Thomboembolic Events in Patients with Breast Cancer: A Population Based Study

BACKGROUND: Thromboembolic events (TEEs) are common in patients with cancer. Metastatic disease, treatment and comorbidities have been associated with increased risk. In this population-based study we sought to evaluate the risk factors and the prevalence of different TEEs in patients with breast cancer.METHODS: Retrospective cohort study using the SEER-Medicare linked database. Patients with breast cancer (stage I-IV) diagnosed from 1992-2002, who were 66 and older, and had full coverage of Medicare A and B were identified. ICD-9, HCPCS codes were used to identify different TEEs that occurred within one year of the breast cancer diagnosis. We identified pulmonary embolism (PE), deep venous thrombosis (DVT)/thrombophlebitis, other TEEs, as well as the use of chemotherapy, radiotherapy, surgery and comorbidities. Analyses were conducted using descriptive statistics and logistic regression.RESULTS: 71,864 patients were included. Age groups were distributed as follows: 66-70 (24.1%), 71-75 (26.4%), 76-80 (23.2%), >80 (26.3%). At diagnosis 52.4% of patients had stage I, 35.2% stage II, 6.6% stage III and 5.8% stage IV. 66.8% of the patients had ER-positive breast cancer. Within one year of diagnosis, 2652 (3.7%) of patients developed a TEE, including 800 patients with at least two events. 3565 total number of events were observed. A total of 596 (0.85%) PEs, 1252 (1.74%) DVT/thrombophlebitis, and 1717 (3.39%) other TEEs were identified. In the univariate analysis race, marital status, education and poverty level, geographical location, stage, tumor grade, estrogen receptor status, comorbidities, as well as surgical modality, radiation therapy and chemotherapy use, were associated with the development of any TEE.After adjusting for potential confounders, the development of any TEE was associated with ER-positive tumors (OR 1.20, 95% CI 1.07-1.34), stage II vs. I (OR 1.22, 95% CI 1.11-1.35), stage III vs. I (OR 1.63, 95% CI 1.40-1.90), stage IV vs. I (OR 2.16, 95% CI 1.82-2.57), chemotherapy (OR 2.02, 95% CI 1.82-2.23), radiotherapy (OR 1.39, 95% CI 1.27-1.52), comorbidity score (OR 1.19, 95% CI 1.08-1.32 and OR 1.74, 95% CI 1.54-1.96 for score 1 and 2 respectively), and type of surgery (OR 1.25, 95% CI 1,13-1.38 for mastectomy vs. breast conservation surgery and OR 1.23, 95% CI 1.02-1.49 for no surgery vs. breast conservation surgery). Borderline association was seen with age (using 66-70 as a reference value, the ORs for the 71-75, 76-80 and >80 year old categories were: 1.14, 95%CI 1.02-1.28; 1.17, 95% CI 1.04-1.32; and 1.15, 95% CI 1.01-1.29 respectively). Relatively similar estimates were seen for the analysis of PE, DVT/thrombophlebitis and other TEEs.CONCLUSION: 3.7% of patients in this cohort developed a TEE within one year from breast cancer diagnosis. Age, stage, type of treatment, comorbidities and receptor status were associated with the development of TEEs. To the best of our knowledge this is the largest cohort of patients older than 66years old, in which the patterns and risk factors associated with TEEs are analyzed. Whether these observations apply to patients younger than age 65, remains to be established.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2053.

Bags with oven-dried moss for the active monitoring of airborne trace elements in urban areas

To define a harmonized methodology for the use of moss and lichen bags as active monitoring devices of airborne trace elements in urban areas, we evaluated the element accumulation in bags exposed in Naples in different spring weather conditions for 6- and 12-weeks. Three different pre-exposure treatments were applied to moss and lichen materials: water-washing, acid-washing and oven-drying. During the different exposure periods in the Naples urban environment the moss accumulated always higher amounts of elements (except Hg) than lichens and the element accumulation increased during wetter weather and higher PM(10) conditions. The oven pre-treatment did not substantially modify the morphology and element composition of moss and the exposure in bags of this material for 6-weeks was sufficient to detect the pattern of airborne trace elements.

