Pulmonary Artery Dilation and Right Ventricular Function in Acute Kawasaki Disease

Coronary artery inflammation and aneurysm formation are the most common complications of Kawasaki disease (KD). Valvulitis and myocarditis are also well described and may lead to valvar regurgitation and left ventricular dysfunction. However, functional changes in the right heart have rarely been reported. We noted several acute KD patients with dilated pulmonary arteries (PA) and thus sought to systematically characterize PA size and right-heart function in an unselected cohort of KD patients cared for at a single clinical center. Clinical, laboratory, and echocardiographic data from 143 acute KD subjects were analyzed. PA dilation was documented in 23 subjects (16.1 %); these subjects had higher median right ventricle myocardial performance index (RV MPI), higher ratio of early tricuspid inflow velocity to tricuspid annular early diastolic velocity (TV E/e'), and lower median TV e' velocity compared to the non-PA dilation group (0.50 vs 0.38 p < 0.01, 4.2 vs 3.6 p < 0.05, and 13.5 vs 15.2 cm/s p < 0.01, respectively). Almost all subjects with PA dilation had improved PA Z-score, RV MPI, and TV E/e' in the subacute phase (p < 0.01). There were no significant differences in indices of left ventricle function between PA dilation group and non-PA dilation group. In summary, PA dilation was documented in 16 % of acute KD subjects. These subjects were more likely to have echocardiographic indices consistent with isolated RV dysfunction that improved in the subacute phase. The long-term consequence of these findings will require longitudinal studies of this patient population.

Abstract P3-14-10: Phase Ia/Ib study of taselisib (GDC-0032), a potent and selective phosphoinositide 3-kinase inhibitor, in Japanese patients with advanced solid tumors or hormone receptor-positive locally advanced or metastatic breast cancer (JO29196 study)

Background:

Taselisib (GDC-0032) is an orally bioavailable, potent and selective phosphoinositide 3-kinase (PI3K) inhibitor. Preclinical data showed that taselisib had increased antitumor activity against PIK3CA (gene encoding the PI3Kα isoform) mutant tumors. This study aimed to investigate the safety, tolerability and pharmacokinetics (PK) of taselisib as monotherapy and in combination with fulvestrant in Japanese patients (pts).

Materials and methods:

A 3+3 design was used. In Phase Ia, pts with advanced solid tumors received taselisib tablet monotherapy (2, 4 or 6 mg once daily [QD]), and safety and PK were evaluated. In Phase Ib, pts with hormone receptor-positive locally advanced or metastatic breast cancer received taselisib (2 or 4 mg QD) in combination with fulvestrant (500 mg at a time), and safety and PK were evaluated. Maximal administered doses of 6 mg QD as a single agent and 4 mg QD in combination with fulvestrant were based upon prior clinical trial experience with taselisib (Juric D. et al. AACR 2013, Abstract LB-64; Juric D. et al. SABCS 2013, Abstract PD1-3).

Results:

As of 15 Mar 2015, 9 pts (PIK3CA mutant: 2 pts) were enrolled in Phase Ia and 3 pts in Phase Ib. Phase Ia dose-escalation study has been completed and Phase Ib is ongoing.

In Phase Ia, no dose-limiting toxicity (DLT) was observed at any dose level tested (maximum administered dose of 6 mg QD). Common (≥3 pts) adverse reactions (ARs) were stomatitis (4 pts), rash (3 pts) and diarrhea (3 pts); the only Grade ≥3 AR was neutropenia (1 pt). Partial response was observed in 1 pt who received taselisib 4 mg and had a PIK3CA mutant breast tumor. Stable disease was observed in 4 pts. Cmax and AUC indicated a dose-proportional PK profile of taselisib within the dose range tested. Moreover, taselisib PK in Japanese pts was consistent with the PK reported from North American and European pts (Juric D. et al. AACR 2013, Abstract LB-64).

In Phase Ib, 3 pts received taselisib 2 mg in combination with fulvestrant and no DLT was observed. Preliminary ARs were similar to those with monotherapy and no Grade ≥3 AR was reported. Confirmation of tolerability of taselisib 4 mg in combination with fulvestrant is under evaluation.

Conclusion:

Taselisib monotherapy was well tolerated in Japanese pts up to a dose of 6 mg, which is the recommended dose in non-Japanese pts. Promising preliminary activity of monotherapy was observed in advanced solid tumors, especially in a pt with PIK3CA mutant tumor. The combination of taselisib 2 mg with fulvestrant is well tolerated. Investigation of tolerability of taselisib 4 mg in combination with fulvestrant is ongoing. Final results of this study will be presented here at the Symposium this year.

Citation Format: Kobayashi T, Nakano K, Tomomatsu J, Nara E, Ito Y, Kobayashi K, Fukada I, Araki K, Shimomura A, Shimoi T, Kodaira M, Yunokawa M, Yonemori K, Shimizu C, Nakamura K, Kotani N, Inatani M, Tamura K, Takahashi S. Phase Ia/Ib study of taselisib (GDC-0032), a potent and selective phosphoinositide 3-kinase inhibitor, in Japanese patients with advanced solid tumors or hormone receptor-positive locally advanced or metastatic breast cancer (JO29196 study). [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 P3-14-10.

Galectin-3 is a marker of myocardial and vascular fibrosis in Kawasaki disease patients with giant aneurysms

BACKGROUNDS

Galectin-3 (Gal-3) is a multifunctional matricellular protein associated with heart failure and cardiovascular events. Gal-3 is required for transforming growth factor-β pathway-mediated myofibroblast activation that is a key process in coronary artery aneurysm formation in Kawasaki Disease (KD). Autopsies from young adults late after KD onset (AKD) have demonstrated bridging fibrosis throughout the myocardium and arteries. In this study, we postulated that Gal-3 may participate in the pathogenesis of myocardial and vascular fibrosis and the remodeling of coronary artery aneurysms following acute KD.

