P2-09-02: Predicting Response to Bevacizumab in Primary Breast Cancer Using 18F-Fluorothymidina (FLT) and 18F-Misonidazole (MISO) Positron Emission/Computed Tomography (PET/CT) as Imaging Biomarkers

Background: To investigate the hypothesis that early changes in tumor proliferation and hypoxic status induced by bevacizumab and assessed by imaging biomarkers might predict response to bevacizumab therapy.

Methods: 73 chemotherapy naïve, stage II-III breast cancer (BC) patients (pts) were enrolled in the training set of this phase II, single-arm, multicenter and prospective clinical trial from October 2009 until November 2010. Pts received single infusion of bevacizumab (15 mg/kg) (C1) 3 weeks prior to the beginning of neoadjuvant chemotherapy (NAC) consisting in 4 cycles of docetaxel (60 mg/mq), doxorubicin (50 mg/mq) and bevacizumab (15 mg/kg) every 21 days (C2-C5) following by surgery. Tumor proliferation and hypoxic status were evaluated using FLT and MISO PET/CT at baseline and 14–21 days after bevacizumab (C1). Standardized uptake values (SUV) for FLT and MISO and ratios to reference tissues, mediastinum (T/Me) or muscle (T/Mu), for MISO were calculated. Pathological response on surgical specimens was assessed according to Miller/Payne grading system. Pts with reduction in tumor cells >30% (G3-G4-G5) or <30% (G1-G2) were respectively considered as responders and no-responders. Association between pathological response, baseline and changes induced by bevacizumab (C1) in imaging biomarkers was analyzed using Mann-Whitney test. Receiver operating characteristic (ROC) curve was performed to test sensitivity and specificity of the biomarker found associated to response. Its value as independent predictor was tested in multivariate analysis using logistic regression. Results: Median baseline MISO and FLT SUV values in tumors were 1.2 (range 0.69−2.39) and 2.89 (range 0.97−7.18). Significant change after C1 was observed in FLT (2.7 vs 1.8, p<0.001) but no in MISO uptake. Fifty-two (74%) pts achieved response (G3-G4-G5) whether 18 (24%) were considered as no responder (G1-G2); for 3 (4%) patients Miller/Payne tumor evaluation was not available. Response showed a trend toward an association with negative estrogen receptors (ER) expression (p=0.08) and triple negative tumors (11/73) (p=0.05). FLT SUV baseline and changes after C1 in MISO SUV, T/Mu and T/Me were all significantly associated with pathological response (p=0.057, 0.03, 0.016, 0.010). ER expression and T/Mu change remained significantly associated with response in multivariate analysis (OR=24.8, IC95% 1.8-334, p=0.01 and OR=0.95, IC 95% 0.92−0.99, p value=0.02). Decrease in MISO T/Mu uptake >20% yielded a ROC curve area of 0.7 (95% CI: 0.56 - 0.85) with 94% sensitivity and 87% specificity. Conclusion: Bevacizumab determined a marked decrease in tumor proliferation. Interestingly, a decrease greater than 20% in tumor hypoxic status after C1 and assessed by MISO was found significantly associated with pathological response suggesting a potential value of early decrease in hypoxic tumor status as predictive biomarker of response. Bevacizumab, causing normalization of the tumor microvasculature, seems to potentiate the effect of cytotoxic agents on primary BC. A validation set is warranted to confirm these findings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-09-02.

P2-08-05: Use of Dynamic Contrast-Enhanced MR Imaging To Predict Pathological Response in Primary Breast Cancer

Purpose: To investigate the effect of bevacizumab infusion on vascular parameters assessed by dynamic contrast-enhanced magnetic resonance (DCE-MR) imaging and to test their association with pathological response in primary breast cancer.

