Role of second-look ultrasound examinations for MR-detected lesions in patients with breast cancer

PURPOSE

To assess the clinical value of second-look ultrasound (US) examination for the evaluation of additional enhancing lesions detected on magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Between May 2008 and February 2011, 794 consecutive patients with histologically confirmed breast cancer underwent breast MR imaging. We included 101 patients with 132 additional enhancing breast lesions detected on MR imaging who underwent second-look US.  The imaging features and lesion category according to the Breast Imaging and Reporting and Data System (BI-RADS) were assessed with MR and US imaging, respectively.

RESULTS

According to the BI-RADS system, 67 lesions (50.8 %) were classified as category 0, 33 lesions (25.0 %) as category 3, and 32 lesions (24.2 %) as category 4. Of the 67 indeterminate lesions on MR imaging, 34 (50.7 %) were demonstrated on second-look US. 11 of these 34 lesions showed suspicious sonographic features, including 1 lesion that showed malignancy (9.1 %, 1/11). Most of the suspicious lesions on MR imaging (26 of 32 BI-RADS category 4 lesions, 81.3 %) were demonstrated on second-look US, and 17 were malignant (65.4 %, 17/26). Of the 6 BI-RADS category 4 lesions without sonographic correlation, 1 was malignant (16.7 %, 1/6).

CONCLUSION

Second-look US examination was useful for evaluating MR-detected lesions in patients with breast cancer.

Quantification of the placental epigenetic signature of the SERPINB5 gene in maternal plasma of pregnancies complicated by small for gestational age

INTRODUCTION

To investigate the association between pregnancies with small for gestational age (SGA) neonates and the concentration of cell-free fetal DNA or cell-free total DNA in maternal plasma during the first and second trimesters using tissue-specific epigenetic characteristics of the SERPINB5 gene.

METHODS

A nested case-control study was conducted with maternal plasma collected at 11 to 26 gestational weeks from 51 women with SGA neonates and 102 controls. We performed a real-time quantitative methylation-specific PCR to quantify concentrations of unmethylated-SERPINB5 (U-SERPINB5) as a cell-free fetal DNA marker and methylated-SERPINB5 (M-SERPINB5) as a cell-free total DNA marker.

RESULTS

A positive correlation was observed between U-SERPINB5 and M-SERPINB5 concentrations in both control (r = 0.363, p < 0.001) and SGA groups (r = 0.548, p < 0.001). Moreover, the concentration of U-SERPINB5 or M-SERPINB5 was significantly positive correlated with gestational age at sampling in both controls (U-SERPINB5: r = 0.397, p < 0.001; M-SERPINB5: r = 0.275, p = 0.005) and SGA (U-SERPINB5: r = 0.274, p = 0.052; M-SERPINB5: r = 0.439, p = 0.001). However, the concentration of U-SERPINB5 or M-SERPINB5 was not correlated with birthweight. At 11-14 weeks, U-SERPINB5 and M-SERPINB5 concentrations in SGA did not differ significantly from those of controls. There were also no statistically significant differences in the concentrations of U-SERPINB5 and M-SERPINB5 between SGA and controls at 15-26 weeks of gestation.

DISCUSSION

Our findings suggest that U-SERPINB5 and M-SERPINB5 concentrations in maternal plasma during early pregnancy are not associated with pregnancies who delivered SGA neonates.

Does background parenchymal enhancement on MRI affect the rate of positive resection margin in breast cancer patients?

OBJECTIVE

The purpose of our study was to evaluate whether strong background parenchymal enhancement (BPE) would be a significant independent factor associated with positive resection margin in patients treated initially with breast-conserving surgery (BCS).

METHODS

Retrospective evaluation of breast MRI examinations of 314 patients with breast cancer was carried out. Breast cancer was histologically confirmed in all patients who underwent BCS from January 2008 to December 2010. BPE was dichotomized into weak (minimal or mild) and strong (moderate or marked) enhancement for statistical analysis. Histopathological features of attained specimens were evaluated by an experienced pathologist and were also dichotomized for statistical analysis.