Zygomycosis in Italy: a survey of FIMUA-ECMM (Federazione Italiana di Micopatologia Umana ed Animale and European Confederation of Medical Mycology)

The aims of the study were to analyze the clinical and epidemiological characteristics and treatments for patients who developed zygomycosis enrolled in Italy during the European Confederation of Medical Mycology of medical mycology survey. This prospective multicenter study was performed between 2004 and 2007 at 49 italian Departments. 60 cases of zygomycosis were enrolled: the median age was 59.5 years (range 1-87), with a prevalence of males (70%). The majority of cases were immunocompromised patients (42 cases, 70%), mainly hematological malignancies (37). Among non-immunocompromised (18 cases, 30%), the main category was represented by patients with penetrating trauma (7/18, 39%). The most common sites of infection were sinus (35%) with/without CNS involvement, lung alone (25%), skin (20%), but in 11 cases (18%) dissemination was observed. According to EORTC criteria, the diagnosis of zygomycosis was proven in 46 patients (77%) and in most of them it was made in vivo (40/46 patients, 87%); in the remaining 14 cases (23%) the diagnosis was probable. 51 patients received antifungal therapy and in 30 of them surgical debridement was also performed. The most commonly used antifungal drug was liposomal amphotericin B (L-AmB), administered in 44 patients: 36 of these patients (82%) responded to therapy. Altogether an attributable mortality rate of 32% (19/60) was registered, which was reduced to 18% in patients treated with L-AmB (8/44). Zygomycosis is a rare and aggressive filamentous fungal infection, still associated with a high mortality rate. This study indicates an inversion of this trend, with a better prognosis and significantly lower mortality than that reported in the literature. It is possible that new extensive, aggressive diagnostic and therapeutic procedures, such as the use of L-AmB and surgery, have improved the prognosis of these patients.

Off-label drug use in women with breast cancer

1016

Background: Despite reports of widespread use of off-label agents in cancer treatment, little is known about the off-label use of agents in the treatment of breast cancer patients. Methods: We used data from the Surveillance, Epidemiology, and End Results (SEER) - Medicare linked database to identify 2082 persons older than 65 years who were diagnosed with distant stage breast cancer between 1991 and 2002 and who were treated with chemotherapy between diagnosis and death. Off versus on-label classification was based upon FDA-approved indication in the treatment of breast cancer. We calculated the percentage of patients receiving off-label chemotherapy and used multivariate logistic regression models to estimate predictors of off-label chemotherapy use. We also evaluated the appropriateness of off-label chemotherapy drugs using DRUGDEX classifications. Results: Overall, 34.9% of patients were treated with off-label chemotherapy drugs. Of the thirty-six agents that were used to treat these patients, only 8 (22%) were FDA-approved for use in the treatment of breast cancer. Off-label use was least common in patients age 80 years and older (OR 1.93, 95% 1.35–2.76 for 80+ vs. 66–70 years) and varied by diagnosis year and geographic region. The most commonly used off-label agents were vinorelbine and gemcitabine, with 16.0% and 8.4% of patients receiving these agents, respectively. While 71% of the drugs used off-label lacked supporting evidence for their use in the treatment of breast cancer, these drugs were used in a small number of patients. Only 6.7% of patients were treated with drugs considered inappropriate for use in the treatment of breast cancer. Conclusions: Off-label chemotherapy use is widespread among patients with metastatic breast cancer. However, the majority of patients who received off-label chemotherapy received drugs with scientific data supporting such use.

No significant financial relationships to disclose.

Phase I trial of escalating doses of weekly everolimus (RAD001) in combination with docetaxel for the treatment of metastatic breast cancer (MBC)

1066

Background: Inhibition of mTOR with everolimus (E) may improve efficacy in combination with docetaxel (D), but both drugs are metabolized by CYP3A4, thus a pharmacokinetic (PK) interaction may also exist. Methods: 15 patients (pts) with MBC were treated with docetaxel and everolimus using the continuous reassessment method (CRM) to determine maximum tolerated dose (MTD). Docetaxel doses were 40–75 mg/m2 IV on day 1 of a 21 day cycle. Everolimus doses were 20–50 mg PO on days 1 and 8 of a 21 day cycle (except cycle 2, where only day 8 was given to allow single agent PK analyses of both drugs). Response was measured every 2 cycles using RECIST. Results: Median age= 58 years and 77% of pts had >2 prior chemotherapies for MBC. Initially 2 of 2 pts treated (D= 75 mg/m2, E= 30 mg) developed DLT (neutropenic fever/infection), prompting a mandatory PK evaluation for all pts enrolled in subsequent cohorts. A second cohort of 3 patients (D=60 mg/m2, E=20mg) had no DLT, but no pts received day 8 of E due to grade 3–4 neutropenia. PK analyses demonstrated a 42% lowered (-42%) D clearance at the 60 mg/m2 in the presence of E (n=1). Subsequent cohorts were accrued at D=40 mg/m2 with escalating doses of E (Table). For the entire group, an 18% decrease (-18%) in D clearance was observed when D was administered concomitantly with E. High interpatient variability of D clearance was observed (range +16% to -135%). No pts had CR/PR, but 6 had SD>4 cycles and 2 had SD=8 cycles. Conclusions: Weekly everolimus appears to cause widely variable and unpredictable changes in docetaxel clearance making this combination unfeasible.

