Abstract PD04-08: Circulating tumor cells (CTC) in peripheral blood of breast cancer patients two years after adjuvant chemotherapy depending on endocrine treatment — The German SUCCESS-Trial

Background: The prognostic significance of CTC in metastatic, as well as in primary breast cancer has been demonstrated (Rack et al., ASCO 2010). The optimal endocrine treatment strategy for postmenopausal patients (pts) with hormone sensitive breast cancer remains unclear.We analyzed the prevalence of CTC two years after primary diagnosis in patients with tamoxifen or anastrozole treatment.

Methods: As part of the translational research project of the German SUCCESS-trial, we analyzed 23ml of peripheral blood from 307 N+ and high risk N-postmenopausal pts with hormone sensitive breast cancer two years after adjuvant taxane based chemotherapy and with tamoxifen or anastrozole treatment. The presence of CTCs was assessed with the CellSearchSystem (Veridex, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labelled with anti-cytokeratin (8,18,19) and anti-CD45 antibodies to distinguish between epithelial cells and leukocytes. Standard within the study was early switch treatment (tamoxifen for 2 years, followed by anastrozle), while pts with contraindications against tamoxifen were allowed to receive anastrozole up-front.

Results: In 10.1% of pts (n=31) >1 CTC was detected after the completion of chemotherapy (range 2-33), while 7.8% (n=24) presented with >1 CTC (range 2-99) two years after completion of chemotherapy. The median age in the tamoxifen group was 59.9 years and 59.8 in the anastrozole group. In the tamoxifen group, 33.0% of the pts had a pT1 tumor, 5.3% G1 grading and 21.6% of the pts were node negative. In the anastrozole group, 30.0% of the pts had a pT1 tumor, 7.5% G1 grading and 22.5% of the pts were node negative, respectively. None of these differences were statistically significant. After the completion of chemotherapy, 9.7% of the pts were CTC positive in the tamoxifen group (range number of cells: 2-33) and 11.3% in the anastrozole group (range of cells: 2-24), p=0.69. Two years after primary diagnosis, 7.9% of the pts were CTC positive in the tamoxifen group (range number of cells:2-99) and 7.5% in the anastrozole group (range cells: 2-5), p=0.90. Actuarial disease free and overall survival will be presented at the meeting.

Conclusions: The prognostic relevance of CTC in peripheral blood of early breast cancer patients both before and after chemotherapy has been demonstrated. The presented data will add information on the monitoring potential of CTC during adjuvant endocrine treatment.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD04-08.

A novel MSC-seeded triphasic construct for the repair of osteochondral defects

Mesenchymal stem cells (MSC) are increasingly replacing chondrocytes in tissue engineering based research for treatment of osteochondral defects. The aim of this work was to determine whether repair of critical-size chronic osteochondral defects in an ovine model using MSC-seeded triphasic constructs would show results comparable to osteochondral autografting (OATS). Triphasic implants were engineered using a beta-tricalcium phosphate osseous phase, an intermediate activated plasma phase, and a collagen I hydrogel chondral phase. Autologous MSCs were used to seed the implants, with chondrogenic predifferentiation of the cells used in the cartilage phase. Osteochondral defects of 4.0 mm diameter were created bilaterally in ovine knees (n = 10). Six weeks later, half of the lesions were treated with OATS and half with triphasic constructs. The knees were dissected at 6 or 12 months. With the chosen study design we were not able to demonstrate significant differences between the histological scores of both groups. Subcategory analysis of O'Driscoll scores showed superior cartilage bonding in the 6-month triphasic group compared to the autograft group. The 12-month autograft group showed superior cartilage matrix morphology compared to the 12-month triphasic group. Macroscopic and biomechanical analysis showed no significant differences at 12 months. Autologous MSC-seeded triphasic implants showed comparable repair quality to osteochondral autografts in terms of histology and biomechanical testing.

Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Surgical technique

BACKGROUND

The treatment of unstable displaced proximal humeral fractures, especially in the elderly, remains controversial. The objective of the present prospective, multicenter, observational study was to evaluate the functional outcome and the complication rate after open reduction and internal fixation of proximal humeral fractures with use of a locking proximal humeral plate.

