Comparison of [(99m)Tc]tilmanocept and filtered [(99m)Tc]sulfur colloid for identification of SLNs in breast cancer patients

Background

The efficacy of sentinel lymph node (SLN) surgery requires targeted removal of first-draining nodes; however, frequently more nodes are removed than necessary. [^99mTc]tilmanocept (TcTM) is a molecular-targeted radiopharmaceutical specifically designed for SLN mapping. We evaluated technical outcomes of SLN biopsy in breast cancer patients mapped with TcTM + vital blue dye (VBD) versus filtered [^99mTc]sulfur colloid (fTcSC) + VBD.

Methods

There were 84 versus 115 patients in the TcTM versus fTcSC cohorts, respectively. Main measures were the number of SLNs removed per patient and factors influencing number of nodes removed. We also evaluated whether the radiotracer injected affected the proportion of positive nodes removed in node-positive patients.

Results

Fewer nodes were removed among patients mapped with TcTM compared to fTcSC (mean TcTM: 1.85 vs. fTcSC: 3.24, p < 0.001). Logistic regression analysis adjusted for tumor characteristics showed that injection of fTcSC (p < 0.001) independently predicted removal of greater than 3 nodes. A similar proportion of patients was identified as node-positive, whether mapped with TcTM or with fTcSC (TcTM: 24 % vs. fTcSC: 17 %, p = 0.3); however, TcTM detected a greater proportion of positive nodes among node-positive patients compared with fTcSC (0.73 vs. 0.43, p = 0.001).

Conclusions

Patients undergoing SLN biopsy with TcTM required fewer SLNs to identify the same rate of node-positive patients compared with fTcSC in breast cancer patients with similar risk of axillary metastatic disease. These data suggest that a molecularly targeted mechanism of SLN identification may reduce the total number of nodes necessary for accurate axillary staging.

Adipose-derived stem cells: methods for isolation and applications for clinical use

Adipose tissue sciences have rapidly expanded since the identification of regenerative cells contained within the stromal vascular fraction (SVF) of fat. Isolation of the SVF, containing adipose-derived stem cells (ADSC), can be accomplished efficiently in the operating room or in the laboratory through enzymatic digestion of the adipose tissue and concentration of SVF. Cells can be directly re-injected as a mesotherapeutic agent, recombined with a tissue scaffold (e.g., cell-enriched fat grafts) or expanded in culture for tissue-engineered cell therapeutics. The potential for cell therapy is under current investigation by researchers around the world. This chapter reviews laboratory methods for isolating ADSCs and the ongoing clinical trials evaluating cell therapeutic efficacy across many specialties, including cardiology, neurology, immunology, tissue engineering, sports medicine, and plastic and reconstructive surgery.

Evaluation of ultra-deep targeted sequencing for personalized breast cancer care

INTRODUCTION

The increasing number of targeted therapies, together with a deeper understanding of cancer genetics and drug response, have prompted major healthcare centers to implement personalized treatment approaches relying on high-throughput tumor DNA sequencing. However, the optimal way to implement this transformative methodology is not yet clear. Current assays may miss important clinical information such as the mutation allelic fraction, the presence of sub-clones or chromosomal rearrangements, or the distinction between inherited variants and somatic mutations. Here, we present the evaluation of ultra-deep targeted sequencing (UDT-Seq) to generate and interpret the molecular profile of 38 breast cancer patients from two academic medical centers.

METHODS

We sequenced 47 genes in matched germline and tumor DNA samples from 38 breast cancer patients. The selected genes, or the pathways they belong to, can be targeted by drugs or are important in familial cancer risk or drug metabolism.

RESULTS

Relying on the added value of sequencing matched tumor and germline DNA and using a dedicated analysis, UDT-Seq has a high sensitivity to identify mutations in tumors with low malignant cell content. Applying UDT-Seq to matched tumor and germline specimens from the 38 patients resulted in a proposal for at least one targeted therapy for 22 patients, the identification of tumor sub-clones in 3 patients, the suggestion of potential adverse drug effects in 3 patients and a recommendation for genetic counseling for 2 patients.

CONCLUSION

Overall our study highlights the additional benefits of a sequencing strategy, which includes germline DNA and is optimized for heterogeneous tumor tissues.