METHODS AND RESULTS

We measured plasma Gal-3 levels in 63 pediatric KD (PKD) and 81 AKD subjects. AKD subjects with giant aneurysms had significantly higher Gal-3 levels compared to the other adult groups (all p<0.05). All PKD groups had significantly higher Gal-3 levels than pediatric healthy controls (HC) (all p<0.05). Histological and immunohistochemical staining was performed on tissues from 10 KD autopsies and one explanted heart. Gal-3 positive staining was detected associated with acute inflammation and in spindle-shaped cells in the myocardium and arterial wall in KD subjects with giant aneurysms.

CONCLUSIONS

AKD subjects with giant aneurysms and PKD subjects had significantly higher plasma Gal-3 levels than HC and Gal-3 expression was increased in the myocardium of KD subjects who died with either acute inflammation or marked myocardial fibrosis. Gal-3 may be a clinically useful biomarker that identifies a subset of KD patients at highest risk of myocardial and vascular fibrosis, and may be an attractive therapeutic target to prevent myocardial dysfunction in this subset.

Role of TGF-β Signaling in Remodeling of Noncoronary Artery Aneurysms in Kawasaki Disease

Coronary artery aneurysms (CAA) remain an important complication of Kawasaki disease (KD), the most common form of pediatric acquired heart disease in developed countries. Potentially life-threatening CAA develop in 25% of untreated children and 5% of children treated with high-dose intravenous immunoglobulin during the acute phase of the self-limited vasculitis. Noncoronary artery aneurysms (NCAA) in extraparenchymal, muscular arteries occur in a minority of patients with KD who also have CAA, yet little is understood about their formation and remodeling. We postulated that activation of the transforming growth factor-β (TGF-β) pathway in KD may influence formation and remodeling of aneurysms in iliac, femoral, and axillary arteries, the most common sites for NCAA. We studied a resected axillary artery from one adult and endarterectomy tissue from the femoral artery from a second adult, both with a history of CAA and NCAA following KD in infancy. Histology of the axillary artery aneurysm revealed destruction of the internal elastic lamina and recanalization of organized thrombus, while the endarterectomy specimen showed dense calcification and luminal myofibroblastic proliferation. Immunohistochemistry for molecules in the TGF-β signaling pathway revealed increased expression of TGF-β2, TGF-β receptor 2, and phosphorylated SMAD3. These findings suggest ongoing tissue remodeling of the aneurysms decades after the acute injury and demonstrate the importance of the TGF-β signaling pathway in this process.

ORGAN CULTURE OF ADULT HUMAN SKIN

Proliferation and differentiation of the epidermis in organ culture of adult human skin by the sponge matrix method were studied histologically and autoradiographically, and the following results were obtained: 1) On the first day of culture, mitotic figures were already observable in the epidermis. The outgrowth of epidermal cells at the margins of the explants started. On the second day, there was transformation to a zone that will be referred to as the newly formed stratum corneum in the upper epidermis. 2) On the third and fourth days, the increased growth of epidermal cells caused thickening of the epidermis. Simultaneously, Malpighian cells progressively differentiated into a cornified layer. 3) On and after the fifth day, the basospinous cell layer was reduced in thickness in most of explants. On the ninth and tenth days, DNA synthesis in the basal layer was still obvious, although the epidermis showed a thickness of only one or two cells overlaid with a large number of horny layers. 4) In the culture medium supplemented with corticosteroid, the epidermal growth was slightly depressed with lessened formation of stratum corneum in the early stages of culture as compared with the explants cultured in the basic medium. The reduction of the basospinous layer was scarcely notable after the fifth day. Even after 10-11 days, epidermal cells were well preserved and their stratified squamous architecture was less disorganized. It seemed that corticosteroid could prolong the survival of adult human skin in vitro. These findings indicate that this culture technique could be used as a model for organ culture of adult human skin.

Cardiovascular pathology in 2 young adults with sudden, unexpected death due to coronary aneurysms from Kawasaki disease in childhood

PURPOSE

Coronary artery aneurysms (CAA) may remain silent after Kawasaki disease (KD) until adulthood when myocardial ischemia can lead to sudden death. We postulated that there would be young adults with sudden, unexpected death due to CAA from KD who would have a state-mandated autopsy performed by the San Diego County Medical Examiner's Office (SDCMEO).

METHODS

We reviewed all autopsy cases <35years of age from 1997 to 2012 at the SDCMEO with a cardiovascular cause of death (n=154).

RESULTS

We found 2 cases meeting inclusion criteria. Case 1 was a 22-year-old Korean male with chronic ischemic changes due to a partially occluded and diffusely calcified 15mm aneurysm at the bifurcation of the left main coronary artery. Interview of the mother revealed that this patient had been diagnosed with KD complicated by giant aneurysms at age two years. Case 2 was a 30-year-old Hispanic male with myocardial infarction due to thrombosis of a calcified left anterior descending artery aneurysm. Histologic findings included diffuse myocardial fibrosis and a recanalized aneurysm in the right coronary artery. Interview of the family revealed a KD-compatible illness in childhood. Immunohistochemical staining showed expression of transforming growth factor β pathway molecules in the aneurysmal arterial wall.

CONCLUSIONS

In a medical examiner's office serving a population of approximately 3 million people, 2 of 154 (1.3%) cardiovascular deaths in persons <35years were attributed to cardiovascular complications of KD in childhood. Antecedent KD should be considered in the evaluation of all cases of sudden, unexpected death in young adults.