METHODS

One hundred and eighty-seven patients (mean age, 62.9 +/- 15.7 years) with an acute proximal humeral fracture were managed with open reduction and internal fixation with a locking proximal humeral plate. At the three-month, six month,and one-year follow-up examinations, 165 (88%), 158 (84%), and 155 (83%) of the 187 patients were assessed with regard to pain, shoulder mobility, and strength. The Constant score was determined at each interval, and the Disabilities of the Arm, Shoulder and Hand (DASH) score was determined for the injured and contralateral extremities at the time of the one-year follow-up.

RESULTS

Between three months and one year, the mean range of motion and the mean Constant score for the injured shoulders improved substantially. Twelve months after surgery, the mean Constant score for the injured side was 70.6 +/- 13.7 points, corresponding to 85.1% +/- 14.0% of the score for the contralateral side. The mean DASH score at the time of the one-year follow-up was 15.2 +/- 16.8 points. Sixty-two complications were encountered in fifty-two (34%) of 155 patients at the time of the one-year follow-up. Twenty-five complications (40%) were related to incorrect surgical technique and were present at the end of the operative procedure. The most common complication, noted in twenty-one (14%) of 155 patients, was intraoperative screw perforation of the humeral head. Twenty-nine patients (19%) had an unplanned second operation within twelve months after the fracture.

CONCLUSIONS

Surgical treatment of displaced proximal humeral fractures with use of the locking proximal humeral plate that was evaluated in the present study can lead to a good functional outcome provided that the correct surgical technique is used. Because many of the complications were related to incorrect surgical technique, it behooves the treating surgeon to perform the operation correctly to avoid iatrogenic errors.

Dose Dependent Effects of G-CSF on Ca27.29 in Early Stage Breast Cancer Patients

Background:13% of 2556 patients (pts) examined in the SUCCESS trial showed elevated levels of Ca27.29 only after chemotherapy (SABCS2008). Early data indicate a possible relationship between the administration of G-CSF and a rise in the tumor marker. This analysis focuses on the dose dependency of this effect.Methods:The SUCCESS Trial is a phase III trial comparing FEC-Docetaxel vs. FEC-Doc-Gemcitabine regime and 2 vs. 5 years of treatment with zoledronate in patients with primary breast cancer in 3754 pts (BC) (N+ or high risk). Blood samples for this analysis are drawn before and after chemotherapy (CHT). Ca27.29 has been measured with ST AIA-PACK Ca27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for Ca27.29 is >=32 U/ml. For chi² analysis patients were grouped to increasing or not increasing values of Ca27.29 and 1 to 6 cycles with G-CSF or no G-CSF at all. The absolute difference of Ca27.29 values before and after CHT was correlated with the number of G-CSF cycles administered.Results:The analysis of Ca27.29 is based on the data of 2556 pts. 1252 pts (49%) received at least one course of G-CSF. 338 pts (13%) exceeded the threshold for CA27.29 only after CHT. In this group 209 pts (62%) received G-CSF and 129 (38%) did not. 1043 pts with stable or decreased CA27.29 received G-CSF (47%) and 1175 did not (53%). This difference was highly significant (p<0.0001). Correlating the number of G-CSF cycles received during CHT with the absolute difference in Ca27.29 levels showed a highly significant positive correlation of 0.13 (Spearman-Rho; p<0.0001[two-sided]).Discussion and Conclusion:This analysis gives strong evidence that there is a dose dependent correlation between elevated levels of CA27.29 post CHT and the application of G-CSF. This might be attributed to an illegitimate expression of MUC-1 in leucocytes during leucopoiesis. Whether this effect is also related to the destruction of remaining disseminated tumor cells needs to be further evaluated.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6030.