Impact of a clinical care online intake form in a breast care clinic

137

Background: An online self-reported clinical care intake form was provided to new surgery patients of the Moores UCSD Breast Care Clinic, as part of a pilot project in collaboration with the University of California Athena Breast Health Network. Clinical care goals were 1) to reduce clinic time by pre-visit collection of patient histories, co-morbidities, and medications and 2) provide patient reported data to clinicians and the electronic medical record (EMR). Clinical research goals were to 1) identify individuals diagnosed with breast cancer, 2) collect baseline measures related to co-morbidities, psychosocial parameters, and lifestyle factors and 3) increase research opportunities and enrollment. Methods: We developed an online intake form for patients to complete at home prior to their appointment. Patients were informed to complete the intake form before their appointment and were sent instructions via email. Patients without an email address had the opportunity to complete their intake form on an iPad in clinic. A summary of intake form answers was uploaded into the EMR for all patients. Patients could consent to future contact, to have their intake data kept in a research registry and/or to provide a blood or tissue sample. Results: From March 2010 to May 2013, 1,224 sequential new breast surgery clinic patients were contacted to complete the online intake form as part of their clinical care. 890 patients completed the intake form prior to their visit (73%). 802 of the 890 patients consented to contact for future research opportunities (90%) and 624 of the 802 consented to share data and EMR access for research (78%). We have coordinated enrollment with our ongoing UCSD biorepository study and have collected 210 blood and 51 tissue samples. Additionally, using future contact consent, we recruited more than 100 participants to multiple lifestyle and survey-based clinical studies. Conclusions: The use of an online intake form is well accepted by patients and provides patient reported data to all clinicians involved in patient care. In conjunction with consented EMR access, these data can be evaluated routinely for quality and efficiency purposes. Initial consent for future contact greatly facilitates participant recruitment to research studies.

Use of clinical care registries to facilitate research study recruitment

129

Background: We developed IRB-approved secure research registries for our Breast Imaging and Breast Care Clinics at Moores UC San Diego Cancer Center, as part of the UC statewide Athena Breast Health Network. Our clinical care registries securely store patient-reported intake data, which are summarized and uploaded into the medical record for patient care. Following consent, data are securely maintained in a separate research registry. In addition to facilitating quality assurance data collection, these registries aim to 1) maintain a data-rich research registry, 2) offer patients research opportunities, and 3) facilitate participant screening and recruitment into research studies. Methods: Breast Imaging or Breast Care clinic patients complete an online clinical intake form prior to their appointment, either at home or using an iPad in clinic, and are given the opportunity to be involved in research. Patients are asked for site-specific consent to keep personally identifiable intake data in a research registry, for consent to be approached about providing a biospecimen sample, and for consent to be contacted for future research opportunities. Data from consented participants are pulled into secure databases available to study personnel. Results: Participants to date include 4,480 patients, of whom 3,246 consented to use of data for research (72%), and 2,627 have agreed to be contacted for future research opportunities (59%). In a pilot biospecimen collection protocol, 46% of patients agreed to be approached and we have collected over 360 blood or saliva and 51 tissue samples. Additionally, with the use of future contact consent, we have facilitated recruitment of more than 370 participants to multiple lifestyle and survey-based clinical studies. Conclusions: Patients are willing to participate in research, especially in a research registry that requires little additional time on their part. The use of research registries allows collection of a variety of data elements useful for prescreening participants for research studies, including body mass index, age, menopausal status and breast cancer diagnosis. Data- and participant-rich research registries facilitate efficient screening and recruitment for other research studies.

Optimization via specific fluorescence brightness of a receptor-targeted probe for optical imaging and positron emission tomography of sentinel lymph nodes

The optical properties of a receptor-targeted probe designed for dual-modality mapping of the sentinel lymph node (SLN) was optimized. Specific fluorescence brightness was used as the design criterion, which was defined as the fluorescence brightness per mole of the contrast agent. Adjusting the molar ratio of the coupling reactants, IRDye 800CW-NHS-ester and tilmanocept, enabled us to control the number of fluorescent molecules attached to each tilmanocept, which was quantified by H1 nuclear magnetic resonance spectroscopy. Quantum yields and molar absorptivities were measured for unconjugated IRDye 800CW and IRDye 800CW-tilmanocept (800CW-tilmanocept) preparations at 0.7, 1.5, 2.3, 2.9, and 3.8 dyes per tilmanocept. Specific fluorescence brightness was calculated by multiplication of the quantum yield by the molar absorptivity and the number of dyes per tilmanocept. It predicted that the preparation with 2.3 dyes per tilmanocept would exhibit the brightest signal, which was confirmed by fluorescence intensity measurements using three optical imaging systems. When radiolabeled with Ga68 and injected into the footpads of mice, the probe identified SLNs by both fluorescence and positron emission tomography (PET) while maintaining high percent extraction by the SLN. These studies demonstrated the feasibility of 800CW-tilmanocept for multimodal SLN mapping via fluorescence and PET-computed tomography imaging.

