes 7% (n=54). The AUC was 0.72 for prediction of node negativity; sensitivity 74% and specificity 64%. AUC was 0.77 for N+ ≥ 4; sensitivity 67% and specificity 79%. The predictive model for N+1-3 macro-metastases is in progress. Tumor size and lymphovascular invasion are the two principal risk variables selected to construct the ANN predictive model for N+ ≥ 4. However, for N0, the predictive model is characterized by a complicated integration of numerous clinicopathological risk variables.

Conclusions

Based on clinicopathological and mammography-screening data, ANN can be valuable in predicting axillary nodal status and as a guidance tool for directing patients to personalized treatment of the axilla.

Citation Format: Dihge L, Edén P, Rydén L. Preoperative prediction of axillary lymph node status based on artificial neural network algorithm model [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-18.

St Gallen molecular subtypes in screening-detected and symptomatic breast cancer in a prospective cohort with long-term follow-up

Background

Diagnosis by screening mammography is considered an independent positive prognostic factor, although the data are not fully in agreement. The aim of the study was to explore whether the mode of detection (screening‐detected versus symptomatic) adds prognostic information to the St Gallen molecular subtypes of primary breast cancer, in terms of 10‐year cumulative breast cancer mortality (BCM).

Methods

A prospective cohort of patients with primary breast cancer, who had regularly been invited to screening mammography, were included. Tissue microarrays were constructed from primary tumours and lymph node metastases, and evaluated by two independent pathologists. Primary tumours and lymph node metastases were classified into St Gallen molecular subtypes. Cause of death was retrieved from the Central Statistics Office.

Results

A total of 434 patients with primary breast cancer were included in the study. Some 370 primary tumours and 111 lymph node metastases were classified into St Gallen molecular subtypes. The luminal A‐like subtype was more common among the screening‐detected primary tumours (P = 0·035) and corresponding lymph node metastases (P = 0·114) than among symptomatic cancers. Patients with screening‐detected tumours had a lower BCM (P = 0·017), and for those diagnosed with luminal A‐like tumours the 10‐year cumulative BCM was 3 per cent. For patients with luminal A‐like lymph node metastases, there was no BCM. In a stepwise multivariable analysis, the prognostic information yielded by screening detection was hampered by stage and tumour biology.

Conclusion

The prognosis was excellent for patients within the screening programme who were diagnosed with a luminal A‐like primary tumour and/or lymph node metastases. Stage, molecular pathology and mode of detection help to define patients at low risk of death from breast cancer.

Low‐risk group identified

Abstract P6-06-26: St Gallen molecular subtypes adds prognostic information beyond detection by screening mammography

Background:

The public mammography screening program was implemented in Sweden 30 years ago and has contributed to detection of primary breast cancer at an earlier stage, but it´s impact on survival is still controversial. In a prospective observational cohort including patients with primary breast cancer between 1999-2002, 442 patients were aged 45-75 and regularly invited to mammography screening. The aim of the study was to relate mode of detection and St Gallen molecular subtypes to 10 years breast cancer specific survival (BCSS) in order study if St Gallen molecular subtypes added prognostic information also in screening detected breast cancer.

Methods:

Tissue microarrays (TMA) were constructed from tissue blocks of primary tumors and lymph node metastasis. The samples were evaluated according to oestrogen receptor (ER), progesterone receptor (PR), Ki67 and human epidermal growth factor receptor 2 (HER2) by immunohistochemistry and in situ hybridisation. Classification according to the St Gallen molecular subtypes (Luminal A (ER+ and/or PR+, low Ki67 and HER2-), luminal B HER2- (ER+ and/or PR+, high Ki67 and HER2-), luminal B HER2+ (ER+ and/or PR+, any Ki67 and HER2+), HER2 type (ER-, PR- and HER2+) and triple-negative (ER-, PR- and HER2-) was possible in 372 primary tumors and 106 lymph node metastasis. The cause of death was retrieved from the National Board of Health.

Results:

Screening detected breast cancer was diagnosed in 52% of the patients. Patients with screening detected breast cancer had smaller tumor size (17.1mm compared to 21.6 mm in clinically detected (p&lt;0.001), were more often node negative (p = 0.002) and had tumors of lower histological grade (p = 0.03). In contrast, there was no statistical difference in distribution of the St Gallen molecular subtypes related to mode of detection (p = 0.2). Patients with tumors detected within the screening program, had a more favorable prognosis with 91% BCSS compared to clinically detected tumors (BCSS 84%), p = 0.02 log rank test. St Gallen molecular subtypes added significant prognostic information in all patients (p = 0.008), which was true in both screening detected and clinically detected breast cancer (p = 0.02 in both groups). In Cox multivariate analysis including mode of detection, tumor size, node status and St Gallen molecular subtype, node status and St Gallen molecular subtypes remained significant prognostic factors. St Gallen molecular subtypes in lymph node metastasis had no prognostic information nor in the whole cohort or in clinically detected breast cancer, but showed that patients with lum A subtype in the lymph node metastasis had an excellent prognosis irrespective of subtype inherence in the primary tumor (p = 0.001) with 100% BCSS.