Sequential Treatment with Epirubicin/Cyclophosphamide, Followed by Docetaxel Is Equieffective, but Less Toxic Than FEC120 in the Adjuvant Treatment of Breast Cancer Patients with Extensive Lymph Node Involvement: The German ADEBAR Phase III Study

Background: Based on meta-analytic evidence, taxane containing adjuvant chemotherapy has been established as standard treatment in node-positive breast cancer. However, in the MA-21 study, adriamycin-cyclophosphamide, followed by paclitaxel (AC-P) was significantly inferior to the gold standard of anthracycline treatment, FEC120 (Burnell, SABCS 2006). We prospectively compared a sequential epirubicin-docetaxel chemotherapy regimen to FEC120.Patients and Methods:The ADEBAR study was a multicenter phase III trial (n=1502) to evaluate whether breast cancer (BC) pts with > 3 axillary lymph node metastases benefit from a sequential anthracycline-docetaxel regimen (E90C–D: 4 cycles epirubicin [E] 90 mg/m2 plus cyclophosphamide [C] 600 mg/m2 q21 days followed by 4 cycles docetaxel [D] 100mg/m2 q21 days) compared to dose-intensive anthracycline-containing polychemotherapy (FE120C: 6 cycles E 60 mg/m² d 1+8, 5-FU 500mg/m² d 1+8 and C 75 mg/m² d 1-14, q4 weeks). The median follow-up time was 47 mts.(range 2-83 mts).Results:Treatment was stopped prematurely in 3.7% of the pts in the E90C–D arm and in 8.0% in the FE120C arm due to toxicity (p=0.0009). Antibiotic treatment was given in 10.4% (E90C–D) vs. 19.7% (FE120C), G-CSF support in 39.2% vs 61.4 % and erythropoietin stimulation in 8.7% vs. 20.0%, respectively (p<0.0001). Haematological toxicity (leucopenia, neutropenic fever, thrombocytopenia, anemia) was significantly higher in the FE120C-arm.At the time of the current analysis, 281 events of recurrence of breast cancer, were observed: 128 events in the FE120C group and 153 in the E90C–D group. The unadjusted hazard ratio (HR) was 0.88 (95 percent confidence interval, 0.694 to 1.115; p=0.2197, log-rank test). Overall survival in the two groups was not significantly different: (84 deaths with FE120C vs. 88 with E90C–D (HR 0.999, 0.738-1.352, p=0.99). Subgroup analyses, stratifying for tumor size, lymph node involvement, hormone receptor and HER2-neu status showed no significant difference between the two treatment arms.Conclusion:Different toxicity profiles given, hematological toxicity in the FE120C group was more severe than in the E90C–D.In contrast to AC-P in earlier studies, EC-Doc provides a feasible and effective alternative option to dose-intensified FEC with different saftey profile in this high risk breast cancer cohort.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 604.

Perilesional changes of focal osteochondral defects in an ovine model and their relevance to human osteochondral injuries

Perilesional changes of chronic focal osteochondral defects were assessed in the knees of 23 sheep. An osteochondral defect was created in the main load-bearing region of the medial condyle of the knees in a controlled, standardised manner. The perilesional cartilage was evaluated macroscopically and biopsies were taken at the time of production of the defect (T0), during a second operation one month later (T1), and after killing animals at three (T3; n = 8), four (T4; n = 8), and seven (T7; n = 8) months. All the samples were histologically assessed by the International Cartilage Repair Society grading system and Mankin histological scores. Biopsies were taken from human patients (n = 10) with chronic articular cartilage lesions and compared with the ovine specimens. The ovine perilesional cartilage presented with macroscopic and histological signs of degeneration. At T1 the International Cartilage Repair Society ‘Subchondral Bone’ score decreased from a mean of 3.0 (sd 0) to a mean of 1.9 (sd 0.3) and the ‘Matrix’ score from a mean of 3.0 (sd 0) to a mean of 2.5 (sd 0.5). This progressed further at T3, with the International Cartilage Repair Society ‘Surface’ grading, the ‘Matrix’ grading, ‘Cell Distribution’ and ‘Cell Viability’ grading further decreasing and the Mankin score rising from a mean of 1.3 (sd 1.4) to a mean of 5.1 (sd 1.6). Human biopsies achieved Mankin grading of a mean of 4.2 (sd 1.6) and were comparable with the ovine histology at T1 and T3.

