BRCA1 immunohistochemistry in high-grade serous ovarian cancers (HGS-OC) characterized for BRCA1 germ-line mutations

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Background: The optimal use of BRCA1 germline testing in patients with HGS-OC is unclear. Moreover, BRCA1 germline testing does not provide information on non-germline mechanisms of BRCA1 loss. We investigated the performance of BRCA1 immunohistochemistry (IHC) testing in HGS-OC with known BRCA1 mutation status. Methods: Eligible patients had HGS-OC, underwent surgery at a single institution between 1997 and 2010, and were tested for germline BRCA1 mutations under IRB-approved protocols. FFPE tumor tissue was used in triplicate to construct a tissue microarray (TMA). Two pathologists, blinded to BRCA1 status, independently scored each sample as BRCA1 IHC present (normal) or absent (abnormal). Whole sections were stained for all samples with absent BRCA1 staining on TMA. A commercially available monoclonal antibody against BRCA1, clone MS110 from Calbiochem (OP92) was used with previously optimized conditions. Results: 123 samples (30 BRCA1 +; 93 BRCA1 wild-type) were analyzed and 47 (38%) had abnormal BRCA1 IHC. Inter-observer agreement on BRCA IHC was high (kappa=0.87). BRCA IHC had a sensitivity of 83.3% (CI: 70.0-96.7%), specificity of 76.3% (CI: 67.7-85.0%), PPV of 53.2% (CI: 38.9-67.5%), and NPV of 93.4% (CI: 87.9-99.0%) for BRCA1 germline mutation. There was a trend towards improved overall survival in the BRCA IHC abnormal vs. normal patients (median survival 82 vs 61 wks, HR 0.70, p=0.12). Conclusions: BRCA1 IHC is a reproducible and inexpensive test with a high NPV for absence of a BRCA1 germline mutation. The 22 (17.7%) cases with abnormal BRCA1 IHC and wild-type BRCA1 germline status may have other mechanisms of protein loss such as promoter hypermethylation or somatic mutation and are currently being tested for these changes. This rate of non-germline BRCA1 loss in HGS-OC is consistent with data generated by the Tumor Cancer Genome Atlas Network. BRCA1 IHC may be useful as a reliable biomarker for risk stratification in HGS-OC. [Table: see text]

Outcomes of primary surgical cytoreduction in patients with BRCA-associated high-grade serous ovarian carcinoma

OBJECTIVE

BRCA-associated and sporadic ovarian cancers have different pathologic and clinical features. Our goal was to determine if BRCA mutation status is an independent predictor of residual tumor volume following primary surgical cytoreduction.

METHODS

We conducted a retrospective analysis of patients with FIGO stage IIIC-IV high-grade serous ovarian cancer classified for the presence or absence of germline BRCA mutations. The primary outcome was tumor-debulking status categorized as complete gross resection (0mm), optimal but visible disease (1-10 mm), or suboptimal debulking (>10 mm) following primary surgical cytoreduction. Overall survival by residual tumor size and BRCA status was also assessed as a secondary endpoint.

RESULTS

Data from 367 patients (69 BRCA mutated, 298 BRCA wild-type) were analyzed. Rate of optimal tumor debulking (0-10 mm) in BRCA wild-type and BRCA-mutated patients were 70.1% and 84.1%, respectively (P=0.02). On univariate analysis, increasing age (10-year OR, 1.33; 95% CI, 1.07-1.65; P=0.01) and wild-type BRCA status (OR, 0.47; 95% CI, 0.23-0.94, P=0.03) were both significantly associated with suboptimal surgical outcome. On multivariate analysis, BRCA mutation status was no longer associated with residual tumor volume (OR, 0.63; 95% CI, 0.31-1.29; P=0.21) while age remained a borderline significant predictor (10-year OR, 1.25; 95% CI, 1.01-1.56; P=0.05). Both smaller residual tumor volume and mutant BRCA status were significantly associated with improved overall survival.

