[Specific types of bladder cancer]

Bladder cancer shows rare variants and special subtypes with diverse prognostic importance and therefore may necessitate different therapeutic approaches. For pathologists it is important to histologically diagnose and specify such variants. Nested variants of urothelial carcinoma with inconspicuous, well-formed tumor cell nests present with an aggressive course. The plasmacytoid variant, which morphologically resembles plasma cells is associated with a shorter survival time and a high frequency of peritoneal metastasis. Micropapillary urothelial carcinoma with small papillary tumor cell islands within artificial tissue retraction spaces and frequent lymphovascular invasion also has a poor prognosis. Other important rare differential variants listed in the World Health Organization (WHO) classification are microcystic, lymphoepithelioma-like, sarcomatoid, giant cell and undifferentiated urothelial carcinomas. Additionally, there are three special types of bladder cancer: squamous cell carcinoma, adenocarcinoma and small cell neuroendocrine carcinoma of the bladder. These tumors are characterized by pure squamous cell or glandular differentiation and are sometimes less responsive to adjuvant (chemo)therapy. Small cell carcinoma of the bladder mimics the neuroendocrine features of its pulmonary counterpart, shows an aggressive course but is sensitive to (neo-)adjuvant chemotherapy. The morphology and histology of the most important variants and special types are discussed in this review.

Collectin Liver 1 and Collectin Kidney 1 of the Lectin Complement Pathway Are Associated With Mortality After Kidney Transplantation

Kidney transplanted patients still have significantly higher mortality compared with the general population. The innate immune system may play an important role during periods, with suppression of the adaptive immune system. In the present study, two soluble pattern recognition molecules of the innate immune system were investigated, collectin liver 1 (CL-L1) and collectin kidney 1 (CL-K1). Potential associations of their pretransplant levels and long-term graft and recipient survival were examined. The levels of CL-L1 and CL-K1 were measured at the time of transplantation in 382 patients (≥17 years) transplanted in 2000-2001. The cohort was subsequently followed until December 31, 2014. Data on patient and graft survival were obtained from the Norwegian Renal Registry. Both high CL-L1 (≥376 ng/mL) and high CL-K1 (≥304 ng/mL) levels were significantly associated with overall mortality in multivariate Cox analyses with hazard ration (HR) 1.50, 95% confidence interval (CI) 1.09-2.07, p = 0.013 and HR 1.43, 95% CI 1.02-1.99, p = 0.038, respectively. Moreover, high CL-K1 levels were significantly associated with cardiovascular mortality. No association between measured biomarkers and death-censored graft loss was found. Finally, there was a significant correlation between these two collectins, r = 0.83 (95% CI 0.80-0.86). In conclusion, CL-L1 and CL-K1 were significantly associated with mortality in kidney transplant recipients.

[Current Practice of Pre- and Postnatal Screening and Future Developments for Evidence Based Guidelines]

Objectives: In this selective review we provide an overview of the current pre- and postnatal screenings up to 18 years established in Germany to inform physicians of different medical fields (gynecologists, pediatricians, general practitioners, other medical specialists who treat children, adolescents or pregnant females). Current State: Research on screening for different types of cancer has frequently failed to show any benefit. Thus, there is a need to broaden the evidence basis related to medical screenings especially for children and adolescents. Outlook: Potential future developments of pre- and postnatal screenings are illustrated including their social impact. The lack of an early detection of mental health problems is pointed out. An interdisciplinary collaboration and research is required to accumulate evidence with regard to medical screenings and to consider health economic and ethical aspects.

[c-MET Oncogene in Renal Cell Carcinomas]

c-Met plays a significant role in multiple cellular processes. Being encoded by a proto-oncogene, tyrosine kinase supports aggressive tumour behaviour such as tumour invasiveness and formation of metastases. For some subtypes of renal cell carcinoma studies have shown a association between c-Met expression and clinical outcome or prognosis. Therefore, c-Met represents a prognostic marker in renal cell carcinoma.Furthermore, c-MET will play a decisive role as a possible target for targeted therapies in the era of personalised medicine. Especially for RCC, the dual inhibition of VEGF and c-MET tyrosine kinase in cases of metastatic, treatment-resistant tumours is gaining clinical relevance. The role of c-Met has not been fully elucidated for all subtypes of renal cell carcinomas. The relevance of c-Met for the remaining subtypes of renal tumours has yet to be clarified.

How do patients with anorexia nervosa "process" psychotherapy between sessions? A comparison of cognitive-behavioral and psychodynamic interventions

OBJECTIVE

Patients' processing of psychotherapy between sessions ("inter-session process" (ISP)) has been repeatedly shown to be related to outcome. The aim of this study was to compare ISP characteristics of cognitive-behavioral vs. psychodynamic psychotherapy in the treatment of anorexia nervosa (AN) and their relation to outcome.

METHODS

Data of 106 patients participating in a randomized-controlled trial who received either 40 sessions of enhanced cognitive-behavioral therapy (CBT-E) or focal psychodynamic therapy (FPT) were analyzed. The ISP was measured with the Inter-session Experience Questionnaire (IEQ). Three outcome classes were distinguished: full recovery, partial recovery, and still fulfilling all AN criteria.

RESULTS

Patients receiving CBT-E reported more on "applying therapy" in the initial and the final treatment phase compared to FPT patients. In terms of process-outcome relations, higher levels of "recreating the therapeutic dialogue between sessions," "recreating the therapeutic dialogue with negative emotions" as well as "applying therapy with negative emotions" in the final phase of treatment predicted negative outcome in FPT, whereas overall higher levels of negative emotions predicted negative outcome in CBT-E.

