P5-13-17: Multigene Signature Assays in Patients with Early-Stage Breast Cancer (ESBC) Receiving Neoadjuvant Chemotherapy: An NCI-Funded Systematic Review and Evidence Summary of Predictive Performance

Background: A comprehensive literature search and evidence synthesis of multigene signatures predictive of response to systemic chemotherapy in patients with breast cancer was initiated as a part of an NCI-funded program on Comparative Effectiveness Research.

Methods: Validation studies were sought of multigene signatures for prediction of chemotherapy response (favorable vs unfavorable) in ESBC patient cohorts different from those used for signature development. Pooled estimates [±95% CI] of assay performance for predicting clinical outcome included sensitivity, specificity, likelihood ratio, predictive value (PV) and predictive odds ratio (POR) utilizing mixed effects models based on the method of Mantel-Haenszel. Exploratory metaregression analyses on log (POR) were also performed. Studies were classified by validation type including cell lines to patients, independent internal sample, random split sample, or external validation. Evidence for publication bias was assessed by Egger's regression intercept and Begg and Mazumdar's rank correction. Results: Dual-blind review of abstracts identified 33 studies of neoadjuvant chemotherapy response of which 29 stratified treatment response by signature classifier category. Classifier development was based on tumor response prediction in 20 studies, prognosis in 5, and molecular classification in 4. The Table shows assay performance measures overall and by study validation type. Assay performance based on the POR was positively associated with overall study quality (P=.015) and journal impact factor (P=.020). However, strong evidence for publication bias was observed based on both regression intercept (P<.001) and rank correlation (P=.005). No significant differences in assay performance were noted for assays originally developed for response prediction (POR=5.3), prognosis (POR=6.6) or molecular classification (P=6.9) (P=.770).

P3-14-04: Assessment of Genomic Prognostic Signatures as Predictors of Response to Neoadjuvant Chemotherapy in Patients with Early Stage Breast Cancer

Background: Based on results from randomized clinical trials, adjuvant and neoadjuvant chemotherapy (NCT) strategies in early stage breast cancer patients (ESBC) achieve comparable long term results. Recently, a number of genomic signatures have been reported, distinguishing patients with low versus high risk of recurrence. While developed primarily as prognostic assays, these classifiers have also been proposed to be predictive of benefit from systemic chemotherapy. Neoadjuvant studies provide an opportunity to evaluate their predictive value for response to NCT.

Methods: A systematic review of gene expression profile studies in ESBC patients receiving chemotherapy was conducted. Medline search of original research articles of human studies published between January 2000 and February 2011 was based on key words and MeSH heading terms. Publications presenting outcomes for chemotherapy treated patients in groups stratified by multi-gene array signatures and utilizing a new independent cohort of patients compared to the original development cohort were selected. Information from eligible studies was extracted by dual abstraction. Reported results were synthesized into combined diagnostic odds ratio (DOR) using method of Mantel-Haenszel. This analysis is restricted to neoadjuvant studies investigating the association of genomic signature prognostic categories with objective tumor response to chemotherapy. Results: A total of 42 articles were eligible for data abstraction. Out of these, 6 publications evaluated response to NCT in good (low risk of recurrence) versus poor prognosis groups based on genomic prediction. Since two of the studies analyzed the same signature on a cohort with large overlap, only 5 studies were included in the final analysis, accounting for n=918 patients. Response consisted of pathologic complete response (pCR) in 3 studies, pCR or minimal residual disease (1 study), and clinical complete response (1 study). Prognostic genomic assays included Oncotype DX (1), MammaPrint (1), Genomic Grade Index (2) and PAM50 Risk of Relapse Score (1). Eight different chemotherapy regimens were utilized. The most common drugs were cyclophosphamide, anthracyclines, taxanes, and 5-fluorouracil. Across all genomic signatures, good prognosis patients, as defined by gene expression data, demonstrated consistently low rates of response to chemotherapy (median 3%, range 0–12%) compared to patients with less favorable prognosis (median 32%, range 19–43%). Odds ratio for response in poor versus good prognosis patients ranged from 3.9 to 21.7 with combined DOR= 6.6 (95% CI 3.9−11.3, P<0.0001). No heterogeneity was determined across studies (P=0.4). The C-statistic estimating assay discriminatory ability was reported in 3 studies ranged from 0.72 to 0.78.