Conclusion:

St Gallen molecular subtypes in primary breast cancer shows similar distribution irrespective of mode of detection, but adds prognostic information in both clinically and screening detected breast cancer and outperforms tumor size and screening detection in multivariate analysis in terms of 10 years BCSS. For patients with screening detected tumors and lymph node metastasis, lum A inherence in the lymph node metastasis identifies a subgroup of patients with excellent prognosis irrespective of node positive disease.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-26.

Early achievements in cardiovascular care as reflected in the Journal of Internal Medicine

This review mirrors progress in cardiovascular medicine as reflected by scientific contributions published in the Journal of Internal Medicine (from 1989), Acta Medica Scandinavica (from 1919 until 1989) and Nordiskt Medicinskt Arkiv (before 1919). A total of 149 articles were identified within this field since the first, published work in this field 1877-1970. The latter year was set as and end for the review since this was the year the first contribution by the author of this review was published in the journal. To cope with the large number individual publications related to different aspects of cardiovascular medicine were grouped together into fields in which Scandinavian contributions were pioneering or for other reasons of particular interest. These articles were briefly summarized together with some information of the author(s) and the contributions were put into the perspective of subsequent importance and/or scientific and clinical development. Among topics with insightful contributions published in the journal are electrophysiology, diagnostic techniques including standardization, endurance exercise and the heart, electrocardiography, myocardial infarction, atrio-ventricular block and cardiac pacing. Some of these early contributions were indeed, considering the methods available at the time for the investigations impressive and many predictions truly insightful and imaginative. Other contributions may, at least by the present day reader, seem somewhat odd.

Sitagliptin improves beta-cell function in patients with acute coronary syndromes and newly diagnosed glucose abnormalities--the BEGAMI study

BACKGROUND

Newly detected impaired glucose tolerance (IGT) or type 2 diabetes mellitus (T2DM) are common in patients with acute coronary syndrome (ACS; i.e. unstable angina/myocardial infarction) and related to disturbed beta-cell function. The aim of this study is to test the hypothesis that treatment with a dipeptidyl peptidase-4 inhibitor initiated soon after a coronary event improves beta-cell function.

METHODS

Acute coronary syndrome ACS patients with IGT or T2DM (n = 71), screened by oral glucose tolerance test (OGTT) 4-23 days (median 6 days) after hospital admission, were randomly assigned to sitagliptin 100 mg (n = 34) or placebo (n = 37) and treated for a duration of 12 weeks. All patients received lifestyle advice but no glucose-lowering agents other than the study drug. The study end-point was beta-cell function assessed using the insulinogenic index (IGI = ΔInsulin30 /ΔGlucose30 ), derived from an OGTT, and acute insulin response to glucose (AIRg) assessed by a frequently sampled intravenous glucose tolerance test.

RESULTS

The IGI and AIRg did not differ at baseline between the sitagliptin and placebo groups (69.9 vs. 66.4 pmol mmol(-1) and 1394 vs. 1106 pmol L(-1) min(-1) respectively). After 12 weeks, the IGI was 85.0 in the sitagliptin and 58.1 pmol/mmol in the placebo group (P = 0.013) and AIRg was 1909 and 1043 pmol L(-1) min(-1) (P < 0.0001) in the sitagliptin and placebo groups respectively. Fasting glucose at baseline was 6.1 mmol L(-1) in sitagliptin-treated patients and 6.0 mmol L(-1) in those who received placebo compared with 5.8 and 5.9 mmol L(-1) respectively, after 12 weeks of treatment. Post load glucose metabolism improved in significantly more sitagliptin-treated patients compared with the placebo group (P = 0.003). Sitagliptin was well tolerated.

CONCLUSION

Sitagliptin improved beta-cell function and glucose perturbations in patients with ACS and newly diagnosed glucose disturbances.

