Accuracy of non-invasive anatomical lead localization in CRT patients: BSPM vs 12-lead ECG

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant agency AZV, Ministry of Health of the Czech Republic

Background

Non-invasive, inverse ECG (iECG), estimating the cardiac activation from ECG signals, may be useful both to support CRT implant and optimization. However, most iECG strategies require a 32-250 electrode body surface potential mapping (BSPM), limiting their clinical utility.

Objective

This proof of concept study evaluates the accuracy of our novel PaceView iECG method to localize the LV/RV pacemaker lead to the cardiac anatomy using either a 96-electrode BSPM or the 12-lead ECG.

Methods

PaceView generates activation sequences in combination with the equivalent double layer source model to simulate the corresponding ECG signals. An initial activation sequence is iteratively optimized to match simulated and measured ECG signals. A BSPM with 96 electrodes and CT were recorded for every patient with implanted CRT. The CT was used to create patient-specific heart/torso model and to localize the ECG electrodes and CRT leads. From a BSPM, 9 signals were selected to obtain the 12-lead ECG. Both BSPM and 12-lead ECG were used to localize the RV/LV lead as the earliest ventricular activation site.

Results

In this study 14 consecutive patients with dilated cardiomyopathy were enrolled: mean age 58±9 years, 7 females. The localization error for the RV/LV lead was 10.4±5.4 (max 22) / 11.3±5.5 (max 20.4) mm using the 12 lead ECG and 11.7±6.1 (max 26.2) / 13.5±5.8 (max 24.5) mm for the BSPM. The time used for a 3D activation map computation was 0.9-1.8 s.

Conclusion

Our preliminary results show that the non-invasive lead localization error, using the 12-lead ECG, is small and comparable with a 96-lead BSPM. Therefore PaceView might be clinically beneficial, by actively localizing the LV/RV pacing sites during CRT implant, and optimize AV or VV delays at CRT follow-ups.

Novel non-invasive 12-lead ECG-based imaging method with potential to guide and optimise right ventricular lead implantation

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Svend Andersens Foundation

Karl G Andersens Foundation

Helsefonden

Background

Right ventricular (RV) pacing may induce electrical and mechanical dyssynchrony which may lead to heart failure. Often, the physician aims for lead implantation at the RV septum as this is expected to result in a more physiologic activation compared to alternative RV lead locations. Fluoroscopy, often in combination with QRS morphology derived from the 12-lead ECG, is used to guide lead implantation. However, this method is inaccurate and can result in a non-optimal RV lead location. We present a novel non-invasive method to create patient-specific 3D electrical activation maps from the 12-lead ECG that has potential to support RV lead implantation.

Methods

Data from 34 patients with an implanted dual chamber pacemaker were used. A contrast-enhanced cardiac CT scan showing the RV lead implantation site was obtained as well as recording of a 12-lead ECG during RV pacing together with a 3D photo documenting the ECG electrode positions. Discrete patient-specific torso and heart models were created from the CT scans. Each torso model was merged with the 3D photo for precise placement of the ECG electrodes in relation to the heart (figure 1). Combining the 12-lead ECGs and the heart/torso models, patient-specific 3D electrical activation maps originating from the RV were created using a novel inverse-ECG technique applying electrophysiological rules. The accuracy of the inverse-ECG method was determined by comparing the earliest site of activation from the 3D activation map with the known RV insertion site marked on the CT scan.

Results

Documented by the implanting physician in the medical records, 33 RV leads were estimated to be septal and one apical. Estimated from the CT scan 9 leads were placed septal, 18 apical and 7 on the free wall. The mean geodesic distance between the initial site of activation in the 3D activation map and the marked RV insertion site from CT was 13.6 ±5.7 mm (range 4.3-28.6). The distance for each patient is shown in figure 2. The initial site of activation was constrained to the discrete nodes of the ventricular model whereas the marker for RV lead position was localized freely on the CT scan. The average distance from the RV CT marker to the nearest discrete node was 4.3 ±2.2 mm. Correcting for this error, the geodesic distance between the initial site of activation and RV CT marker was 9.3 ±5.4 mm (range 0.0-24.6). The average time used for 3D activation map computation was 1.1 ±0.4 s per ECG.

Conclusions

We demonstrated a novel non-invasive 12-lead ECG-based method to accurately and effectively localize the RV lead in relation to the ventricular anatomy during RV pacing. Furthermore, we confirmed that the RV lead was often implanted in an unintended position. With further advancements, this method has the potential to support physicians during pacemaker implantation to ensure optimal RV lead positioning. Further studies are needed to confirm the accuracy.

Measurement of electrical dyssynchrony in CRT patients: 12-lead ECG versus 96-lead body surface map

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant agency AZV, Ministry of Health of the Czech Republic

Background

Quantification of electrical dyssynchrony would allow optimization of lead placement and timing in patients with CRT. The standard deviation of activation times (SDAT) derived from body surface maps (BSM) was proposed as a measure of electrical dyssynchrony in CRT patients. However, SDAT derived from standard 12-lead ECG would be clinically preferred.

Objective

To evaluate and compare the SDAT measured from BSM and 12-lead ECG for assessment of electrical resynchronization in patients with implanted CRT.

Methods

CRT patients with sinus rhythm and LBBB at baseline (n=19, 58% males; age 60±11 years; NYHA class II-III; QRS 160±29) were studied using 96-lead BSM. For each ECG lead, the activation time was automatically detected and SDAT was calculated using either 96 leads or standard 12 leads. Electrical dyssynchrony was assessed during native sinus rhythm and 6 different pacing modes (see figure).

Results

SDAT calculated from BSM and 12-lead ECG decreased during optimal BiV pacing as compared to sinus rhythm by 26% (p=0.006) and 30% (p=0.003), respectively. The two other BiV setups showed also a decrease in SDAT values. Importantly, a high degree of reliability was found between values of SDAT obtained from12-lead ECG and 96-lead BSM for different pacing modes, the intraclass correlation coefficient was 0.8 to 0.9 (95% CI 0.7 - 0.9, p<0.001).

Conclusion

SDAT assessment is considered an important metric of electrical dyssynchrony in CRT. Our results suggest that 12-lead ECG provides similar results as BSM and thus, allows simplification of the measurement. Further prospective studies are necessary to verify the clinical utility of SDAT from 12-lead ECG.