Global gene expression profiling identifies new therapeutic targets in acute Kawasaki disease

Background

Global gene expression profiling can provide insight into the underlying pathophysiology of disease processes. Kawasaki disease (KD) is an acute, self-limited vasculitis whose etiology remains unknown. Although the clinical illness shares certain features with other pediatric infectious diseases, the occurrence of coronary artery aneurysms in 25% of untreated patients is unique to KD.

Methods

To gain further insight into the molecular mechanisms underlying KD, we investigated the acute and convalescent whole blood transcriptional profiles of 146 KD subjects and compared them with the transcriptional profiles of pediatric patients with confirmed bacterial or viral infection, and with healthy control children. We also investigated the transcript abundance in patients with different intravenous immunoglobulin treatment responses and different coronary artery outcomes.

Results

The overwhelming signature for acute KD involved signaling pathways of the innate immune system. Comparison with other acute pediatric infections highlighted the importance of pathways involved in cell motility including paxillin, relaxin, actin, integrins, and matrix metalloproteinases. Most importantly, the IL1β pathway was identified as a potential therapeutic target.

Conclusion

Our study revealed the importance of the IL-1 signaling pathway and a prominent signature of innate immunity and cell migration in the acute phase of the illness.

Electronic supplementary material

The online version of this article (doi:10.1186/s13073-014-0102-6) contains supplementary material, which is available to authorized users.

Can oncologists predict survival for patients with progressive disease after standard chemotherapies?

BACKGROUND

Prediction of prognosis is important for patients so that they can make the most of the rest of their lives. Oncologists could predict survival, but the accuracy of such predictions is unclear.

METHODS

In this observational prospective cohort study, 14 oncologists treating 9 major adult solid malignancies were asked to complete questionnaires predicting survival based on performance status, oral intake, and other clinical factors when patients experienced progressive disease after standard chemotherapies. Clinically predicted survival (cps) was calculated by the oncologists from the date of progressive disease to the predicted date of death. Actual survival (as) was compared with cps using Kaplan-Meier survival curves, and factors affecting inaccurate prediction were determined by logistic regression analysis. The prediction of survival time was considered accurate when the cps/as ratio was between 0.67 and 1.33.

RESULTS

The study cohort consisted of 75 patients. Median cps was 120 days (interquartile range: 60-180 days), and median as was 121 days (interquartile range: 40-234 days). The participating oncologists accurately predicted as within a 33% range 36% of the time; the survival time was overestimated 36% of time and underestimated 28% of the time. The factors affecting the accuracy of the survival estimate were the experience of the oncologist, patient age, and information given about the palliative care unit.

CONCLUSIONS

Prediction of cps was accurate for just slightly more than one third of all patients in this study. Additional investigation of putative prognostic factors with a larger sample size is warranted.

Survival of HER2-positive primary breast cancer patients treated by neoadjuvant chemotherapy plus trastuzumab: a multicenter retrospective observational study (JBCRG-C03 study)

We investigated the disease-free survival (DFS) of HER2-positive primary breast cancer patients treated with neoadjuvant chemotherapy plus trastuzumab, as well as predictive factors for DFS and pathologic response. Data from 829 female patients treated between 2001 and 2010 were collected from 38 institutions in Japan. Predictive factors were evaluated using multivariate analyses. The 3-year DFS rate was 87 % [95 % confidence interval (CI) 85-90]. The pathologic complete response (pCR: ypT0/is + ypN0) rate was 51 %. The pCR rate was higher in the ER/PgR-negative patients than in the ER/PgR-positive patients (64 vs. 36 %, P < 0.001). Patients with pCR showed a higher DFS rate than patients without pCR (93 vs. 82 %, P < 0.001). Multivariate analysis revealed three independent predictors for poorer DFS: advanced nodal stage [hazard ratio (HR) 2.63, 95 % CI 1.36-5.21, P = 0.004 for cN2-3 vs. cN0], histological/nuclear grade 3 (HR 1.81, 95 % CI 1.15-2.91, P = 0.011), and non-pCR (HR 1.98, 95 % CI 1.22-3.24, P = 0.005). In the ER/PgR-negative dataset, non-pCR (HR 2.63, 95 % CI 1.43-4.90, P = 0.002) and clinical tumor stage (HR 2.20, 95 % CI 1.16-4.20, P = 0.017 for cT3-4 vs. cT1-2) were independent predictors for DFS, and in the ER/PgR-positive dataset, histological grade of 3 (HR 3.09, 95 % CI 1.48-6.62, P = 0.003), clinical nodal stage (HR 4.26, 95 % CI 1.53-13.14, P = 0.005 for cN2-3 vs. cN0), and young age (HR 2.40, 95 % CI 1.12-4.94, P = 0.026 for ≤40 vs. >40) were negative predictors for DFS. Strict pCR (ypT0 + ypN0) was an independent predictor for DFS in both the ER/PgR-negative and -positive datasets (HR 2.66, 95 % CI 1.31-5.97, P = 0.006 and HR 3.86, 95 % CI 1.13-24.21, P = 0.029, respectively). These results may help assure a more accurate prognosis and personalized treatment for HER2-positive breast cancer patients.

Pregnancy in women with a history of Kawasaki disease: management and outcomes

OBJECTIVE

To characterise the obstetrical management and outcomes in a series of women with a history of Kawasaki disease (KD) in childhood.

DESIGN

Retrospective case series.

SETTING

Tertiary healthcare setting in the USA.

POPULATION

Women with a history of KD in childhood.

METHODS

Women completed a detailed health questionnaire and participated in research imaging studies as part of the San Diego Adult KD Collaborative Study.