Postmastectomy reconstruction is associated with improved survival in patients with invasive breast cancer: a single-institution study

Breast reconstruction after mastectomy positively affects psychosocial well-being; however, the influence of reconstruction on cancer outcomes is unknown. The objective of our study was to compare survival in reconstructed versus nonreconstructed patients after mastectomy. All consecutive female patients diagnosed with invasive breast cancer and treated with mastectomy between 2002 and 2011 were identified from our single-institution database. All cancer operations were performed by two surgeons. Survival was calculated using the Kaplan-Meier method and compared using the log-rank test. To identify the effect of reconstruction on survival, a multivariate Cox regression analysis was performed. Of 474 patients treated, 340 (71.7%) underwent breast reconstruction. At a mean follow-up 3.3 years, reconstructed patients had a longer 5-year survival (91 vs 74%, P < 0.001). After controlling for age, race, payer source, cancer stage, triple negative status, and receipt of radiation or chemotherapy, reconstructed patients maintained a survival advantage over nonreconstructed patients (hazard ratio, 0.47; 95% confidence interval, 0.25 to 0.88; P = 0.02). Patients with breast cancer who undergo reconstruction have longer survival than nonreconstructed patients. The explanation for this finding may be related to improved psychosocial qualities of life versus possible antitumorigenic effects of implants.

Comparison of [99mTc] tilmanocept and [99mTc] sulfur colloid for identification of sentinel lymph nodes in clinically node-negative breast cancer patients

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Background: Receptor-targeted (CD206) [99mTc] tilmanocept is a radiopharmaceutical specifically engineered for sentinel lymph node (SLN) identification that has recently completed phase III clinical trials. The agent has been compared to vital blue dye in prior studies, but has not yet been compared to radio-labeled sulfur colloid. We compared the performance of [99mTc]tilmanocept vs. filtered [99mTc]sulfur colloid (fTcSC) in two cohorts of clinically node-negative breast cancer patients (BCP) who underwent SLN mapping at a single institution. Outcomes were degree of SLN localization and % positive nodes among those removed. Methods: The [99mTc]tilmanocept cohort was composed of UCSD-specific patients pooled from two phase III clinical trials (Jun 2008-Jun 2009, Jul 2010-Apr 2011); the fTcSC cohort was composed of consecutive BCP undergoing SLN mapping at UCSD (Mar 2011-Feb 2012). Demographic, lymph node-specific, and cancer characteristics were compared between groups. A zero-inflated binomial model compared %-positive nodes among nodes removed. Results: There were 85 vs.120 patients in the [99mTc]tilmanocept and fTcSC cohorts, respectively. The groups did not differ in demographic or clinicopathologic factors predictive of axillary metastatic disease (age, race, cancer stage, histologic subtype and grade, hormone and HER2-Neu status or presence of lymphovascular invasion). The [99mTc]tilmanocept group had significantly fewer SLNs removed (mean 1.9 vs. 3.9, p<0.001), achieved higher gamma counts/node (28 vs. 1.6 kcps, p<0.001), and detected a significantly higher percent of tumor-positive SLNs (73% vs. 49%, p=0.016) while identifying the same rate of node-positive patients (24% vs. 18%, p=0.4). Conclusions: [99mTc]Tilmanocept identified the same rate of node positive patients and removed fewer SLNs compared to fTcSC among BCP with similar risk of axillary metastatic disease. These data suggest that [99mTc]tilmanocept more precisely targets true SLNs and may minimize morbidity while maintaining or improving the accuracy of axillary staging in clinically node-negative breast cancer patients.

An ex vivo investigation of the effect of the TATE canine elbow arthroplasty system on kinematics of the elbow

OBJECTIVE

To devise a kinematic technique to objectively ascertain the location and orientation of the centre of rotation of the canine elbow and to compare this axis following arthroplasty with the first generation TATE™ prosthesis in an ex vivo model.

METHODS

Five pairs of cadaveric forelimbs were obtained and proximal limb soft tissues removed. Pin-mounted reflective markers were applied to the humerus and ulna. Limbs were mounted on a frame and six trials of the elbow manually cycled through its sagittal range of motion captured using 4 Qualisys cameras at 120 Hz. Radiography was performed to identify marker position. TATE™ cartridges were implanted and kinematic analysis repeated. Kinematic data were imported into custom software and the three-dimensional joint centre of rotation defined using a closed-form solution for absolute orientation. Paired t tests were performed to determine if the centre of rotation of the elbow differed significantly (P<0·05) pre- and postoperatively and between left and right limbs.

RESULTS

There was no significant difference in three-dimensional orientation of the elbow axis between pre and postoperative measurements or between left and right limbs.

CLINICAL SIGNIFICANCE

A critical factor in obtaining a successful functional outcome following elbow arthroplasty in humans is accurate reconstruction of the anatomic centre of rotation. The first generation TATE canine elbow arthroplasty cartridge and its instrumentation accurately reconstructed the anatomic centre of rotation in 8 of the 10 elbows assessed in this ex vivo model.

Comparative evaluation of [(99m)tc]tilmanocept for sentinel lymph node mapping in breast cancer patients: results of two phase 3 trials

BACKGROUND

Sentinel lymph node (SLN) surgery is used worldwide for staging breast cancer patients and helps limit axillary lymph node dissection. [(99m)Tc]Tilmanocept is a novel receptor-targeted radiopharmaceutical evaluated in 2 open-label, nonrandomized, within-patient, phase 3 trials designed to assess the lymphatic mapping performance.

