Abstract P2-10-38: Prognostic factors uPA/PAI-1: measurement in core needle biopsies

Background: The urokinase-type plasminogen activator (uPA) and its inhibitor PAI-1 are validated as prognostic factors at the highest level of evidence within the node-negative group of breast cancer patients (Harris L et al., JCO 2007; 25:5287).

Usually, patients receive a core-needle biopsy before surgery. A prior feasibility study showed that the method of sampling (ex vivo from the surgical specimen using a small core needle or the larger excision specimen) doesn't influence the uPA and PAI-1 results (Thomssen et al., J Natl Cancer 2009; 101:1028). With the current study, we assessed how well uPA and PAI-1 values obtained from the core needle biopsy (in vivo) predict the expression level of these prognostic factors in the later surgical specimen.

Material and Methods: Fresh frozen material of 2–3 core needle biopsies (min 10 mg each) and the corresponding tumor material (min 50 mg) removed by subsequent surgery were collected from 110 patients in two hospitals. Only areas of the surgical specimen were selected for testing that had a sufficient distance to the needle biopsy defect. The uPA and PAI-1 concentrations were analysed using a commercially available ELISA test (FEMTELLE™; American Diagnostica, Inc., Stamford, CT). The predictive values (and sensitivity/specificity) of the core-needle biopsy data were calculated to forecast the uPA and PAI-1 values of the corresponding surgical specimen results.

Results: Sensitivity, specificity, the positive (ppv) and negative (npv) predictive values for uPA, PAI-1 and for the combination of uPA/PAI-1 are listed in table 1. Low concentrations of uPA in the core needle biopsies correlate with low concentrations in the surgical specimens across the entire study cohort as well as in the group with an intermediate (G2, N0) risk (npv = 0.91).

The clinical and pathological data of the cohort and the risk assessment will be presented.

[Breast cancer - Treatment guidelines and new treatment options in 2012, a medical oncology prospective]

Breast cancer is the leading cancer in women with an annual incidence rate of 110/100.000 women in all age groups in Europe. The incidence rate increases in older women. Treatment includes surgery, radiotherapy, chemotherapy with or without antibody therapy and hormonal treatment. During the last 40 years the survival rate has significantly improved. From the 1970ies to 2010 the five year survival rate has risen from 85% to 98% early breast cancer. Similarly, in metastatic breast cancer 5-year survival has increased from below 10% in 1970 to 26% in 2010. This was possible because of better treatment options and better screening causing earlier diagnosis of breast cancer. This article reviews the standard treatment of breast cancer according to ESMO/ASCO guidelines and discusses new treatment options and new therapeutic strategies for breast cancer.

The accuracy of BI-RADS classification of breast ultrasound as a first-line imaging method

PURPOSE

The aim was to evaluate the accuracy of BI-RADS categories 3 - 5 in breast ultrasound (US) as the first-line imaging method.

MATERIALS AND METHODS

5077 examinations of a consecutive, unselected and mixed collective of symptomatic and asymptomatic patients were performed. Of these examinations, 835 cases of BIRADS 3 - 5 could be analyzed.

RESULTS

The PPV with respect to a malignant lesion for BI-RADS 3, 4, 5 was 0.03, 0.48, and 0.97, respectively. When BI-RADS 4 and 5 cases are considered to be suspicious, the ratio of benign to malignant findings corresponds to 1:1.8. Analyzing BIRADS 3 - 5 lesions, the sensitivity, specificity and accuracy are 0.92, 0.85, and 0.87, respectively.

CONCLUSION

The data support the feasibility of US for discriminating malignant from benign findings corresponding to the ACR BI-RADS classification without excessively increasing the number of unnecessary biopsies.

A psychosocial evaluation process for living liver donors: the University of Rochester model

OBJECTIVE

The donation of livers by living donors entails complex processes, both surgically and psychosocially, potentially involving risks in both domains. Thorough psychosocial evaluation is necessary to minimize those risks, yet little has been written about the donor assessment process. This article describes one such process, utilized by a transplant program in upstate New York.