Conclusions: Across all genomic prognostic signatures reported, only a very small proportion of patients with signature predicted good prognosis achieved complete response to NCT. This suggests low sensitivity to chemotherapy among good prognosis patients, as determined by the prognostic genomic signatures. This further confirms the association between poor prognosis tumors and higher responsiveness to chemotherapy.

Funding: NCI: UC2CA14041-01

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-14-04.

Rapid Optical Imaging of Breast Tumor Margins: Final Results from a 100-Patient Clinical Study

Background: Increasing attention has been given to the surgical margin status in primary breast conserving therapy (BCT) due to reports which indicate that 20-70% of patients undergoing BCT must undergo multiple surgeries for complete tumor resection. For the past 4 years, our multidisciplinary group has been working to address this clinical need via the development of an optically-based intraoperative breast tumor margin assessment device. This device, based on diffuse reflectance spectroscopy, is sensitive to biochemical and morphological changes associated with cancer and has a sensing depth of 1-2 mm which is compatible with widely used criteria for cancer-free margins. The device is capable of surveying the entire specimen surface intraoperatively in imaging mode. Here we report the results of a non-significant-risk study of the device in over 100 patients at Duke University Medical Center.Materials and Methods: Under an institutionally-approved protocol, we tested our device on consented patients undergoing a partial mastectomy at DukeUniversity Medical Center for invasive or in situ malignancies. Optical spectral images of tumor margins were recorded within 20 minutes of excision and converted into tissue compositional parameter maps that reflect the vascular density, fat content and cell density in the tissue. The pathologic status of the imaged margins was collected from standard post-operative surgical pathology reports. Intraoperative frozen section and touch prep analysis was not performed on these specimens. Margins were considered positive if residual malignancy was found within 2 mm of the tissue surface.Results and Discussion: BCT specimens from 121 patients have been imaged with the optical device. One to four margins were imaged on each BCT specimen. Data from 112 patients were retained for analysis (51 negative margins, and 47 margins containing cancer within 1mm). Images of negative margins from patients with at least one positive margin (9 patients) elsewhere on the specimen were excluded from analysis due to the potential for presence of margin positivity that was not identified pathologically. For each margin, a set of 8 tissue composition maps were generated, from which a set of 36 image-descriptive variables were obtained. Wilcoxon rank-sum tests were used to determine which of the variables best separated negative from positive margins. A predictive model was developed using conditional inference trees to identify the optimal partitions from all 36 image-descriptive variables. The model selected variables related to the light scattering properties, total hemoglobin content, and β-carotene content of the underlying tissue, which are related to tissue density and morphology, vascular volume, and fat content, respectively. This model resulted in a sensitivity of 80% for detecting cancer at the margin, a sensitivity of 73% for detecting residual disease within 1mm of the margin, and a specificity of 65%. These results are promising and a prospective validation trial of the device is under development.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5017.

Characterizing the clinical relevance of an embryonic stem cell phenotype in lung adenocarcinoma

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Background: Cancer cells possess traits reminiscent of those ascribed to normal stem cells. It is unclear whether these phenotypic similarities between normal/embryonic stem cells and mature tumor cells, specific to lung cancer, are a result of underlying biologic processes, such as specific molecular pathways and regulatory networks. Methods: Using a large cohort of lung cancer cell lines with associated gene expression data, genes associated with an embryonic stem cell identity were used to develop a ‘signature’ representative of embryonic stemness (ES) activity specific to lung adenocarcinoma. Differential biology was evaluated using Gene Set Enrichment Analysis (GSEA) and signatures of oncogenic pathway deregulation. The ES signature was applied to three independent early (stage I - IIIa) lung adenocarcinoma data sets (N = 634) with clinically annotated gene expression data. The relationship between the ES phenotype and cisplatin sensitivity was also evaluated. Results: Using Bayesian regression analysis, a 100 gene signature representative of ES activity in lung adenocarcinoma was developed and validated in a leave-one-out-analysis. GSEA identified gene sets significantly represented in the ES signature: signature of neoplastic transformation, signature of undifferentiated cancer, BRCA pathway, and fibroblast serum response pathway, all associated with cancer invasiveness. Adenocarcinomas with ES demonstrated increased activation of RAS (p = 0.0002), MYC (p = 0.0057), wound healing (angiogenesis) (p < 0.0001), chromosomal instability (p < 0.0001), and invasiveness (p < 0.0001) gene signatures. Adenocarcinomas (N= 634) with ES had a decreased survival (p<0.04). The ES signature was not prognostic in prostate, ovarian, or breast adenocarcinomas. Lung tumors (N=634) and adenocarcinoma cell lines (N=31) with ES were more resistant to cisplatin (p<0.0001 and p=0.0063, respectively). Conclusions: Lung adenocarcinomas that share a common gene expression pattern with normal stem cells were associated with decreased survival and increased likelihood of resistance to cisplatin, indicating the aggressiveness of lung tumors with a stem cell phenotype.