METHODS

A total of 13 centers contributed 148 patients with breast cancer. Each patient received [(99m)Tc]tilmanocept and vital blue dye (VBD). Lymph nodes identified intraoperatively as radioactive and/or blue stained were excised and histologically examined. The primary endpoint, concordance (lower boundary set point at 90 %), was the proportion of nodes detected by VBD and [(99m)Tc]tilmanocept.

RESULTS

A total of 13 centers contributed 148 patients who were injected with both agents. Intraoperatively, 207 of 209 nodes detected by VBD were also detected by [(99m)Tc]tilmanocept for a concordance rate of 99.04 % (p < 0.0001). [(99m)Tc]tilmanocept detected a total of 320 nodes, of which 207 (64.7 %) were detected by VBD. [(99m)Tc]Tilmanocept detected at least 1 SLN in more patients (146) than did VBD (131, p < 0.0001). In 129 of 131 patients with ≥1 blue node, all blue nodes were radioactive. Of 33 pathology-positive nodes (18.2 % patient pathology rate), [(99m)Tc]tilmanocept detected 31 of 33, whereas VBD detected only 25 of 33 (p = 0.0312). No pathology-positive SLNs were detected exclusively by VBD. No serious adverse events were attributed to [(99m)Tc]tilmanocept.

CONCLUSION

[(99m)Tc]Tilmanocept demonstrated success in detecting a SLN while meeting the primary endpoint. Interestingly, [(99m)Tc]tilmanocept was additionally noted to identify more SLNs in more patients. This localization represented a higher number of metastatic breast cancer lymph nodes than that of VBD.

The pedicled myocutaneous flap as a choice reconstructive technique for immediate adjuvant brachytherapy in sarcoma treatment

Successful treatment of soft-tissue sarcomas is highly dependent on total tumour resection coupled with adjuvant radiation therapy to achieve local control and decrease recurrence. Reconstruction of soft-tissue defects after resection aims to cover vital structures, while providing enough stable tissue to withstand adjuvant brachytherapy treatment. In the present study, pedicled myocutaneous flaps were used as a vital adjunct in the treatment of soft-tissue sarcoma, and our experience with 2 such patients is described. The flaps served to reconstruct large three-dimensional defects while providing stable coverage over brachytherapy hardware to allow for delivery of radiation in the immediate postoperative period. Pedicled locoregional myocutaneous flaps provide a safe, easy, and reliable reconstructive technique in the treatment of soft-tissue sarcoma.

Abstract P2-06-01: Breast-to-breast metastasis can cause hormone-receptor positive/triple negative bilateral synchronous tumors

Background: Prior work suggests that synchronous bilateral breast cancers may be clonal, with one tumor a metastasis, although prior techniques lacked resolution to prove this relationship. We used deep whole exome and shallow whole genome sequencing to compare bilateral tumors in two cases. In both cases, tumors were invasive and node negative with one tumor ER+/PR+/HER2− (HR+) lobular and the other triple negative (TN) ductal. Case 1 is a 75-year-old African American woman and Case 2 a 70-year-old white woman. With 44 and 12 months of follow up, respectively, neither patient has recurred.

Methods: Agilent SureSelect All Exon 50Mb Target Enrichment Kits were used for exome capture. Paired-end sequencing was performed with 200 base pair reads on the Illumina HiSeq 2000. Sequencing depth was targeted to cover 80% of the genome at 100x for three tumors with 70% cellularity, 200x for one tumor with 40% cellularity and 30x for germline. Tumor and germline exome results were compared to identify high confidence somatic single nucleotide variants (HC SNV). HC SNV's were called using GATK and stringent custom filtering to avoid false positives resulting from unrecognized germline single nucleotide polymorphisms. For each tumor pair, we define a clonality likelihood score (CLS) as the ratio of the number of HC SNV called at the same site and with the same alternate base in both tumors, to the total number of sites with an HC SNV called in either tumor. For comparison we analyzed the called SNV data from The Cancer Genome Atlas (TCGA) for exome sequenced HR+ or TN breast cancers.

Results: In Case 1, of 102 HC SNVs called in either tumor, 82 were shared, for a CLS of 80.3%. Additionally, 11 shared SNVs were synonymous, consistent with clonality. Lastly the non-shared HC SNVs were asymmetrically found in the TN tumor, consistent with clonal evolution during metastasis. Copy number analysis (CNA) showed Case 1 to have a deletion in 6q, including the ESR1 gene, unique to the TN tumor.

To assess significance of the CLS, we found three primary/metastatic clonal pairs in the TCGA to serve as positive controls. To serve as negative controls, from 357 ER+ and 46 TN primary TCGA tumors, we formed a total of 16,422 independent ER+/TN pairs. For the 3 clonal TCGA pairs, the CLS values were 39.3%, 58.5% and 60.0%. Most of the independent TCGA pairs had a CLS of zero (98.5%), with a maximum CLS of 2.8%. As the CLS for Case 1 lies above maximum observed CLS among 16,422 independent tumor pairs, we reject the hypothesis that this tumor pair is independent, at p &lt; 0.0001. For Case 2, of 222 HC SNV sites, 5 were shared for a CLS of 2.3%, consistent with independence.