METHOD

Donor candidates undergo multiple psychosocial interviews early in the overall transplant evaluation process. Evaluators subsequently meet as a group, along with an independent ethicist, to determine psychosocial candidacy prior to final medical/surgical clearance.

RESULTS

Between 2003 and 2007, 416 donor candidates initiated and/or underwent full evaluation, resulting in a 17.5% surgery and 55.5% exclusion rate among those individuals. Of those ruled out, 20.8% were for (medical or psychosocial) reasons associated with the recipient, and 8.7% were for donor-related psychosocial issues.

CONCLUSION

Given the primacy ofpsychosocial and ethical issues in living liver donor candidate evaluation, the multiple interview process, followed by team discussion and overseen by an ethicist removed from other transplant program functions, has advantages as a donor assessment model.

P4-09-05: CA15-3 Adds Prognostic Information in “Luminal” Type Breast Cancer – A Single Center Experience Evaluating 700 Patients with a Median Follow-Up of 5 Years

Background: Prognostic markers are essential for the decision about individual therapy for patients with newly diagnosed breast cancer. Biological meaningful cancer types are revealed by gene expression analysis. Steroid hormone receptor (HR) and HER2 status of the tumor by immunohistochemistry (IHC) are more easily available and predominantly resemble these cancer types. The “luminal” type as HR pos. and HER2 neg., the “luminalHER2” type as HR pos. and HER2 pos., the “HER2” type as HR neg. and HER2 pos. and the “triple neg.” type as HER neg. and HER2 ***neg.. We evaluated preoperative serum CA 15–3 and CEA within IHC-cancer types and outcome using our own cohort from 1999–2010.

Material and Methods: Since 1999 all patients with breast cancer were entered in our tumor registry. Patients were treated by surgery and adjuvant therapy according to national guidelines (www.ago-online.de). Data was entered into SPSS by a specially trained study nurse. Follow-up was obtained yearly using our own out-patient clinic, information from general practitioners and the general cancer registry. Informed consent was taken from the patients at time of diagnosis. CA 15–3 and CEA were defined elevated if above 25 U/ml or 4,6 μg/l respectively.

Results: Preoperative serum CA15-3 available for 1149 patients. Patients with elevated results showed a reduced 5year disease-free survival (DFS) of 74.4% as compared to 84.7% (p<0.001). CA15-3 remained an independent prognostic factor in multivariate analysis (nodal status, grading, HR). Within HR positive disease, normal CA15-3 values predict a significantly better 5years DFS of 89.9% compared to 79.7% (p<0.001). No significant difference was seen in HR negative patients (5year DFS 57.5% vs 68.4%; p=n.s.). Patients with HER2 status available (n=700) were classified into biological tumor types by IHC. Significant differences in DFS were seen for “luminal” (n=435) tumors only (5year DFS 81.0% vs 91.8% (p<0.001). Only trends of differences in DFS were seen in the other less frequent tumor types “luminalHER2” (n=90) or “triple neg.” (n=112) types. Within the “HER2” (n=63) group no discrimination by serum levels of CA15-3 was seen. CEA did not add information on prognosis.

Discussion: Decision on adjuvant therapy is increasingly based on tumor biology. Particularly, in “luminal” tumors additional prognostic information is needed to decide on adjuvant chemotherapy. CA15-3 may be an easily available, independent marker to identify patients with a higher risk of recurrence within this group. Prospective validation and comparison to molecular typing is needed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-05.

P2-08-13: Does Routine Use of Preoperative Magnetic Resonance Imaging (MRI) in Breast Cancer Influence the Outcome?

Introduction: The role of routine preoperative breast MRI in patients diagnosed with breast cancer is still under discussion. In a milestone review, Houssami et al. (CA Cancer J Clin 2009;59;290) did not demonstrate an advantage with regard to DFS or OS. We reviewed our case series (n=793) in order to add evidence to the current discussion of whether or not preoperative MRI would influence the outcome.