The perilesional cartilage in the animal model became chronic at one month and its histological appearance may be considered comparable with that seen in human osteochondral defects after trauma.

Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study

BACKGROUND

The treatment of unstable displaced proximal humeral fractures, especially in the elderly, remains controversial. The objective of the present prospective, multicenter, observational study was to evaluate the functional outcome and the complication rate after open reduction and internal fixation of proximal humeral fractures with use of a locking proximal humeral plate.

METHODS

One hundred and eighty-seven patients (mean age, 62.9 +/- 15.7 years) with an acute proximal humeral fracture were managed with open reduction and internal fixation with a locking proximal humeral plate. At the three-month, six-month, and one-year follow-up examinations, 165 (88%), 158 (84%), and 155 (83%) of the 187 patients were assessed with regard to pain, shoulder mobility, and strength. The Constant score was determined at each interval, and the Disabilities of the Arm, Shoulder and Hand (DASH) score was determined for the injured and contralateral extremities at the time of the one-year follow-up.

RESULTS

Between three months and one year, the mean range of motion and the mean Constant score for the injured shoulders improved substantially. Twelve months after surgery, the mean Constant score for the injured side was 70.6 +/- 13.7 points, corresponding to 85.1% +/- 14.0% of the score for the contralateral side. The mean DASH score at the time of the one-year follow-up was 15.2 +/- 16.8 points. Sixty-two complications were encountered in fifty-two (34%) of 155 patients at the time of the one-year follow-up. Twenty-five complications (40%) were related to incorrect surgical technique and were present at the end of the operative procedure. The most common complication, noted in twenty-one (14%) of 155 patients, was intraoperative screw perforation of the humeral head. Twenty-nine patients (19%) had an unplanned second operation within twelve months after the fracture.

CONCLUSIONS

Surgical treatment of displaced proximal humeral fractures with use of the locking proximal humeral plate that was evaluated in the present study can lead to a good functional outcome provided that the correct surgical technique is used. Because many of the complications were related to incorrect surgical technique, it behooves the treating surgeon to perform the operation correctly to avoid iatrogenic errors.

Effects of G-CSF on circulating tumor cells (CTC) and CA 27.29 in breast cancer patients

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Background: Some recent publications indicated that the use of G-CSF could be connected to an increase in CTC as well as elevated levels of tumor markers such as CA 27.29. In the SUCCESS Trial CTC and CA27.29 are examined before and after adjuvant chemotherapy (CHT) in 3754 breast cancer patients (pts). Methods: The SUCCESS Trial is a phase III trial comparing FEC-Docetaxel vs. FEC-Doc-Gemcitabine regime and 2 vs. 5 years of treatment with zoledronate in patients with primary breast cancer (BC) (N+ or high risk). Blood samples are taken before and after CHT. CTC were assessed with the CellSearchSystem (Veridex, Warren, USA). After immunomagnetic enrichment with an anti-Epcam-antibody, cells were labeled with anti-cytokeratin (8,18,19) and anti-CD45 antibodies to distinguish epithelial cells and leukocytes. CA27.29 has been measured with ST AIA-PACK Ca27.29 reagent using MUC-1 for AIA-600II (Tosoh Bioscience, Tessenderlo, Belgium). The cutoff for CA27.29 is 32 U/ml and >1 cell for the CTC analysis. Patients were grouped to CTC/CA27.29 raise or no raise and 1 to 6 cycles with G-CSF or no G-CSF at all. Results: Data on 1510 pts are available for CTC analysis. 745 pts (49%) received at least one course of G-CSF. 117 pts (8%) showed an increase in CTC after CHT. In this group 52 (3%) pts received G-CSF and 65 (4%) did not. 693 pts with stable or decreased CTC received G-CSF (46%) and 700 did not (46%). There was no significant difference (p=0.29). The analysis of CA27.29 is based on the data of 2556 pts. 1252 pts (49%) received at least one course of G-CSF. 338 pts (13%) exceeded the threshold for CA27.29 only after CHT. In this group 209 pts (8%) received G-CSF and 129 (5%) did not. 1043 pts with stable or decreased CA27.29 received G-CSF (41%) and 1175 did not (46%). This difference was highly significant (p<0.0001). Conclusions: No evidence can be provided for a significant correlation between an increase in the number of CTC and the application of G-CSF over CHT. Nevertheless the results on CA27.29 showed a highly significant correlation between the administration of G-CSF and elevated CA27.29 levels directly after CHT. This could be a possible explanation for the often observed increase of tumor markers after CHT.