Conclusion: Somatic single nucleotide mutations identified by exome sequencing found that the two tumors in Case 1 share &gt;80% of SNVs, consistent with clonal evolution of metastasis. The two tumors from Case 2 have few shared SNVs, consistent with independent origin. CNA results were consistent. This is the first clonality analysis reported from deep sequencing of phenotypically discordant synchronous bilateral breast cancers, and demonstrates that next-generation sequencing can distinguish clonal from independent tumor pairs with high confidence.

Funding: The Breast Cancer Research Foundation

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P2-06-01.

Combined analysis of phase III trials evaluating [⁹⁹mTc]tilmanocept and vital blue dye for identification of sentinel lymph nodes in clinically node-negative cutaneous melanoma

Background

[^99mTc]Tilmanocept is a CD206 receptor-targeted radiopharmaceutical designed for sentinel lymph node (SLN) identification. Two nearly identical nonrandomized phase III trials compared [^99mTc]tilmanocept to vital blue dye.

Methods

Patients received [^99mTc]tilmanocept and blue dye. SLNs identified intraoperatively as radioactive and/or blue were excised and histologically examined. The primary end point, concordance, was the proportion of blue nodes detected by [^99mTc]tilmanocept; 90 % concordance was the prespecified minimum concordance level. Reverse concordance, the proportion of radioactive nodes detected by blue dye, was also calculated. The prospective statistical plan combined the data from both trials.

Results

Fifteen centers contributed 154 melanoma patients who were injected with both agents and were intraoperatively evaluated. Intraoperatively, 232 of 235 blue nodes were detected by [^99mTc]tilmanocept, for 98.7 % concordance (p < 0.001). [^99mTc]Tilmanocept detected 364 nodes, for 63.7 % reverse concordance (232 of 364 nodes). [^99mTc]Tilmanocept detected at least one node in more patients (n = 150) than blue dye (n = 138, p = 0.002). In 135 of 138 patients with at least one blue node, all blue nodes were radioactive. Melanoma was identified in the SLNs of 22.1 % of patients; all 45 melanoma-positive SLNs were detected by [^99mTc]tilmanocept, whereas blue dye detected only 36 (80 %) of 45 (p = 0.004). No positive SLNs were detected exclusively by blue dye. Four of 34 node-positive patients were identified only by [^99mTc]tilmanocept, so 4 (2.6 %) of 154 patients were correctly staged only by [^99mTc]tilmanocept. No serious adverse events were attributed to [^99mTc]tilmanocept.

Conclusions

[^99mTc]Tilmanocept met the prespecified concordance primary end point, identifying 98.7 % of blue nodes. It identified more SLNs in more patients, and identified more melanoma-containing nodes than blue dye.

A receptor-targeted fluorescent radiopharmaceutical for multireporter sentinel lymph node imaging

PURPOSE

To determine the imaging and receptor-binding properties of a multireporter probe designed for sentinel lymph node (SLN) mapping via nuclear and fluorescence detection.

MATERIALS AND METHODS

The animal experiments were approved by the institutional animal care and use committee. A multireporter probe was synthesized by covalently attaching cyanine 7 (Cy7), a near-infrared cyanine dye, to tilmanocept, a radiopharmaceutical that binds to a receptor specific to recticuloendothelial cells. In vitro binding assays of technetium 99m (99mTc)-labeled Cy7 tilmanocept were conducted at 4°C by using receptor-bearing macrophages. Optical SLN imaging after foot pad administration was performed by using two molar doses of Cy7 tilmanocept. Six mice were injected with 0.11 nmol of 99mTc-labeled Cy7 tilmanocept (low-dose group); an additional six mice were injected with 31 nmol of 99mTc-labeled Cy7 tilmanocept (high-dose group) to saturate the receptor sites within the SLN. After 2.5 hours of imaging, the mice were euthanized, and the sentinel and distal lymph nodes were excised and assayed for radioactivity for calculation of SLN percentage of injected dose and extraction. Four mice were used as controls for autofluorescence. Standard optical imaging software was used to plot integrated fluorescence intensity against time for calculation of the SLN uptake rate constant and scaled peak intensity. Significance was calculated by using the Student t test.

RESULTS

In vitro binding assays showed subnanomolar affinity (mean dissociation constant, 0.25 nmol/L±0.10 [standard deviation]). Fluorescence imaging showed a detection sensitivity of 1.6×10(3) counts·sec(-1)·μW(-1) per picomole of Cy7. All four imaging metrics (percentage of injected dose, SLN extraction, SLN uptake rate constant, and expected peak fluorescence intensity) exhibited higher values (P=.005 to P=.042) in the low-dose group than in the high-dose group; this finding was consistent with receptor-mediated image formation.