Abstract P4-06-08: The spatial localization of immune cells predicts prognosis and response to therapy in inflammatory breast cancer

Introduction

The mechanisms contributing to the aggressive biology of inflammatory breast cancer (IBC) are still under investigation. Our lab reported a 79-gene signature that is shaped by specific immune response programs and discriminates between IBC and non-IBC (nIBC). Furthermore, the presence of cytotoxic CD8+ immune cells is associated with a better prognosis in proliferative subtypes of breast cancer. However, not only the presence of CD8+ cells, but also the interaction with other immune cells plays a role in the functional immune response. In this study we assessed the spatial associations between immune cells in IBC.

Methodology

Affymetrix gene expression data of 105 IBC patients were analyzed using CIBERSORT and xCell modules to narrow down the number of stainings for the immunophenotyping. To analyze the composition of the immune infiltrate, we used five validated antibodies: CD79α (B-cell lineage), CD8 (cytotoxic T-cells), FOXP3 (Tregs), CD163 (Tumor associated macrophages, TAMs) and the SP142 PDL1 antibody.

A standard H&E stained section was used to mark the tumor area on pretreatment biopsy sections. Subsequently, 5 slides were stained according to a validated protocol, scanned and evaluated using VISIOPHARM® software that makes virtual multiplexing possible after the alignment of the scanned images. Using both point pattern analysis and the Morisita–Horn index (MHI), developed for ecological studies, we assessed the co-localization of the different types of immune cells. Currently, we report the result of our validation cohort (30 patient samples).

Results

Most of our IBC patients presented with a hormone receptor positive carcinoma (64.7%). Almost a quarter of the patients (23.3%) with initially localized disease achieved complete pathological response (pCR) after neo-adjuvant chemotherapy (NACT). For every staining we report the median relative marker area (RMA), MHI for colocalization with CD8 applying a square tessellation of 100 μm and the number of cells in a radius of 30 μm around CD8+ cells (direct cell-cell contact) in table 1.

  RMAMHI # X+ cells (30 μm)CD80.33 %  CD1630.12 %0.7213.13CD79α0.04 %0.6522.52FOXP30.01 %0.7011.37PDL1 0.7460.70Table 1: Median spatial properties.

The RMA of CD8 predicted pCR after NACT (RMA= 1.07% pCR vs 0.35% no pCR, P=0.04), but was not prognostic for OS (P= 0.445). PDL1 positivity predicted neither pCR nor OS in this cohort. However, OS of patients with more PDL1+ cells ( > 0.703) in close contact with the CD8+ cells was significantly shorter (5y OS: 50% vs 68%, P= 0.03).

Interestingly, the colocalization of CD8+ cells with TAMs (MHI= 0.69 no pCR vs. 0.75 pCR, P= 0.04) and CD79α+ B-cells (MHI= 0.63 no pCR vs. 0.69 pCR, P= 0.04) was also associated with pCR after NACT, while the number of CD163+ or CD79α+ cells was not.

Conclusion

In this study we described the dynamic interplay between cancer and immune cells. In a validation cohort of 30 patient samples we showed that the colocalization of TAMs or B-cells with cytotoxic T cells was associated with pCR after NACT. Furthermore, patients with more PDL1+ cells around CD8+ cells (r= 30 μm) had a worse prognosis while solely the number of PDL1+ or CD8+ cells was not prognostic. By December we will present data on 179 IBC patients.

Citation Format: Van Berckelaer C, Colpaert C, Rypens C, Marien KM, Waumans Y, Kockx M, Vermeulen P, Dirix L, Van Laere S, Van Dam P. The spatial localization of immune cells predicts prognosis and response to therapy in inflammatory breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-08.

Abstract P2-04-09: The prognostic and predictive effect of tumor infiltrating lymphocytes is not determined by B-cells or PD-L1 expression in inflammatory breast cancer

Background

The tumor stroma with tumor infiltrating lymphocytes (TILs) plays a crucial role in the aggressive inflammatory breast cancer (IBC) phenotype and a gene signature enriched for immunity-related genes showed that response to neo-adjuvant chemotherapy was associated with immunity related processes in IBC. In both IBC and non-inflammatory breast cancer (nIBC), tumors are infiltrated by B-cells, but their role in regulating anti-tumor immunity is not well understood. In this study we looked at the prognostic and predictive effect of B-cells in the immune infiltrate of 178 IBC and 247 nIBC patients.

Methods

TIL scoring was done on standard H&E stained sections of formalin-fixed paraffin-embedded pre-treatment tumor tissue according to international guidelines (Salgado et al., 2015). B-cells in the immune infiltrate were defined as CD79α (clone JCB117) positive cells and scoring was done semi-quantitatively, both intra- and peritumorally. Slides, stained with a validated PD-L1 assay (clone SP142) were scored on immune cells (IC) according to Herbst et al., 2014.

Results

Most of our IBC patients presented with a grade 3 (67.7%), ductal (91.1%) carcinoma. A quarter of the patients (25.7%) with initially localized disease (71.6%) achieved complete pathological response (pCR) after neo-adjuvant chemotherapy.The mean TIL score was 18.02% (1.0 – 80.0) and 67 out of 156 patients (42,9%) were PD-L1 positive. Categorical scores of the immune infiltrate are summarized in the table.

 Category 1 (< 10%)Category 2 (≥ 10, < 40%)Category 3 (≥ 40 %)TIL score (n=178)34.73% (n= 61)53.4% (n= 95)12.4% (n=22)Intratumoral CD79α score (n= 175)69.1% (n= 121)22.3% (n= 175)8.6 % (n= 15)Peritumoral CD79α score (n= 171)48.5 % (n= 83)38.0 % (n= 65)13.5 % (n= 23)

TILs were significantly higher in oestrogen receptor negative (ER-) groups compared to ER+ groups (21.26% vs. 15.58%, p= 0.017). In IBC, univariate analysis showed that achieving pCR was significantly associated with more TIL infiltration (p< 0.001), PD-L1 IC expression (p= 0.013) and intratumoral CD79α scores (p= 0.036). However, in multivariate analysis the effect of PD-L1 and CD79α positive cells was lost. When corrected for different molecular subtypes the predictive effect of TILs was only present in ER- groups. Survival analysis showed a significant beneficial effect of TILs (p= 0.014) but only in the ER+ groups, while PD-L1, intra- and peritumoral CD79α scores were not significant. Intratumoral CD79α scores correlated with both TIL score (p= 0.024) and PD-L1 expression (p= 0.007) in multivariate analysis.