RESULTS

On univariate analysis, positive extensive intraductal component (p < 0.001), strong BPE (p = 0.001) and human epidermal growth factor receptor 2 (HER2) positivity (p = 0.08) had significant association with positive surgical margin. Tumour size, axillary lymph node metastasis, nuclear grade, histological grade, lymphovascular invasion, oestrogen receptor and progesterone receptor did not show significant correlation with positive surgical margin. On multivariate analysis, the significant independent predictors were extensive intraductal component [odds ratio, 5.68; 95% confidence interval (CI), 2.72-11.82] and strong BPE (odds ratio, 2.39; 95% CI, 1.20-4.78).

CONCLUSION

Strong BPE is a significant independent factor for positive resection margin along with positive extensive intraductal component, and performing MRI during the period of lower parenchymal enhancement is needed in patients with strong BPE.

ADVANCES IN KNOWLEDGE

As far as we know, this is the first study to reveal that BPE is a significant independent factor associated with positive resection margin.

Prognostic and predictive values of EGFR overexpression and EGFR copy number alteration in HER2-positive breast cancer

Background:

Epidermal growth factor receptor (EGFR) is overexpressed in a subset of human epidermal growth factor receptor 2 (HER2)-positive breast cancers, and coexpression of HER2 and EGFR has been reported to be associated with poor clinical outcome. Moreover, interaction between HER2 and EGFR has been suggested to be a possible basis for trastuzumab resistance.

Methods:

We analysed the clinical significance of EGFR overexpression and EGFR gene copy number alterations in 242 HER2-positive primary breast cancers. In addition, we examined the correlations between EGFR overexpression, trastuzumab response and clinical outcome in 447 primary, and 112 metastatic HER2-positive breast cancer patients treated by trastuzumab.

Results:

Of the 242 primary cases, the level of EGFR overexpression was 2+ in 12.7% and 3+ in 11.8%. High EGFR gene copy number was detected in 10.3%. Epidermal growth factor receptor overexpression was associated with hormone receptor negativity and high Ki-67 proliferation index. In survival analyses, EGFR overexpression, but not high EGFR copy number, was associated with poor disease-free survival in all patients, and in the subgroup not receiving adjuvant trastuzumab. In 447 HER2-positive primary breast cancer patients treated with adjuvant trastuzumab, EGFR overexpression was also an independent poor prognostic factor. However, EGFR overexpression was not associated with trastuzumab response, progression-free survival or overall survival in the metastatic setting.

Conclusions:

Epidermal growth factor receptor overexpression, but not high EGFR copy number, is a poor prognostic factor in HER2-positive primary breast cancer. Epidermal growth factor receptor overexpression is a predictive factor for trastuzumab response in HER2-positive primary breast cancer, but not in metastatic breast cancer.

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate

OBJECTIVE

To evaluate the safety and feasibility of N-butyl cyanoacrylate (N-BCA) embolization of percutaneous transhepatic portal venous access tract and to establish an appropriate technique.

METHODS

40 consecutive patients underwent percutaneous transhepatic portal venous intervention for various reasons. Embolization of percutaneous transhepatic portal venous access tract was performed after the procedure in all of the patients using N-BCA and Lipiodol® (Lipiodol Ultra Fluide; Laboratoire Guerbet, Aulnay-sous-Bois, France) mixture. Immediate ultrasonography and fluoroscopy were performed to evaluate perihepatic haematoma formation and unintended embolization of more than one segmental portal vein. Follow-up CT was performed, and haemoglobin and haematocrit levels were checked to evaluate the presence of bleeding.

RESULTS

Immediate haemostasis was achieved in all of the patients, without development of perihepatic haematoma or unintended embolization of more than one segmental portal vein. Complete embolization of percutaneous access tract was confirmed in 39 out of 40 patients by CT. Seven patients showed decreased haemoglobin and haematocrit levels. Other complications included mild pain at the site of embolization and mild fever, which resolved after conservative management. 16 patients died during the follow-up period owing to progression of the underlying disease.