Materials and Methods: 73 patients (median age, 47 ys; age range, 29–70 ys) with biopsy-proven, previously untreated, primary breast cancer were recruited from October 2009 to November 2010 in this phase II, multicenter and non-randomized clinical trial. Patients (pts) received single infusion of bevacizumab (15 mg/kg) (C1) 3 weeks prior to the beginning of neoadjuvant chemotherapy consisting in 4 cycles of docetaxel (60 mg/mq), doxorubicin (50 mg/mq) and bevacizumab (15 mg/kg) every 21 days (C2-C5) following by surgery. All pts underwent DCE-MR imaging before and 14–21 days after C1. Quantitative and semiquantitative kinetic parameters were calculated at baseline and after C1, including the volume transfer constant (K(trans)), which primarily reflects the wash-in of the contrast agent, the backflow rate contrant (K(ep)), extracellular volume fraction (V(e)) and the initial area under the gadolinium concentration-time curve over 60 seconds (IAUGC(60)). Changes in the DCE-MRI kinetic parameters K(trans), K(ep), V(e) and IAUGC(60) were calculated and Wilcoxon test was used to assess significant effects induced by bevacizumab on kinetic parameters. Pathological response on surgical specimens after C5 was assessed according to Miller and Payne classification. Pts with tumor reduction >30% were considered as responders (G3-G4-G5) whether tumor reduction <30% were considered as no responders (G1-G2). DCE-MR imaging parameters and clinical-pathological characteristics were correlated with pathological response using Mann-Whitney test in univariate and logistic regression in multivariate analyses. Receiver operating curves (ROC) was used to define the best cut-off of the parameter found associated with pathological response.

Results: DCE-MRI was performed before (n=72) and after (n=71) C1. K(trans), K(ep), V(e) and IAUCG(60) values were significantly different at the baseline and after C1 (p<0.01). Median changes were, respectively, −51, −101, −52.5 and −4.8. Fifty-two (74%) pts achieved response (G3-G4-G5) after C5 whether 18 (24%) were considered as no responder (G1-G2); for 3 (4%) patients Miller/Payne tumor evaluation was not available. At univariate analysis, negative estrogen receptor (ER) status and higher post-C1 K(ep) (p=.057) showed a trend toward an association with response. At multivariate analysis, only ER status remains a significant predictor of response (p= .04). Area under ROC curve for K(ep) was 0.65 (IC95% 0.05−0.8, p=.057)

Conclusion: Bevacizumab affects tumor vasculature, perfusion and permeability as showed by the significantly reduction in all kinetic vasculature parameters obtained in DCE-MR imaging after C1. However, in our population these changes were not associated with pathological response. On the other hand, backflow rate constant, K(ep), a perfusion-related parameter derived from DCE-MRI yielded after C1 major than 80, may be associated with higher pathological response with a specificity of 88% and sensitivity of 90%. Future studies are warranted to confirm these findings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-05.

P5-13-04: Changes in Phosphorylation Status at VEGFR2 and Basal Tumor Hypoxic Volume Assessed by Misonidazol (MISO) Positron Emission Tomography (PET/CT) as Potential Biomarkers for Predicting Response to Bevacizumab in Breast Cancer

Background: To evaluate the expression of novel putative biomarkers as predictors of benefit from bevacizumab in stage II-III, previously untreated breast cancers (BC) patients (pts) in the context of a phase II, single-arm, multicenter and prospective clinical trial. To address this aim, we examined baseline and induced changes after a single bevacizumab administration as potential early predictors of response. Methods: Pts received a single infusion of bevacizumab (15 mg/kg) (C1) 3 weeks prior to the beginning of neoadjuvant chemotherapy consisting in 4 cycles of docetaxel (60 mg/mq), doxorubicin (50 mg/mq) and bevacizumab (15 mg/kg) every 21 days (C2-C5) following by surgery. Early assessment of tumor changes was performed by paired tumor-biopsies and MISO PET/CT before and 14–21 days after bevacizumab administration (C1). Biomarker expression was assessed by immunohistochemistry (IHC) (Ki67, CD31, CD31/Ki67, VEGFR2, pVEGFR2 [Y951]) on formalin-fixed, paraffin-embedded tissue before and after bevacizumab infusion (C1). MISO SUV and tumor volume depicted by PET were calculated. Pathological response on surgical specimens was assessed according to Miller/Payne classification. Pts with tumor reduction >90% were considered as best responders (G4-G5) whether tumor reduction <90% were considered as no responders. Association between pathological response, IHC and MISO biomarkers was analyzed using Mann-Whitney test. ROC curve was performed to test sensibility and specificity of the biomarker found significantly associated with response and its value as independent predictor was tested in the multivariate analysis using logistic regression.

Results: This analysis was performed on the training set including 73 patients (49 yr, range 29–70). Twenty (27%) patients obtained best response (G4-G5) whether 50 (68%) were considered as no responder (G1-G2-G3). Response was associated with negative estrogen receptors expression (p=0.02) and high Ki67 basal and after C1 expression (p=0.009 and p=0.01). Six (54%) of triple negative tumors were responders (p=0.05). Interestingly, change in pVEGFR2 [Y951] staining induced by bevacizumab administration and basaline MISO tumor volume was found significantly associated with response (p=0.03 and 0.057). Decrease in the phosphorilation status of VEGFR2 (Y951) >70% yielded a receiver operating characteristic (ROC) curve area of 0.681 (95% CI: 0.536 — 0.825) with 84% sensitivity and 95% specificity. The positive and negative predictive values for this marker were 60% and 64%, respectively. The change in phosphorilation status of VEGFR2p remains a significant predictor biomarker of response in multivariate analysis (OR=0.9, IC%95 0.96−0.99, p=0.04) after adjusting for clinical-pathological characteristics.

