Quantitative adjustment for macroprolactin is an integral part of laboratory assessment of hyperprolactinaemia

INTRODUCTION

Prolactin circulates predominantly as a 23-kDa monomer, and a high-molecular-weight form largely consisting of a complex of prolactin and an anti-prolactin IgG autoantibody, called macroprolactin. This cross-reacts with conventional laboratory assays for prolactin. We here describe how quantitative adjustment for this may assist patient management.In a consecutive series of 218 patients with prolactin elevated to 400 mu/L or more in men (normal range ≤ 180) (n=79, 36.2% of sample) and 1 000 mu/L or more in women (normal range ≤ 500) (n=139, 63.8%) a macroprolactin screen was performed using PEG precipitation.

RESULTS

Where present, median macroprolactin as a proportion of total prolactin was in women 13% (percentile 25-percentile 75: 7-25%) and in men 15% (7-30%).The distribution of macroprolactin as a proportion of total prolactin was markedly skewed to the left with 69.7% of women and 62.9% of men having macroprolactin proportion of 20% or less. There was no relation between %macroprolactin and total measured prolactin, age or gender.Of relevance to clinical management, in 24% of men and 20.5% of women, correction for estimated macroprolactin gave an adjusted monomeric prolactin level below the agreed threshold for further investigation, potentially avoiding unnecessarily referral.In our clinical series, quotation of an adjusted monomeric prolactin would have resulted in unnecessary further investigation being avoided in a number of cases.

DISCUSSION

Screening for macroprolactin is a key element of laboratory assessment for hyperprolactinaemia.In cases where measured total prolactin is significantly raised, quantitative reporting of estimated monomeric prolactin instead of just 'macroprolactin' positive' can avoid unnecessary investigations.

Acute effects of varying doses of propranolol upon oxygen haemoglobin affinity in man

1 The effect of propranolol 2 h following doses of 10, 30, or 100 mg upon the blood oxygen-haemoglobin dissociation curves has been studied in four normal subjects. 2 The pO(2) at 50% saturation (p50) was not changed significantly under control conditions or after 10 and 100 mg doses. There was a just significant increase of 2 mmHg in the p50 value after the 30 mg dose. 3 There was no significant change in red cell adenosine triphosphate or 2,3-diphosphoglycerate nor in plasma phosphate. 4 There was no correlation between plasma propranolol concentration and changes in blood p50.

P3-03-03: Congruence between Patterns of microRNA Expression and Histologic Grading of Invasive Breast Carcinomas

Background

Histologic grading may be used as an indicator of prognosis in breast cancer; patients with low-grade carcinomas have ∼85% ten-year survival compared to just 45% survival in patients with high-grade disease. Although useful for risk stratification, assigning nuclear grade is subjective, and a large proportion of carcinomas are classified as intermediate-grade with uncertain prognosis, thus limiting clinical utility. MicroRNAs (miRNAs) regulate gene expression and serve an important role in breast cancer development. In this study we examined miRNA expression profiles in low-grade and high-grade breast carcinomas to determine if miRNA expression is associated with pathological classifications of tumor grade.

Methods: Breast tumors were obtained from 69 patients enrolled in the Clinical Breast Care Project. Samples were partitioned into low-grade (n=30) or high-grade (n=39) categories using the Nottingham Histologic Score. Following laser microdissection of frozen tissue sections, miRNA was isolated from pure populations of breast tumor cells and hybridized to Affymetrix GeneChip® miRNA arrays containing over 800 human miRNA probes. Expression profiles were analyzed with Partek Genomics Suite using the miRNA Expression Module.

Results: We identified 30 unique miRNAs that showed differential expression at a False Discovery Rate (FDR) p<0.05 between low-grade and high-grade breast carcinomas. Gene targets for these miRNAs function primarily in metabolism and cell communication. Expression of hsa-miR-18a and hsa-miR-572 was significantly different between histologic grades at an FDR p<1×10−8 and hierarchical clustering based on these miRNAs correctly classified 97% (29/30) of low-grade and 90% (35/39) of high-grade tumors. miR-18a has been shown to inhibit ER signaling and promote cellular differentiation, while the role of miR-572 in breast carcinogenesis is not well known.

Conclusions: Dysregulation of miRNAs may accompany changes in cellular morphology typically used in histologic classification of breast carcinomas. Patterns of miRNA expression may improve reproducibility and clinical utility of tumor grading and may prove useful for prediction of recurrence and survival for patients with intermediate-grade carcinomas.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-03-03.