CONCLUSION

Embolization of percutaneous transhepatic portal vein access tract with N-BCA is feasible and technically safe. With the appropriate technique, N-BCA can be safely used as an alternate embolic material since it is easy to use and inexpensive compared with other embolic materials.

ADVANCES IN KNOWLEDGE

This is the first study to investigate the efficacy of N-BCA for percutaneous transhepatic portal venous access tract embolization.

Sevoflurane post-conditioning increases nuclear factor erythroid 2-related factor and haemoxygenase-1 expression via protein kinase C pathway in a rat model of transient global cerebral ischaemia

BACKGROUND

The antioxidant mechanism of sevoflurane post-conditioning-induced neuroprotection remains unclear. We determined whether sevoflurane post-conditioning induces nuclear factor erythroid 2-related factor (Nrf2, a master transcription factor regulating antioxidant defence genes) and haemoxygenase-1 (HO-1, an antioxidant enzyme) expression, and whether protein kinase C (PKC) is involved in Nrf2 activation, in a rat model of transient global cerebral ischaemia/reperfusion (I/R) injury.

METHODS

Eighty-six rats were assigned to five groups: sham (n=6), control (n=20), sevoflurane post-conditioning (two cycles with 2 vol% sevoflurane inhalation for 10 min, n=20), chelerythrine (a PKC inhibitor; 5 mg kg(-1) i.v. administration, n=20), and sevoflurane post-conditioning plus chelerythrine (n=20). The levels of nuclear Nrf2 and cytoplasmic HO-1 were assessed 1 or 7 days after ischaemia (n=10 each, apart from the sham group, n=3).

RESULTS

On day 1 but not day 7 post-ischaemia, Nrf2 and HO-1 expression were significantly higher in the sevoflurane post-conditioning group than in the control group. Chelerythrine administration reduced the elevated Nrf2 and HO-1 expression induced by sevoflurane post-conditioning.

CONCLUSIONS

Sevoflurane post-conditioning increased Nrf2/HO-1 expression via PKC signalling in the early phase after transient global cerebral I/R injury, suggesting that activation of antioxidant enzymes may be responsible for sevoflurane post-conditioning-induced neuroprotection in the early phase after cerebral I/R injury.

The evaluation of combined chemical and physical treatments on the reduction of resident microorganisms and Salmonella Typhimurium attached to chicken skin

This study was conducted to evaluate the efficacy of sodium hypochlorite (NaOCl, 0-200 mg/kg), thiamine dilauryl sulfate (TDS, 1,000 mg/kg), and ultrasound (37 kHz, 380 W) on reducing Salmonella Typhimurim, mesophilic aerobic bacteria (MAB), and coliforms on chicken skin. Chemical and physical treatments were applied for 5 min either singly or jointly, and Salmonella previously inoculated on chicken skin were quantitatively assessed using brilliant green agar, and the populations of MAB and coliforms in the native flora were enumerated using plate count agar and violet red bile agar, respectively. In the evaluation of bacterial attachment/detachment, chicken skin was quantitatively assessed for loosely, intermediately, and tightly attached bacteria. The treatment effects on bacteria detachment were also visualized using field emission scanning electron microscopy. In addition, color and textural properties of the skin after treatments were evaluated using a color difference meter and texture analyzer. Antimicrobial activity of NaOCl increased as the NaOCl concentration was increased, especially for loosely attached cells. The combination of 200 mg/kg NaOCl and ultrasound (NaOCl/ultrasound) significant reduced loosely, intermediately, and tightly attached bacteria populations by 0.75 to 0.47, 0.43 to 0.41, and 0.83 to 0.54 log cfu/g for MAB, coliforms, and Salmonella Typhimurium, respectively. However, the combination of NaOCl and TDS (NaOCl/TDS) did not sufficiently reduce those cells on chicken skins, except for loosely attached MAB and coliforms. The NaOCl/ultrasound combination produced a higher reduction in numbers of inoculated and native bacteria flora than any single application, with no negative effect on skin color or texture. Generally, the loosely attached bacteria were less resistant to the chemical and physical treatments than the intermediately and tightly attached bacteria in chicken skin, presumably due to their location in deeper skin layer and crevices. Further research is needed to investigate how the intermediately and tightly attached microorganisms can be effectively eliminated from chicken skin.