Conclusion: These findings underline the potential value of early decrease in phosphorilation status of VEGFR2 after bevacizumab infusion as predictive biomarker of response to anti-angiogenic therapy in breast cancer. Moreover, tumor hypoxic volume obtained by MISO might be associated with response. A validation set is warranted to confirm these findings.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-13-04.

How to integrate current knowledge in selecting patients for first line in NSCLC?

Non-small-cell lung cancer (NSCLC) accounts for 80% of all lung cancer, which is the leading cause of cancer mortality. The majority of NSCLC patients present with advanced disease at diagnosis. Standard chemotherapy using platinum-containing doublets has reached a therapeutic plateau with a median survival of ~1 year. The development of more effective strategies in the first-line setting remains challenging. In selected chemotherapy-naïve, advanced, non-squamous patients, the combination of bevacizumab with chemotherapy was shown to produce better outcomes than chemotherapy alone. The potential benefit of maintenance/sequential treatment after initial platinum-based chemotherapy should be discussed in detail with each patient. Epidermal growth factor receptor (EGFR) mutation determination should be carried out in subgroups of patients characterized by a high prevalence of sensitizing mutations. When a mutation is present, first-line treatment with an EGFR tyrosine kinase inhibitor may be considered. Finally, a phase I study using an oral ALK inhibitor has produced promising results in NSCLC patients with ALK rearrangements, indicating that ALK represents a new therapeutic target in a molecularly defined subset of NSCLC. Ongoing studies in first-line therapy are focusing on targeted therapies and patient selection.

The search for alternative aqueous film forming foams (AFFF) with a low environmental impact: physiological and transcriptomic effects of two Forafac(®) fluorosurfactants in turbot

Fluorosurfactants are the key components in aqueous film forming foams (AFFF). They provide these fire fighting agents with the required low surface tension and they enable film formation on top of lighter fuels to prevent burn back. Development of effective and environmentally acceptable PFOS alternatives is one of the most important priorities in the fire fighting foam industry. DuPont™ offers the fluorosurfactant mixtures Forafac(®)1157 and Forafac(®)1157N for the formulation of AFFFs which are alternatives to the persistent and toxic perfluorooctane sulphonate (PFOS). Ecotoxicological testing of these inadequately documented mixtures is necessary to include them in AFFF hazard and risk assessment. Juvenile turbot (Scophthalmus maximus) were exposed for 14 days to 0.1; 0.5 and 1.5mg/L of the fluorosurfactant mixtures used in Forafac(®)1157 and Forafac(®)1157N. In an initial transcriptomics experiment, microarray analysis revealed differentially expressed transcripts of genes which were mainly involved in digestion and in the immune system. This discovery-driven screening approach offered the basis for new hypotheses that were tested in two subsequent experiments in which food intake, energy reserves, growth and a set of haematological parameters were examined. Additionally, effects of the two mixtures were compared to those of PFOS. Based on the results of this study, the mode of action of Forafac(®)1157N was the activation of the acute phase reaction resulting in increased leukocyte concentrations and the inhibition of growth due to the high energetic cost of toxicant exposure. For Forafac(®)1157, evidences of immunosuppression were found on the transcriptional level and the altered differential leukocyte profiles indicated that stress was induced in these fish. However, food intake, energy reserves and growth were not compromised, even at high exposure concentrations, which was in contrast to the effects seen after PFOS exposure. Taking into account that Forafac(®)1157 appeared to be less toxic than PFOS, this mixture could be considered as a more environmentally acceptable PFOS alternative for the use in AFFFs.

Alcohol dependence in a psychiatric interconsultation unit

Aims

To determine the pattern of alcohol dependence among medical impatients who requires Psychiatric Interconsultation, with the purpose of achieve a better understanding of the problem and to suggest prevention strategies.

Methods

Sample studied was collected among all inpatients with diagnosis of alcohol dependence (DSM-IV-TR) admitted in our hospital during a study period of 3 years, from january 2007 to may 2010, who required psychiatric interconsultation.