CONCLUSION

The multireporter probe 99mTc-labeled Cy7 tilmanocept exhibits in vitro and in vivo receptor-binding properties for successful receptor-targeted SLN mapping with nuclear and optical imaging.

The efficacy of Tilmanocept in sentinel lymph mode mapping and identification in breast cancer patients: a comparative review and meta-analysis of the ⁹⁹mTc-labeled nanocolloid human serum albumin standard of care

Sentinel lymph node (SLN) mapping is common, however question remains as to what the ideal imaging agent is and how such an agent might provide reliable and stable localization of SLNs. (99m)Tc-labeled nanocolloid human serum albumin (Nanocoll) is the most commonly used radio-labeled colloid in Europe and remains the standard of care (SOC). It is used in conjunction with vital blue dyes (VBDs) which relies on simple lymphatic drainage for localization. Although the exact mechanism of Nanocoll SLN localization is unknown, there is general agreement that Nanocoll exhibits the optimal size distribution and radiolabeling properties of the commercially available radiolabel colloids. [(99m)Tc]Tilmanocept is a novel radiopharmaceutical designed to address these deficiencies. Our aim was to compare [(99m)Tc]Tilmanocept to Nanocoll for SLN mapping in breast cancer. Data from the Phase III clinical trials of [(99m)Tc]Tilmanocept's concordance with VBD was compared to a meta-analysis of a review of the literature to identify a (99m)Tc albumin colloid SOC. The primary endpoints were SLN localization rate and degree of localization. Six studies were used for a meta-analysis to identify the colloid-based SOC. Five studies (6,134 patients) were used to calculate the SOC localization rate of 95.91 % (CI 0.9428-0.9754) and three studies (1,380 patients) were used for the SOC SLN degree of localization of 1.6683 (CI 1.5136-1.8230). The lower bound of the confidence interval was used for comparison to Tilmanocept. Tilmanocept data included 148 patients, and pooled analysis revealed a 99.99 % (CI 0.9977-1.0000) localization rate and degree of localization of 2.16 (CI 1.964-2.3600). Tilmanocept was superior to the Nanocoll SOC for both endpoints (P < 0.0001).

Tracking With a Hierarchical Partitioned Particle Filter and Movement Modelling

We present an approach to track human subjects using an articulated human framework. First, we describe the articulated hierarchical human model. Second, we develop a stochastic hierarchical, partitioned, particle filter based on the natural structure and limb dependency of the human body. We apply this to track human subjects in video sequences using likelihoods adapted to the hierarchical process. Finally, we evaluate the effectiveness of the described approach using publicly available datasets.

Recent trends and clinical features of childhood vitamin D deficiency presenting to a children's hospital in Glasgow

BACKGROUND

The incidence of vitamin D deficiency is unclear in the context of continuing demographic changes and the introduction of new public health measures.

METHODS

All cases in which vitamin D deficiency was suspected as the primary cause of the clinical presentation were studied.

RESULTS

Between 2002 and 2008, 160 cases of symptomatic vitamin D deficiency were identified with twice as many cases in 2008 (n, 42) as in the previous years. The median age of the cohort was 24 months (range 2 weeks-14 years).Three cases were recorded in children of European background, whereas the rest were in children of South Asian, Middle Eastern or sub-Saharan ethnic background. Presenting features included bowed legs in 64 (40%) and a fit in 19 (12%). In one infant, concerns were raised following a presentation with cardiac failure and hypocalcaemia.

SUMMARY

Symptomatic vitamin D deficiency remains prevalent in the West of Scotland. There is a need for effective public health education, action and surveillance.

A multicentre evaluation of the new Beckman Coulter anti-Müllerian hormone immunoassay (AMH Gen II)

Background

The measurement of anti-Müllerian hormone (AMH) has been by two commercial enzyme-linked immunosorbent (ELISA) assays: Diagnostics Systems Laboratory (DSL 10-14400) and Immunotech (A11893 IVD EU only). Beckman Coulter has developed a new assay for AMH (AMH Gen II A79765), which uses the DSL antibodies but is standardized to the Immunotech calibration. As a result, comparative data are urgently required between the old DSL assay and its replacement AMH Gen II.

Methods

An evaluation of the AMH Gen II assay was performed at three sites, each with extensive experience of measuring circulating AMH in the adult female. Results were compared with the original DSL ELISA assay. The analysis was performed on a total of 271 patients' samples, approximately 90 at each site.

Results

Performance characteristics were evaluated for the AMHGen II assay. Linearity was acceptable with observed values close to the expected (mean recovery 106.3%). The functional sensitivity (20% coefficient of variation), calculated from precision profile data, was 1.5 pmol/L. Within- and between-batch imprecision, assessed over the concentration range of 5–70 pmol/L, were 5.3–11.4% and 3.8–17.3%, respectively. There was good agreement between assays with a Bablok-Passing regression equation AMH Gen II = 1.40 DSL–0.62 pmol/L, r = 0.96, n = 271.