When comparing IBC to nIBC, TILs were significantly higher in IBC patients (15.58 % vs. 11.29%, p= 0.009) in the ER+ group, while in the ER- group they were significantly lower (21.27% vs. 37.19%, p < 0.001). This was also seen for CD79α peritumoral positivity, but logistic regression revealed that this was a TILs effect.

Conclusion

A high TIL score correlates with a better OS and pCR in IBC, depending on the ER status. B-cells and PD-L1 expressing IC appear not to contribute to this effect, but do correlate independently with each other. Further research is needed to unravel the driving and targetable components of the immune responses in IBC.

Citation Format: Van Berckelaer C, Parizel M, Van Dam P, Dirix L, Rypens C, Bertucci F, Schats KA, Kockx MM, Van Laere S, Colpaert C. The prognostic and predictive effect of tumor infiltrating lymphocytes is not determined by B-cells or PD-L1 expression in inflammatory breast cancer [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 P2-04-09.

Current view on ductal carcinoma in situ and importance of the margin thresholds: A review

Ductal carcinoma in situ (DCIS) is a heterogeneous group of diseases that differ in biology and clinical behaviour. Until 1980, DCIS represented less than 1% of all breast cancer cases. With the increased utilization of mammography, DCIS now accounts for 15% to 25% of newly diagnosed breast cancer cases. The Van Nuys Prognostic Index (VPNI) is a commonly used tool for ductal carcinoma in situ (DCIS) treatment approach. Patient age, tumour size, tumour margins and pathological grade are used in order to stratify patients into three groups pertaining to risk of local recurrence: low-, intermediate- and high risk. Patients in the low-risk subgroup will always be treated with excision alone, while in the highest subgroup mastectomy is the safest option. Just like invasive breast cancer (IBC) there might be a curative dilemma in the intermediate-risk group. Many trials confirm that tumour margins are the most important prognostic factor of local recurrence for DCIS patients treated with breast conserving surgery alone or with breast conserving surgery plus radiotherapy. In this article we focused specifically on the literature concerning margin thresholds.

Abstract P1-01-24: Preoperative ultrasound staging of the axilla superfluous peroperative examination of the sentinel node

Background:

Axillary surgery in breast cancer is tailored. The current standard is to perform a frozen section or dep examination of the sentinel node during surgery. If the sentinel node is found positive (≥ macrometastases) a complete axilliary resection is recommended. Preoperative identification of positive nodes will lead to a further improvement of the tailored therapy.

Hypothesis:

A percentage of less than 5% of patients who would needed an additional operation is considered acceptable.

Material and Method:

From 2010 – 2012 all breast cancer patients of the Multidisciplinary Breast Clinic Antwerpen had an ultrasound evaluation of the axilla as part of their staging.

Fine needle aspiration cytology was performed of suspicious lymph nodes. If this showed to be positive, sentinel node biopsy was bypassed. Patients with normal nodes or benign/non diagnostic biopsy had removal of the sentinel node(s) without peroperative pathological examinations.

Results:

A total of 275 breast patients had an ultrasound staging (table 1). The sensitivity, specificity, positive predictive value and negative predictive value was respectively 90%, 85%, 77% and 94%.

Table 1: Ultrasound stagingEchoLN +LN -N1 (n = 117)9027N0 (n = 158)10148

Ten of the 275 patients (3.6%) needed an axillary clearance as a second procedure.

Discussion

Preoperative detection of invaded lymph nodes has several advantages. First of all it will allow you to identify patients with positive nodes, who can participate in neoadjuvant trial. Secondly it will save operating time and avoid overloading of the system for direct examination and reduces tissue loss. This approach will reduce costs for the health system and anesthetic time for the patient, with an acceptable reoperation rate.

Conclusion

Preoperative evaluation ultrasound staging of the axillare lymph nodes will avoid peroperative examination of the sentinel node at an acceptable reoperation rate. It is better for the patient, the physicians and the health care system.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-24.

Abstract P5-09-04: The effect of nuclear factor kappa B activation on cell proliferation of estrogen receptor positive breast cancer cell lines with different HER2-status

Introduction:Endocrine treatment is the mainstay of therapy for patients with Estrogen Receptor positive (ER+) breast cancer.Unfortunately, primary and secondary resistance to endocrine therapy are a major clinical problem. Previous studies have suggested a possible role for NFkB transcription factor family members in this resistance due to their effect on ER signaling. In this study, we aim to elucidate the interaction between both transcription factor families (ER and NFkB) and the consequence thereof on the growth pattern of ER+ cell lines.

Materials and methods:For this study, 2 ER+ breast cancer cell lines (i.e. MCF7 and MDA-MB-361) were selected based on a documented attenuated NFkB activity in these cell lines and a different ErbB2 status.Prior to treatment with estrogen (E2), TNFα (NFkB activation) and/or parthenolide (NFkB inhibition), cells were seeded in 48 well plates. Proliferation was measured by means of a crystal violet assay. ELISA experiments to measure NFkB DNA-binding in nuclear protein extracts and qRT-PCR for NFkB target genes was performed.

Results:Treatment of MCF7cells with different concentrations of TNFα initially increased cell proliferation, but after 48hrs, apoptosis occurred. Evaluation of NFkB DNA-binding showed a clear increase in RelA (p65), RelB (p62) and NFkB1 (p50) DNA-binding after 4hrs and up until but no longer than 24hrs of treatment. Results were confirmed by qRT-PCR for NFkB target genes.Due to the dynamics of NFkB activation secondary to TNFα treatment, we limited further experiments to 24hrs of treatment. Combination of E2and TNFα gave an additive effect in MCF7 cell proliferation compared to E2 alone, an effect counteracted by parthenolide in a concentration dependent manner. In the ErbB2+ cell line MDA-MB-361 our initial results suggest that addition of TNFα does not affect E2-driven cell proliferation.

Conclusion: Our results so far suggest a different, ErbB2-dependent role for NFkB on the proliferation of ER+ breast cancer cells. Interestingly, the effect of NFkB seems to depend on both RelA- and RelB-dependent pathways. Experiments are currently being performed to elaborate on the present results.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-09-04.