[Table: see text]

No significant financial relationships to disclose.

Recent divergence, intercontinental dispersal and shared polymorphism are shaping the genetic structure of amphi-Atlantic peatmoss populations

Several lines of evidence suggest that recent long-distance dispersal may have been important in the evolution of intercontinental distribution ranges of bryophytes. However, the absolute rate of intercontinental migration and its relative role in the development of certain distribution ranges is still poorly understood. To this end, the genetic structure of intercontinental populations of six peatmoss species showing an amphi-Atlantic distribution was investigated using microsatellite markers. Methods relying on the coalescent were applied (IM and MIGRATE) to understand the evolution of this distribution pattern in peatmosses. Intercontinental populations of the six peatmoss species were weakly albeit significantly differentiated (average F(ST) = 0.104). This suggests that the North Atlantic Ocean is acting as a barrier to gene flow even in bryophytes adapted to long-range dispersal. The im analysis suggested a relatively recent split of intercontinental populations dating back to the last two glacial periods (9000-289,000 years ago). In contrast to previous hypotheses, analyses indicated that both ongoing migration and ancestral polymorphism are important in explaining the intercontinental genetic similarity of peatmoss populations, but their relative contribution varies with species. Migration rates were significantly asymmetric towards America suggesting differential extinction of genotypes on the two continents or invasion of the American continent by European lineages. These results indicate that low genetic divergence of amphi-Atlantic populations is a general pattern across numerous flowering plants and bryophytes. However, in bryophytes, ongoing intercontinental gene flow and retained shared ancestral polymorphism must both be considered to explain the genetic similarity of intercontinental populations.

Survival differences among women with newly diagnosed stage IV and recurrent breast cancer

Abstract #2077

Background 
 The objective of this retrospective study was to determine whether differences in survival exist between women with newly diagnosed stage IV disease and those with recurrent breast cancer.
 Methods
 Women with newly diagnosed stage IV disease or recurrent breast cancer with distant metastases diagnosed between 1992 and 2007 were identified from the Breast Cancer Management System Database at UTMDACC. Among women with recurrent breast cancer, distant disease-free interval (DDFI) was defined as the time from diagnosis of primary breast cancer to the date of the first distant metastases. For all patients, overall survival (OS) was measured from the date of first distant metastases to the date of death from any cause or last follow-up. The Kaplan-Meier product limit method was used to estimate OS, and OS was compared across groups using log-rank statistic. Cox-proportional hazards models were fit to determine the association between stage IV breast cancer (recurrent versus newly diagnosed) and OS after controlling for other patient and tumor characteristics.
 Results
 The analysis included 3524 patients of whom 643 (18.2%) had newly diagnosed disease and 2881 (81.8%) had recurrent disease. Median follow-up was 19 months. Median OS among patients with newly diagnosed stage IV disease and recurrent disease was 39.2 and 27.2 months, respectively (p<0.0001). Patients with recurrent disease with DDFI < 5 years had worse OS compared to those with newly diagnosed disease (p<0.0001). Patients with DDFS >5years had better OS compared to those with newly diagnosed stage IV disease (p<0.005). In the multivariable model patients with recurrent disease had an increased risk of death compared to patients with newly diagnosed stage IV disease (HR=1.75, 95% CI 1.47-2.08, p<0.0001). When the multivariable model was stratified by DDFI, patients with recurrent disease with DDFI <5 years had 1.74 times the risk of death compare to those with newly diagnosed stage IV disease (95% CI 1.44-2.10, p<0.0001). The risk of death was not statistically different among patients with recurrent disease with DDFI >5 years compared to those with newly diagnosed stage IV disease (HR=1.11, 95% CI 0.88-1.41, p=0.38).
 ConclusionThis large cohort study provides further insight into the natural history of recurrent and newly diagnosed stage IV breast cancer. Compared to women with newly diagnosed stage IV disease, those with recurrent disease whose DDFI was >5 years and <5 years had similar and worse OS respectively.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2077.