CONCLUSION

BRCA mutation status is not associated with the rate of optimal tumor debulking at primary surgery after accounting for differences in patient age. Improved survival of BRCA carriers is unlikely the result of better surgical outcomes but instead intrinsic tumor biology.

Improved survival for BRCA2-associated serous ovarian cancer compared with both BRCA-negative and BRCA1-associated serous ovarian cancer

BACKGROUND

Multiple observational studies have suggested that breast cancer gene (BRCA)-associated ovarian cancers have improved survival compared with BRCA-negative ovarian cancers. However, most of those studies combined BRCA1 and BRCA2 patients or evaluated only BRCA1 patients. The objective of the current study was to examine whether BRCA1-associated and BRCA2-associated ovarian cancers were associated with different outcomes.

METHODS

This was a single-institution, retrospective analysis of patients who had a new diagnosis of histologically confirmed stage III or IV serous ovarian, fallopian tube, or primary peritoneal cancer between January 1, 1996 and February 1, 2011 and who underwent BRCA mutation testing on 1 of 2 institutional review board-approved follow-up studies. Patients who had been tested for BRCA mutations beyond 24 months of diagnosis were excluded from analysis to minimize selection bias from including patients who were referred for genetic testing because of long survival.

RESULTS

Data from 190 patients (143 BRCA-negative patients, 30 BRCA1-positive patients, and 17 BRCA2-positive patients) were analyzed. During the study period, 73 deaths were observed (60 BRCA-negative patients, 10 BRCA1-positive patients, 3 BRCA2-positive patients). The median follow-up for the remaining 117 survivors was 2.5 years. At 3 years, 69.4%, 90.7%, and 100% of BRCA-negative patients, BRCA1-positive patients, and BRCA2-positive patients were alive, respectively. On univariate analysis, age, BRCA2 mutations, debulking status, and type of first-line therapy (intravenous or intraperitoneal) were significant predictors of overall survival. On multivariate analysis, BRCA2 mutations (hazard ratio, 0.20; 95% confidence interval, 0.06-0.65; P = .007), but not BRCA1 mutations (hazard ratio, 0.70; 95% confidence interval, 0.36-1.38; P = .31), predicted for improved overall survival compared with BRCA-negative patients. When carriers of BRCA2 mutations were directly compared with carriers of BRCA1 mutations, BRCA2 mutations appeared to confer improved overall survival (hazard ratio, 0.29; 95% confidence interval, 0.08-1.05; P = .060), although this finding did not reach significance.

CONCLUSIONS

The current data suggests that BRCA2 mutations confer an overall survival advantage compared with either being BRCA-negative or having a BRCA1 mutation in high-grade serous ovarian cancer. This finding may have important implications for clinical trial design.

Topotecan in patients with BRCA-associated and sporadic platinum-resistant ovarian, fallopian tube, and primary peritoneal cancers

OBJECTIVE

To evaluate the efficacy of topoisomerase I inhibitor, topotecan, in patients with recurrent BRCA+ versus BRCA- ovarian, fallopian tube, and primary peritoneal carcinomas.

METHODS

A single-institution retrospective analysis of platinum-resistant patients characterized for the presence or absence of known deleterious BRCA mutations. Patients received topotecan at a dose and schedule determined by their treating physician (five day or weekly). Response rate and progression-free survival (PFS) were assessed.

RESULTS

A total of 50 patients (9 BRCA+, 41 BRCA-) were treated with topotecan. Both groups were well balanced in terms of age, stage, grade, and number of prior therapies. All patients had high-grade serous carcinoma. The clinical benefit rate in BRCA+ and BRCA- patients was 0% and 26.8% (6 PRs, 6 SDs), respectively (p=0.18). Median PFS in BRCA+ and BRCA- pts was 1.7 months (95% CI: 1.0-2.8 months) and 2.5 months (95%CI: 1.9-2.8 months), respectively (p=0.057). Median time to best response was 1.9 months, and median response duration 2.6 months.