Gene expression profiles of inflammatory breast cancer: correlation with response to neoadjuvant chemotherapy and metastasis-free survival

BACKGROUND

Inflammatory breast cancer (IBC) is an aggressive disease. To date, no molecular feature reliably predicts either the response to chemotherapy (CT) or the survival. Using DNA microarrays, we searched for multigene predictors.

PATIENTS AND METHODS

The World IBC Consortium generated whole-genome expression profiles of 137 IBC and 252 non-IBC (nIBC) samples. We searched for transcriptional profiles associated with pathological complete response (pCR) to neoadjuvant anthracycline-based CT and distant metastasis-free survival (DMFS) in respective subsets of 87 and 106 informative IBC samples. Correlations were investigated with predictive and prognostic gene expression signatures published in nIBC (nIBC-GES). Supervised analyses tested genes and activation signatures of 19 biological pathways and 234 transcription factors.

RESULTS

Three of five tested prognostic nIBC-GES and the two tested predictive nIBC-GES discriminated between IBC with and without pCR, as well as two interferon activation signatures. We identified a 107-gene signature enriched for immunity-related genes that distinguished between responders and nonresponders in IBC. Its robustness was demonstrated by external validation in three independent sets including two IBC sets and one nIBC set, with independent significant predictive value in IBC and nIBC validation sets in multivariate analysis. We found no robust signature associated with DMFS in patients with IBC, and neither of the tested prognostic GES, nor the molecular subtypes were informative, whereas they were in our nIBC series (220 stage I-III informative samples).

CONCLUSION

Despite the relatively small sample size, we show that response to neoadjuvant CT in IBC is, as in nIBC, associated with immunity-related processes, suggesting that similar mechanisms responsible for pCR exist. Analysis of a larger IBC series is warranted regarding the correlation of gene expression profiles and DMFS.

Circulating tumour cell (CTC) detection: a direct comparison between the CellSearch system, the AdnaTest, CK19/MAM RT-PCR and unmethylated/methylated free DNA in patients with metastatic breast cancer

Abstract #5025

Introduction: The detection, enumeration and isolation of CTC has considerable potential to influence the clinical management of patients with breast cancer. There is however a substantial variability in the rates of positive samples using existing detection techniques. This study was designed to compare the sensitivities and specificities of three techniques for detecting CTC in blood of patients with metastatic breast cancer (MBC). Furthermore, correlations between CTC and circulating total and tumor-related methylated DNA were investigated.
 Material and Methods: The presence of CTC in blood samples of 80 patients with MBC and 20 healthy controls was assessed by two commercial systems: i) the CellSearch System (Veridex LLC, Warren, NJ), in which epithelial cells are immunomagnetically separated and fluorescently labeled, and nucleated (DAPI+) cells with the EpCAM+, cytokeratin (CK) 8/18/19+, and CD45- phenotype are counted as CTC and ii) the AdnaTest and a real-time qRT-PCR assay for the detection of CK-19 and mammaglobin (MAM) transcripts. Plasma total DNA levels were measured by a qPCR method. Sera were analyzed by methylation-specific qPCR for three methylated markers: APC, RASSF1A and ESR1. The results obtained with AdnaTest are being analyzed and will be presented at the meeting.
 Results: Numbers of CTC identified by the CellSearch test were significantly higher in blood samples of patients with MBC than in healthy controls: the median number of CTC detected in 7.5 ml of blood was 1 (range 0-2617) in patients with MBC and 0 (range 0-1) in controls (P<0.001). Using ≥2 cells as a threshold for positivity, which corresponds to 100% specificity in the control population, 34% of samples from patients with MBC were positive with the CellSearch test. Using a cut-off to ensure 100% specificity in the control population, 31% of patients were positive for CK-19, 49% for MAM and 61% for CK-19 and/or MAM by qRT-PCR. When the CellSearch test and the qRT-PCR for CK-19 and MAM were compared, the concordance was 57%. Positive samples with the CellSearch test, but not with the qRT-PCR assay, also showed significantly higher levels of circulating total DNA and were more likely to be positive for one of the methylated DNA markers in serum.
 Conclusion : We observed a substantial variation in the detection rates of CTC in blood from breast cancer patients using different techniques. A higher rate of positive samples was observed using a combined qRT-PCR approach for CK-19 and MAM, which suggests that this is currently the most sensitive technique for detecting CTC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5025.

Angiogenic escape and tumour progression in two patients with metastatic breast cancer receiving bevacizumab treatment

Abstract #1029

Background: Vascular endothelial growth factor A (VEGF-A) has an important role in tumour progression by promoting angiogenesis. VEGF-A inhibitors, such as bevacizumab (Bev) and VEGF-Trap are being introduced into the treatment of breast cancer in order to target angiogenesis by inhibiting VEGF-A.
 Material and Methods: Two patients with metastatic breast cancer are described having tumour progression while being treated with single agent Bev. Both patients participated in the AVADO clinical phase III study, where shown to have received Bev in combination with docetaxel (D) as first line treatment for metastatic breast cancer. The first patient (A) had received 6 cycles of D and Bev and was for 4 months on single agent Bev (15mg/kg/3wk) before progressing. Pt B had received 9 cycles of D and Bev and was on 7 months of single agent Bev (15mg/kg/3wk) before disease progression. Tumour biopsies of progressing lesions were obtained after informed consent. Routine histological assessment and a CD34/Ki67 double staining were performed on their primary tumour as well as on the newly developed metastasis (A+B). Chalkley counts (CC) and endothelial cell proliferation fractions (ECP) were assessed by two independent observers. RT-PCR Taqman low density arrays with a gene panel of 94 angiogenesis related genes were performed in triplicate on both metastasis and compared to 10 other primary breast tumours.
 Results: Both lesions showed a high CC, respectively 7.5±0.62 (A) and 4.8±0.2 (B). Both lesions had elevated ECP values of 14% (A) and 8% (B).
 Using the 2 (-__CT) method and 18S as an internal control, the VEGFR1 mRNA was highly overexpressed in both A (25.18±0.12 fold change) and B (38.60±0.07 fold change) compared to the mean of 10 unselected primary breast tumours serving as controls (p<10-7). Similarly, in metastasis B, VEGF-B, TGFB1 and PDGFRA were found to be overexpressed, i.e. out of range [min-max] of the 10 primary breast tumours. A had out of range overexpression of VEGF-C. The gene expression of VEGF-A, VEGF-D, VEGFR2, VEGFR3, PDGFB and PDGFRB in both A and B were found to be in the range of the 10 controls.
 Conclusion: We describe two patients with progressive disease while being treated with Bev after an initial response on the combination of D and Bev. These new sites of disease showed a highly angiogenic and apparently vascular dependent growth pattern, in spite of high dosed anti-VEGF-A regimen. This suggests the existence of an important VEGF-A independent alternative modality of the tumour to promote angiogenesis. VEGFR1 was remarkably overexpressed in both metastases compared to controls. The expression of placental growth factor, a VEGFR1 specific ligand is further being explored. Knowledge of the biology of Bev resistance is essential since it could be useful in designing well considered combinations of targeted therapies.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1029.