CONCLUSIONS

In outpatient treatment in AN, the processing of therapy as measured by the IEQ showed surprisingly few differences between CBT-E and FPT. However, different ISP patterns were predictive of outcome, pointing to different mechanisms of change.

Characterization of primary chondrocytes harvested from hips with femoroacetabular impingement

OBJECTIVE

Acetabular chondral lesions are common in patients with femoroacetabular impingement (FAI) syndrome. The aim of this study was (1) to evaluate the proliferation potential of primary human chondrocytes (hC) derived from both acetabular and femoral site and (2) to validate cellular differentiation during three-dimensional (3D) cultivation as a prerequisite for autologous matrix-assisted cartilage regeneration of the hip joint.

METHODS

hC were isolated from cartilage samples obtained from N = 6 patients during offset reconstruction. Proteoglycan content was assessed by Safranin-O staining. Proliferation and cell viability were quantified by microscopic cell counting and Trypan Blue exclusion. Messenger ribonucleic acid (mRNA) expression levels of collagen type 1 and 2, aggrecan (ACAN), and interleukin-1β (IL-1β) genes were assessed upon monolayer cultivation, after 48 h/4-10°C - transport simulation and after 14 days of 3D hydrogel cultivation.

RESULTS

Primary hC from acetabular and femoral damaged sites were viable. No significant intergroup differences were observed concerning cell viability (>95%) after monolayer cultivation and transport simulation. Harvest yields from acetabular and femoral cartilage samples were comparable to that known from knee joints (mean ± standard deviation (SD), 13.4 × 10(6) ± 5 × 10(6) cells per culture vs 20 × 10(6) cells). Redifferentiation was induced during 3D hydrogel cultivation as observed by increased levels of collagen II (1000-fold) and ACAN (10-fold) gene vs monolayer cultivation (P < 0.001).

CONCLUSION

hC derived from damaged acetabular and femoral site are qualified for autologous matrix-assisted cartilage transplantation paving the way for cell-based cartilage regeneration in FAI patients.

Review Article. Doppler examination of the allografted kidney

A comprehensive ultrasound examination of the transplanted kidney includes a Doppler examination. Duplex Doppler, color Doppler and power Doppler can all reveal important information. In addition, calculation of the resistance and pulsatility indices to quantify changes in the spectral Doppler waveform can be of great help, particularly in the first weeks and months following a transplantation. The Doppler part of the examination should evaluate the vessels to and from the transplant, as well as the parenchyma with calculations of indices to detect the presence of increased vascular resistance. The conclusions drawn from the Doppler-derived information combined with the results from gray-scale scanning and clinical information will very often be of clinical significance for the handling of the patient.

FamilyPso - a new questionnaire to assess the impact of psoriasis on partners and family of patients

BACKGROUND

Psoriasis is a lifelong disease for which there is no cure. It has been conclusively shown across all ethnicities that patients suffering from psoriasis have a significantly reduced health-related quality of life and a high disease burden.

OBJECTIVE

Surprisingly little is known about the impact of a patient's psoriasis on partners or family members.

METHODS

To address this issue a systematic literature search has been conducted and interviews with relatives of psoriasis patients living in the same household were performed. From this collected information, items were generated that were commonly mentioned to affect living and tested in a large group of relatives before the final item selection was done.

RESULTS

A first set of 29 items was selected and tested in a study with 96 patient relatives. After adjustment and statistical analysis, the final FamilyPso questionnaire was condensed to 15 items to assess the burden of partners or family members living together with psoriasis patients.

CONCLUSION

The FamilyPso enables physicians to achieve a better understanding of the impact of psoriasis as a lifelong chronic disease on partners and the family environment.

[Hereditary renal tumors: More common than expected?]

Renal cell carcinomas are associated with hereditary tumor syndromes in approximately 5 % of cases. In patients with a hereditary predisposition, tumors show an earlier age of onset, often with a multicentric and bilateral manifestation. While some patients with renal cell carcinoma can be classified into well-characterized kidney cancer syndromes others have a genetic background which is still poorly understood. Most of the specific tumor syndromes are associated with a histopathologically distinct renal cell tumor phenotype. The recognition of patients with hereditary renal cell carcinoma and the identification of individual family members with a higher risk of development of renal tumors is important for early tumor detection and treatment. This manuscript reviews the clinical pathological and molecular findings of hereditary renal cell carcinoma syndromes.

First molecular detection of Mycobacterium bovis in environmental samples from a French region with endemic bovine tuberculosis

AIMS

The aim of the study was to determine the prevalence of Mycobacterium bovis (the causative agent of bovine tuberculosis, bTB) in environmental matrices within a French region (Côte d'Or) affected by this zoonotic disease.

METHODS AND RESULTS

We report here the development and the use of molecular detection assays based on qPCR (double fluorescent dye-labelled probe) to monitor the occurrence of Mycobacterium tuberculosis complex (MTBC) or Myco. bovis in environmental samples collected in pastures where infected cattle and wildlife had been reported. Three qPCR assays targeting members of the MTBC (IS1561' and Rv3866 loci) or Myco. bovis (RD4 locus) were developed or refined from existing assays. These tools were validated using Myco. bovis spiked soil, water and faeces samples. Environmental samples were detected positive for the presence of MTBC strains and Myco. bovis in the environment of bTB-infected farms in the Côte d'Or region.

CONCLUSIONS

The development of molecular assays permitted testing of several types of environmental samples including spring water, sediment samples and soils from badger setts entrance located in the vicinity of these farms, which were repeatedly contaminated with Myco. bovis (up to 8·7 × 10(3) gene copies per gram of badger sett soil). For the first time, direct spoligotyping of soil DNA enabled identification of Myco. bovis genotypes from environmental matrices.