[Table: see text]

[Joint reconstruction with autologous bone cylinder and locked intramedullary nail: proximal humeral shaft fracture with ipsilateral reverse Hill-Sachs lesion]

The case of a 51-year-old patient is presented, with a humeral shaft fracture in combination with an ipsilateral reverse Hill-Sachs lesion, presumably after posterior shoulder dislocation as a result of an electrical accident followed by a fall from a ladder. After corresponding diagnostics, osteosynthesis of the shaft fracture was performed with a locked antegrade intramedullary nail. Simultaneously the reverse Hill-Sachs lesion was elevated und supplemented with the bone core that accrues during drilling of the nail entrance. In the follow-up period good fragment alignment, persistent joint stability and freedom of pain could be observed. On the basis of this case and the current literature the injury mechanism and potential therapy alternatives are discussed.

[Lesser tuberosity avulsion in combination with multifragment fracture of the greater tuberosity. A rare entity at the proximal humerus]

Isolated fractures of the greater tuberosity represent 14-21% of all proximal humeral fractures. Lesser tuberosity fractures have mainly been mentioned in case reports. We report a rare case of a combination of a lesser tuberosity avulsion with a multifragment fracture of the greater tuberosity of the proximal humerus in a young man. The injury mechanism might be a complex interaction between abduction and external rotation with impaction and shearing against the glenoid and acromion.

Cartilage tissue engineering by collagen matrix associated bone marrow derived mesenchymal stem cells

In this study we compared the in vitro formation of cartilaginous grafts composed of collagen type I hydrogel with both ovine primary articular chondrocytes (AC) and bone marrow derived mesenchymal stem cells (MSC). During 4 weeks of culture, aggregate properties were quantitatively verified, cell viability and the expression of cartilage markers were assayed. Different microscopic techniques indicated a subdivision of MSC based scaffolds into a central construct region with uniformly distributed stem cells with low levels of apoptosis, and peripheral layers of proliferative cells, which undergo differentiation. Immunohistochemical staining and quantitative measurements of sulfated glycosaminoglycans (s-GAG) of MSC hydrogels showed a significant increase in matrix deposition, mainly in outer areas. Furthermore, semi-quantitative RT-PCR of MSC specimens reflected a constant collagen type I activity with enhanced collagen type II, aggrecan and Sox9 expression which would suggest hyaline-like cartilage formation. We propose the application of MSC seeded grafts for the repair of focal cartilage lesions.

Fresh meniscal allograft transplantation and autologous ACL/PCL reconstruction in a patient with complex knee trauma following knee dislocation--a case report

Instability of the knee joint, particularly in combination with the loss of one meniscus, regularly leads to the early development of arthritis. This paper describes the case of a 19-year-old male with ruptures of the anterior (ACL) and posterior cruciate ligament (PCL) along with the loss of the medial meniscus due to knee dislocation. Combined, time-delayed reconstruction of both the ACL and PCL and the allogenic fresh meniscal transplantation of the medial meniscus without bone plugs were performed. The control arthroscopy performed 6 months post-transplantation revealed good vitality and integration of the grafts as assessed both macroscopically and histologically. A small portion of the posterior horn had to be refixated, and the anterior horn was atrophic. At 24 months after trauma and 13 months following meniscal transplantation, the patient achieved a Lysholm score of 88 points and clinical examination indicated a stable knee. Fresh meniscal allograft transplantation, in combination with autologous ACL and PCL reconstruction, constitutes--in specialized centers--an alternative treatment option for complex trauma of the knee joint with loss of a meniscus.