Isolation of circulating tumour cells in patients with metastatic breast cancer by filter technology

Abstract #5026

Introduction. Metastasis is the leading cause of cancer-related death. For several decades, numerous attempts have been made to develop reliable assays enabling the detection and enumeration of circulating tumor cells (CTC) in the peripheral blood. The LeukoLOCK™ Total RNA Isolation System (Ambion®) combines leukocyte depletion filter technology intended to isolate leukocytes from whole blood, with RNALater® as a means of stabilizing the RNA in the cells captured on the filter. We hypothesized that this innovative system would also allow for the isolation of carcinoma cells by filtration, because of their larger size in comparison to peripheral blood leukocytes. The RNA extracted from the filter device could thus be used for further quantification of CTCs by qRT-PCR.
 Materials and methods. The CellSearch™ Circulating Tumor Cell Test (Veridex®) was used to enrich and enumerate CTCs in all of the blood samples. The CellSearch System™utilizes iron nano-particles (ferrofluid) conjugated to EpCAM to capture CTC. Immuno-fluorescent staining for cytokeratins (CK) 8,18,19 and the nucleus (DAPI) is used to positively identify intact CTC. CTC are defined as nuclear cells, expressing cytokeratins and lacking CD45 expression. Blood samples of 5 patients with known elevated CTC were screened again after filtration with the LeukoLOCK™filter device to ensure that CTC did not slip through the filter (Table 1). The cell count obtained with the Veridex system was compared in these 5 samples, with the quantification CK19 and mammaglobin (MAM) transcripts obtained from the cells retained by the filter. In a further study on 79 patients with metastatic breast cancer, CTCs were enumerated using LeukoLOCK™Total RNA Isolation System (Ambion®) as a means of RNA isolation and compared with the Veridex system. qRT-PCR was performed to detect the presence of CTC transcripts for CK19 in the total RNA obtained from the cells captured on the filter in all of the 79 cases.
 Results. In only one sample (PAT113) could one CTC be detected in the filtered blood. The values obtained for RGE for both CK19 and MAM are in agreement with that observation.
 
 A significant correlation was found between CTC levels and qRT-PCR normalized relative gene expression (nRGE) values for CK19 originating from the total cell population captured by the LeukoLOCK™filter device (n=79, r=0.446, p<0.001).
 Conclusion. The LeukoLOCK™ system does not only enrich for leukocytes but can be considered as a reliable system for the enrichment and stabilization of CTC in patients with MBC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5026.

Brain metastases (BM) in patients presenting with HER-2 amplified advanced breast cancer (ABC)

Abstract #1060

Background : The HER-2 amplified breast cancer phenotype is suggested to have an increased propensity for CNS metastasis. The introduction of trastuzumab might be related to this association. In order to elucidate this relationship we analyzed our prospectively collected database of all patients presenting with metastatic HER-2 amplified breast cancer in the time frame between Jan 2002 until Dec 2004.
 Material and Methods : The AZ-Augustinus Breast Cancer Tissue Bank was initiated in 1999. It ensures the prospective entry of all clinical and pathological features of patients presenting in our Breast Clinic clinical database. The data entry is performed by dedicated Datamanagers and is linked to the Biological Repository Collection (tissue, serum, plasma, bone marrow). Patients presenting with primary metastatic, HER-2 amplified ( FISH +) between 2002 and 2004 were analyzed for this study. Since Jan 2002, all patients presenting with metastatic disease underwent a routine CT-scan of the brain as initial staging procedure.
 Results : A total of 33 patients presented with HER-2 +, unpretreated metastatic breast cancer. Mean age: 53 years (range 30-69). Sites of metastases at diagnosis ( % of patients) : liver: 71 %, lung: 36 %, bone: 86 %, brain (BM): 15 % (5), lymph nodes and others: 20%. In total 5/33 (15%)
 presented with brain only metastasis. During the follow-up period 17 more patients developed BM, amounting to 22/33 (67%). The median time between diagnosis of BM after diagnosis of ABC was 22 months (0 – 98). Mean time to developing BM was 18 months. In total 62 lesions in the CNS were counted on MRI in these 22 patients. 23 lesions (38%) had a cerebellar localisation.
 Conclusions: Assuming that the presentation with metastasis is a reflection of the unperturbed biology of disease, our data suggest that the CNS is not an exceptionally preferred site for metastasis in untreated HER-2 + advanced breast cancer. A preference for a cerebellar localisation is suggested.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1060.

Phase II study of docetaxel, carboplatin and trastuzumab (THC) in patients with locally advanced breast cancer

1062

Background: Preclinical and clinical data suggest that docetaxel, trastuzumab and platinum compounds act synergistically. Studies in the metastatic disease are conflicting. In this phase II study the activity of this regimen was assessed and correlated with changes in circulating biomarkers. Methods: Patients with locally advanced, FISH+ HER2 amplified, breast cancer were treated in this protocol with TCH as initial neo-adjuvant treatment. Patients received Docetaxel 75 mg/sqm, carboplatinum AUC 6mg/mL.min and trastuzumab 6 mg/kg (with a loading dose in cycle 1). Six cycles were intended provided no progression occured. No prophylactic G-CSF or antibiotics were administered. Measurement of circulating ECD HER2, CTC (RT-PCR mammaglobin and CK-19), and total plasma DNA was performed prior to the start of therapy, after cycle 1 and after 3 and 6 cycles. A cardiac MUGA exam was performed every three cycles. All patients were intented to undego mastectomy and axillary clearance after the end of chemotherapy. Results: 40 patients have been treated with a median age of 56 year. No patient suffered from progression of disease while on THC. All patients received 6 cycles, 4 patients received respectively 7, 7, 8 and 9 cycles. In total 247 cycles were administered. No cases of CHF were observed. 5 patients suffered from a asymptomatic decline > 10% in LVEF. A clinical CR and PR was obtained in 32 (80%). A pathological CR both in breast axilla was obtained in 16/39 (41%). Tumor response was predicted by changes in both CTC and ECD HER-2. Conclusions: THC was confirmed to be a very active and safe regimen in patients with HER-2 amplified breast cancer. Changes in biomarkers rapidly predicted response.