MAIN OUTCOME MEASURES

Obstetrical management, complications during pregnancy and delivery, and infant outcomes.

RESULTS

Ten women with a history of KD in childhood carried a total of 21 pregnancies to term. There were no cardiovascular complications during labour and delivery despite important cardiovascular abnormalities in four of the ten subjects. Pregnancy was complicated by pre-eclampsia and the post-partum course was complicated by haemorrhage in one subject each. Two of the 21 progeny subsequently developed KD.

CONCLUSIONS

Women with important cardiovascular sequelae from KD in childhood should be managed by a team that includes both a maternal-fetal medicine specialist and a cardiologist. Pre-pregnancy counselling should include delineation of the woman's current functional and structural cardiovascular status and appropriate adjustment of medications, but excellent outcomes are possible with appropriate care. Review of the English and Japanese literature on KD and pregnancy revealed the occurrence of myocardial infarction during pregnancy in women with missed KD and aneurysms that were not diagnosed until their acute event. Our study highlights the need for counselling with regard to the increased genetic risk of KD in offspring born to these mothers.

Specificity of regulatory T cells that modulate vascular inflammation

Intravenous immunoglobulin therapy (IVIG) is the treatment of choice for many immune-mediated diseases, yet its mechanisms of action are incompletely elucidated. We investigated the possibility that IVIG played a direct role in the expansion of regulatory T cells (Treg) that recognize the heavy chain constant region of immunoglobulin G (Fc) as a mechanism for the recovery of Kawasaki disease (KD), a T cell mediated pediatric vasculitis of the coronary arteries. We successfully generated Fc-specific Treg clones from sub-acute KD subjects that did not develop arterial complications after IVIG and defined an unusual functional phenotype: Fc-specific Treg secrete IL-10 and small amounts of IL-4 but not TGF-β. Antigen presentation studies demonstrated that these Treg clones can be activated by autologous B cells that express IgG on their cell surface in the absence of exogenous Fc. The IgG molecule has to be canonically processed and presented by autologous MHC molecules to be recognized by Treg. In support of the importance of this novel Treg population in downsizing vascular inflammation, KD patients with dilated coronary arteries or aneurysms despite IVIG treatment failed to expand Fc-specific Treg. Our results point to a specificity of a previously un-described Treg population for the clinical benefit provided by IVIG therapy in children.

Immune-monitoring in Kawasaki disease patients treated with infliximab and intravenous immunoglobulin

The expansion of regulatory T cells (Treg ) controls inflammation in children with acute Kawasaki disease (KD). Blockade of tumour necrosis factor (TNF)-α is an emerging therapy for KD patients with refractory inflammation, but there is concern that this therapy could impede the host immune regulation. To define the effect of TNF-α blockade, we conducted ex-vivo immune-monitoring in KD subjects who participated in a randomized, double-blind, placebo-controlled clinical trial of the addition of infliximab to standard intravenous immunoglobulin (IVIG) therapy. We enumerated circulating myeloid and plasmocytoid dendritic cells (DC), regulatory T cells (Treg ) and memory T cells (Tmem ) in 14 consecutive, unselected KD patients (seven treated with IVIG, seven with IVIG + infliximab) at three time-points: (i) acute phase prior to treatment, (ii) subacute phase and (iii) convalescent phase. Myeloid DC (mDC), but not plasmacytoid DC (pDC), were numerous in the peripheral blood in acute KD subjects and decreased in the subacute phase in both IVIG(-) and IVIG (+)  infliximab-treated groups. The co-stimulatory molecule for antigen presentation to T cells and CD86 decreased in mDC from acute to subacute time-points in both treatment groups, but not in the single patient who developed coronary artery aneurysms. We also defined tolerogenic mDC that expand in the subacute phase of KD not impaired by infliximab treatment. Treg and Tmem expanded after treatment with no significant differences between the two groups. Treatment of KD patients with infliximab does not adversely affect generation of tolerogenic mDC or the development of T cell regulation and memory.

Abstract P5-08-12: Histopathological and immunohistochemical findings for epithelial-to-mesenchymal transition were associated with clinical progressive disease of triple-negative breast cancers during neoadjuvant chemotherapy

Background: Clinical progressive disease (cPD) occurs during neoadjuvant therapy (NAC) in 3 to 5% of breast cancer patients. By gene expression profiling analyses using DNA microarray, the expression of epithelial-to-mesenchymal transition (EMT)-associated genes were shown to be correlated with chemoresistant phenotype of breast cancer cell lines. In order to reveal clinical implication of EMT-associated molecules on the acquisition of cPD property, we designed a retrospective histopathilogical and immunohistochemical case-control study. Patients and Methods: From pathology database of patients who received surgical resection, 86 patients with early triple-negative breast cancer (TNBC) were identified: 23 patients suffered cPD during NAC (PD group) and 63 control group patients did not receive NAC (C group), in whom &gt;95% of patients was estimated to be non-PD group if NAC was performed. For these 86 cases, histopathological classification was performed and negativity of hormone receptors and HER2 was confirmed. As EMT markers, we immunohistochemically examined the expressions of vimentin, Twist, Twist NB and Snail. The chi-square test was used to assess statistically significant differences between the groups.Results: Histologically, PD group comprised 12 invasive ductal carcinomas (IDCs) (52%) and 11 metaplastic carcinomas (MPCs) (48%), and they all were nuclear grade 3. In C group, 52 (83%) were IDCs and 10 (16%) were histological types other than IDC or MPC, and there was only 1 MPC (1%) (p = 4.31E-08). Nuclear grade was 1, 2, and 3 in 1, 9, and 53, respectively. Vimentin was positive in cytoplasm of 74% of PD group and the incidence was higher than that in C group (49%) (p = 0.016). Cytoplasmic twist-2 and cytoplasmic and nuclear Snail expressions were detected almost equally between PD group and C group. Cytoplasmic Twist NB expression was more frequent in PD group (26%) than in C group (1.6%) (p = 0.0002). In PD group, a total of 17 cases comprising 9 MPCs and 8 IDCs, were positive for vimentin. In these 17 vimentin-positive cases, 14 were stable disease or partial response with an anthracyclin-containing regimen while all 16 patients receiving a taxane-containing regimen became cPD during the taxane-containing regimen.