Conclusions

Our results demonstrate that similar precision and excellent between-assay agreement should be obtained when laboratories change from the DSL to the AMH Gen II ELISA and they should expect an increase in AMH values of approximately 40%.

Abstract LB-416: Evaluation of phase 3 multicenter clinical data of receptor targeted (CD206) Tc99m-tilmanocept for sentinel node evaluation (ILM) in breast cancer and melanoma

Background: Sentinel lymph node (SLN) mapping is widely used for staging clinically node-negative breast cancer and melanoma. [99mTc]tilmanocept is a new receptor-targeted (CD206) radiopharmaceutical designed for SLN mapping. The purpose of this review is to report the results of the Phase 3 clinical data designed to assess the concordance of [99mTc]tilmanocept with vital blue dye, considered the standard for identifying sentinel lymph nodes in these two malignancies.

Methods: The Phase 3 program was a multicenter, prospective, open label, evaluation of [99mTc]tilmanocept in patientswith clinically localized melanoma or breast cancer. Within the Intent-to-treat population, [99mTc]tilmanocept and vital blue dye were administered to patients and standard SLN mapping was performed, during which all identified radioactive and/or blue-stained lymph nodes were excised and histologically examined. The primary endpoint was concordance of [99mTc]tilmanocept with vital blue dye. The patient concordance rate was defined as the percentage of patients for whom all nodes detected by blue dye were also detected by [99mTc]tilmanocept.

Results: At least one blue-stained lymph node was exhibited by 91% patients and 98.0% had at least one “hot” node. The concordance of [99mTc]tilmanocept with vital blue dye was statistically significant with ∼98% concordant. Of the melanoma patients, ∼97% were concordant; and within the breast cancer patients, ∼99% were concordant. In contrast, vital blue dye had a concordance rate with [99mTc]tilmanocept of &lt;55%. No severe adverse events were related to the administration of [99mTc]tilmanocept.

Conclusions: [99mTc]Tilmanocept was well tolerated and effectively identifies sentinel nodes with a statistically significant degree of concordance to blue dye in either breast cancer or melanoma surgery. Additional outcomes will be presented. (Also refer to ClinicalTrials.gov, key word, tilmanocept)

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr LB-416. doi:10.1158/1538-7445.AM2011-LB-416

Abstract 1604: Development of breast cancer patient-derived xenograft models as preclinical tool for drug discovery

Based on gene expression profile and hormone receptor status breast cancer is usually classified into the following subtypes, luminal A, luminal B, Her2 overexpressed, basal, normal-like, and the newly identified subtype, claudin-low. For a long time sub-cutaneous and orthotopic xenograft of established human cancer cell lines have served as the primary in vivo models for drug evaluation preclinically, however their prognostic value to clinical trials has not been to our satisfaction. In an effort to overcome the limitations of traditionally used cell line models and to develop preclinical models that better represent the diversity of human breast cancer, we generated a series of human -in-mouse orthotopic xenograft models using primary tumor specimens from patients. These models are characterized in depth, including tumor histology, genomics, gene expression profiles, and chemosensitivities to standard of care compounds. They will serve as great tools to breast cancer research and discovery.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 1604. doi:10.1158/1538-7445.AM2011-1604

Abstract P3-12-06: Biomarkers of Malignant Potential in Breast Tissue in Relation to Short-Term Breast Cancer Risk

Background:

Biomarkers expressed in benign or normal breast tissue may be important indicators of subsequent risk of malignancy, but investigations identifying such have been few. Limited previous evidence suggests that loss of expression of several breast cancer tumor markers in benign tissue, relative to normal tissue, may contribute to malignant progression. We examined expression of markers implicated in tumorigenesis among women who developed breast cancer shortly after benign biopsy. Material and Methods:

We conducted a nested case-control study within a population-based cohort of 15,000 women who received benign breast biopsies between 1996 and 2005 in six New Mexico counties. We identified 95 women who developed breast cancer within 5 years of biopsy, and matched them to 3 similar controls who did not develop cancer. Benign breast as well as adjacent normal tissue was assayed using immunohistochemistry for epithelial and stromal markers plausibly related to risk of cancer development. Logistic regression models were employed to estimate odds ratios and 95% confidence intervals for breast cancer risk after adjustment for age, race/ethnicity, and risk category of benign biopsy. Results:

Women who expressed estrogen receptor alpha in their normal tissue (10% or greater staining) had a 2.9-fold increased breast cancer risk (95% confidence interval (CI) 1.0-8.3). Those who expressed Cytokeratin 5/6 (Odds ratio (OR) 3.3; 95% CI 1.2-8.8) or Her2/neu (30% or greater staining) (OR 8.2; 95% CI 0.9-70.6) in normal tissue also appeared to have an elevated breast cancer risk, relative to those with expression below the threshold. In contrast, the presence of these markers in benign tissue was unrelated to subsequent development of breast cancer. Estrogen receptor staining of 10% or greater in normal tissue, but absence of staining in benign tissue, was not a risk factor for progression to breast malignancy (OR 4.9; 95% CI 0.7-34.8) Discussion:

Our results suggest that biomarker expression in normal breast tissue may be an important component of risk assessment among women whoreceive benign breast biopsies. Findings such as these aim to identify women at highest risk for breast cancer development, allowing for the implementation of more frequent follow-up and new targeted interventions, while classifying most women as at low risk, providing reassurance and reducing the need for chemoprevention.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-12-06.