Sudden death in psychiatric patients

Introduction

Studies using death certificates have indicated an excess of sudden cardiac deaths among users of antipsychotic drugs compared to the general population, but may have underestimated the presence of other known causes of sudden and unexpected death.

Objectives

To assess the cause and risk factors for sudden death discovered by contemporaneous investigation of all deaths occurring over a 26-year period (1984–2009) in adult patients registered for care in one large psychiatric hospital in New York.

Methods

Circumstances of death, psychiatric diagnoses, psychotropic drugs and past medical history were extracted from the root cause analyses of sudden unexpected deaths. After the exclusion of suicides, homicides and drug overdoses, explained and unexplained cases were compared regarding clinical variables and the utilization of antipsychotics.

Results

One hundred cases of sudden death were identified among of 119, 500 patient-years. The death remained unexplained in 52 cases. The incidence of unexplained sudden death was 125/100,000 (95% CI 88.9–175.1/100,000) patient-years in 2005–2009, 53/100,000 (95% CI 31.7–88.5/100,000) patient-years in 1999–2004 and 7/100,000 (95% CI 3.7–19.4/100,000) patient-years in 1984–1998. Explained and unexplained cases were similar regarding psychiatric diagnoses and treatment with any psychotropic class, including first- and second-generation antipsychotics. Dyslipidemia (p = 0.012), diabetes (p = 0.055) and co-morbid dyslipidemia and diabetes (p = 0.008) were more common in the unexplained than in the explained cases.

Conclusions

In a consecutive cohort of psychiatric patients, the unexplained sudden deaths were associated with known risk factors for coronary artery disease, but not with higher utilization of first- or second-generation antipsychotics.

Abstract P4-07-09: The Impact of Matrix Metalloproteinase-1 Promoter 1G/2G Polymorphism on Breast Diseases

Background: Matrix Metalloproteinase-1 (MMP-1) is a ubiquitously expressed interstitial collagenase. Overexpression of MMP-1 has a role in initiating mammary tumorigenesis by degrading stroma and by releasing growth factors. A single guanine insertion polymorphism in the MMP-1 promoter creates the binding site, 5'-GGAA-3', for the Ets transcription factor, and increases transcription of MMP-1. The MMP-1 2G polymorphism is linked to early onset, increased risk or aggressiveness of several cancers. Its relationship with other potential markers in invasion and metastasis of breast cancer is unknown.

Experimental Design: To study the impact of the 2G polymorphism on breast cancer we analyzed the genotypes of 109 patients (52 invasive breast cancer [IBC], 29 ductal carcinoma in situ [DCIS], 13 atypical ductal hyperplasia [ADH] and 15 benign breast disease). Immunohistochemical (IHC) data for MMP-1, HER2, ER/PR and P53 from these donors were also analyzed. IHC results for MMP-1 were scored as 0 (no expression) or increasing expression of+1, +2 or +3. Data were analyzed using Pearson's chi-square test to identify statistical significance.

Results: A significantly higher number of patients in the IBC group expressed high MMP-1 (+2 and +3; p <0.001) while the benign group had the least number of patients expressing higher MMP-1 (score +3; p = 0.0075). In the IBC group, among patients with low levels of MMP-1 (+1), 57% had the 1G/1G phenotype, and among those expressing high levels of MMP-1 (+2 and +3), over 70% were 1G/2G heterozygotes or 2G/2G homozygotes. The 2G allele frequency in the ADH group was 0.62 and these patients had higher MMP-1 expression (+2 and +3). Further analyses of HER2, ER/PR and P53 in relation to the MMP-1 polymorphism within the IBC group showed MMP-1 allelic variation in Her-2 positive group was significantly different compared with Her-2 negative group (p = 0.039), with a distribution curve shifted to a greater frequency of 2G homozygosity. A similar result was also observed in P53 positive group when compared with P53 negative group (p = 0.043).

Conclusions: 1) In the IBC group, the 2G insertion polymorphism contributes to MMP-1 over expression. 2) Increased expression of MMP-1 in ADH and higher 2G allele frequency are consistent with the hypothesis that increased MMP-1 2G polymorphism plays a role in initiation of ADH through up regulation of MMP-1 expression. 3) Earlier studies show prognostic role for the coexistence of increased expression of HER2 and P53 in breast cancer. Our observation of a significant increase in the 2G homozygotes in HER2 and P53 positive patients supports a prognostic role for this polymorphism and suggests its possible association with other breast cancer markers. Thus, the MMP-1 2G polymorphism may both contribute to breast disease onset and serve as a prognostic marker for breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-07-09.