No significant financial relationships to disclose.

Clip migration after vacuum-assisted stereotactic breast biopsy: a pitfall in preoperative wire localization

Vacuum-assisted stereotactic breast biopsy has become an irreplaceable instrument in the management of suspicious mammographic lesions. If the initial mammographic lesion becomes obscured or absent following the biopsy, a clip is commonly placed by interventional breast radiologists at the biopsy site. This enables future wire localization if atypical or malignant histology warrants excision. Currently, clip malposition or migration has become increasingly recognized in the literature as a possible complication of stereotactic breast biopsy. As in this case, recognition of migration of the clip was crucial in the planning of the patient's subsequent wire localization procedure. This article aims to increase the awareness of radiologists and surgeons of this potential pitfall to prevent false-negative biopsies and minimize positive surgical margins after wire-guided breast conservation surgery. Routine evaluation of pre- and postbiopsy mammograms and prospective identification of inaccurate clip placement before stereotactic wire localization and excision should be performed.

Real-time RT-PCR detection of disseminated tumour cells in bone marrow has superior prognostic significance in comparison with circulating tumour cells in patients with breast cancer

This study assessed the ability of real-time reverse transcription–polymerase chain reaction (RT–PCR) analysis to detect disseminated epithelial cells (DEC) in peripheral blood (PB) and bone marrow (BM) of patients with breast cancer (BC). Detection of DEC in BM is an obvious choice in BC, but blood sampling is more convenient. The aim of this study was to evaluate whether the detection of DEC in either PB or BM predicts overall survival (OS). Peripheral blood and BM samples were collected from 148 patients with primary (stage M0, n=116/78%) and metastatic (stage M+, n=32/21%) BC before the initiation of any local or systemic treatment. Peripheral blood of healthy volunteers and BM of patients with a nonmalignant breast lesion or a haematological malignancy served as the control group. Disseminated epithelial cells was detected by measuring relative gene expression (RGE) for cytokeratin-19 (CK-19) and mammaglobin (MAM), using a quantitative RT–PCR detection method. The mean follow-up time was 786 days (+/− 487). Kaplan–Meier analysis was used for predicting OS. By taking the 95 percentile of the RGE of CK-19 (BM: 26.3 and PB: 58.7) of the control group as cutoff, elevated CK-19 expression was detected in 42 (28%) BM samples and in 22 (15%) PB samples. Mammaglobin expression was elevated in 20% (both PB and BM) of the patients with BC. There was a 68% (CK-19) and 75% (MAM) concordance between PB and BM samples when classifying the results as either positive or negative. Patients with an elevated CK-19 or MAM expression in the BM had a worse prognosis than patients without elevated expression levels (OS: log-rank test, P=0.0045 (CK-19) and P=0.025 (MAM)). For PB survival analysis, no statistical significant difference was observed between patients with or without elevated CK-19 or MAM expression (OS: log-rank test, P=0.551 (CK-19) and P=0.329 (MAM)). Separate analyses of the M0 and M+ patients revealed a marked difference in OS according to the BM CK-19 or MAM status in the M+ patient group, but in the M0 group, only MAM expression was a prognostic marker for OS. Disseminated epithelial cells, measured as elevated CK-19 or MAM mRNA expression, could be detected in both PB and BM of patients with BC. Only the presence of DEC in BM was highly predictive for OS. The occurrence of DEC in the BM is probably less time-dependent and may act as a filter for circulating BC cells. The use of either larger volumes of PB or performing an enrichment step for circulating tumour in blood cells might improve these results.

Sentinel node detection in a patient with recurrent endometrial cancer initially treated by hysterectomy and radiotherapy

This is the first article reporting sentinel node identification in a patient with endometrial cancer recurring in the vagina. A 79-year-old woman presented with a midvaginal recurrence of a stage IB, grade II endometroid carcinoma that had been treated 3 years earlier by a total abdominal hysterectomy, bilateral salpingoophorectomy, and pelvic lymph node sampling, followed by adjuvant brachytherapy to the vaginal vault. A staging examination under anesthetic was performed. Preoperatively, 60-MBq technetium-labeled nannocolloid was injected in the mucosa at 3, 6, 9, and 12 o'clock just adjacent to the tumor recurrence. Three sentinel nodes were detected, respectively, in the left obturator fossa (two) and the right external iliac region, using a laparoscopic probe (Navigator) and removed for pathological assessment. As they proved to be negative, the patient underwent a total vaginectomy, parametrectomy with pelvic lymphadenectomy. The tumor was completely removed, and all lymph nodes proved to be negative. The accuracy of sentinel node identification in patients with recurrent gynecological tumors needs further evaluation. This unique case shows that sentinel node detection is possible after previous radiotherapy and surgery and hopes to stimulate further research in this field.

Sentinel node detection in a patient with recurrent endometrial cancer initially treated by hysterectomy and radiotherapy

This is the first article reporting sentinel node identification in a patient with endometrial cancer recurring in the vagina. A 79-year-old woman presented with a midvaginal recurrence of a stage IB, grade II endometroid carcinoma that had been treated 3 years earlier by a total abdominal hysterectomy, bilateral salpingoophorectomy, and pelvic lymph node sampling, followed by adjuvant brachytherapy to the vaginal vault. A staging examination under anesthetic was performed. Preoperatively, 60-MBq technetium-labeled nannocolloid was injected in the mucosa at 3, 6, 9, and 12 o'clock just adjacent to the tumor recurrence. Three sentinel nodes were detected, respectively, in the left obturator fossa (two) and the right external iliac region, using a laparoscopic probe (Navigator) and removed for pathological assessment. As they proved to be negative, the patient underwent a total vaginectomy, parametrectomy with pelvic lymphadenectomy. The tumor was completely removed, and all lymph nodes proved to be negative. The accuracy of sentinel node identification in patients with recurrent gynecological tumors needs further evaluation. This unique case shows that sentinel node detection is possible after previous radiotherapy and surgery and hopes to stimulate further research in this field.