Material and Methods: In our database we identified four years of diagnosis (2004-07) in which a high percentage (72%) of patients (349 of 483) with histologically confirmed invasive breast cancer received preoperative MRI. In the following years (2008/09), MRI was still done in 31% of the cases (97 of 309). All pts were treated according to national guidelines; however, patients with additional lesions in MRI were subjected to an additional MRI-guided needle biopsy or additional wire-guided excision. The median follow-up time was 31.5 months (0-81). The patients were followed clinically. In most cases local surveillance was done by mammography.

Results: In the total cohort, 20% of the patients had additional needle biopsies and/or wire-localisation due to MRI-findings. By MRI, lesions that subsequently led to an additional preoperative needle biopsy were found in 82 pts. Interestingly, only ten contralateral second cancers were found. In 357 pts, MRI was used as guidance during the operation with (n=118) or without MRI-supported wire localization (n=238). The percentage of additional MRI-needle biopsy or MRI-supported localisation did not differ between invasive ductal (n=655) and lobular cancer (n=91): 10% versus 13% needle biopsies and 15% versus 20% wire localisations. The number of surgical procedures to achieve tumor-free margins did not differ between patients with or without preoperative MRI. In this series, 69 of 100 patients who received neoadjuvant chemotherapy, also had MRI-imaging. Considering the patient cohort with follow-up available (n=737), no significant difference of DFS probability was observed between pts with and without preoperative MRI.

Discussion: This retrospective analysis did not demonstrate any advantage for routine preoperative MRI with regard to local treatment and DFS probability. The observed rate of 20% additional operative procedures corresponds to similar published data (16% additional multicentric or multifocal lesions found by MRI, Solin, Breast. 2010;19:7).

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-13.

Characterization of a-SiCx:H Films for c-Si Surface Passivation

Amorphous intrinsic silicon carbide (a-SiCx:H(i)) films and amorphous phophorous doped silicon carbide (a-SiCx:H(n)) films deposited by plasma enhanced chemical vapor deposition (PECVD) from silane/methane mixtures provide excellent electronic passivation of p-type c-Si. Effective surface recombination velocities (Seff) lower than 23 cm s-1 have been reported for a- SiCx:H(i) films and Seff < 11 cm s-1 for a-SiCx:H(n) films. The analysis of the dependence of Seff on the injection level indicates that the good electronic passivation is due to field-effect passivation resulting from a high fixed charge (Qf) created in the a-SiCx:H film. In this work the absorption of SiH bonds in infrared transmission spectra of a-SiCx:H films is quantitatively analysed resulting in about 30% smaller amount of SiH bonds in phosphorous doped films compared to intrinsic films. Furthermore, a strong reciprocal correlation of the hydrogen content in the films and the Qf created at the a-SiCx:H/c-Si interface is observed.

[Displaced pain pump because of a pendulous abdomen - dermatolipectomy as solution of the problem]

A female patient with a chronic pain syndrome after multiple operation on her muskuloskeletal system presented with a displaced pain pump in her lower left abdominal region. After an excessive weight loss due to gastric banding the patient developed a massive pendulous abdomen causing the complication. An interdisciplinary dermatolipectomy together with a refixation of the pump was performed. Since this operation a recurrence of the displacement has not been observed and consecutively the filling of the pump could be accomplished without radiological investigations. This rare case demonstrates the significance of interdisciplinary treatment in which a primarily aesthetic intervention was necessary for a successful therapeutic outcome.