No significant financial relationships to disclose.

Patient preference as a determinant of breast cancer adjuvant chemotherapy use in older women: CALGB #369901

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Background: Decisions about use of breast cancer chemotherapy in women 65 and older (“older”) can be complex due to comorbidity, uncertain efficacy and limited data on patient preference. Methods: Older women diagnosed with invasive, non-metastatic breast cancer between 2004 and 2008 were recruited from 53 CALGB sites for an observational study of preferences and chemotherapy use. Data on preferences and other factors were collected from patient interviews and clinical data were abstracted from charts. Generalized estimating equation regression was used to assess associations between chart-reported chemotherapy and independent variables; associations were also evaluated in 2 subgroups: “chemotherapy indicated” (estrogen receptor [ER] negative and/or node positive) and “consider chemotherapy” (ER positive and node negative). Results: Among 935 eligible women registered, 815 (87.2%) completed interviews. The mean age of the cohort was 73 years (range 65–100); 38% were node positive, 82% were ER positive and all had tumors ≥ 1 cm (44% were AJCC stage 1, 44% stage 2 and 12% stage 3). Based on ER and nodal status, chemotherapy was “indicated” for 47% and could be “considered” for 53%. Crude chemotherapy rates were 70% in the “indicated” group and 17% in the “considered” group, for an overall rate of 42%. Women who would choose chemotherapy for an increase in survival of ≤12 months were 4.1 times (95% CI 2.5–6.7, p<.0001) more likely to receive chemotherapy than women who would only choose chemotherapy if it added more than 12 months, controlling for age, tumor factors, comorbidity and other covariates. Stronger preferences were seen among women with “indications” for chemotherapy (OR 7.9, 95% CI 3.7–17.0, p<.001) than in those where treatment might be “considered” (OR 1.8, 95% CI 0.9–3.4, p=.08). Higher patient rating of communication with providers was independently related to a decision to use chemotherapy among women where chemotherapy could be “considered” but not among those where chemotherapy was “indicated”. Conclusions: Beyond clinical indications, older women's preferences and communication with providers are important correlates of chemotherapy use.

[Table: see text]

Thermometry in paediatric practice

Body temperature is commonly measured to confirm the presence or absence of fever. However, there remains considerable controversy regarding the most appropriate thermometer and the best anatomical site for temperature measurement. Core temperature is generally defined as the temperature measured within the pulmonary artery. Other standard core temperature monitoring sites (distal oesophagus, bladder, and nasopharynx) are accurate to within 0.1-0.2 degrees C of core temperature and are useful surrogates for deep body temperature. However, as deep-tissue measurement sites are clinically inaccessible, physicians have utilised other sites to monitor body temperature including the axilla, skin, under the tongue, rectum, and tympanic membrane. Recent studies have shown that tympanic temperature accurately reflects pulmonary artery temperature, even when body temperature is changing rapidly. Once outstanding issues are addressed, the tympanic site is likely to become the gold standard for measuring temperature in children.

Transcriptomic analysis of F344 rat nasal epithelium suggests that the lack of carcinogenic response to glutaraldehyde is due to its greater toxicity compared to formaldehyde

Formaldehyde is cytotoxic and carcinogenic to the rat nasal respiratory epithelium inducing tumors after 12 months. Glutaraldehyde is also cytotoxic but is not carcinogenic to nasal epithelium even after 24 months. Both aldehydes induce similar acute and subchronic histopathology that is characterized by inflammation, hyperplasia, and squamous metaplasia. Because early aldehyde-induced lesions are microscopically similar, we investigated whether transcriptional patterns using cDNA technology could explain the different cancer outcomes. Treatments included 1-, 5-, or 28-day exposure by nasal instillation of formaldehyde solution (400 mM) or glutaraldehyde solution (20 mM). Animals were euthanized and the nasal respiratory epithelium removed for gene expression analysis and a subset of rats treated for 28 days was processed for microscopic examination. RNA was isolated and processed for expression assessment using Clontech Atlas Toxicology II Arrays. Both aldehydes induced hyperplasia, squamous metaplasia, and inflammatory infiltrates with scattered apoptotic bodies in the epithelium covering luminal surfaces of the nasoturbinate, maxilloturbinate, and nasal septum. A subset of 80 genes that were the most variant between the treated and control included the functional categories of DNA repair and apoptosis. Hierarchical clustering discriminated chemical treatment effects after 5 days of exposure, with 6 clusters of genes distinguishing formaldehyde from glutaraldehyde. These data suggest that although both aldehydes induced similar short-term cellular phenotypes, gene expression could distinguish glutaraldehyde from formaldehyde. The gene expression patterns suggest that glutaraldehyde's lack of carcinogenicity may be due to its greater toxicity from lack of DNA-repair, greater mitochondrial damage, and increased apoptosis.