Results

101 admissions with diagnosis of alcohol dependence were reviewed. There were 80 men (79,20%) and 21 women (20,8%). The mean of age was 53,13 years. The mean days of stay was 14,13. In this study, 60 subjects (59,40) there are medical history of alcohol dependence and 58 (57,42%) psychiatrc history.

Aims of admission

Alcohol deprivation 13 cases (12,87%); convulsion 6 (5,94%); acute agitation 5 (4,95%); cranioencephalic trauma 5 (4,95%); alcohol intoxication 5 (4,95%); fracture 4 (3,96%); suicide attempt 6 (3,96%); psychiatric indication 10 (9,9%); primary care indication 3 (0,029%); organic problem secondary to alcohol 32 (31,68%); other 12 (6,11%). 42 patients were admitted in Unidade Medica de Alta precoz (41,58%); Medical 21 (20,79%); Traumatology department 4 (3,96%); Gastroenterology 12 (6,11%); Neurology 3 (0,029%); Other departments 19 (18,81%).

Conclusions

The main cause of medical admission are somatic complications of alcohol, finding that only 9.9% of the income was indicated by the psychiatrist and to 0.029% for the primary care physician. Primary, secondary and tertiary prevention 1, 2 and 3 of these complications should be a target of psychiatry.

Stabilization of substilisin E in organic solvents by site-directed mutagenesis

Subtilisin E was rationally engineered to improve its stability in polar organic solvents such as dimethylformamide (DMF). A charged surface residue, Asp248, was substituted by three amino acids of increasing hydrophobicity, Asn, Ala, and Leu; all three variants were stabilized with respect to wild type in 80% DMF. This stabilization was only observed in the presence of high concentrations of the organic solvent: no stability enhancements were observed in 40% DMF. In contrast, the mutation Asn218 --> Ser alters internal hydrogen bonding interactions and stabilizes subtilisin E in both 40% and 80% DMF. This study provides additional evidence that substitution of surface-charged residues is a generally useful mechanism for stabilizing enzymes in organic media and that the stabilizing effects of such substitutions are unique to highly altered solvent environments. The effects of the single amino acid substitutions on free energies of stabilization are additive in the Asp248 --> Asn + Asn218 --> Ser combination variant, yielding an enzyme that is 3.4 times more stable than wild type in 80% DMF.

Leukocyte perturbation associated with Fabry disease

Fabry disease is an X-linked lysosomal storage disorder of glycosphingolipid catabolism due to the deficient activity of the enzyme alpha-galactosidase A. The non-degraded substrate, mainly globotriaosylceramide (Galα1-4Galβ1-4Glcβ1-1Cer; Gb(3)) accumulates progressively in the lysosome of various cells. The aim of this work was to analyse changes in leukocyte subpopulations and surface markers and to determine whether Gb(3) is increased in leukocytes of patients with untreated and treated Fabry disease. Blood samples obtained from 22 male Fabry patients (11 untreated and 11 on enzyme replacement therapy) and 22 normal controls were subjected to flow cytometric analysis of Gb(3) intracellular content, leukocyte subpopulations and cell markers. Based on the fluorescence intensity of bound monoclonal antibody, and relative to normal control leukocytes, Gb(3) appeared significantly increased in lymphocytes (but not in monocytes or granulocytes) from patients with Fabry disease. A significantly higher percentage of lymphocytes and CD19(+) cells and a reduced proportion of monocytes, CD8(+) cells and myeloid dendritic cells were detected in samples from Fabry patients compared with normal controls. CD1d expression was significantly lower and MHC class II surface expression was significantly higher in monocytes from Fabry patients than in normal controls. As previously observed for other adhesion molecules, the expression of CD31 (PECAM) was higher in leukocytes from Fabry patients. In conclusion, the differences recorded in this study reveal a leukocyte perturbation associated with the disease state in Fabry patients, whereas some abnormalities are less marked in treated patients.

In search of an optimum plutonium density measurement fluid

Density measurements of plutonium metal and its alloys are performed at Los Alamos National Laboratory (LANL) using a technique based on the Archimedes principle. The goal is to find and characterize a fluid for density determination of large objects made of plutonium to replace the currently used monobromobenzene. Physical and chemical properties must be considered while selecting the fluid. Chemical properties of the fluid must ensure low corrosion rates and good resistance to radiological decomposition. The study was carried on to evaluate the corrosion rates of Pu metal cause by FC-43 and the FC-43 decomposition products of radiolysis. The results of these studies proved favourable for this application. The evaluation of the surface reactions between FC-43 and Pu metal will be conducted in the near future.