Posterior root of lateral meniscus: the detailed anatomic description on 3T MRI

BACKGROUND

Although there have been some attempts to reveal the anatomy of the posterior root of the lateral meniscus (PRLM) through cadaver studies, arthroscopy, or imaging, it has not yet been described fully.

PURPOSE

To describe clearly the unique features of the PRLM, including its course, configuration, and size, using 3.0-T magnetic resonance imaging (MRI).

MATERIAL AND METHODS

A total of 105 knee 3.0-T MR examinations of 103 patients with arthroscopically proven intact PRLM were reviewed retrospectively. Based on fat-saturated, proton-density-weighted (PDW) axial/coronal images and PDW sagittal images, the course, configuration, and attachment sites of the PRLM were evaluated.

RESULTS

The majority of PRLM (76.2%) had two attachment sites: the medial tubercle along the intertubercular crest, just posteromedial to the tibial attachment of the anterior cruciate ligament (ACL), and the posterior slope of the lateral tubercle. The remaining cases (23.8%) had a solitary insertion on the intertubercular area (17 cases), or the posterior slope of the lateral tubercle (eight cases). The PRLM of the intertubercular area appeared as a dark signal line parallel to the tibial plateau on the mid-sagittal image and dark signal foci traversing the intertubercular crest on contiguous coronal images.

CONCLUSION

The PRLM inserts mainly in the intertubercular area with a thin, long anterior extension to the point just posteromedial to the tibial attachment of the ACL. It is well delineated on PDW 3.0-T MRI as a dark signal line parallel to the tibial plateau on mid-sagittal images and dark signal foci traversing the intertubercular crest on contiguous coronal images.

Double-blind, randomized non-inferiority trial of a novel botulinum toxin A processed from the strain CBFC26, compared with onabotulinumtoxin A in the treatment of glabellar lines

BACKGROUND

Botulinum toxins have been widely used in cosmetic dermatology. Neurotoxin from the CBFC26 strain (NTC) is a recently developed botulinum toxin type A product manufactured through refined procedures.

OBJECTIVE

A double-blinded, randomized, multicentre-designed, phase III trial to investigate the non-inferiority of NTC to existing botulinum toxin A, onabotulinumtoxin A in the treatment of moderate to severe glabellar lines.

METHODS

A total of 272 subjects were randomized in a 1 : 1 ratio to receive 20 U of NTC or onabotulinumtoxin A. The primary endpoint was the response rate of physicians' assessment (PA) using the Facial Wrinkle Scale at week 4. The secondary endpoints included the response rate of PA at weeks 8, 12 and 16, and photographic assessment at weeks 4, 8, 12 and 16. Subjects' improvement assessment and subjective self-satisfaction levels were also investigated.

RESULTS

Response rates for maximum frown were 89.3% in the NTC group and 81.9% in the onabotulinumtoxin A group at week 4. NTC also resulted in comparable results for both the response rates of the other evaluation points and incidence of adverse events compared to those of onabotulinumtoxin A. In subjects' improvement assessment and photographic evaluations, NTC even demonstrated better results compared with onabotulinumtoxin A in the early phase after treatment. Analysis of these results strongly supports the non-inferiority of NTC to onabotulinumtoxin A in the efficacy and safety.

CONCLUSION

NTC is as effective as onabotulinumtoxin A in the treatment of glabellar lines, and both products were well tolerated.

Comparison of three-dimensional isotropic and conventional MR arthrography with respect to the diagnosis of rotator cuff and labral lesions: focus on isotropic fat-suppressed proton density and VIBE sequences

AIM

To compare the diagnostic accuracies of three-dimensional (3D) isotropic magnetic resonance arthrography (MRA) using fat-suppressed proton density (PD) or volume interpolated breath-hold examination (VIBE) sequences with that of conventional MRA for the diagnosis of rotator cuff and labral lesions.