A comparison of brain angiotensin II receptors during lactation and diestrus of the estrous cycle in the rat

During lactation there are many dramatic alterations in the hypothalamic-pituitary (HP) axis, as well as an increased demand for food and water. The renin-angiotensin system (RAS) is one of the major mediators of the HP axis. This study examined the receptors for ANG II in the rat brain during lactation and diestrus. Compared with diestrus, lactating rats had significant decreases in ANG II receptor binding in several forebrain regions, most notably in the arcuate nucleus/median eminence, dorsomedial hypothalamic nucleus (DMH), and lateral hypothalamic area (LHA). In contrast, there was an increase in ANG II receptor binding in the preoptic area during lactation. These significant changes in ANG II binding in the brain during lactation support the hypothesis that changes in the RAS may contribute to the dramatic changes in the HP axis during lactation. In addition, the significant reduction in ANG II binding in the DMH and LHA may be indicative of a role in the regulation of food intake, a function only recently associated with the RAS.

Association of fever and severe clinical course in bronchiolitis

Little attention has been given to the relation between fever and the severity of bronchiolitis. Therefore, the relation between fever and the clinical course of 90 infants (59 boys, 31 girls) hospitalised during one season with bronchiolitis was studied prospectively. Fever (defined as a single recording > 38.0 degrees C or two successive recording > 37.8 degrees C) was present in 28 infants. These infants were older (mean age, 5.3 v 4.0 months), had a longer mean hospital stay (4.2 v 2.7 days), and a more severe clinical course (71.0% v 29.0%) than those infants without fever. Radiological abnormalities (collapse/consolidation) were found in 60. 7% of the febrile group compared with 14.8% of the afebrile infants. These results suggest that monitoring of body temperature is important in bronchiolitis and that fever is likely to be associated with a more severe clinical course and radiological abnormalities.

Predictors of survival and the role of gender in postoperative myocardial infarction

PURPOSE

To identify risk factors for mortality after postoperative myocardial infarction.

METHOD

Retrospective study of 266 patients.

RESULTS

The crude in-hospital mortality rate was 25%. This was more than twice as high as the mortality rate in patients admitted from home with an acute myocardial infarction. Women with postoperative infarction were the same age as men, but had a lower Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to infarction (P = 0.03) and a higher crude mortality rate. Multivariate analysis showed that female gender (relative risk 2.2, 95% confidence limits 1.2 to 4.2), current cigarette smoking (relative risk 2.3 [1.2 to 4.7]), a history of congestive heart failure (relative risk 2.1 [1.04 to 4.1], resuscitation status (relative risk 8.1 [2.0 to 32.9]), and high preoperative APACHE II score were significant independent predictors of in-hospital mortality.

CONCLUSION

Postoperative myocardial infarction is one of the most serious events a patient can experience. Women and current smokers are at especially high risk for mortality after postoperative myocardial infarction.

Thrombin and vascular smooth muscle cell proliferation: implications for atherosclerosis and restenosis

Despite long-standing knowledge about the relationship between thrombosis and atherosclerosis, the specific role of thrombin in modulating atherosclerosis and the response to vascular injury is not well understood. Thrombin receptor stimulation in vitro signals many cellular events that are associated with the response to vascular injury (atherosclerosis) in vivo. Proliferation of smooth muscle cells (SMCs) is an important component of the response to vascular injury. We have previously shown that human alpha-thrombin and the 14-amino acid human thrombin receptor-activating peptide (huTRAP-14) stimulate proliferation of cultured rat aortic SMCs. However, thrombin-induced SMC proliferation demonstrates delayed kinetics relative to platelet-derived growth factor (PDGF-BB, another potent SMC mitogen). Several mechanisms may be responsible for these delayed kinetics in vitro, including production of necessary secondary growth factors and thrombin-induced upregulation of its receptor. In vivo studies have demonstrated that thrombin inhibition limits the response to vascular injury in a hypercholesterolemic rabbit model of focal femoral atherosclerosis. However, this effect does not appear to be mediated by effects on early SMC proliferation. In this discussion, we will address the mechanisms of thrombin-induced SMC proliferation in vitro and apply this knowledge to our understanding of the role of thrombin inhibition in limiting the response to vascular injury in vivo.