SIGNIFICANCE AND IMPACT OF THE STUDY

All together, these results suggest that Myco. bovis occurs at low levels in environmental matrices in Côte d'Or within the bTB-infected area. Drinking contaminated water or inhaling contaminated bioaerosols might explain cattle infection in some cases.

Comparison of prognostic and predictive impact of genomic or central grade and immunohistochemical subtypes or IHC4 in HR+/HER2- early breast cancer: WSG-AGO EC-Doc Trial

INTRODUCTION

Potential prognostic and predictive markers in early, intermediate-risk breast cancer (BC) include histological grade, Ki-67, genomic signatures, e.g. genomic grade index (GGI), and intrinsic subtypes. Their prognostic/predictive impact in hormone receptor (HR: ER and/or PR) positive/HER2- BC is controversial. WSG-AGO EC-Doc demonstrated superior event-free survival (EFS) in patients with 1-3 positive lymph node receiving epirubicin/cyclophosphamide-docetaxel (EC-Doc) versus 5-fluoruracil/epirubicin/cyclophosphamide (FEC).

METHODS

In a representative trial subset, we quantify concordance among factors used for clinical chemotherapy indication. We investigate the impact of central histology (n = 772), immunohistochemistry for intrinsic subtyping and IHC4, and dichotomous (GG) or continuous (GGI) genomic grade (n = 472) on patient outcome and benefit from taxane chemotherapy, focusing on HR+/HER2- patients (n = 459).

RESULTS

Concordance of local grade (LG) with central (CG) or genomic grade was modest. In HR+/HER2- patients, low (GG-1: 16%), equivocal (GG-EQ: 17%), and high (GG-3: 67%) GG were associated with respective 5-year EFS of 100%, 93%, and 85%. GGI was prognostic for EFS within all LG subgroups and within CG3, whereas IHC4 was prognostic only in CG3 tumors.In unselected and HR+/HER2- patients, CG3 and luminal-A-like subtype entered the multivariate EFS model, but not IHC4 or GG. In the whole population, continuous GGI entered the model [hazard ratio (H.R.) of 75th versus 25th = 2.79; P = 0.01], displacing luminal-A-like subtype; within HR+/HER2- (H.R. = 5.36; P < 0.001), GGI was the only remaining prognostic factor.In multivariate interaction analysis (including central and genomic grade), luminal-B-like subtype [HR+ and (Ki-67 ≥20% or HER2+)] was predictive for benefit of EC-Doc versus FEC in unselected but not in HR+/HER2- patients.

CONCLUSION

In the WSG-AGO EC-Doc trial for intermediate-risk BC, CG, intrinsic subtype (by IHC), and GG provide prognostic information. Continuous GGI (but not IHC4) adds prognostic information even when IHC subtype and CG are available. Finally, the high interobserver variability for histological grade and the still missing validation of Ki-67 preclude indicating or omitting adjuvant chemotherapy based on these single factors alone.

TRIAL REGISTRATION

The WSG-AGO/EC-Doc is registered at ClinicalTrials.gov, NCT02115204.

Abstract P6-04-14: Integrating whole genome sequencing data with RNAseq, pathway analysis, and quantitative proteomics to determine prognosis after standard adjuvant treatment with trastuzumab and chemotherapy in primary breast cancer patients

Background: Despite improvements in the treatment of HER2+ breast cancer (BC), almost all patients (pts) progress in the metastatic setting. Three examples of resistance mechanisms are: PI3K mutations, lack of ADCC, or low expression of HER2. We recently showed that among 237 pts who had HER2 amplifications, 49% had normal or low levels of HER2 RNA. In addition, quantification of HER2 protein by selected reaction monitoring mass spectrometry (SRM-MS) accurately predicted HER2 expression status compared with IHC (3+)/ISH (≥2.0). Here we report a comprehensive panomic approach that integrates whole genome sequencing (WGS), RNASeq, quantitative proteomics, and pathway analysis to determine associations between tumor molecular profiles and prognosis among HER2+ pts.

Methods: Matched tumor-normal samples (FFPE tumors and blood) were obtained from 58 pts with HER2+ BC who had received standard adjuvant chemotherapy and trastuzumab. Pts were divided into 2 groups: those who had no recurrence after 5 years and those who had developed metastases. The HER2 status of each pt was previously determined using IHC/FISH. Samples underwent WGS and RNASeq according to NantOmics CLIA-approved assay specifications. WGS data were processed using Contraster; RNASeq data confirmed the presence of gene mutations and was used to identify mutational and transcript abundance. PARADIGM was used to reveal associations between gene mutations and pathway levels. SRM-MS was used for proteomics analysis of a panel of 53 proteins. Tumor areas from FFPE tissue sections were analyzed after laser microdissection. Absolute protein quantitation was accomplished through simultaneous detection of endogenous target and synthetic labeled heavy peptide identical to analytical targets. Genetic alterations in germline and tumor DNA were compared in pts with vs without recurrence.

Results: There was no statistically significant difference in the mean concentration of HER2 in the tumors of pts with vs without recurrence: 2.34 fmol/µL vs 2.56 fmol/µL. Other analyzed proteins did not appear to be associated with recurrence; however, expected correlations between pt and tumor characteristics and protein expression were found. With regard to clinically relevant mutations, we found one germline BRCA2 mutation in a pt with no family history of this mutation. The most commonly found somatic mutations were in TP53 (11 pts), AMBRA1 (11 pts), MORC4 (10 pts), SETD2 (8 pts), CDC27 (6 pts), BCLAF1 (5 pts), ZNF479 (4 pts) , PIK3CA (3 pts), PIK3R1 (3 pts), RUNX1 (3 pts), and GATA3 (3 pts).