CONCLUSIONS

This analysis in a heavily pretreated cohort of patients fails to support the superiority of topotecan in BRCA+ platinum-resistant ovarian, fallopian tube, and primary peritoneal cancers. Further study of this class of agents, specifically in less heavily-pretreated patients, may still be warranted.

Sarcoidosis and opportunistic infections

Two patients receiving steroid therapy for sarcoidosis had a potentially fatal opportunistic infection that was difficult to differentiate from the underlying illness, but was successfully treated after the diagnosis was made. The effects of sarcoidosis on the immune system and the additional effects of steroid therapy on cell-mediated immunity seem to be of real clinical significance, rather than being of theoretical interest alone, because of the risk of infection with intracellular infecting organisms, even if such infections occur relatively infrequently.

Outcomes across the care continuum. Home health care

OBJECTIVES

This article describes one approach to measuring outcomes across the continuum of care.

METHODS

Development and testing of the outcome-based quality-improvement methodology as developed by the University of Colorado Center for Health Services Research in Denver, Colorado are summarized.

RESULTS

Reliable and valid measures for home health care covering end results (pure outcome), intermediate results (instrumental outcome), and use (proxy outcome) were developed and are useful in demonstrating patient improvement or stabilization as well as decline. Further, these measures can be aggregated by agency and, with appropriate severity or risk adjustment, can be used to compare outcomes over time and across agencies.

CONCLUSIONS

National testing of the methodology is currently ongoing, with refinements underway in measures, risk adjustment, and operational implementation.

Recurrence of primary spontaneous pneumothorax

BACKGROUND

Primary spontaneous pneumothorax (PSP) is a common clinical problem and its incidence is thought to be increasing. The risk of recurrence is high and various studies quote rates of 20-60%. Factors which may or may not predispose to recurrence have not yet been established.

METHODS

In a study period of four years 291 cases with a diagnosis of pneumothorax were reviewed; 153 patients with PSP were included in the study. Their risk of recurrence was analysed with particular reference to the following variables: age, sex, height and body mass index (BMI) of the patient, the initial size of pneumothorax, the smoking status of the patient, and the primary form of treatment employed. Univariate analysis was carried out by chi 2 testing and multivariate analysis was calculated by a logistic regression model.

RESULTS

A retrospective study of 275 episodes of PSP in 153 patients over a four year period confirmed a high incidence of recurrence (54.2%). PSP was twice as common in men as in women, though women were significantly more likely to develop a recurrence (chi 2 = 7.58, df = 1, p < 0.01). Male height was the second most important factor, and smoking cessation the only other variable which significantly influenced the risk of recurrence.

CONCLUSIONS

Analysis of several potential risk factors revealed that recurrence was not related to the BMI of the patient, the initial treatment of the pneumothorax, nor to its size. Recurrence was more common in taller men and in women. Smoking cessation appeared to reduce the risk of recurrence. These findings are discussed in the context of the possible aetiology of spontaneous pneumothorax, recurrences, and the management thereof.

Spontaneous pneumothorax in a patient with an azygos lobe

The association between a spontaneous pneumothorax and an azygos lobe is surprisingly rare. A case is reported in which surgical management was difficult; it is suggested that thoracotomy is preferable to video-assisted thoracoscopic surgery in this situation. It is possible that the presence of an azygos lobe might protect against the subsequent development of a spontaneous pneumothorax, and the possible mechanism of this is discussed.

Recurrent respiratory papillomatosis with pulmonary cystic disease in a child, following maternal genital warts

Human papillomavirus (HPV) infection of the genital tract is associated with the development of genital warts. A causal link between maternal HPV infection and development of laryngeal papillomatosis in the offspring has been proposed. We report a case of pulmonary cystic disease, a rare but serious complication of laryngeal papillomatosis in a child, following maternal genital warts.