Patient characteristics PD group (N = 23)Control group(N = 63)Age median (range)42(25-62)55(25-77)Clinical stage:I/II/III0/11/127/44/12Diagnosi at operation:IDC/MPC or MPC containing/others12/11/052/1/10Nuclear grade:1/2/30/0/231/9/53Tumor size at diagnosis4.8(2-14)2.8(1.2-12.0)Neoadjuvant chemoterapy regimen  Anthracyclin containing:AC/CEF11/12-Taxane: paclitaxel/docetaxel20/2-

Conclusion: EMT features detected by metaplastic phenotype and cytoplasmic vimentin expression could be predictors for cPD during NAC for TNBC. The tumors of these phenotypes were likely to be resistant to a taxane-containing regimen.

Immunohistochemical profilingantibodyPD group (N = 23)Control group (N = 63)p-valueVimentin(cytoplasm)17 (74%)31 (49%)0.0411Twist-2(cytoplasm)21(91%)59 (94%)0.7849Snail-2(cytoplasm)12 (52%)38 (60%)0.5548Snail-2(nucleus)14 (61%)34 (54%)0.4677Twist NB(cyroplasm)6 (26%)1 (1.6%)0.0002

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-08-12.

Abstract P6-06-20: Predictive factors for pathologic complete response and disease-free survival after neoadjuvant chemotherapy with trastuzumab: A multicenter retrospective observational study in patients with HER2-positive primary breast cancer (JBCRG-C03 study)

BACKGROUND:

Addition of trastuzumab to neoadjuvant chemotherapy (NAC) improved pathologic complete response (pCR) rate in HER2-positive breast cancer. Although recent trials have shown favorable prognosis with NAC plus trastuzumab, clinicopathological factors to predict the outcome have not been fully understood. The aim of this study was to investigate the survival after NAC with trastuzumab and to explore the predictive factors.

PATIENTS AND METHODS:

This is a multicenter retrospective observational study. Patients with HER2-positive primary breast cancer treated with NAC plus trastuzumab from 2001 to 2010 were identified from the institutional database. Primary end point was disease-free survival (DFS). pCR was defined as ypT0/is+ypN0. Kaplan-Meier method was used to estimate DFS. Logistic regression and proportional hazard analysis were used to identify clinicopathological factors to predict pCR and DFS, respectively.

RESULTS:

733 patients were included in the analysis (whole dataset). 425 were ER/PgR-negative (HR- dataset) and 306 were ER/PgR-positive (HR+ dataset). Radiation therapy was performed in 90% of lumpectomy and 31% of mastectomy. Hormonal therapy was performed in 84% of HR+ dataset. pCR rate was 45% in whole dataset, 60% in HR- dataset, and 34% in HR+ dataset. Table 1 showed the result of multivariate analysis for pCR in whole dataset. When HR+ and HR- dataset were analyzed separately, no definitive predictors for pCR were identified in multivariate analysis. Although the patients with pCR showed a significantly favorable prognosis than those without pCR at 3 years DFS, in whole dataset (93% vs 83%, p&lt;0.0001) and HR- dataset (94% vs 80%, p&lt;0.0001), there was no significant difference in HR+ dataset (89% vs 86%, p = 0.10). Different predictors were selected for DFS when multivariate analysis was conducted separately between HR- and HR+ dataset (Table 2).

CONCLUSIONS:

In this observational study, we clarified predictors for pCR and DFS in HER2-positive patients treated with neoadjuvant trastuzumab containing therapy based on tumor subtype. Our results may help us to predict the prognosis more precisely and to simulate the disease course.

Table 1) Multivariate logistic regression analysis for pCR in whole datasetFactorsOR95%CIp-valuePost- vs Pre-menopause1.50(1.05-2.15)0.026*cT1-2 vs cT3-41.72(1.16-2.59)0.008*ER/PgR-negative vs ER/PgR-positive3.32(2.30-4.82)&lt;0.0001*Grade 3 vs 1-21.28(0.89-1.84)0.183

Table 2) Multivariate proportional hazard analysis for DFSFactors†HR95%CIp-valueWhole dataset   Pre- vs Post-menopause1.61(1.04-2.52)0.033*cN2-3 vs cN03.06(1.58-6.24)0.001*cN1 vs cN02.26(1.23-4.41)0.007*Grade 3 vs 1-21.87(1.20-2.97)0.006*non-pCR vs pCR1.90(1.18-3.13)0.008*HR- dataset   Pre- vs Post-menopause1.70(1.01-2.85)0.046*cT3-4 vs cT1-21.86(1.09-3.17)0.024*non-pCR vs pCR3.28(1.90-5.87)&lt;0.0001*HR+ dataset   cN2-3 vs cN05.01(1.79-16.19)0.002*cN1 vs cN03.50(1.40-10.61)0.006*Grade 3 vs 1-22.95(1.52-5.87)0.001*†Only factors with statistical significance

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-06-20.