MATERIALS AND METHODS

Eighty-six patients who underwent arthroscopic surgery were included. 3D isotropic sequences were performed in the axial plane using fat-suppressed PD (group A) in 53 patients and using VIBE (group B) in 33 patients. Reformatted images were obtained corresponding to conventional images, and evaluated for the presence of labral and rotator cuff lesions using conventional and 3D isotropic sequences. The diagnostic performances of each sequence were determined using arthroscopic findings as the standard.

RESULTS

Good to excellent interobserver agreements were obtained for both 3D isotropic sequences for the evaluation of rotator cuff and labral lesions. Excellent agreement was found between two-dimensional (2D) and 3D isotropic MRA, except for supraspinatus tendon (SST) tears by both readers and for subscapularis tendon (SCT) tears by reader 2 in group B. 2D MRA and 3D isotropic sequences had high diagnostic performances for rotator and labral tears, and the difference between the two imaging methods was insignificant.

CONCLUSIONS

The diagnostic performances of 3D isotropic VIBE and PD sequences were similar to those of 2D MRA.

Unusual maternal uniparental isodisomic x chromosome mosaicism with asymmetric y chromosomal rearrangement

Infertile men with azoospermia commonly have associated microdeletions in the azoospermia factor (AZF) region of the Y chromosome, sex chromosome mosaicism, or sex chromosome rearrangements. In this study, we describe an unusual 46,XX and 45,X mosaicism with a rare Y chromosome rearrangement in a phenotypically normal male patient. The patient's karyotype was 46,XX[50]/45,X[25]/46,X,der(Y)(pter→q11.222::p11.2→pter)[25]. The derivative Y chromosome had a deletion at Yq11.222 and was duplicated at Yp11.2. Two copies of the SRY gene were confirmed by fluorescence in situ hybridization analysis, and complete deletion of the AZFb and AZFc regions was shown by multiplex-PCR for microdeletion analysis. Both X chromosomes of the predominant mosaic cell line (46,XX) were isodisomic and derived from the maternal gamete, as determined by examination of short tandem repeat markers. We postulate that the derivative Y chromosome might have been generated during paternal meiosis or early embryogenesis. Also, we suggest that the very rare mosaicism of isodisomic X chromosomes might be formed during maternal meiosis II or during postzygotic division derived from the 46,X,der(Y)/ 45,X lineage because of the instability of the derivative Y chromosome. To our knowledge, this is the first confirmatory study to verify the origin of a sex chromosome mosaicism with a Y chromosome rearrangement.

Abstract P1-08-39: Tumor-infiltrating CD8+ lymphocytes as an independent predictive factor for pathologic complete response to primary systemic therapy in breast cancer

Background: Tumor infiltrating lymphocytes (TILs), stem cell phenotype and epithelial-mesenchymal transition (EMT) are known to be associated with response to primary systemic therapy (PST) in breast cancer. However, these markers are strongly correlated with triple negative breast cancer, which shows high pathologic complete response (pCR) to PST. This study was conducted to evaluate clinical implication of these markers as predictive factor for pCR after PST in breast cancer and to find independent predictive factors, irrespective of breast cancer subtype.

Methods: The pre-chemotherapeutic biopsy specimens of 153 breast cancer patients who underwent surgical resection after anthracycline-or anthracycline/taxane-based PST were enrolled. TILs (CD4, CD8, and FOXP3), breast cancer stem cell phenotype (CD44+/CD24-, and ALDH1), expression of EMT markers [vimentin, smooth muscle actin (SMA), osteonectin, E-cadherin, and N-cadherin] were evaluated by immunohistochemistry and were correlated with pCR after PST.