Abstract 2971: Genomic instability of breast stroma

Background: Research in the past decade has demonstrated the importance of the tumor microenvironment in breast cancer development and progression. Allelic imbalance evaluation of tumor and stromal components suggests a limited number of alterations in the tumor may lead to cellular transformation while tumor behavior may be driven by molecular changes in the surrounding stroma. Recent studies evaluating copy number changes in frozen stromal tissue, however, found no chromosomal alterations and suggested that earlier studies represent artifacts from the use of archive tissues.

Methods: High-quality flash-frozen specimens were collected from breast quadrants from 14 patients undergoing mastectomy; patient characteristics ranged from prophylactic mastectomy to stage IV breast cancer. DNA was isolated (Gentra) from benign tissue sections and hybridized to GeneChip Human Mapping 250K arrays (Affymetrix). Genomic DNA from peripheral blood for each patient was genotyped to assess copy number variation (CNV) by paired analysis. CNVs were identified using Genome Console 3.0.2 (Affymetrix) with a minimum genomic size/fragment of 500 Kb and a minimum of 50 markers/segment.

Results: Copy number changes ranging in size from 586-5061 kb were detected in 50% (7/14) patients in at least one quadrant, with a single patient having copy number changes present in each quadrant. 21% of quadrants (12/57) showed detectable copy number changes affecting 1 - 18 chromosomal arms. Copy number changes were detected not only in stroma from diseased breasts, but in prophylactic mastectomies, as well. Copy number changes were observed in all quadrants irrespective of tumor location. While copy number alterations on chromosomes 1q21, 2p21, 12p13, 14q12 and 18q12 were shared between patients, no patient had the same patterns of CNVs across all quadrants.

Conclusions: Chromosomal alterations were detected in high-quality frozen breast stroma specimens utilizing genome-wide SNP array data, supporting earlier claims that breast stroma may be genetically unstable. Half of the patients in this study demonstrated copy number alterations in breast stroma distant from the tumor, suggesting that for a subgroup of breast cancer patients, widespread chromosomal instability may increase risk of recurrence.

Note: This abstract was not presented at the AACR 101st Annual Meeting 2010 because the presenter was unable to attend.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2971.

Self-assembled nanoparticle necklaces network showing single-electron switching at room temperature and biogating current by living microorganisms

A network of one-dimensional (1D) Au nanoparticle necklaces is synthesized and shown to exhibit electronic switching, that is, gating, by the metabolic activity of yeast cells deposited on the structure. Without the cells, the network exhibits the Coulomb blockade effect at room temperature with a sharp threshold voltage, V(T) of approximately 0.45 V, which corresponds to a switching energy of approximately 20 kT. Although the enhancement in V(T) from approximately 70 mV for a single (10 nm) Au particle to >1 V is well-known for a 2D array, the uniqueness of the network topology is the relatively weak dependence of V(T) on temperature that leads to room temperature switching behavior, in contrast to an array where the blockade effect vanishes at ambient temperatures. The coupling between the biochemical process of the cell and the electronics of the network has potential applications for making electrodes for biofuel cells and highly sensitive biosensors using the cell as the specific sensing moiety.

Role of phosphoserine phosphatase-like in breast disease in African American women