Conclusion: Whereas HER2 expression status was predictive of OS and PFS in pts treated with trastuzumab (Nuciforo et al. Mol Onc. 2015), in this small exploratory study of HER2+ BC pts, HER2 expression status was not predictive of recurrence. To better understand the molecular mechanisms driving recurrence beyond HER2 status alone, genomic sequencing may define a signature of recurrence after anti-HER2 therapy.

Citation Format: Benz SC, Rabizadeh S, Cecchi F, Beckman MW, Brucker SY, Hartmann A, Golovato J, Hembrough T, Janni W, Rack B, Sanborn JZ, Schneeweiss A, Vaske CJ, Soon-Shiong P, Fasching PA. Integrating whole genome sequencing data with RNAseq, pathway analysis, and quantitative proteomics to determine prognosis after standard adjuvant treatment with trastuzumab and chemotherapy in primary breast cancer patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-04-14.

Touch Imprint Cytology and Stereotactically-Guided Core Needle Biopsy of Suspicious Breast Lesions: 15-Year Follow-up

Introduction: Stereotactically-guided core needle biopsies (CNB) of breast tumours allow histological examination of the tumour without surgery. Touch imprint cytology (TIC) of CNB promises to be useful in providing same-day diagnosis for counselling purposes and for planning future surgery. Having addressed the issue of accuracy of immediate microscopic evaluation of TIC, we wanted to re-examine the usefulness of this procedure in light of the present health care climate of cost containment by incorporating the surgical 15-year follow-up data and outcome. Patients and Methods: From January until December 1996 we performed TIC in core needle biopsies of 173 breast tumours in 169 patients, consisting of 122 malignant and 51 benign tumours. Histology of core needle biopsies was proven by surgical histology in all malignant and in 5 benign tumours. Surgical breast biopsy was not performed in 46 patients with 46 benign lesions, as the histological result from the core needle biopsy and the result of the TIC were in agreement with the suspected diagnosis from the complementary breast diagnostics. A 15-year follow-up of these patients followed in 2013 and follow-up data was collected from 40 women. Results: In the 15-year follow-up of the 40 benign lesions primarily confirmed using CNB and TIC, a diagnostic sensitivity, specificity, positive and negative predictive value and accuracy of 100 % was found. Conclusion: TIC and stereotactically guided CNB showed excellent long-term follow-up in patients with benign breast lesions. The use of TIC to complement CNB can therefore provide immediate cytological diagnosis of breast lesions.

[Molecular classification of bladder cancer. Possible similarities to breast cancer]

Therapeutic decisions for breast cancer are increasingly becoming based on subtype-specific gene expression tests. For bladder cancer very similar subtypes have been identified by genome-wide mRNA analysis, which as for breast cancer differ with respect to the prognosis and response to therapy on the basis of their hormone dependency. At the DNA level, however, the type of mutations and their frequencies within the subtypes are strikingly different between bladder and breast cancers. It will be interesting to see whether possible driver mutations can serve as therapeutic targets in both indications. In contrast, the apparent hormone dependency of a substantial number of bladder carcinomas suggests that hormonal and anti-hormonal treatment can be valid therapy options similar to breast cancer. Moreover, gender-specific differences with respect to the incidence and aggressiveness of male compared to female bladder cancers can be explained by hormonal effects. Together with forthcoming immunomodulatory therapies these multiple therapy options raise and give new hope to efficiently combat this aggressive disease.

Serum Calcification Propensity Is a Strong and Independent Determinant of Cardiac and All-Cause Mortality in Kidney Transplant Recipients

Calcification of the vasculature is associated with cardiovascular disease and death in kidney transplant recipients. A novel functional blood test measures calcification propensity by quantifying the transformation time (T50 ) from primary to secondary calciprotein particles. Accelerated T50 indicates a diminished ability of serum to resist calcification. We measured T50 in 1435 patients 10 weeks after kidney transplantation during 2000-2003 (first era) and 2009-2012 (second era). Aortic pulse wave velocity (APWV) was measured at week 10 and after 1 year in 589 patients from the second era. Accelerated T50 was associated with diabetes, deceased donor, first transplant, rejection, stronger immunosuppression, first era, higher serum phosphate and lower albumin. T50 was not associated with progression of APWV. During a median follow-up of 5.1 years, 283 patients died, 70 from myocardial infarction, cardiac failure or sudden death. In Cox regression models, accelerated T50 was strongly and independently associated with both all-cause and cardiac mortality, low versus high T50 quartile: hazard ratio 1.60 (95% confidence interval [CI] 1.00-2.57), ptrend   = 0.03, and 3.60 (95% CI 1.10-11.83), ptrend   = 0.02, respectively. In conclusion, calcification propensity (T50 ) was strongly associated with all-cause and cardiac mortality of kidney transplant recipients, potentially via a cardiac nonAPWV-related pathway. Whether therapeutic improvement of T50 improves outcome awaits clarification in a randomized trial.

Outcomes of direct pulp capping: interrogating an insurance database

AIM

To evaluate the effectiveness of direct pulp capping under general practice conditions. It was hypothesized that direct pulp capping is an effective procedure in the majority of cases and prevents the need for root canal treatment or extraction.