Results: High infiltration of TILs (CD4+, CD8+, and FOXP3+), expression of stem cell markers (CD44+/CD24-, ALDH1+) and expression of EMT markers (expression of vimentin, SMA and osteonectin; loss of E-cadherin) were significantly associated with high histologic grade and triple negative breast cancer. Of them, high TILs (CD4+, CD8+, and FOXP3+) and expression of ALDH1, vimentin and osteonectin were associated with pCR. In multivariate analysis, CD8+ TILs and a conventional predictive marker, Ki67 were found to be independent predictors for pCR. In subgroup analyses, high CD8+ TILs was remained as a predictive factor for pCR, irrespective of PST regimen and tumor subtype.

Conclusion: CD8+ TILs could therefore be used as a reliable predictor of response to PST in breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-39.

Abstract P2-06-06: ALU and LINE-1 hypomethylation is associated with HER2+/ER- subtype of breast cancer

The changes in DNA methylation status in cancer cells are characterized by hypermethylation of promoter CpG islands and diffuse hypomethylation of non-coding genomic regions. ALU and long interspersed nucleotide element-1 (LINE-1) are non-coding genomic repetitive sequences and methylation of these elements can be used as a surrogate marker for genomewide methylation status. This study was designed to evaluate the changes of ALU and LINE-1 hypomethylation during breast cancer progression from normal to pre-invasive lesions and invasive breast cancer (IBC), and their relations with characteristics of IBC. We analyzed the methylation status of ALU and LINE-1 in 145 cases of breast samples including normal breast tissue (n = 30), atypical ductal hyperplasia/ flat epithelial atypia (ADH/FEA, n = 30), ductal carcinoma in situ (DCIS, n = 35) and IBC (n = 50), and another set of 129 cases of IBC by pyrosequencing. LINE-1 methylation was significantly decreased from normal to ADH/FEA, while ADH/FEA, DCIS and IBC were not different each other. There was no difference in ALU methylation levels during progression of breast cancer. In IBC, ALU hypomethylation was correlated with negative estrogen receptor (ER) status (p = 0.007) and LINE-1 hypomethylation was associated with negative ER status (p&lt;0.001), positive HER2 status (p = 0.005) and p53 overexpression (p = 0.024). ALU-1 and LINE-1 methylation status was significantly different between breast cancer subtype and the HER2+/ER- subtype had significantly lower methylation levels and frequencies than the other subtypes. Our findings suggest that LINE-1 hypomethylation is an early event during breast cancer progression and prominent hypomethylation of ALU and LINE-1 in HER2+/ER- subtype may be related to chromosomal instability of this specific subtype.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-06-06.

Abstract P1-08-38: HER2 heterogeneity affects trastuzumab responses and survival in patients with HER2-postive metastatic breast cancer

Purpose: Heterogeneity of HER2 gene amplification is found in a subset of breast cancers. However, it is not known whether breast cancers with heterogeneous HER2 amplification respond differently to HER2-targeted therapy than those with homogeneous amplification. In this study, we investigated the relationship between HER2 heterogeneity and trastuzumab resistance and clinical outcomes in patients with HER2-positive metastatic breast cancer.

Patients and methods: We studied tumor tissues from 127 patients with HER2-positive metastatic breast cancers who had received trastuzumab-based chemotherapy. Regional and genetic heterogeneity of HER2 amplification was determined in three different areas of each tumor by immunohistochemistry (IHC) and silver in situ hybridization. We also assessed the overall levels of HER2 amplification, and the proportion of tumor cells with a HER2/CEP17 ratio &gt;2.2 or HER2 overexpression (IHC score of 3+). HER2status including HER2 heterogeneity was correlated with trastuzumab responses and survival of the patients.

Results: HER2regional and genetic heterogeneity was confirmed in 7.8% and 3.6% of cases, respectively. Poor response to trastuzumab was associated with overall low-level amplification, HER2regional heterogeneity, HER2/CEP17 ratio &gt;2.2 in &lt;80% of tumor cells, and HER2 IHC score of 3+ in &lt;75% of tumor cells. In survival analyses, low-level HER2 amplification, HER2regional heterogeneity, and HER2/CEP17 ratio &gt;2.2 in &lt;80% of tumor cells were associated with shorter time to progression and lower overall survival in univariate and multivariate analyses.