Treatment response in Kawasaki disease is associated with sialylation levels of endogenous but not therapeutic intravenous immunoglobulin G

Objectives

Although intravenous immunoglobulin (IVIG) is highly effective in Kawasaki disease (KD), mechanisms are not understood and 10-20% of patients are treatment-resistant, manifesting a higher rate of coronary artery aneurysms. Murine models suggest that α2-6-linked sialic acid (α2-6Sia) content of IVIG is critical for suppressing inflammation. However, pro-inflammatory states also up-regulate endogenous levels of β-galactoside:α2-6 sialyltransferase-I (ST6Gal-I), the enzyme that catalyzes addition of α2-6Sias to N-glycans. We asked whether IVIG failures correlated with levels of α2-6Sia on infused IVIG or on the patient’s own endogenous IgG.

Methods

We quantified levels of α2-6Sia in infused IVIG and endogenous IgG from 10 IVIG-responsive and 10 resistant KD subjects using multiple approaches. Transcript levels of ST6GAL1, in patient whole blood and B cell lines were evaluated by RT-PCR. Plasma soluble (s)ST6Gal-I levels were measured by ELISA.

Results

There was no consistent difference in median sialylation levels of infused IVIG between groups. However, α2-6Sia levels in endogenous IgG, ST6GAL1 transcript levels, and ST6Gal-I protein in serum from IVIG-resistant KD subjects were lower than in responsive subjects at both pre-treatment and one-year time points (p <0.001, respectively).

Conclusions

Our data indicate sialylation levels of therapeutic IVIG are unrelated to treatment response in KD. Rather, lower sialylation of endogenous IgG and lower blood levels of ST6GALI mRNA and ST6Gal-I enzyme predict therapy resistance. These differences were stable over time, suggesting a genetic basis. Because IVIG-resistance increases risk of coronary artery aneurysms, our findings have important implications for the identification and treatment of such individuals.

Coronary artery outcomes among children with Kawasaki disease in the United States and Japan

OBJECTIVE

It has been claimed that the aneurysm rate for Kawasaki disease (KD) patients in Japan is lower than in the U.S. However it has been difficult to compare coronary artery (CA) outcomes between the two countries because of different definitions for CA abnormalities. Therefore, we compared CA internal diameters between Japanese and U.S. KD patients using standard definitions and methods.

STUDY DESIGN

We retrospectively reviewed CA outcomes in 1082 KD patients from 2 centers in the U.S. and 3 centers in Japan and compared Z-max scores (maximum internal diameter for the left anterior descending or right coronary artery expressed as standard deviation units from the mean (Z-score) normalized for body surface area) obtained within 12 weeks after onset and calculated using two different regression equations from Canada (Dallaire) and Japan (Fuse). We defined a Z-max of < 2.5 as normal and a Z-max of ≥ 10 as giant aneurysm.

RESULT

The median Z-max for the U.S. and Japanese subjects was 1.9 and 2.3 SD units, respectively (p < 0.001). There was no significant difference in rates of patients with Z-max ≥ 5.0 between the countries. In a multivariable model adjusting for age, sex, and treatment response, being Japanese was still associated with a higher Z-max score.

CONCLUSION

Previously reported differences in aneurysm rates between Japan and the U.S. likely resulted from use of different definitions and nomenclature. Adoption of Z-scores as a standard for reporting CA internal diameters will allow meaningful comparisons among different countries and will facilitate international, collaborative clinical trials.

Lymph-node-first presentation of Kawasaki disease compared with bacterial cervical adenitis and typical Kawasaki disease

OBJECTIVE

To identify characteristics differentiating the node-first presentation of Kawasaki disease (NFKD) from bacterial cervical lymphadenitis (BCL) and typical Kawasaki disease (KD).

STUDY DESIGN

From our prospectively collected database, we compared clinical, laboratory, and imaging characteristics of NFKD and BCL cohorts and performed multivariable logistic regression to identify variables that distinguish NFKD from BCL. We then compared outcomes of patients with NFKD and patients with typical KD treated during the same period.

RESULTS

Over 7 years, 57 patients were hospitalized for NFKD, 78 for BCL, and 287 for typical KD. Patients with NFKD were older and had more medical encounters and longer duration of illness before the correct diagnosis was made than did patients with BCL. Of patients with NFKD, 33% had an admission diagnosis of bacterial adenitis or abscess. Compared with patients with BCL, patients with NFKD had lower leukocyte (white blood cell), hemoglobin, and platelet counts and higher absolute band counts (ABCs), C-reactive protein (CRP), alanine transaminase and γ-glutamyl transpeptidase levels, and erythrocyte sedimentation rates. In the multivariable analysis, smaller nodes, lower white blood cell count, and higher ABC and CRP were independently associated with NFKD. Patients with NFKD had multiple enlarged solid nodes and comparable rates of retropharyngeal edema. Compared with patients with typical KD, patients with NFKD were older, had more severe inflammation, and had similar rates of coronary artery abnormalities and resistance to intravenous immune globulin.

CONCLUSIONS

High ABC and CRP values and multiple enlarged solid nodes in febrile patients with cervical adenopathy should prompt consideration of NFKD to prevent delayed diagnosis of KD. Retropharyngeal edema on radiography should not dissuade from the diagnosis of NFKD.

Abstract P2-11-02: Perception and practice of reproductive specialists towards fertility preservation of young breast cancer patients

Background: The potential for infertility caused by treatment is one of the important quality-of-life issues in young breast cancer (YBC) patients. Insufficient communication and partnership between oncologists and reproductive specialists has been identified as a major barrier to meeting their needs. However, the perception of reproductive specialists towards fertility preservation (FP) of YBC has not been evaluated.