Risk Assessment in Node-Negative Breast Cancer by the Invasion Factors (Urokinase-Type Plasminogen Activator) and Its Inhibitor PAI-1. Correlation to the Tumor Characteristics in the Prospective NNBC 3-Europe Trial. On Behalf of the NNBC-3 Trial Group

Background:ASCO Tumor Marker Guidelines 2007 recommended clinical routine use of the invasion markers uPA and PAI-1 for risk assessment in N0 breast cancer patients (Harris et al. JCO 2007; 25:5287). We conducted the prospective NNBC 3-Europe trial addressing the direct comparison between risk-assessment by uPA/PAI-1 and clinico-pathological factors, and optimization of adjuvant chemotherapy for high-risk N0 pts: FEC*3-Doc*3 vs. standard FE100C*6.Study Design:Risk assessment was based on grade, and in G2 tumors either by uPA/PAI-1 status (UP) or by a St. Gallen adapted algorithm (CP). Type of assessment was decided by each centre prior to study participation. High-risk patients received adjuvant chemotherapy according to randomisation. Adjuvant endocrine therapy is given according to guidelines. Use of fresh tissue sampling was necessary for determination of uPA/PAI-1 by ELISA. All laboratories took part on the central quality assurance program. HER2 overexpression was confirmed centrally.Results:From Dec 2002 to Jan 2009, 153 centres recruited 4,150 pts (4,145 evaluable). In 2,497 pts., risk was assessed by UP, and in 1,648 by CP. By UP, 38.7% were assigned to the low-risk group, whilst 61.3% of the patients still had to receive adjuvant chemotherapy; by CP-assessment (n=1,648) the risk groups comprised 31.3%, and 68.7 %.Tab.1. Tumor characteristics.risk groupUP lowUP highCP lowCP hightotaln9671,5305161,1324,145age (median)54 (31-70)53 (21-70)57 (34-70)53 (21-70)54 (21-70)pT2178 (18.4%)544 (35.6%)24 (4.7%)603 (53.3%)1,349 (33%)Steroid hormone receptor status pos.951 (98.3%)1,116 (72.9%)513 (99.4%)739 (65.3%)3,331 (80.4%)HER2 overexpression45 (4.7%)284 (18.6%)6 (1.2%)247 (21.8%)582 (14.0%)triple negative (TNBC)15 (1.6%)319 (20.8%)2 (0.4%)295 (26.1%)631 (15.2%)Grading 1417 (43.1%)-164 (32.0%)15 (1.3%)596 (14.4%)Grading 2550 (56.9%)750 (48.9%)345 (67.4%)464 (40.7%)2,115 (51.0%)Grading 3-780 (50.9%)7 (1.4%)639 (56.1%)1,424 (34.4%)uPA value [ng/mg] median1.33.8--2.4PAI-1 value [ng/mg]median9.121.5--15.4 More pT2 tumors were listed as low risk by the UP method. Typical high risk groups (e.g. TNBC, HER2) were identified by UP. A substantial number of HER2 overexpressing tumors (4.7%) in UP were assigned to the low risk group, suggesting an independent effect of UP and HER2. In the QA programm, mean coefficients of variations were 12% for uPA and PAI-1 determination. In total 1,335 pts. were randomised to receive FEC-Doc, and 1.327 to receive FEC. The chemotherapy was well tolerated. However, we observed four therapy related deaths.Conclusions:Determination of uPA and PAI-1 in frozen tissue is feasible and reliable. Using UP for additional prognostic information may prevent chemotherapy from many patients. The effect of the taxane containing regimen will be evaluated with longer follow-up.Cooperation: EORTC Patho-Biology Group, AGO Breast Group, GBG, Unrestricted grants by Sanofi-Aventis, Pfizer, American Diagnostica, Martin-Luther-University Halle-Wittenberg.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4040.