[Thrombocytopenia associated with brucellosis: a case report]

Brucellosis, a common disease in some areas of the world, beside its typical signs and symptoms, as fever, arthropathy, hepatomegaly and splenomegaly, sometimes can complicate into thrombocytopenia, even in severe forms. The pathogenesis of thrombocytopenia in course of brucellosis is variable, and a main role is played by immunological reactions. Authors describe a case report of an eight years child who presented a severe thrombocytopenia in course of acute brucellosis. The patient responded efficaciously to the antibiotic therapy combined with immunoglobulin intravenous therapy.

Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder?

Transgender children who are not treated for their condition are at high risk of violence and suicide. As a matter of survival, many are willing to take whatever help is available, even if this is offered by illegal sources, and this often traps them into the juvenile criminal system and exposes them to various threats. Endocrinology offers a revolutionary instrument to help children/adolescents with gender identity disorder: suspension of puberty. Suspension of puberty raises many ethical issues, and experts dissent as to when treatment should be commenced and how children should be followed up. This paper argues that suspension of puberty is not only not unethical: if it is likely to improve the child's quality of life and even save his or her life, then it is indeed unethical to defer treatment.

Natural and pre-treatments induced variability in the chemical composition and morphology of lichens and mosses selected for active monitoring of airborne elements

To enhance the reliability of the moss and lichen transplant technique for active biomonitoring of trace metals in urban environments, we evaluated the natural variability in the chemical composition of the (epilithic and epiphytic) moss Hypnum cupressiforme and the epiphytic lichen Pseudevernia furfuracea from two reference areas in NE Italy. Green shoots of epilithic mosses and lobes of epiphytic lichens from larch branches showed rather homogenous composition and were selected for the exposure in nylon bags. As different physico-chemical pre-treatments are usually applied to selected cryptogamic material before its exposure, we also evaluated the effects of oven-drying at 120 degrees C for 24h, washing in 1N HNO3 solution, and in 0.5% NH4 oxalate solution at 85 degrees C for 15 h on the chemical composition and morphology of water-washed moss shoots and lichen lobes. Pre-treatments remarkably changed the chemical composition of selected materials but not their surface morphology.

Silencing the MET oncogene leads to regression of experimental tumors and metastases

In spite of the established knowledge of the genetic alterations responsible for cancer onset, the genes promoting and maintaining the invasive/metastatic phenotype are still elusive. The MET proto-oncogene, encoding the tyrosine kinase receptor for hepatocyte growth factor (HGF), senses unfavorable micro-environmental conditions and drives cell invasion and metastasis. MET overexpression, often induced by tumor hypoxia, leads to constitutive activation of the receptor and correlates with poor prognosis. To establish the role of MET in different phases of tumor progression, we developed an inducible lentiviral delivery system of RNA interference. Silencing the endogenous MET gene, overexpressed in tumor cells, resulted in (i) impairment of the execution of the full invasive growth program in vitro, (ii) lack of tumor growth and (iii) decreased generation of experimental metastases in vivo. Notably, silencing MET in already established metastases led to their almost complete regression. This indicates that persistent expression of the MET oncogene is mandatory until the advanced phases of cancer progression.

Trends in survival of stage IV breast cancer (BC) among Caucasian and African American (AA) BC patients (pts)