METHODOLOGY

Claims data were collected from the digital database of a major German national health insurance company. Only patients who had been insurance members for the entire 3 year period 2010 to 2012 were eligible. Kaplan-Meier survival analyses were conducted for all teeth with direct pulp capping. Success was defined as not undergoing root canal treatment. Survival was defined as not undergoing extraction. Differences between survival functions were tested with the log rank test.

RESULTS

A total of 148 312 teeth were included. The overall success rate was 71.6% at 3 years. The overall survival rate was 95.9% at 3 years. The success rates for single-rooted teeth (71.8%) and multirooted teeth (71.5%) were similar although significantly different (P < 0.001). Best 3-year success rates were found at low (79.7%; <18 years.) and very high age (81.8%; >85 years.).

CONCLUSIONS

After direct pulp capping, more than two-thirds of the affected teeth did not undergo root canal treatment within 3 years. Although this study has the typical limits of a claims data analysis, it can be concluded that direct pulp capping is an effective intervention to avoid root canal treatment and extraction in a general practice setting.

Contribution of therapeutic strategies for understanding the Tourette syndrome

Motion is a behavior involving a motor act programmed and executed in a particular cognitive and emotional context. Deep structures of the brain, including the basal ganglia, appear to play a crucial role in the integration of these three kinds of cortex information (motion, cognition, emotion). Through its organization, the basal ganglia system enables learning and memorization of behavioral sequences, which can then be executed as routines. Their dysfunctions seem to be associated with many psychopathological situations. Thus, tics in Tourette's syndrome (TS) can be seen as a control routines defect that may result from wiring anomaly between the cortex and the basal ganglia. By precisely targeting deep brain circuits implicated in psychiatric disorders, deep brain stimulation (DBS) offers hope for the alleviation of severe illnesses resistant to drug therapies and provides a novel tool to investigate the neuroanatomic and physiological bases of certain disorders, including Obsessive-Compulsive Disorder (OCD) and TS, for which early results indicate positive therapeutic outcomes, even during the long-term follow-up. The pathophysiologies of OCD and of TS share dysfunctions of the associative and limbic circuits running between cortical and sub-cortical structures. Recent pathophysiological hypotheses suggest that TS symptoms result from a dysfunction of the basal ganglia circuitry, notably of the ventral striatum. These data are consistent with the supposed function of cortico-basal ganglia circuits in habit learning and routine performance of habits. Based on early reports indicating that high-frequency stimulation of structures along the cortico-basal ganglia axis might be effective in alleviating TS symptoms, DBS is being tested across the world at several nodes of this circuit, including the pallidum, and thalamus. Increasing our knowledge of the functional organization of the cortico-basal ganglia circuits and of their dysfunction in pathological repetitive behaviors would certainly contribute to better define the surgical therapeutic targets, thereby improving available treatments.

Hormone Therapy and its Effect on the Prognosis in Breast Cancer Patients

Introduction: Use of hormone therapy (HT) has declined dramatically in recent years. Some studies have reported that HT use before a diagnosis of breast cancer (BC) may be a prognostic factor in postmenopausal patients. This study aimed to examine the prognostic relevance of HT use before BC diagnosis. Methods: Four BC cohort studies in Germany were pooled, and 4492 postmenopausal patients with HT use data were identified. Patient data and tumor characteristics were compared between users and nonusers, along with overall survival (OS), distant metastasis-free survival (DMFS), and local recurrence-free survival (LRFS). Cox proportional hazards models were stratified by study center and adjusted for age at diagnosis, tumor stage, grading, nodal status, and hormone receptors. Results: Women with HT use before the diagnosis of BC were more likely to have a lower tumor stage, to be estrogen receptor-negative, and to have a lower grading. With regard to prognosis there were effects seen for OS, DMFS and LRFS, specifically in the subgroup of women with a positive hormone receptor. In these subgroups, BC patients had a better prognosis with previous HT use. Conclusions: HT use before a diagnosis of BC is associated with a more favorable prognosis in women with a positive hormone receptor status. It may be recommended that the prognostic factor HT should be documented and analyzed as a confounder for prognosis in studies of postmenopausal hormone-responsive breast cancers.

Hcmv-miR-UL22A-5p: A Biomarker in Transplantation With Broad Impact on Host Gene Expression and Potential Immunological Implications

Cytomegalovirus (CMV) encodes multiple microRNAs. While these have been partially characterized in vitro, their relevance to clinical CMV infection has not been evaluated. We analyzed samples from a cohort of solid organ transplant patients with CMV disease (n = 245) for viral microRNA expression. Several CMV microRNAs were readily detectable in patients with CMV disease in variable relative abundance. Expression level generally correlated with DNA viral load and the absence of viral microRNA was associated with faster viral clearance. Detection of hcmv-miR-UL22A-5p at baseline independently predicted the recurrence of CMV viremia upon discontinuation of antiviral therapy (OR 3.024, 95% CI: 1.35-6.8; p = 0.007). A combination of direct mRNA targeting by the microRNA and indirect modulation of gene expression involving isoforms of the transcriptional regulator C-MYC may be responsible for the broad effects seen in the association of gene transcripts with the RNA-induced silencing complex and in global protein expression upon hcmv-miR-UL22A-5p transfection. This novel study of in vivo viral microRNA expression profiles provides unique insight into the complexity of clinical CMV infection following transplantation. We provide evidence that viral microRNAs may have complex effects on gene expression and be associated with specific virologic and clinical outcomes, and thus could be further evaluated as biomarkers.