Conclusion: Accurate assessment of HER2 status including HER2 heterogeneity is important in predicting trastuzumab responses and outcomes in patients with HER2-positive metastatic breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-38.

Does it matter what you call it? A randomized trial of language used to describe palliative care services

INTRODUCTION

Integration of palliative care into oncology practice remains suboptimal. Misperceptions about the meaning of palliative care may negatively impact utilization.

PURPOSE

We assessed whether the term and/or description of palliative care services affected patient views.

METHODS

2x2 between-subject randomized factorial telephone survey of 169 patients with advanced cancer. Patients were randomized into one of four groups that differed by name (supportive care vs. palliative care) and description (patient-centered vs. traditional). Main outcomes (0-10 Likert scale) were patient understanding, impressions, perceived need, and intended use of services.

RESULTS

When compared to palliative care, the term supportive care was associated with better understanding (7.7 vs. 6.8; p = 0.021), more favorable impressions (8.4 vs. 7.3; p = 0.002), and higher future perceived need (8.6 vs. 7.7; p = 0.017). There was no difference in outcomes between traditional and patient-centered descriptions. In adjusted linear regression models, the term supportive care remained associated with more favorable impressions (p = 0.003) and higher future perceived need (p = 0.022) when compared to palliative care.

CONCLUSIONS

Patients with advanced cancer view the name supportive care more favorably than palliative care. Future efforts to integrate principles of palliative medicine into oncology may require changing impressions of palliative care or substituting the term supportive care.

High-dose vitamin C management in dapsone-induced methemoglobinemia

Methylene blue is the first-choice treatment of methemoglobinemia, but it is not readily available in most Korean emergency departments because of an import suspension. An 84-year-old woman with dapsone-induced massive methemoglobinemia visited our emergency department for unclear mentality and cyanosis. Because methylene blue was not available, we intravenously administrated vitamin C (VC) for symptomatic methemoglobinemia, although VC is not a universally accepted treatment. Vitamin C (10 g intravenously) administered 6 hourly successfully treated the dapsone-induced methemoglobinemia and did not adversely affect renal functions. Thus,we recommend that if methylene blue is unavailable, 6 hourly intravenous administrations of 10 g of VC should be considered for dapsone-induced methemoglobinemia.

Afamin stimulates osteoclastogenesis and bone resorption via Gi-coupled receptor and Ca2+/calmodulin-dependent protein kinase (CaMK) pathways

BACKGROUND

Afamin was recently identified as a novel osteoclast-derived coupling factor that can stimulate the in vitro and in vivo migration of preosteoblasts.

AIM

In order to understand in more detail the biological roles of afamin in bone metabolism, we investigated its effects on osteoclastic differentiation and bone resorption.

METHODS

Osteoclasts were differentiated from mouse bone marrow cells. Tartrate-resistant acid phosphatase (TRAP)-positive multinucleated cells were considered as osteoclasts, and the resorption area was determined by incubating the cells on dentine discs. The intracellular cAMP level was determined using a direct enzyme immunoassay. Signaling pathways were investigated using western blot and RT-PCR. Recombinant afamin was administered exogenously to bone cell cultures.

RESULTS

Afamin stimulated both osteoclastogenesis and in vitro bone resorption. Consistently, the expressions of osteoclast differentiation markers were significantly increased by afamin. Although afamin mainly affected the late-differentiation stages of osteoclastogenesis, the expression levels of receptor activator of nuclear factor-κB ligand (RANKL)-dependent signals were not changed. Afamin markedly decreased the levels of intracellular cAMP with reversal by pretreatment with pertussis toxin (PTX), a specific inhibitor of Gi-coupled receptor signaling. In addition, PTX almost completely blocked afamin-stimulated osteoclastogenesis. Furthermore, pretreatment with KN93 and STO609 - Ca2+/cal - mo dulin-dependent protein kinase (CaMK) and CaMK kinase inhibitors, respectively - significantly prevented decreases in the intracellular cAMP level by afamin while attenuating afamin-stimulated osteoclastogenesis.