Abstract #2095

Background: Although breast cancer incidence is higher among Caucasian women (CW), mortality is higher in African American women (AAW). AAW also tend to be diagnosed at a younger age and with larger and more aggressive tumors. Previously, we have found that gene expression patterns in AAW and CW differ in both breast tissues from women without breast disease as well as those from women with invasive breast cancer. Characterization of these differentially expressed genes is critical to understanding breast pathogenesis in AAW.
 Methods: Total RNA was isolated from breast tissue from 29 AAW and 26 CW without evidence of breast disease using the RNeasy Lipid Tissue Midi kit (Qiagen) and from laser microdissected primary breast tumors from 23 AAW and 24 CW using the RNAqueous Micro kit (Ambion). Based on earlier microarray results, genes were selected for validation by quantitative real-time PCR using TaqMan Gene Expression Assays (Applied Biosystems). All TaqMan assays were performed on duplicate samples using the iCycler Real-Time Detection System (Bio-Rad). Relative expression levels were determined using the Comparative Ct Method. A Wilcoxon test was used to determine significance.
 Results: Among those genes that were confirmed to be differentially expressed in breast tissues from AAW and CW was phosphoserine phosphatase-like, or PSPHL. PSPHL showed significantly higher expression in both disease-free samples as well as primary tumors from AAW when compared to the same sample type from CW. In tissues from disease-free women, the relative level of PSPHL expression was significantly higher in AAW (median = 17.15) compared to CW (median = 0; P<0.000001). Similarly, primary tumors from AAW also had higher levels of PSPHL expression (median = 42.22) compared to those from CW (median = 0; P<0.0005).
 Discussion: The current study has confirmed that expression of PSPHL is significantly higher in both disease-free and invasive breast tissues from AAW than those from CW. Recently, PSPHL has also been shown to have higher expression in prostate tumors from African American men than those from Caucasian men. The function of PSPHL is unknown; however, its increased expression has been associated with aberrant cellular proliferation and cell cycle progression in Fanconi anemia. Higher expression of PSPHL in both normal and diseased breast tissues may, therefore, increase cellular proliferation, contributing to the initial development and/or aggressiveness of breast tumors in AAW.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2095.

Haloperidol versus chlorpromazine for schizophrenia

BACKGROUND

Chlorpromazine and haloperidol are benchmark antipsychotic drugs. Both are said to be equally effective when used at equivalent doses, but have different side-effect profiles.

OBJECTIVES

To compare the effects of haloperidol and chlorpromazine for people with schizophrenia and schizophrenia-like psychoses.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's register (August 2006). We searched references of all included studies for further trials. We contacted pharmaceutical companies and authors of relevant trials.

SELECTION CRITERIA

We included all randomised controlled trials that compared haloperidol with chlorpromazine for people with schizophrenia and/or schizophrenia-like psychoses.

DATA COLLECTION AND ANALYSIS

Citations and, where possible, abstracts were independently inspected by at least two reviewers, papers ordered, re-inspected and quality assessed. We independently extracted data. For dichotomous data we calculated the relative risk (RR), 95% confidence interval (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis using a random-effects model. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We found 14 relevant studies, mostly of short duration, poorly reported and conducted in the 1970s (total n=794 participants). Nine of these compared oral formulations of both compounds, and five compared intramuscular formulations. Haloperidol was associated with significantly fewer people leaving the studies early (13 RCTs, n=476, RR 0.26 CI 0.08 to 0.82). The efficacy outcome 'no significant improvement' tended to favour haloperidol, but this difference was not statistically significant (9 RCTs, n=400, RR 0.81 CI 0.64 to 1.04). Movement disorders were more frequent in the haloperidol groups ('at least one extrapyramidal side effect': 6 RCTs, n=37, RR 2.2 CI 1.1 to 4.4, NNH 5 CI 3 to 33), while chlorpromazine was associated with more frequent hypotension (5 RCTs, n=175, RR 0.31 CI 0.11 to 0.88, NNH 7 CI 4 to 25). Similar trends were found when studies comparing intramuscular formulations and studies comparing oral formulations were analysed separately.

AUTHORS' CONCLUSIONS

Given that haloperidol and chlorpromazine are global standard antipsychotic treatments for schizophrenia, it is surprising that less than 800 people have been randomised to a comparison and that incomplete reporting still makes it difficult for anyone to draw clear conclusions on the comparative effects of these drugs. However, it seems that haloperidol causes more movement disorders than chlorpromazine, while chlorpromazine is significantly more likely to lead to hypotonia. We are surprised to have to say that we feel further, large, well designed, conducted and reported studies are required.

Survival and treatment morbidity with therapeutic lymphadenectomy for regional nodal metastases from melanoma