Early inflammatory response in soft tissues induced by thin calcium phosphates

The inflammatory response to titanium and hydroxyapatite (HA)-coated titanium in living tissue is controlled by a number of humoral factors, of which monocyte chemoattractant protein-1 (MCP-1) has been specifically linked to the recruitment of monocytes. These cells subsequently mature into tissue-bound macrophages. Macrophages adhering to the proteins adsorbed at the implant surface play a pivotal role in initiating the rejection or integration of the foreign material. Despite this, little is known about the initial inflammatory events that occur in soft tissues following the implantation of titanium and HA-coated titanium implants. In this study, circular discs of commercially pure titanium (c.p. Ti) with either a thin crystalline HA coating or amorphous HA coating or uncoated were implanted subcutaneously into rats. The implants were retrieved after 24 and 72 h. The lactate dehydrogenase (LD) activity, DNA content, expression of MCP-1, interleukin-10 (IL-10), tumor necrosis factor α (TNF-α), as well as monocyte and polymorphonuclear granulocyte counts in the exudate surrounding the implants were analyzed. There were significantly higher DNA and LD levels around the titanium implants at 24 h compared with HA-coated titanium. A rapid decrease in MCP-1 levels was observed for all the implants over the period of observation. No statistically significant differences were found between the two HA-coated implants. Our results suggest a difference in the early soft-tissue response to HA-coated implants when compared with titanium implants, expressed as a downregulation of inflammatory cell recruitment. This suggests that thin HA coatings are promising surfaces for soft tissue applications.

Prognostic implications of glucose-lowering treatment in patients with acute myocardial infarction and diabetes: experiences from an extended follow-up of the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 Study

AIMS/HYPOTHESIS

This post hoc analysis from the Diabetes Mellitus Insulin-Glucose Infusion in Acute Myocardial Infarction (DIGAMI) 2 trial reports on extended long-term outcome in relation to glucose-lowering agents in patients with myocardial infarction and type 2 diabetes.

METHODS

Patients were randomised as follows: group 1, insulin-based treatment; group 2, insulin during hospitalisation followed by conventional glucose control; and group 3, conventional treatment. Treatment according to the above protocol lasted 2.1 years. Using the total DIGAMI 2 cohort as an epidemiological database, this study presents mortality rates in the randomised groups, and mortality and morbidity rates by glucose-lowering treatment during an extended period of follow-up (median 4.1 and max 8.1 years).

RESULTS

Follow-up data were available in 1,145 of the 1,253 patients. The mortality rate was 31% (72% cardiovascular) without significant differences between treatment groups. The total number of fatal malignancies was 37, with a trend towards a higher risk in group 1. The HR for death from malignant disease, compared with group 2, was 1.77 (95% CI 0.87-3.61; p = 0.11) and 3.60 (95% CI 1.24-10.50; p = 0.02) compared with group 3. Insulin treatment was associated with non-fatal cardiovascular events (OR 1.89 95% CI 1.35-2.63; p = 0.0002), but not with mortality (OR 1.30, 95% CI 0.93-1.81; p = 0.13). Metformin was associated with a lower mortality rate (HR 0.65, 95% CI 0.47-0.90; p = 0.01) and a lower risk of death from malignancies (HR 0.25, 95% CI 0.08-0.83; p = 0.02).

CONCLUSIONS/INTERPRETATION

Patients with type 2 diabetes and myocardial infarction have a poor prognosis. Glucose-lowering drugs appear to be of prognostic importance. Insulin may be associated with an increased risk of non-fatal cardiac events, while metformin seems to be protective against risk of death.

Mannose-binding lectin genotype and phenotype in patients with type 2 diabetes and myocardial infarction: a report from the DIGAMI 2 trial

OBJECTIVE

The present study characterizes mannose-binding lectin (MBL), an activator of the complement system and thereby important for inflammatory activation, in patients with diabetes and myocardial infarction.

RESEARCH DESIGN AND METHODS

Serum (S)-MBL was determined at hospital admission in 387 patients with type 2 diabetes (median age 70 years; 68% male) with myocardial infarction, and genotyping was performed in 287 patients. Cardiovascular events (cardiovascular mortality and nonfatal myocardial infarction or stroke) were recorded during 2.5 years.

RESULTS

Median S-MBL was 1,212 μg/l (interquartile range [IQR] 346-2,681 μg/l). Of the subjects, 54% in the geno- and phenotype subgroup had a high-coding MBL genotype (median S-MBL=2,658 μg/l [IQR 1,715-3,829]) and 46% a low-coding MBL genotype (373 μg/l [100-765]). S-MBL did not correlate with age, BMI, creatinine clearance, glucose, or A1C. Cardiovascular events occurred in 136 (35%) patients. S-MBL did not predict events in univariable analyses (hazard ratio 0.93 [95% CI 0.85-1.01]; P=0.09). In unadjusted analyses, the risk of events was lower in patients with a high genotype and S-MBL above the median for their genotype (0.49 [0.26-0.92]; P=0.026) than for patients with a low genotype and S-MBL below the median for their genotype. The prediction capacity of the geno- and phenotype model was of borderline significance in adjusted Cox regression.

CONCLUSIONS

Patients with type 2 diabetes and myocardial infarction have MBL genotypes that are similar to those known in the general population. The combination of a low-coding MBL genotype with a low S-MBL appears to be prognostically unfavorable, but the association is blunted by traditional risk markers.