Die winkelstabile Plattenosteosynthese (LPHP®) proximaler Humerusfrakturen über den kleinen anterolateralen Delta-Splitting-Zugang - Technik und erste Ergebnisse

The Locking-Proximal-Humerus-Plate (LPHP) was slided from proximally to distally through a small anterior-lateral-deltoid-splitting-approach following a closed reduction. Additional tension band wiring for the rotator cuff was fixed at the plate after screw insertion. The prospective study included 35 patients (age median: 63 years, range: 33-92; male: 13, female: 22) from 08/01-05/02. The follow-up period was set to 3 months postoperatively, whereas 29 patients were able to attend. The patient-group with 2-part fractures (n = 8) showed an average Constant score of 77.6 points (+/- 10.7, "good"), the patients with 3-part fractures (n = 16) an average score of 75.1 points (+/- 14.4, "good") and the patients with 4-part fractures (n = 5) an average score of 64.8 points (+/- 10. 4, "moderate"). Specific, approach-related problems were not observed. Almost all fractures revealed bony union during the first 3 months and only one loss of reduction was found. A screw loosening in 2 cases and a break of the plate in 3 cases were seen as implant related problems, and furthermore in 5 cases the screws placed in the humeral head were too long. Only one early re-osteosynthesis with the same plate was necessary due to an initial non-correct reposition. As demonstrated by these good short-term results, this technique seems to be a suitable procedure for displaced humeral head fractures.

[Arthroscopy for anterior joint pathology at the upper ankle joint --pathogenesis, therapy and results]

The conservative treatment of chronic ankle pain and at the so-called "footballer's joint" is of limited success. Arthroscopy is a possibility of operative treatment. 25 arthroscopies were carried out at the upper ankle joint at anterior joint pathology from January 1998 to June 1999. 21 patients could be examined in a median follow-up of 16 months (4-24). The median age was 31 years (17-56; female: 6, male: 15). Synovilitis was found in all cases. In 9 cases exophytes of the tibia, in 10 cases osteochondral lesions and in 7 cases antero-lateral impingement ware seen. The preoperative Score of Mazur of median 63 (21-85) points showed a significant raise (p < 0.05) in follow-up to median 93 (81-100) points. The complete athletic rehabilitation could be restored in 2/3 of the patients. The conservative therapy represents a good method of treatment chronic troubles in the upper ankle joint. Arthroscopy is indicated if no recovery can be attained.

Proximal humeral fractures: how stiff should an implant be? A comparative mechanical study with new implants in human specimens

BACKGROUND

The objective of this study was to determine the in vitro characteristics of the clinically used and newly developed implants for the stabilization of proximal humeral fractures under static and cyclic loading. The goal was to optimize implant stiffness for fracture stabilization even in weak bone stock.

METHODS

In a laboratory study using 35 fresh human humeri, the specimens were randomized into 5 groups, which included the clinically used humerus T-plate (HTP), the cross-screw osteosynthesis (CSO), the unreamed proximal humerus nail with spiral blade (UHN), the recently developed Synclaw Proximal Humerus Nail (Synclaw PHN) and the angle-stable Locking Compression Plate Proximal Humerus (LCP-PH). The implant stiffness was determined for three clinically relevant load cases: axial compression, torsion and varus bending. In addition, a cyclic varus-bending test was performed to determine the implant properties under cyclic loading.

RESULTS

In contrast to a rather elastic and minimally invasive implant(LCP-PH), the conventionally designed ones (Synclaw PHN, CSO, HTP, UHN) showed rather high stiffness values under static loading. In cyclic loading, a strong decrease in stiffness ( p<0.05) was found for the rigid implants HTP and UHN. In comparison with the other implants, only the elastic implant (LCP-PH) showed a significantly lower load reduction in a weak bone stock (17+/-6.2%).

CONCLUSION

The high initial stiffness of rigid implants led to an early loosening and failure of the implant-bone interface under cyclic loading. Implants with low stiffness and elastic characteristics, however, appear to minimize the peak stresses at the bone-implant interface, making them particularly suitable for fracture fixation in osteoporotic bone.