8p deletion is strongly linked to poor prognosis in breast cancer

Deletions of chromosome 8p occur frequently in breast cancers, but analyses of its clinical relevance have been limited to small patient cohorts and provided controversial results. A tissue microarray with 2,197 breast cancers was thus analyzed by fluorescence in-situ hybridization using an 8p21 probe in combination with a centromere 8 reference probe. 8p deletions were found in 50% of carcinomas with no special type, 67% of papillary, 28% of tubular, 37% of lobular cancers and 56% of cancers with medullary features. Deletions were always heterozygous. 8p deletion was significantly linked to advanced tumor stage (P < 0.0001), high-grade (P < 0.0001), high tumor cell proliferation (Ki67 Labeling Index; P < 0.0001), and shortened overall survival (P < 0.0001). For example, 8p deletion was seen in 32% of 290 grade 1, 43% of 438 grade 2, and 65% of 427 grade 3 cancers. In addition, 8p deletions were strongly linked to amplification of MYC (P < 0.0001), HER2 (P < 0.0001), and CCND1 (p = 0.001), but inversely associated with ER receptor expression (p = 0.0001). Remarkably, 46.5% of 8p-deleted cancers harbored amplification of at least one of the analyzed genes as compared to 27.5% amplifications in 8p-non-deleted cancers (P < 0.0001). In conclusion, 8p deletion characterizes a subset of particularly aggressive breast cancers. As 8p deletions are easy to analyze, this feature appears to be highly suited for future DNA based prognostic breast cancer panels. The strong link of 8p deletion with various gene amplifications raises the possibility of a role for regulating genomic stability.

[Molecular Characterisation of Urothelial Bladder Cancer: Will it Improve Patient Care?]

Urothelial bladder cancer is characterised by high recurrence and progression rates despite multimodal treatment. Only slight improvements have been achieved during the last decades. The current histopathological classification and clinical risk stratification tools are inaccurate. Hence, a better understanding of the tumour biology is essential for the improvement of patient care. The molecular characterisation of bladder cancer may be translated into useful diagnostic and predictive biomarkers. Many potential therapeutic targets have been identified such as FGFR3 (Fibroblast growth factor receptor 3), HER2 (human epidermal growth factor receptor 2) and PD1/PDL1 (programmed cell death-1). They need validation in clinical trials. We now review the molecular biology of urothelial bladder carcinoma and discuss clinical applications of biomarkers and targeted therapies.

[Anamnesis, Pathological Assessment, Therapeutic Features and Course of Disease: Retrospective Study on Clinical-Based Factors for Prediction of Cancer-Specific Survival of 378 Patients with Stage pT1 Urothelial Bladder Carcinoma]

BACKGROUND

Urothelial carcinoma of the bladder (UBC) at stage pT1 is a heterogenous disease. Established criteria for prognosis prediction are not suitable for every patient. Choosing the right therapeutic strategy for the individual patient thus remains a challenge. The aim of the present study was to identify clinical parameters regarding cancer-specific survival (CSS) in patients with pT1 UBC.

MATERIALS AND METHODS

A retrospective analysis of clinical parameters of all patients with a pT1 UBC between 1989 and 2012 from a single centre was performed. Treatment consisted of transurethral resection, second resection followed by initially bladder sparing treatment. Anamnestic data, histopathological reports and clinical course were assessed with CSS being defined as primary endpoint. Kaplan-Meier analysis, uni- and multivariate analysis were performed using SPSS (Version 22, IBM).

RESULTS

378 patients (78% male, median age 72 years) were included, median follow-up was 35 months. Pathological stage pT1G3 (66 vs. 91%, p<0.001), lack of instillation therapy (66 vs. 83%, p<0.001), presence of a second malignoma (41 vs. 77%, p=0,004), diagnosis after 2000 (75 vs. 76%, p=0,018) and tumour progress (42 vs. 85%, p<0.001) were associated with a worse CSS in univariate and Kaplan-Meier analysis. Multivariate analysis revealed the presence of a second malignoma (HR 2.267; CI 95% 1.143-4.497, p=0.019), pathological stage pT1G3 at initial diagnosis (HR 4.567; CI 95% 2.040-10.22, p<0.001) and tumour progress (HR 3.742; CI 95% 1.544-9.069, p=0.003) as independent negative predictors of CSS. Instillation therapy was a prognostic factor for improved CSS (HR 0.368; CI 95% 0.212-0.638, p<0.001).

CONCLUSION

The present study identified the presence of a second malignoma, pathological stage pT1G3 and tumour progress as negative predictive factors for CSS. Maintenance instillation therapy after reresection was associated with an improved CSS.

[Personality and comorbidity: are there "difficult patients" in hip arthroplasty?]

BACKGROUND

Concomitant disorders at the time of surgery in addition to psychological and socioeconomic patient characteristics may influence treatment outcomes in hip arthroplasty.

OBJECTIVES

To describe the impact of these factors on perioperative complications and postoperative results in terms of function, quality of life, and patient satisfaction.

MATERIALS AND METHODS

Review of relevant clinical studies, meta-analyses, and presentation of our own results.

RESULTS

Comorbidities in general, especially in combination, increase the perioperative risk profile. Socioeconomic factors (education, professional qualifications, social deprivation) in addition to psychological variables (depression, distressed personality) can have a major impact on postoperative functional outcomes and patient satisfaction.

CONCLUSIONS

It is of crucial importance to avoid inequalities in the provision of joint replacement for patients with hip osteoarthritis and co-existing risk factors. Preventive strategies should be implemented to reduce the negative impact of comorbidities on treatment outcome. Personalized communication and education may be helpful in avoiding unrealistic patient expectations before hip replacement.

[Arthroplasty for osteoarthritis secondary to hip dysplasia: Problem-oriented treatment strategies]

BACKGROUND

Because of anatomical variations total hip arthroplasty (THA) can be demanding in patients with osteoarthritis secondary to hip dysplasia.