8571

Background: Therapeutic lymphadenectomy (TL) is potentially curative therapy for clinically palpable nodal metastatic melanoma. However, TL is associated with significant morbidity and a dismal prognosis. Methods: Review of the melanoma database identified 275 patients who underwent TL. Patient, tumor, and treatment-related variables associated with recurrence and overall survival were analyzed. Results: The study group comprised of 63% males with a nodal basin distribution of 47% axilla, 35% groin and 18% neck. Median age, number of positive lymph nodes and size of the largest lymph node were 51 years 2 nodes and 2.5 cm respectively. Median survival was 27.4 months (77%, 55% and 34% at 1, 2 and 5-years respectively). Regional recurrence at the lymphadenectomy site occurred in 76 (28%) patients. Distant metastases developed in 67 (88%) patients with and 126 (63%) without regional recurrence. On multivariate analysis, the most powerful predictor of both survival and regional recurrence was lymph node ratio (LNR- number of positive nodes/total dissected nodes). Median survival for LNR <0.13 was 39 months versus 19 months for ≥0.13 (p = 0.005). Older age and male sex were also predictive of a decreased survival. Treatment-related morbidity was rare and included lymphedema (12%), wound complications (3%) and nerve injury (1%). Conclusion: The overall survival and acceptable morbidity justifies TL for clinically positive nodal metastatic melanoma. LNR is predictive of survival and regional recurrence following TL. Due to significant distant and regional failure rates, in addition to systemic adjuvant therapy these patients may benefit from radiation therapy.

No significant financial relationships to disclose.

Correlation of Levels and Patterns of Genomic Instability With Histological Grading of DCIS

BACKGROUND

Histological grading of ductal carcinoma-in-situ (DCIS) lesions separates DCIS into three subgroups (well-, moderately, or poorly differentiated). It is unclear, however, whether breast disease progresses along a histological continuum or whether each grade represents a separate disease. In this study, levels and patterns of allelic imbalance (AI) were examined in DCIS lesions to develop molecular models that can distinguish pathological classifications of DCIS.

METHODS

Laser microdissected DNA samples were collected from DCIS lesions characterized by a single pathologist including well- (n = 18), moderately (n = 35), and poorly differentiated (n = 47) lesions. A panel of 52 microsatellite markers representing 26 chromosomal regions commonly altered in breast cancer was used to assess patterns of AI.

RESULTS

The overall frequency of AI increased significantly (P < .001) with increasing grade (well differentiated, 12%; moderately differentiated, 17%; poorly differentiated, 26%). Levels of AI were not significantly different between well- and moderately differentiated grades of disease but were significantly higher (P < .0001) in poorly differentiated compared with well- or moderately differentiated disease. No statistically significant differences in patterns of AI were detected between well- and moderately differentiated disease; however, AI occurred significantly more frequently (P < .05) in high-grade lesions at chromosomes 6q25-q27, 8q24, 9p21, 13q14, and 17p13.1, and significantly more frequently in low-grade lesions at chromosome 16q22.3-q24.3.

CONCLUSIONS

The inability to discriminate DCIS at the genetic level suggests that grades 1 and 2 DCIS may represent a single, non-high-grade form of DCIS, whereas poorly differentiated DCIS seems to be a genetically more advanced disease that may represent a discrete disease entity, characterized by a unique spectrum of genetic alterations.

Treatment of schizophrenia with paliperidone extended-release tablets: a 6-week placebo-controlled trial

BACKGROUND

Paliperidone extended-release tablet (paliperidone ER) is an investigational oral psychotropic developed for schizophrenia treatment. It utilizes OROS technology to provide a unique pharmacokinetic profile, eliminating the need for titration and potentially leading to improved tolerability. Furthermore, paliperidone undergoes limited hepatic metabolism.

METHODS

The efficacy and safety of once-daily paliperidone ER (6 mg, 9 mg and 12 mg) were assessed versus placebo in 628 patients with acute schizophrenia in a 6-week, multicenter, double-blind, randomized, parallel-group study.

RESULTS

All doses of paliperidone ER demonstrated significant improvement in PANSS score, all PANSS Marder factor scores (p<0.001) and personal and social functioning versus placebo (p<0.001). The PANSS total score also improved significantly in the olanzapine treatment arm. Significantly higher percentages of paliperidone ER patients demonstrated a > or =30% reduction in PANSS total score versus placebo (p<0.001). The incidence of movement disorder-related AEs and rating scales measurements were similar to placebo for the paliperidone ER 6 mg group and higher in the 9 mg and 12 mg groups. In the paliperidone ER groups there were no reports of glucose-related AEs or clinically relevant changes in plasma lipid levels and changes in mean bodyweight<1 kg.

CONCLUSION

In this study, all doses of paliperidone ER were effective in significantly improving the symptoms of schizophrenia and personal and social functioning and were generally well tolerated. Paliperidone ER offers a distinctive treatment profile and may provide a valuable new treatment option for patients with schizophrenia.