Effect of gender on prognosis in patients with myocardial infarction and type 2 diabetes

BACKGROUND

Diabetes is associated with a markedly increased cardiovascular risk, but the role of gender on the combined effects of diabetes and myocardial infarction has been less well explored.

METHODS

The Diabetes Mellitus and Insulin Glucose Infusion in Acute Myocardial Infarction 2 (DIGAMI2) trial recruited 837 men and 416 women with type 2 diabetes hospitalized due to myocardial infarction and followed for a median of 2.1 years. The effects of gender on diabetes-specific risk factors and conventional cardiovascular risk predictors of unfavourable outcome were analysed using a Cox proportional hazards model.

RESULTS

Women were older, more frequently had hypertension and previous heart failure than men, and were more often treated with diuretics. More men were smokers. Treatment during hospitalization, at discharge and during follow-up, did not differ significantly, apart from the more frequent use of diuretics in women. Total mortality did not differ between genders, but the combined cardiovascular end-point of death, re-infarction or stroke was more common in women (38.9% vs. 32.1%). This difference disappeared after age adjustment. Age and previous heart failure were independent risk predictors in both genders, whereas diabetes complications were an additional risk factor in women only. Blood glucose level at randomization and updated glucose concentration during follow-up were independent predictors of poor outcome in men but not in women.

CONCLUSIONS

Age and not gender itself explained the increased cardiovascular event rate seen in women compared with men. A heavier risk factor burden was seen amongst women. Improved risk factor control instituted before the development of a myocardial infarction should be attempted as a possible means of improving the outcome.

Lipid lowering versus pleiotropic effects of statins on skin microvascular function in patients with dysglycaemia and coronary artery disease

OBJECTIVES

To investigate the impact of lipid lowering therapy by different means on skin microvascular function in patients with dysglycaemia and coronary artery disease (CAD).

DESIGN AND SETTING

Thirty-six patients were randomized to simvastatin 80 mg daily (S80, n = 19) or ezetimibe 10 mg and simvastatin 10 mg daily (E10/S10, n = 17) for 6 weeks. Skin microvascular function was assessed by laser Doppler fluxmetry (LDF) at rest, following arterial occlusion (peak postocclusive LDF) and following local heating on the forearm (heat arm LDF) and foot (heat foot LDF). LDF parameters and serum lipids were evaluated at baseline and follow-up.

RESULTS

At follow-up, LDL cholesterol had decreased from 3.1 (2.7-3.5) to 1.6 (1.5-1.8) (mmol L(-1)) and 3.0 (2.4-3.9) to 1.3 (1.1-1.8) (mmol L(-1)) in the E10/S10 and S80 groups respectively. In the entire study group (n = 32), LDF parameters increased significantly; postocclusive LDF from 22 (17-27) to 26 (21-32) perfusion units (PU) (P < 0.001), heat foot LDF from 61 (44-82) to 66 (45-83) PU (P < 0.001) and heat arm LDF from 60 (48-121) to 75 (54-125) PU (P < 0.01). The changes in LDF parameters did not differ between the E10/S10 and S80 groups.

CONCLUSIONS

Lipid lowering improves microvascular function in patients with dysglycaemia and CAD. The data suggest that lipid lowering per se is more important than pleiotropic effects of statins for this effect.

The Skaraborg hypertension project. I. The prevalence of hypertension

The prevalence of hypertension in the age group 40-69 in the County of Skaraborg, Sweden (265000 inhabitants) was estimated using diagnostic criteria commonly accepted in Sweden in recent years. The prevalence was higher than expected (16%) and most of the patients (80%) were previously identified and undergoing treatment. The quantitative aspect of hypertension was even more impressive in the ages above 69 years. Eighteen per cent of the men and 33% of the women aged 75 years were on antihypertensive medication. An unexpectedly large proportion of the population had a borderline pressure requiring further follow-up (16%). It is concluded that quantitative aspects must be taken into consideration when planning hypertension care and deciding diagnostic criteria.

Improved cardiac performance during exercise following hydralazine treatment in chronic heart failure

Nine male patients with stable chronic heart failure of different etiology and optimally treated with digoxine and diuretics were given hydralazine, 50 mg b.i.d., during three months. Hemodynamic parameters were evaluated during upright submaximal exercise. An increase in cardiac index due to an increased stroke volume was noted following the first dose of hydralazine. After three months' treatment, cardiac index was further increased. The arteriovenous oxygen difference was initially unchanged, but significantly decreased following long-term treatment. These findings may indicate different effects of hydralazine acutely and after long-term treatment. It is suggested that the initial increase in blood flow is directed mainly to regions other than the exercising muscles, while more blood is directed to the muscles after long-term treatment. A possible mechanism to explain this postulated difference is discussed.