ASCO-recommended prognostic factors uPA/PAI-1 in node-negative (N0) breast cancer patients (pts) compared to clinicopathological risk assessment within the NNBC 3-Europe trial

544

Background: ASCO Tumor Marker Guidelines 2007 recommended clinical routine use of the invasion markers uPA (urokinase-type plasminogen activator) and its inhibitor PAI-1 for risk assessment in N0 breast cancer pts (Harris et al, J Clin Oncol. 2007;25:5287). Ten-year follow-up data of the confirmatory prospective clinical uPA/PAI-1 trial (CHEMO-N0) will be presented at the ASCO 2009 Meeting (Harbeck et al.). We conducted a further prospective trial (NNBC 3-Europe) addressing the direct comparison between risk-assessment by uPA/PAI-1 (UP) and clinico-pathological factors (C), and optimization of adjuvant chemotherapy for high-risk N0 pts: FEC*3-Doc*3 vs. standard FEC*6. Methods: From December 2002 to January 2009, 4,040 pts were recruited by 151 centres. For uPA and PAI-1 ELISA, tumors samples were snap frozen und processed. Risk assessment was based on grade and in G2 tumors, either by UP or by a St. Gallen adapted C algorithm. High-risk pts were randomized for adjuvant chemotherapy. All laboratories took part in central quality assurance (QA) for uPA/PAI-1 determination. Results: Risk assessment was performed for 1,590 pts based on C and for 2,445 pts based on UP. End of accrual was planned when 2,572 high risk pts were randomised for chemotherapy and thus ends Jan 31, 2009. Current status shows 1,291 high-risk pts in the FEC-Doc and 1,294 in the FEC arm. In the low-risk arm, 1,450 pts have endocrine therapy, only. By both risk stratifications, 42% of the G2 tumors were assigned as low risk, but in total, more pts were classified as low-risk by UP (39%) than by C (31%). Median uPA level were at 2.40 ng/mg protein (below cutoff), median PAI-1 at 15.9 (above cutoff). In the QA programm, mean coefficients of variations are 12% for uPA and PAI-1 determination. Conclusions: The prospective biomarker trial using uPA/PAI-1 has just ended accrual with more than 4,000 patients. Routine uPA/PAI-1 determination is reliable and feasible even in core needle specimens. Using tumor grade and uPA/PAI-1, adjuvant chemotherapy may be avoided in about 39% of N0 breast cancer pts. Cooperation: EORTC Patho-Biology Group, AGO Breast Group, GBG, Unrestricted grants by Sanofi-Aventis, Pfizer, American Diagnostica, Martin-Luther-Universitaet Halle-Wittenberg.

[Table: see text]

Hepatocyte differentiation of mesenchymal stem cells from human adipose tissue in vitro promotes hepatic integration in vivo

OBJECTIVE

The hepatic integration of human adipose tissue derived mesenchymal stem cells (hAT-MSCs) in vivo with or without prior differentiation to hepatocyte-like cells in vitro was investigated.

METHODS AND RESULTS

Cells, isolated either from peritoneal or subcutaneous adipose tissue, expressed mesenchymal stem cell surface markers and featured multiple lineage differentiation. Under conditions favouring hepatocyte differentiation, hAT-MSCs gained hepatocytic functions in vitro including urea formation, glycogen synthesis, cytochrome P450 enzyme activity, and expression of hepatocyte-specific transcripts of carbamoylphosphate synthetase, albumin and cytochrome P450 type 3A4 (CYP3A4). Transgenic expression of green fluorescent protein emerged upon hepatocyte differentiation when driven by the hepatocyte-specific promoter of the cytosolic phosphoenolpyruvate carboxykinase gene but was constitutive from the ubiquitin gene promoter. Human AT-MSCs were transplanted into livers of immunodeficient Pfp/Rag2-/- mice with or without prior hepatocyte differentiation in vitro. Donor-derived human cells engrafted in the mouse host liver predominantly in the periportal region of the liver lobule. They expressed HepPar1 and albumin, typical features of differentiated human hepatocytes, in the otherwise negative mouse liver background. Engraftment was significantly more efficient using hAT-MSCs pre-differentiated to hepatocyte-like cells in vitro as compared with undifferentiated cells.

CONCLUSIONS

Pre-differentiation of human MSCs from adipose tissue into hepatocyte-like cells in vitro facilitates long term functional hepatic integration in vivo.