Intratumoral hypoxia resulting in the presence of a fibrotic focus is an independent predictor of early distant relapse in lymph node-negative breast cancer patients

AIMS

To examine the importance of a fibrotic focus-a scar-like area in a carcinoma-as a marker of intratumoral hypoxia that correlates with angiogenesis and with clinical outcome in node-negative breast cancer.

METHODS AND RESULTS

One hundred and four T1-2N0M0 breast carcinoma patients were divided into two groups: group 1 (n=46) showing early distant relapse (median disease-free survival 25 months) and group 2 (n=58) showing no evidence of disease (median follow-up 91.5 months). All tumours were evaluated for medial/lateral location, size, histological grade, mitotic activity, necrosis, fibrotic focus, angiogenesis, vascular permeation and growth pattern. Multiple regression analysis showed that only histological grade and the presence of a fibrotic focus were independent predictors of early distant relapse. A fibrotic focus was present in 53% of the tumours. The relative size (fibrotic focus/tumour ratio) was significantly correlated with an unfavourable outcome. The presence of necrosis inside the fibrotic focus and the absolute and relative size of the fibrotic focus were significantly correlated with angiogenesis. A fibrotic focus was significantly associated with large, expansively growing tumours with high histological grade and numerous mitoses.

CONCLUSION

A fibrotic focus can be used as a surrogate for quantifying angiogenesis and is an independent predictor of early metastasis in lymph node-negative breast cancer.

Early distant relapse in "node-negative" breast cancer patients is not predicted by occult axillary lymph node metastases, but by the features of the primary tumour

Early distant relapse occurs in a minority of node-negative breast cancer patients. Whether this poor prognosis can be predicted by the features of the primary tumour, or by the presence of occult metastases in the "negative" lymph nodes (LNs), remains a matter of debate. One hundred and four T(1-2)N(0)M(0) breast carcinoma patients were divided into two groups: group 1 (44%) showing early distant relapse with a median disease-free survival of 25 months, and group 2 (56%) showing no evidence of disease after a median follow-up of 91.5 months. All patients had received locoregional treatment only. All tumours were evaluated for medial/lateral location, histological type, size, grade, mitotic activity, fibrotic focus, necrosis, angiogenesis, growth pattern, and lymphatic vessel permeation. The haematoxylin and eosin-stained slides of all axillary LNs were revised and two additional levels were cut from each paraffin block for cytokeratin immunohistochemistry. In 24 patients (23%), occult metastases were found. These consisted of single cells or small clusters (SCs) in the marginal sinus in 17 patients (16%) and of larger colonies of cells in seven patients (7%). All detected metastases were smaller than 2 mm in diameter (micrometastases). There was no significant correlation between the presence of occult LN metastases (SCs or colonies) and the prognostically important features of the primary tumour. Early metastatic disease was significantly correlated with larger tumour size (p=0.02), higher histological grade (p=0.0008), mitotic activity (p<0.0001), presence of necrosis (p=0.0004), presence of fibrotic foci (p=0.0005), angiogenesis (p=0.0009), and lymphatic vessel permeation (p=0.018). Multiple logistic regression analysis showed that histological grade and the presence of a fibrotic focus were the only independent prognostic factors and that the presence of occult LN metastases was inversely correlated with early distant relapse. Prospective prognostic studies of occult LN metastases should consider the features of the primary tumour in a multivariate analysis.

The association between vascular endothelial growth factor, microvessel density and clinicopathological features in invasive cervical cancer

OBJECTIVE

The aim of this study was to analyse the vascular endothelial growth factor (VEGF) expression in a series of cervical carcinomas and to compare the results with the microvessel density (MVD) and clinicopathological features.

STUDY DESIGN

The immunoreactivity for VEGF was studied in 130 invasive cervical carcinomas and in 22 patients with a carcinoma in situ of the cervix. The results were compared with the MVD.

RESULTS

Staining for VEGF of less then 50% per slide occurred in 80% of the invasive carcinomas and in 82% of the in situ carcinomas. The median MVD was 261 vv/mm(2) (range: 11-1000) in the invasive group and 146 vv/mm(2) (range: 25-536) in the in situ group. Unlike the microvessel density there was no association between VEGF expression and survival. The MVD was higher in VEGF poorer (<50%) tumours (P=0.055). Beside tumour histology (P=0.012) there were no other significant relationships between the remaining histopathological findings and VEGF expression.

CONCLUSION

Tissue VEGF expression has no prognostic value in contrast with the MVD in patients with invasive cervical cancer.

Interval debulking surgery: an alternative for primary surgical debulking?

Retrospective analyses suggest that a subgroup of patients with Stage III and IV ovarian carcinoma can be treated with neo-adjuvant chemotherapy followed by interval debulking surgery. The absolute indications for neo-adjuvant chemotherapy appear to be Stage IV disease (excluding pleural fluid) or metastases of more than 1 g at sites where resection is impossible. In patients with an estimated total metastatic tumor load of >100 g, the presence of at least two of the following relative indications for neo-adjuvant chemotherapy are considered to be necessary: 1) uncountable (>100) peritoneal metastases, 2) estimated metastatic tumor load of >1000 g, 3) presence of large (>10 g) peritoneal metastatic plaques, 4) large volume ascites, and 5) World Health Organization (WHO) status II or III. Interval debulking surgery in patients with suboptimal primary debulking surgery has been proven effective in increasing overall survival and progression-free survival in a large prospective, randomized trial of the European Organization for Research and Treatment of Cancer (EORTC). The strategy of neo-adjuvant chemotherapy, followed by interval debulking surgery, should be confirmed in a prospective randomized trial. The EORTC 55971 trial is currently addressing this issue. We will review the studies on primary chemotherapy, interval debulking surgery, and the indications for primary chemotherapy followed by interval debulking surgery, and ongoing trials.