1000

Background: The aim of this review was to look at the trends in survival over time in patients(pts) with de novo stage IV BC and to identify factors that impact survival. Methods: We searched the SEER registry to identify pts with de novo stage IV breast cancer diagnosed between 1988 and 2003. Pts who were male, did not have microscopic confirmation of disease, had more than one primary, and who had a prior malignancy were excluded. Pts were divided into three groups based on their year of diagnosis separated into 5-year intervals: 1988 - 1993, 1994 - 1998, and 1999 -2003. Overall survival (OS) and BC specific survival (BCS) were calculated from the date of diagnosis to the date of death, last follow-up, or 12/31/03. Survival outcomes were estimated by the Kaplan-Meier method, and Cox models were fit to determine the characteristics that were independently associated with survival. Follow-up time was censored at 3 years for Cox analyses. Results: 15,438 pts were identified. 3796 pts were diagnosed from 1988–1993, 3954 from 1994–1998, and 7688 from 1999–2003. Median age was 62 years. Median follow-up was 16 months (mos) (range 0–191), 18 mos (range 0–199), and 11 mos (range 0–59) in periods 1988 - 1993, 1994 - 1998, and 1999 - 2003 respectively. Median OS was 18 mos overall and 16, 18, and 20 mos respectively for each time period. Median BCS was 23 mos overall and 20, 21, and 25 mos for each time period. In the multivariable model, more distant year of diagnosis, Grade 3 disease, higher number of positive LN, increasing age, being unmarried, ER- disease, PR- disease, and no surgery were all independently associated with worse BCS. The interaction term between ER and year of diagnosis was of borderline significance, indicating that over time, pts with ER+ disease had decreasing risk of death compared to patients with ER- disease (HR 0.98, 95% CI 0.96–1.00). An interaction term between race and year of diagnosis was significant, such that with each increasing year of diagnosis AA pts had increasing risk of death compared to whites (HR 1.04, 95% CI 1.01–1.07). Conclusions: The survival of de novo stage IV BC pts has modestly improved over time. Of concern, survival disparities between AA and white patients increased rather than diminished over time.

No significant financial relationships to disclose.

Defective ubiquitinylation of EGFR mutants of lung cancer confers prolonged signaling

Several distinct mutations within the kinase domain of the epidermal growth factor receptor (EGFR) are associated with non-small cell lung cancer, but mechanisms underlying their oncogenic potential are incompletely understood. Although normally ligand-induced kinase activation targets EGFR to Cbl-mediated receptor ubiquitinylation and subsequent degradation in lysosomes, we report that certain EGFR mutants escape this regulation. Defective endocytosis characterizes a deletion mutant of EGFR, as well as a point mutant (L858R-EGFR), whose association with c-Cbl and ubiquitinylation are impaired. Our data raise the possibility that refractoriness of L858R-EGFR to downregulation is due to enhanced heterodimerization with the oncogene product HER2, which leads to persistent stimulation.

Lichen and moss bags as monitoring devices in urban areas. Part II: trace element content in living and dead biomonitors and comparison with synthetic materials

Lobes of the lichen Pseudevernia furfuracea (L.) Zopf and shoots of the moss Hypnum cupressiforme Hedw. were subjected to different treatments (water washing, oven drying, HNO3 washing, NH4-oxalate extraction) to assess the influence of vitality on accumulation efficiency, during a 6-week exposure in bags in two Italian cities, Trieste and Naples. No trend emerged between treatments, in terms of accumulation ability, for major and trace elements. Only water-washed lichens showed an increased C and N content after exposure in both cities. Element concentrations generally reached higher values in mosses than in lichens, especially for Al, Fe, and Zn (both cities), and for Cu, Mg and Na (Naples). Surface development strongly influenced accumulation capacity of the biomonitors. Quartzose and cation exchange filters revealed, on a weight basis, a poor performance. In urban environments, surface interception of atmospheric particulate seems to play a major role in accumulation, irrespective of organism vitality.

Lichen and moss bags as monitoring devices in urban areas. Part I: influence of exposure on sample vitality

Samples of the lichen Pseudevernia furfuracea (L.) Zopf and the moss Hypnum cupressiforme Hedw. were exposed for 6 weeks in nylon bags in two air pollution monitoring stations in Trieste and Naples (Italy) with different climates and pollution loads to evaluate influence of environmental conditions on sample vitality. This was assessed before and after exposure by transmission electron microscopy observations, K cellular location, and measurements of C, N, S and photosynthetic pigments content, CO2 gas exchange, and chlorophyll fluorescence. Almost all data sets indicate that exposures caused some damage to the species, considerably heavier in the moss, especially in Naples. The two cryptogams differed significantly in accumulation and retention of C, N, and S, the lichen clearly reflecting NO2 availability. The difference in vitality loss was related to the different ecophysiology of the species, because concentrations of phytotoxic pollutants were low during exposure. Critical notes on the analytical techniques are also given.