OBJECTIVES

Depending on the degree of bony deformation, hip dislocation and soft tissue alteration numerous treatment strategies are available. This review describes current approaches that address frequent deformities.

MATERIALS AND METHODS

Review of relevant clinical studies, meta-analyses, and presentation of our own approach.

RESULTS

Pre-operative planning (based on a thorough clinical and radiographic examination) is essential. Acetabular reconstruction close to the primary acetabulum should always be intended. Roof augmentation and/or cup medialization can support stable bony implant fixation. Subtrochanteric shortening osteotomy of the femur is a demanding but reliable technique that avoids nerve damage in cases where inappropriate lengthening would be necessary (i.e., high riding dislocation).

CONCLUSIONS

Although the post-operative complication rate is elevated after THA for dysplastic hips compared with primary osteoarthritis, the overall functional results and implant survival are comparable.

[Ipsilateral THA after stemmed TKA: Risk of interprosthetic fracture?]

BACKGROUND

There is an increasing number of patients who have undergone stemmed total knee arthroplasty and total hip arthroplasty in the same leg. These patients may be at increased risk of periprosthetic and interprostethic fracture. Etiology and the potential therapy strategies are not well represented in the current literature.

OBJECTIVES

Determination of the risk factors for interprosthetic fractures and possible prevention.

MATERIALS AND METHODS

We performed a review of the literature and additionally a survey among experts (members of the German Association for Arthroplasty [AE]) to investigate the risk and the necessity for a preventive internal fixation.

RESULTS

There are only a few biomechanical studies. The interprosthetic distance seems to have little influence on the fracture risk, but the thickness of the cortex and the cortical area at the diaphysis seems to be important. The value of a bridging osteosynthesis remains uncertain. Ninety experts took part in the survey. The risk of fracture risk was estimated to be only slight to medium. Opinions regarding the necessity of preventive internal fixation were heterogeneous.

CONCLUSIONS

The indication for preventive internal fixation could be derived neither from the literature nor from the survey of experts. The thickness of the cortex and co-morbidities (osteoporosis, tendency to fall, and medication) seem to be more important than the interprosthetic distance.

Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study

BACKGROUND

Folate receptor 1 (FOLR1) is expressed in the majority of ovarian carcinomas (OvCa), making it an attractive target for therapy. However, clinical trials testing anti-FOLR1 therapies in OvCa show mixed results and require better understanding of the prognostic relevance of FOLR1 expression. We conducted a large study evaluating FOLR1 expression with survival in different histological types of OvCa.

METHODS

Tissue microarrays composed of tumour samples from 2801 patients in the Ovarian Tumour Tissue Analysis (OTTA) consortium were assessed for FOLR1 expression by centralised immunohistochemistry. We estimated associations for overall (OS) and progression-free (PFS) survival using adjusted Cox regression models. High-grade serous ovarian carcinomas (HGSC) from The Cancer Genome Atlas (TCGA) were evaluated independently for association between FOLR1 mRNA upregulation and survival.

RESULTS

FOLR1 expression ranged from 76% in HGSC to 11% in mucinous carcinomas in OTTA. For HGSC, the association between FOLR1 expression and OS changed significantly during the years following diagnosis in OTTA (Pinteraction=0.01, N=1422) and TCGA (Pinteraction=0.01, N=485). In OTTA, particularly for FIGO stage I/II tumours, patients with FOLR1-positive HGSC showed increased OS during the first 2 years only (hazard ratio=0.44, 95% confidence interval=0.20-0.96) and patients with FOLR1-positive clear cell carcinomas (CCC) showed decreased PFS independent of follow-up time (HR=1.89, 95% CI=1.10-3.25, N=259). In TCGA, FOLR1 mRNA upregulation in HGSC was also associated with increased OS during the first 2 years following diagnosis irrespective of tumour stage (HR: 0.48, 95% CI: 0.25-0.94).

CONCLUSIONS

FOLR1-positive HGSC tumours were associated with an increased OS in the first 2 years following diagnosis. Patients with FOLR1-negative, poor prognosis HGSC would be unlikely to benefit from anti-FOLR1 therapies. In contrast, a decreased PFS interval was observed for FOLR1-positive CCC. The clinical efficacy of FOLR1-targeted interventions should therefore be evaluated according to histology, stage and time following diagnosis.

Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study

BACKGROUND

Folate receptor 1 (FOLR1) is expressed in the majority of ovarian carcinomas (OvCa), making it an attractive target for therapy. However, clinical trials testing anti-FOLR1 therapies in OvCa show mixed results and require better understanding of the prognostic relevance of FOLR1 expression. We conducted a large study evaluating FOLR1 expression with survival in different histological types of OvCa.

METHODS

Tissue microarrays composed of tumour samples from 2801 patients in the Ovarian Tumour Tissue Analysis (OTTA) consortium were assessed for FOLR1 expression by centralised immunohistochemistry. We estimated associations for overall (OS) and progression-free (PFS) survival using adjusted Cox regression models. High-grade serous ovarian carcinomas (HGSC) from The Cancer Genome Atlas (TCGA) were evaluated independently for association between FOLR1 mRNA upregulation and survival.