Objective: To investigate the perception and needs of reproductive specialists towards FP of YBC patients.

Methods: A cross-sectional survey was developed and sent to 423 certified reproductive specialists registered to the Japan Society for Reproductive Medicine to self-evaluate their perceptions and practices regarding FP in YBC patients.

Results: Two hundred reproductive specialists (47%) responded to the survey.

The role of TGF-β and myofibroblasts in the arteritis of Kawasaki disease

Inflammation of medium-sized, muscular arteries and coronary artery aneurysms are hallmarks of Kawasaki disease (KD), an acute, self-limited vasculitis of children. We previously reported that genetic variation in transforming growth factor (TGF)-β pathway genes influences both susceptibility to KD and coronary artery aneurysm (CAA) formation. TGF-β signaling has been implicated in the generation of myofibroblasts that influence collagen lattice contraction, antigen presentation, and recruitment of inflammatory cells as well as the generation of regulatory T-cells (Tregs). These processes could be involved in aneurysm formation and recovery in KD. Coronary artery tissues from 8 KD patient autopsies were stained to detect proteins in the TGF-β pathway, to characterize myofibroblasts, and to detect Tregs. Expression of proteins in the TGF-β pathway was noted in infiltrating mononuclear cells and spindle-shaped cells in the thickened intima and adventitia. Coronary arteries from an infant who died on Illness Day 12 showed α-smooth muscle actin (SMA)-positive, smoothelin-negative myofibroblasts in the thickened intima that co-expressed IL-17 and IL-6. CD8+ T-cells expressing HLA-DR+ (marker of activation and proliferation) were detected in the aneurysmal arterial wall. Forkhead box P3 (FOXP3), whose expression is essential for Tregs, was also detected in the nucleus of infiltrating mononuclear cells, suggesting a role for Tregs in recovery from KD arteritis.TGF-β may contribute to aneurysm formation by promoting the generation of myofibroblasts that mediate damage to the arterial wall through recruitment of pro-inflammatory cells. This multi-functional growth factor may also be involved in the induction of Tregs in KD.

Calcineurin inhibitor treatment of intravenous immunoglobulin-resistant Kawasaki disease

OBJECTIVE

To describe the clinical course and outcome of 10 patients with Kawasaki disease (KD) treated with a calcineurin inhibitor after failing to respond to multiple therapies.

STUDY DESIGN

Demographic and clinical data were prospectively collected using standardized case report forms. T-cell phenotypes were determined by flow cytometry, and KD risk alleles in ITPKC (rs28493229), CASP3 (rs72689236), and FCGR2A (rs1801274) were genotyped.

RESULTS

Intravenous followed by oral therapy with cyclosporine (CSA) or oral tacrolimus was well tolerated and resulted in defervescence and resolution of inflammation in all 10 patients. There were no serious adverse events, and a standardized treatment protocol was developed based on our experiences with this patient population. Analysis of T-cell phenotype by flow cytometry in 2 subjects showed a decrease in circulating activated CD8(+) and CD4(+) T effector memory cells after treatment with CSA. However, suppression of regulatory T-cells was not seen, suggesting targeting of specific, proinflammatory T-cell compartments by CSA.

CONCLUSION

Treatment of refractory KD with a calcineurin inhibitor appears to be a safe and effective approach that achieves rapid control of inflammation associated with clinical improvement.

Disruption of vascular homeostasis in patients with Kawasaki disease: involvement of vascular endothelial growth factor and angiopoietins

OBJECTIVE

In Kawasaki disease (KD), a pediatric vasculitis of medium-sized arteries, the coronary arteries are most commonly affected. Angiopoietins and vascular endothelial growth factor (VEGF) play an important role in maintaining vascular homeostasis. Recently, we identified ANGPT1 and VEGFA as susceptibility loci for KD. This study was undertaken to fine-map these associations and to gain further insight into their role in this vasculitis of unknown etiology to further the search for improved diagnostic and therapeutic options.

METHODS

A total of 292 single-nucleotide polymorphisms (SNPs) located in VEGF and ANGPT and their receptors were genotyped in 574 families, including 462 trios. For replication, 123 cases and 171 controls were genotyped.

RESULTS

A significant association with KD susceptibility was observed with 5 SNPs in the ANGPT1 gene (most significantly associated SNP +265037 C>T; Pcombined=2.3×10(-7) ) and 2 SNPs in VEGFA (most significantly associated SNP rs3025039; Pcombined=2.5×10(-4) ). Both ANGPT1 +265037 C>T and VEGFA rs3025039 are located in 3' regulatory regions at putative transcription factor binding sites. We observed significantly down-regulated transcript levels of angiopoietin 1 (Ang-1) in patients with acute KD compared to patients with convalescent KD. In patients with acute KD, high serum protein levels of VEGF and Ang-2 were observed compared to patients with convalescent KD and to both controls with and controls without fever. Immunohistochemistry demonstrated VEGF and angiopoietin expression in the coronary artery wall in autopsy tissue.

CONCLUSION

Our data support the hypothesis that dysregulation of VEGF and angiopoietins contributes to the disruption of vascular homeostasis in KD.