Abstract P2-06-16: Total Choline Measurement in Human Breast Using High-Speed MR Spectroscopic Imaging at 3T

PURPOSE: We developed a novel, quantitative and high-speed MR spectroscopic imaging (MRSI) method to map total Choline (tCho), a sensitive biomarker of breast tumor status, as an adjunct to enhance the limited specificity of routine dynamic-contrast enhanced (DCE) MRI. Quantitative tCho maps measured in 7 minutes were compared with tCho obtained with conventional Single Voxel Spectroscopy (SVS). METHOD AND MATERIALS: Measurements on a total of 18 healthy female subjects (mean age: 25.6±5) were performed using 3T MR scanners (Siemens Trio, Erlangen, Germany) located at the two partner sites equipped with 4-channel breast coil (Siemens, Erlangen, Germany) or 8-channel breast coil (Sentinelle Medical, Toronto, Canada). 2D MRSI data of an entire oblique slice were collected using Proton-Echo-Planar-Spectroscopic-Imaging (PEPSI) [1] with MEGA lipid suppression. Acquisition parameters were: TR/TE=1500ms/125ms, matrix size=32x32, voxel size=2x2x2mm3 (8cc), number of signal averages= 16 with weighted k-space sampling and total acquisition time=7 minutes. PRESS SVS data were acquired with 8 cc voxel size using identical TR/TE and acquisition time. The absolute metabolite concentration was calculated in reference to tissue water (millimoles of tCho per kilogram of solute) using LCModel (s-provencher.com) fitting to estimate the Choline peak baseline and subsequent spectral integration using a Cramer-Rao lower bound threshold of 25%.

RESULTS: tCho was detected in 7 of the 15 subjects (47%) in both SVS and PEPSI data. In the PEPSI data sets, tCho was detected in multiple voxels (Fig. 1). Subjects in which tCho was detected exhibited narrower water line width and smaller lipid content than subjects in which tCho was not detectable (2-tailed t-test, P&lt;0.01). The absolute tCho concentrations corrected for relaxation effects in these 7 subjects using SVS and PEPSI was 0.43±0.34 mmol/kg and 0.51±0.19 mmol/kg, respectively. In comparison with SVS data (21.8±8.6Hz), PEPSI spectra demonstrated larger water line width (33.9±12.6Hz) and displayed greater lipid contamination from adipose tissue areas and larger baseline distortion due to the spatial point spread function.

CONCLUSION: Despite less favorable shimming and lipid suppression conditions compared to SVS, it is feasible to quantitatively map tCho in healthy breast tissue using high-speed MRSI, with concentration values that are consistent with those from SVS. Studies in breast cancer patients are in progress to assess the feasibility of breast cancer diagnosis and treatment monitoring with MRSI. Results will be reported at the Symposium. The long-term goals are to utilize high-speed MRSI as an early predictor of treatment failure in women undergoing systemic therapy (i.e. chemotherapy, endocrine therapy) for breast cancer and to develop an improved screening protocol for high risk patients. Fig. 1: PEPSI slice localization (left) and spectral array (right) with superimposed LCModel fit and integrated tCho peak

Ref: (1) Posse et al. Magn. Reson. Med. 2007;58(2):236-244.

Comparison of the prognostic value of tumour- and patient-related factors in patients undergoing potentially curative surgery for colon cancer

AIM

To comprehensively compare the prognostic value of tumour- and patient-related factors in patients undergoing curative surgery for colon cancer.

METHOD

From a database of 287 patients who underwent elective resection between 1997 and 2005, tumour factors including stage and host factors including systemic inflammatory response [modified Glasgow Prognostic Score (mGPS)] were identified.

RESULTS

Median follow-up was 65 months. Over this period, 125 patients died, 80 from cancer. On multivariate analysis of all significant patient and tumour related factors, Dukes stage (P < 0.01), vascular invasion (P < 0.01) and the mGPS (P < 0.01) were independently associated with cancer-survival. Of the patient-related factors, age (P < 0.01), haemoglobin (P < 0.01), white-cell (P < 0.01), neutrophil (P < 0.01) and platelet (P < 0.01) counts, and alkaline phosphatase (P < 0.01) were most significantly associated with the mGPS.

CONCLUSION

In addition to tumour-related factors such as Dukes stage and vascular invasion, the preoperative mGPS should be included to guide prognosis in patients undergoing curative resection for colon cancer.