[Primary malignant melanoma of the female urethra]

Primary malignant melanomas of the urethra are extremely rare. Clinically they are usually mistaken for other malignant diseases or even benign lesions. The case of a 66-year-old woman is reported, who presented with local bleeding of the urethra. Macroscopically a polypoid tumor was seen on the meatus externus of the urethra. A biopsy was taken and the histology report revealed a malignant melanoma. There were no signs of metastases and therefore the treatment consisted of a wide local excision only. A review of literature regarding therapy and prognosis is presented.

Study of numerical aberrations of chromosome 1 by fluorescent in situ hybridization and DNA content by densitometric analysis on (pre)-malignant cervical lesions

In an attempt to determine whether the fluorescent in situ hybridization (FISH) can be used as a rapid approach for the identification of aneuploidy in premalignant cervical smears, a centromeric probe for chromosome 1 was used. The results from the FISH experiments were compared with measurements of the overall DNA content obtained by means of an image analysis system. With progression to neoplasia, a decrease of the frequency of cells with two spots was observed, due to an increasing polysomy of chromosome 1. As far as the DNA content was concerned, an increasing DNA index and 5C-exceeding ratio (fraction of cells with a DNA content higher than 5C) was observed. Classification of the FISH results by a linear discriminant analysis revealed that 67.6% of the cases were classified in agreement with the CIN classification. These data suggest that chromosome 1 may be considered as a marker chromosome for pre-malignant cervical lesions and that the DNA content measurements are complementary to the FISH results.

Detection of premalignant stages in cervical smears with a biotinylated probe for chromosome 1

Fluorescence in situ hybridization with (peri-)centromeric probes is an easy method to detect numerical aberrations in nonmitotic and mitotic cells. In this study, cervical smears of premalignant and malignant stages (26 controls, 15 CIN I, 12 CIN II, and 15 CIN III cervical smears) were analyzed for the presence of numerical aberrations of chromosome 1 with a centromeric DNA probe (1q12). With more severe stages a decrease of disomy was observed, merely due to a gain of extra copies of chromosome 1; in some cases, however, monosomy was detected. The frequencies of disomy for chromosome 1 ranged from 65.3% to 95.0% in the controls, from 71.3% to 94.3% in CIN I, from 59.2% to 91.5% in CIN II, and from 23% to 96.2% in CIN III. Polysomy ranged from 0% to 5.7% in the controls, from 0% to 14.4% in CIN I, from 0.9% to 30.8% in CIN II, and from 0.8% to 69.6% in CIN III. Monosomy ranged from 2.6% to 34.1% in the controls, from 0% to 17.5% in CIN I, from 3.6% to 27.5% in CIN II, and from 0.9% to 31.4% in CIN III. The results show that screening for aneuploidy of chromosome 1 allows a good discrimination between control samples and dysplasia. These data suggest that chromosome 1 may be a marker chromosome. They are in accordance with previous cytodensitometric analyses, where already in the preneoplastic stages an increased DNA content (polyploidization with subsequent aneuploidization) is observed.

Treatment of advanced carcinoma of the vulva with chemoradiotherapy - can exenterative surgery be avoided?

Thirty-seven patients with advanced FIGO stage (17 stage III, 20 stage IV) carcinoma of the vulva whose extent of disease would have required extenterative surgery were treated with chemoradiotherapy (CRT). Radiotherapy was given as a split course (2500 cGy mid-plane dose in 10 daily fractions, repeated 1 month later) to the first seven patients. Subsequently radiotherapy was given as a continuous course (4500 cGy mid-plane dose in 20-25 daily fractions). Chemotherapy included mitomycin c as an intravenous bolus and 5 fluorouracil as a continuous intra-venous infusion over 4-5 days, with variations in timing and dose according to the type of radiotherapy course. Fifteen (47%) complete and 11 (34%) partial responses were seen at 3 months after completion of treatment. Of the 15 patients with complete response, 10 remained disease-free for a median of 24 months (range 6-36 months). The median sur-vival for complete and partial responding patients was 15 and 11 months, respectively (range 2-37 months). Acute toxicity included moist perineal desquamation, diarrhea and myelosupression. One death secondary to neutropaenic sepsis occurred in the split course group. WHO grade 3 radiation enteritis occurred in one patient (14%) in the split course and two patients (6%) in the continuous CRT groups. Using CRT, very high response rates have been obtained with relatively low toxicity. There is a useful role for CRT in the treatment of patients with locally advanced recurrent disease although its place in the management of extensive primary disease requires further evaluation.

Extramammary Paget's disease of the axilla

A case of extramammary Paget's disease of the axilla in an 84-year-old patient is presented. No underlying carcinoma was found and the lesion was treated successfully by wide local excision. Immunohistochemical staining showed nuclear immunoreactivity for c-myc and cytoplasmic staining for CEA, EMA, CAM 5.2, EGRF, c-erbB-2 and pan-cytokeratin in all the Paget cells. No immunoreactivity of the lesion was observed for S-100 protein, pan-ras, H-ras, K-ras, and p53 oncoproteins. Further research is needed to establish whether oncoprotein overexpression plays a role in the pathogenesis of extramammary Paget's disease and can be used as a diagnostic or prognostic marker.

Clinical aspects in the surgical treatment of varicocele in subfertile men. I. Comparison of observed and expected pregnancy rates

Ninety-six couples, consulting for primary (n = 73) or secondary (n = 23) infertility, and thought to be infertile due to a varicocele in the husband associated with sperm abnormalities, were subjected to a follow-up study. Of these, 57 were surgically corrected and 39 were not, depending only on the patient's choice. All women were intensively treated where necessary. From our data we conclude that (1) fertility prognosis is significantly better in couples with secondary subfertility than in couples with primary subfertility, (2) surgical correction of varicocele in cases of secondary subfertility does not increase subsequent pregnancy rates, and (3) surgical correction of varicocele in cases of primary subfertility significantly increases subsequent pregnancy rates, since cumulative observed pregnancy rates are more than double the cumulative theoretically expected treatment-independent pregnancy rates.

Renal failure in pregnancy, treated by hemodialysis

A patient with renal failure in pregnancy is presented. Prior to pregnancy she was known to have impaired renal function due to chronic pyelonephritis. Renal insufficiency was successfully treated by hemodialysis. The literature concerning etiology and proper management of renal failure in pregnancy and the results and complications of its treatment with hemodialysis are reviewed. A multidisciplinary approach is important for the successful outcome of these pregnancies.