Amlodipine combined with beta blockade for chronic angina: Results of a multicenter, placebo-controlled, randomized double-blind study

Amlodipine, a potent long-acting dihydropyridine calcium antagonist, was compared with placebo in a parallel, randomized, double-blind study in 134 patients with chronic stable angina pectoris maintained on beta-adrenergic blocking agents. After a single-blind, two-week placebo period, patients were randomized to receive either amlodipine (2.5, 5, and 10 mg) or placebo once daily for four weeks. The effects of amlodipine on maximal exercise time, work, time to angina onset, and subjective indices including angina frequency, nitroglycerin tablet consumption, and patient and investigator ratings were assessed. Each dose of amlodipine produced increases in exercise time and calculated total work accomplished compared to baseline. Improvements at 5 and 10 mg were significantly greater than placebo which produced no significant change (p less than 0.05). Qualitative improvements in the severity of angina were produced by amlodipine at 5 and 10 mg daily assessed by patient-rating questionnaires (p less than 0.05). Reductions in angina frequency attacks per week and weekly nitroglycerin tablet consumption occurred but were not statistically significant when compared with placebo. Adverse effects observed during amlodipine treatment prompted discontinuation of treatment in only 2 out of 100 patients. Three patients discontinued treatment for reported lack of efficacy. No laboratory abnormalities prompted treatment discontinuation and minor side effects of dizziness, nausea, headache, and fatigue were observed infrequently. The results of this controlled, large-scale multicenter trial suggest that amlodipine significantly increased exercise capacity and was well tolerated when added to the antianginal regimen of patients remaining symptomatic while receiving beta-blocking agents.

Intravenous immunoglobulin therapy for toxic shock syndrome

Staphylococcus aureus and group A Streptococcus pyogenes produce toxic shock syndrome characterized by hypotension and multisystem organ failure. While conventional therapy has consisted of antibiotics and intensive supportive care, some experimental evidence suggests that immunoglobulins directed against the toxins may be effective additional therapy. We report a case of "toxic strep syndrome" in which intravenous immunoglobulin was administered when signs and symptoms were worsening while the patient was receiving conventional therapy. Within hours of administration of the intravenous immunoglobulin, the patient experienced dramatic clinical improvement. This response suggests a possible therapeutic benefit of intravenous immunoglobulin in toxic shock syndrome.

Once or twice daily theophylline in childhood asthma

We conducted a randomized, single-blind, crossover trial to compare two sustained release theophylline preparations. Fifty-nine chronic asthmatics, aged 7-14 years, were randomly allocated to receive Slophyllin (SP) twice daily followed by Uniphyllin (UP) taken as a single dose at bedtime, or UP followed by SP. Two 4-week periods on therapeutic doses of each preparation were compared. Thirty-six patients completed the study. Eight were non-compliant, seven defaulted and eight withdrew because of theophylline related side-effects (seven on UP). Symptom scores, beta-agonist usage, compliance by pill counts, evening peak flow rates and maximal expiratory flow-volume curves were similar on both treatments. Blood levels of theophylline at 11 am and morning peak flow rates were significantly higher on UP. UP may be more helpful for patients with early morning symptoms, but is associated with an increased frequency of severe side effects.

Measurement of choroidal melanomas: a comparison of methods

The prognosis for death from metastatic choroidal melanoma following enucleation has been shown to be strongly correlated with a number of risk factors of which the most important are age of onset, aggressive cell types and tumour volume. The advantages of enucleation for the treatment of choroidal melanomas are put into question by the singular lack of a parallel increase in life expectancy following this treatment, and evidence that it may promote the development of metastatic disease. Alternative forms of treatment have been introduced including observation of small and asymptomatic tumours. We are using a computer-aided system for serial measurement and statistical analysis of area and volume of choroidal melanomas. A comparison of results using our method and the conventional method of estimating volume by the product of basal area and height for 51 measurements on 15 eyes over a 6-month period showed an overestimation of volume by conventional methods which could be corrected by applying a "shape constant" determined by linear regression. Calculation of tumour growth rates is also shape-dependent, and a slowing in growth rate or even a reduction in melanoma size is possible.