P4-01-21: An Estrogen-Inducible Transcription Factor FOXP1 Promotes Estrogen-Dependent Cell Proliferation of Breast Cancer Cells and Is Associated with 5-Year Disease-Free Survival in Patients with Tamoxifen-Treated Breast Cancer

Estrogen signaling pathways are involved in the growth and development of breast tumors through the activation of estrogen receptor a (ERα). ERα is expressed in most breast cancers and involves in estrogen-dependent proliferation by acting as transcription factors activating the expression of target genes. Various coregulators and transcription factors are associated with ERα-mediated transcriptional control of target genes. Therefore, a comprehensive understanding of estrogen signaling pathways in breast cancer is required for both treatment and diagnosis of the disease. Forkhead box P1 (FOXP1) is a member of the forkhead box transcription factor family and has been reported to be associated with various types of tumors. Here, we investigated the expression pattern of FOXP1 by immunohistochemistry in a series of 133 invasive breast cancers and compared it with clinicopathological factors. The expression of FOXP1 was detected in nuclei in 89 cases (67%) and correlated positively with tumor grade and hormone receptor status, including ERα and progesterone receptor (PgR), and negatively with pathological tumor size (pT). And in ERα-positive MCF-7 breast cancer cells, we demonstrated that FOXP1 mRNA was upregulated by estrogen and that ERα recruitment to ER binding sites within the FOXP1 gene region identified by ChIP-chip analysis was increased. We also demonstrated that proliferation of MCF-7 cells was increased by exogenously transfected FOXP1 and decreased by FOXP1-specific siRNA. Moreover, in MCF-7 cells, FOXP1 enhanced estrogen response element (ERE)-driven transcription. Finally, FOXP1 immunoreactivity was significantly more elevated in relapse-free breast cancer patients treated with tamoxifen than in relapse patients treated with it. Taken together, these results suggest that FOXP1 plays an important role in proliferation of breast cancer cells by modulating estrogen signaling and that FOXP1 immunoreactivity might be associated with the estrogen dependency of breast cancer clinically, which may predict favorable prognosis in the patients treated with tamoxifen.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-01-21.

P2-12-21: Impact of Recent Parity on Histopathological Tumor Features and Outcome of Young Women with Breast Cancer

Background

Younger age has been associated with worse outcome in breast cancer patients (pts) and recent parity has been epidemiologically identified as worse prognostic factor among women with breast cancer. The objective of this study was to explore potential factors associated with worse prognosis in young breast cancer pts, and to demonstrate the impact of parity on the histopathological tumor feature and patient outcome.

Materials and Methods: We retrospectively analyzed 634 early breast cancer pts younger than 45 years old who underwent surgery between 2000 and 2009. For statistical analysis, Pearson's and Fisher's exact test were used. Survival analysis was performed only for pts diagnosed before 2006 in order to obtain a minimum follow up 5 years.

Results: 108 women were diagnosed within 5 years since last parity (Group A), 216 were diagnosed &gt; 5 years since last parity (Group B) and 310 were nulliparous (Group C). Median age at diagnosis was 37 (range 26–44), 41 (range 32–44), and 38.5 (range 22–44) and family history (FH) of breast and/or ***ovarian cancer within second degree was found in 23, 22, and 23% of the pts in Groups A, B, and C, respectively. In Groups A, B and C, clinical stage was III in 22, 10 and 12% (p= .025), ER was positive in 65, 69 and 70% (p= .650), PgR was positive in 64, 75 and 74% (p= .057), and HER2 was positive in 25, 14 and 14% (p=.017), respectively. Tumors in Group A had higher histological grade (grade 3: 60/44/47%, p=.019), higher nuclear grade (grade 3: 61/47/48%, p=.036) and more lymph vessel invasion (61/52/45%, p=.015) compared to those in Groups B and C, respectively. Median follow up time was 85.1 months (range 1.8−137.1 months) during which there were 61 deaths. In univariate analysis, age and FH were not correlated with overall survival (OS). OS in Group A was significantly lower than in Group B (hazard ratio (HR) 3.51, 95% confidential interval (CI) 1.80−6.84, p&lt;.001) and in Group C (HR 2.42, 95%CI 1.36−4.29, p=.002), while OS did not differ significantly between Groups B and C. In the pts without FH, the HR of cancer death was more pronounced in Group A than in Group B (HR 4.25, 95%CI 1.97−9.14, p&lt;.001) or Group C (HR 2.67, 95%CI 1.43−5.01, p=.002), while there was no significant difference among the groups in pts with FH. In multivariate analysis among the pts without FH, lymph vessel invasion (HR 4.51, 95%CI 1.89−10.76, p=.001), Group A women (HR 2.28, 95%CI 1.25−4.17, p=.007), histological grade 3 (HR 2.72, 95%CI 1.28−5.77, p=.009), PgR negativity (HR 2.23, 95%CI 1.19−4.18, p=.013) and clinical stage II and III (HR 2.92, 95%CI 1.04−8.21, p=.04) were significantly associated with poor prognosis, adjusting for age.

Conclusion: Recent parity was associated with worse histopathological features in breast cancer of women younger than 45. It was also associated with worse outcome, especially among pts without FH. Recent parity seems to be a confounding factor for the worse outcome in young breast cancer patients, which justifies further studies to elucidate underlying biology.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-21.

P5-23-02: Clinicopathological Features of Young Patients Age &lt;35 Years with Breast Cancer in Japan

Background: The aim of this study is to clarify clinicopathological features of breast cancer in young women.

Materials and methods: Clinicopathological characteristics were compared between young (&lt;35) patients and non-young (≥35) patients among 109,617 records of JBCS database registered from 2004 to 2009, and overall survival (10-yr OS) were calculated among 146,690 records from 1975 to 2000 with 8.6 years of median follow up period. Results: Clinicopathological factors of 2,982 young patients (2.7%) were compared with 106,295 non-young patients. Young patients had more familial history of breast cancer, more subjective symptom, less bilateral tumor, lower BMI, larger tumor, more inflammatory breast cancer, more positive node, less ER-positive, more HER2−positive, more triple-negative tumor, and more advanced TNM-stage.

Comparison of clinicopathological factors between young and non-young patients with breast cancer