RESULTS

FOLR1 expression ranged from 76% in HGSC to 11% in mucinous carcinomas in OTTA. For HGSC, the association between FOLR1 expression and OS changed significantly during the years following diagnosis in OTTA (Pinteraction=0.01, N=1422) and TCGA (Pinteraction=0.01, N=485). In OTTA, particularly for FIGO stage I/II tumours, patients with FOLR1-positive HGSC showed increased OS during the first 2 years only (hazard ratio=0.44, 95% confidence interval=0.20-0.96) and patients with FOLR1-positive clear cell carcinomas (CCC) showed decreased PFS independent of follow-up time (HR=1.89, 95% CI=1.10-3.25, N=259). In TCGA, FOLR1 mRNA upregulation in HGSC was also associated with increased OS during the first 2 years following diagnosis irrespective of tumour stage (HR: 0.48, 95% CI: 0.25-0.94).

CONCLUSIONS

FOLR1-positive HGSC tumours were associated with an increased OS in the first 2 years following diagnosis. Patients with FOLR1-negative, poor prognosis HGSC would be unlikely to benefit from anti-FOLR1 therapies. In contrast, a decreased PFS interval was observed for FOLR1-positive CCC. The clinical efficacy of FOLR1-targeted interventions should therefore be evaluated according to histology, stage and time following diagnosis.

[Tularemia lymphadenitis. An emerging differential diagnosis of necrotizing granulomatous cervical lymphadenitis]

Tularemia is emerging as an important differential diagnosis of necrotizing granulomatous lymphadenitis, particularly in the head and neck region. The causal organism, Francisella tularensis is a Gram-negative coccoid bacterium. Tularemia usually presents with necrotizing granulomatous purulent lymphadenitis featuring multiple mostly small granulomas with geographic necrosis bordered by palisades of histiocytes. Diagnosis is mainly based on these characteristic but non-pathognomonic histological features in conjunction with negative tests for mycobacterial infections and serological confirmation of tularemia-specific antibodies or detection by polymerase chain reaction (PCR). This article describes our experiences with five patients with tularemia lymphadenitis and gives an overview of the diverse histopathological features and the differential diagnosis of this uncommon but possibly underrecognized disease.

[Focal meningitis in a California sea lion (Zalophus californianus)--diagnostic procedure and pathology]

A 15-year-old female California sea lion (Zalophus californianus) with progressive lameness of the hindlimbs and a chronic skin lesion was presented for clinical examination. The clinical neurological examination, showing a paraparesis, was completed by magnetic resonance imaging. MR images of the cervical and thoracic spine showed a well-defined muscle infiltrating lesion between the seventh cervical vertebra (C7) and the second thoracic vertebra (T2), which extended through the intervertebral foramina between C7 and T1 into the vertebral canal, causing spinal cord compression and displacement. Pathological examination revealed focal purulent meningitis resulting from widespread fistulas of the chronic skin leasion, which was infected with Escherichia coli var. haemolytica and Clostridium perfringens.

[Complications of metal-on-metal tribological pairing]

BACKGROUND

Metal-on-metal (MoM) tribological pairing results in less volumetric abrasion than pairing with the conventionally used polyethylene and is associated with a lower risk of material failure compared to other hard-hard pairings. An increased frequency of problem cases in recent years has led to a great increase in uncertainty. Against this background in this article the current aspects of epidemiology, etiology, diagnostics and treatment of complications in MoM hip joint endoprostheses will be discussed.

EPIDEMIOLOGY AND ETIOLOGY

Based on the results from national endoprosthesis registers and selected clinical studies an evaluation of the rate of local complications from MoM tribological pairings was undertaken. A differentiation was made between MoM pairings in pedicled small head prostheses (≤ 32 mm), large head (> 32 mm) and surface replacement (OFE) endoprostheses. Each year MoM endoprostheses release on average 10(12)-10(14) cobalt (Co) and chromium (Cr) nanoparticles per patient. This release of metal ions and particles can lead to a variety of tissue reactions.

DIAGNOSTICS

A differentiation must be made between regular routine diagnostics within the framework of implant follow-up screening and specific investigations due to the occurrence of complaints. The diagnostics for patients treated with MoM hip endoprostheses consists of a standardized step-wise approach considering possible differential diagnoses and the utilization of modern laboratory chemical and radiological methods. When problems occur, a differentiation should preferentially be made between complaints not caused by metal and mechanical problems (e.g. prosthesis loosening and impingement) and symptoms due to periprosthetic infections.

THERAPY OF COMPLICATIONS

The normal standards for hip endoprosthetics are also valid for periprosthetic infections, fractures and other general complications. Specific measures are, however, necessary for complications due to metal-specific risks.

Time and Resources Needed to Document Patients with Breast Cancer from Primary Diagnosis to Follow-up - Results of a Single-center Study

Aim: Certification of breast centers helps improve the quality of care but requires additional resources, particularly for documentation. There are currently no published data on the actual staff costs and financial resources required for such documentation. The aim of this study was to determine the time and resources required to document a patient with primary breast cancer from diagnosis to the end of follow-up, to establish a database for future strategic decisions. Material and Methods: All diagnostic and therapeutic procedures of patients with primary breast cancer were recorded at the University Breast Center of Franconia. All time points for documentation were evaluated using structured interviews. The times required to document a representative number of patients were determined and combined with the staff costs of the different professional groups, to calculate the financial resources required for documentation. Results: A total of 494 time points for documentation were identified. The study also identified 21 departments and 20 different professional groups involved in the documentation. The majority (54 %) of documentation was done by physicians. 62 % of all documentation involved outpatients. The results of different scenarios for the diagnosis, therapy and follow-up of breast cancer patients in a certified breast center showed that the time required for documentation can be as much as 105 hours, costing € 4135. Conclusion: This analysis shows the substantial staffing and financial costs required for documentation in certified centers. A multi-center study will be carried out to compare the costs for certified breast centers of varying sizes with the costs of non-certified care facilities.