CONCLUSION

Afamin enhances osteoclastogenesis by decreasing intracellular cAMP levels via Gi-coupled receptor and CaMK pathways.

Tumour-infiltrating CD8+ lymphocytes as an independent predictive factor for pathological complete response to primary systemic therapy in breast cancer

Background:

Tumour-infiltrating lymphocytes (TILs) are known to be associated with response to primary systemic therapy (PST) in breast cancer. This study was conducted to assess the association of TIL subsets with pathological complete response (pCR) after PST in breast cancer in relation to breast cancer subtype, breast cancer stem cell (BCSC) phenotype and epithelial–mesenchymal transition (EMT).

Methods:

The pre-chemotherapeutic biopsy specimens of 153 breast cancer patients who underwent surgical resection after anthracycline- or anthracycline/taxane-based PST were analysed. TIL subsets (CD4+, CD8+, and FOXP3+ TILs), BCSC phenotype, and the expression of EMT markers were evaluated by immunohistochemistry and were correlated with pCR after PST.

Results:

Infiltration of CD4+ and CD8+ T lymphocytes was closely correlated with BCSC phenotype and EMT. High levels of CD4+, CD8+, and FOXP3+ TILs were associated with pCR, and CD8+ TILs were found to be an independent predictive factor for pCR. In addition, CD8+ TILs were associated with pCR irrespective of breast cancer subtype, CD44+/CD24− phenotype, EMT, and chemotherapeutic regimen in subgroup analyses.

Conclusion:

These findings indicate that CD8+ cytotoxic T lymphocytes are a key component of TILs associated with chemo-response and can be used as a reliable predictor of response to anthracycline- or anthracycline/taxane-based PST in breast cancer.

Suppression of PU.1-linked TLR4 expression by cilostazol with decrease of cytokine production in macrophages from patients with rheumatoid arthritis

BACKGROUND AND PURPOSE

The present study assessed the effects of cilostazol on LPS-stimulated TLR4 signal pathways in synovial macrophages from patients with rheumatoid arthritis (RA). These effects were confirmed in collagen-induced arthritis (CIA) in mice.

EXPERIMENTAL APPROACH

Expression of TLR4, PU.1, NF-κB p65 and IκBα on synovial fluid macrophages from RA patients was determined by Western blotting, and cytokines were measured by ELISA. Anti-arthritic effects were evaluated in CIA mice.

KEY RESULTS

Intracellular cAMP was concentration-dependently raised by cilostazol (1-100 μM). Cilostazol significantly suppressed LPS-stimulated increase of TLR4 expression by blocking PU.1 transcriptional activity in RA macrophages. In addition, cilostazol decreased LPS-induced myeloid differentiation factor 88 (MyD88) expression, but not that of TNF receptor-associated factor 6 (TRAF6). Cilostazol also suppressed IkBα degradation and NF-κB p65 nuclear translocation. Moreover, LPS-induced increase of cytokine production (TNF-α, IL-1β) was inhibited by cilostazol, an effect which was accompanied by suppression of IκBα degradation, and NF-κB p65 nuclear translocation. However, expression of anti-inflammatory IL-10 was elevated by cilostazol and forskolin/IBMX. In mice with CIA, post-treatment with cilostazol (30 mg kg⁻¹ day⁻¹) decreased expression of TLR4 in knee joints in association with decreased recruitment of macrophages. Consequently, synovial inflammation, proteoglycan depletion and bone erosion were significantly inhibited by cilostazol treatment.

CONCLUSIONS AND IMPLICATIONS

Cilostazol down-regulated LPS-stimulated PU.1-linked TLR4 expression and TLR4/MyD88/NF-κB signal pathways, and then suppressed inflammatory cytokine production in synovial macrophages from RA patients. Also cilostazol markedly inhibited the severity of CIA in mice.