Hard metal lung disease and pneumothorax

This case report describes a case of spontaneous pneumothorax in a metal grinder that failed to resolve with medical management. A lung biopsy taken during the subsequent thoracotomy revealed changes that were characteristic of giant cell interstitial pneumonia, as seen in hard metal disease. Pneumothorax has been described in many forms of interstitial lung disease but not in this type of occupational disease. Awareness of this possible association can result in: (1) the removal of an affected worker from his adverse work environment before advanced disease develops; and (2) the safe control of the work environment, to the advantage of other similarly exposed workers.

Home care: moving forward with continuous quality improvement

The utility of examining the effectiveness of home care is illustrated by selected examples and applications. The growth rate of home care over the past decade, questions regarding the possibly substantial differences between the quality of home care in rural and urban America, and empirical evidence that suggests inferior quality of home care for health maintenance organization patients support the need for measuring and monitoring outcomes of home care. The conclusions of a research program targeted at developing a system of outcome measures for home care, and the resulting national demonstration program to implement and refine that system, are summarized.

Outcome-based quality improvement in home care

A system of outcome measures of service quality was developed and tested. The findings of this project will provide a framework for moving forward with outcome-based quality improvement in home care. Using outcome measures will permit agencies to analyze their performance in terms of effectiveness of care.

Home health agency quality: Medicare certification findings compared to patient outcomes

As part of an evaluation of the Medicare certification program for home health agencies (HHAs), we examined the extent to which certification findings were related to patient outcomes. In a previous study, we collected longitudinal patient data for a national sample of 42 HHAs and developed precise patient outcome measures. In this study, the outcome measures were compared to certification findings for the same HHAs and time period (1991-93). We found relatively little association between the two sets of measures. The findings indicate that the Medicare HHA survey process does not yet successfully incorporate patient outcomes.

Measuring and assuring the quality of home health care

The growth in home health care in the United States since 1970, and the exponential increase in the provision of Medicare-covered home health services over the past 5 years, underscores the critical need to assess the effectiveness of home health care in our society. This article presents conceptual and applied topics and approaches involved in assessing effectiveness through measuring the outcomes of home health care. Definitions are provided for a number of terms that relate to quality of care, outcome measures, risk adjustment, and quality assurance (QA) in home health care. The goal is to provide an overview of a potential systemwide approach to outcome-based QA that has its basis in a partnership between the home health industry and payers or regulators.

Extracorporeal membrane oxygenation as emergency treatment for life-threatening acute severe asthma

We report a case of acute severe asthma that was resistant to full medical treatment, mechanical ventilation and halothane inhalation. Because a fatal outcome appeared likely extracorporeal membrane oxygenation, involving partial cardiac bypass, using femoral artery and femoral vein cannulation was instituted as an urgent measure. The patient then made a satisfactory recovery.

Postal survey of bronchoscopic practice by physicians in the United Kingdom

In 1983 a postal survey of the bronchoscopic practice of chest physicians in the United Kingdom produced a 90% response rate. Two hundred and thirty one physicians were carrying out bronchoscopy; they had performed about 40 000 bronchoscopies in the preceding year, 87% of these being fibreoptic procedures with topical anaesthesia. The mortality rate of fibreoptic bronchoscopy was 0.04%, with a 0.12% incidence of major complications. Transbronchial biopsy carried both an appreciably higher mortality rate of 0.12% and a major complication rate of 2.7%. There is wide variation in the use and choice of sedative drugs for fibreoptic bronchoscopy. Many of the drug combinations could be criticised on pharmacological grounds. The mean dose of lignocaine was 342 mg, most operators exceeding the usual maximum recommended dose; but adverse reactions were rare. Routine supplemental oxygen was given by only 18% of bronchoscopists. Basic resuscitation equipment was often inadequate. Radiological screening was used for transbronchial lung biopsy by 53% of respondents and significantly reduced the incidence of pneumothorax from 2.9% to 1.8%. Both the number of bronchoscopies performed and the complication rate were higher than previous estimates. Bronchoscopists should re-examine their policy on drugs and safety precautions to minimise the risks of the procedure.