A single institution experience with skin sparing mastectomy and immediate breast reconstruction

INTRODUCTION

Skin sparing mastectomies (SSMs) represent a surgical approach that preserves the natural skin envelope of the breast and, when combined with immediate reconstruction, offers a good cosmetic outcome. The aim of this retrospective study was to compare the risk of local recurrence (LR) in this series with the known rate of recurrence following a conventional mastectomy.

METHODS

A total of 108 patients with breast cancer who underwent an SSM and immediate breast reconstruction over a 6-year period were reviewed.

RESULTS

A follow-up of more than eight years showed that three patients (2.78%) had developed LR.

CONCLUSIONS

The rate of LR is low with SSMs and is comparable to that seen with conventional mastectomies.

Small bowel hemangioma diagnosed with laparoscopy: Report of two pediatric cases

Hemangiomas of the small bowel are rare tumors that often present with gastrointestinal bleeding. Diagnosis can be difficult and exploratory laparotomy has often proved to be the only method with which to determine the presence and location of these tumors. We report two cases of small bowel hemangioma in children aged 10 and 7 years, in which the diagnosis was made by laparoscopy. Laparoscopy identifies the affected segment of bowel and allows delivery to a minimally extended umbilical port site. The avoidance of an open laparotomy helps to reduce post-operative analgesic requirement and achieves an early return of bowel function.

Elevated incidence of fractures in solid-organ transplant recipients on glucocorticoid-sparing immunosuppressive regimens

This study was conducted to assess the occurrence of fractures in solid-organ transplant recipients. Methods. Medical record review and surveys were performed. Patients received less than 6 months of glucocorticoids. Results. Of 351 transplant patients, 175 patients provided fracture information, with 48 (27.4%) having fractured since transplant (2-6 years). Transplants included 19 kidney/liver (50% male), 47 kidney/pancreas (53% male), 92 liver (65% male), and 17 pancreas transplants (41% male). Age at transplant was 50.8 ± 10.3 years. Fractures were equally seen across both genders and transplant types. Calcium supplementation (n = 94) and bisphosphonate therapy (n = 52) were observed, and an association with a lower risk of fractures was noted for bisphosphonate users (OR = 0.45 95% C.I. 0.24, 0.85). Fracture location included 8 (16.7%) foot, 12 (25.0%) vertebral, 3 (6.3%) hand, 2 (4.2%) humerus, 5 (10.4%) wrist, 10 (20.8%) fractures at other sites, and 7 (14.6%) multiple fractures. The estimated relative risk of fracture was nearly seventeen-times higher in male liver transplant recipients ages 45-64 years compared with the general male population, and comparable to fracture rates on conventional immunosuppressant regimens. Conclusion. We identify a high frequency of fractures in transplant recipients despite limited glucocorticoid use.

Abstract P6-10-01: The Association between the Use of Selective COX-2 Inhibitors and Breast Cancer Recurrence

Introduction:

There have been biological findings alluding to the role of selective COX-2 inhibitors in reducing the risk of developing cancers including breast cancer. Epidemiological data suggest that COX-2 inhibitors may prevent the development of cancers, including colorectal, esophageal and lung cancer. To date, there exists no study that reported any relationship between their use and the risk of breast cancer recurrence. Thus, we investigated the associations between the use of COX-2 inhibitors and the risk of tumor recurrence among breast cancer patients.

Methods: We reviewed the medical records of female patients diagnosed with stage II/III breast cancer in Albert Einstein Medical Center between 1999 and 2005 and later reached no evident disease (NED) stage. Follow up period was from 1999 to 2008 with mean and maximum being 4.4 years and 9.8 years, respectively. COX-2 inhibitor user was defined as patients taking the medication in NED stage for at least 6 months. Age, race, family history, smoking history, menopausal status, diabetes, HER2/Neu status, hormone receptor status, TNM stage, histology, and treatment received were compared between COX-2 inhibitor users and nonusers. The primary outcome was disease free survival. The secondary outcome was overall survival. Multivariate analyses were performed using Cox proportional hazard model.

Results: Of 682 cancer patients, 7.3 % (n=50) were prescribed COX-2 inhibitor; 10.0 % (5/50) of patients developed recurrence among COX-2 inhibitor users, while 22.0% (139/632) did among nonusers (chi-square test: P<0.05). COX-2 inhibitor use was negatively associated with cancer recurrence (hazard ratio [HR], 0.41; 95% confidence interval[CI], 0.17-1.00; P=0.05). Variables associated with recurrence in multivariate model were race (Caucasian vs. non-Caucasian; adjusted hazard ratio [AHR], 1.83; 95% CI, 1.20-1.84; P<0.01) and number of nodes ≥3 (AHR, 2.22; 95% CI, 1.24-3.98; P<0.01). In multivariate analysis, the association between COX-2 inhibitor use and cancer recurrence only suggestive (AHR, 0.35; 95% CI; 0.11-1.12; P=0.07). Kaplan-Meier survival analysis revealed that COX-2 inhibitor use was related to disease-free survival benefit (log-rank test P<0.05). 5 year survival was 0.88 for COX-2 inhibitor users, and 0.77 for non-users. However, COX-2 inhibitor use was not associated with reduced overall mortality in breast cancer patients (AHR, 0.49; 95% CI: 0.15-1.58; P=0.23; log-rank test P=0.12) K-M Survival Curve of Breast Cancer Recurrence

Conclusions: The use of COX-2 inhibitors seems to be related to a reduced risk of developing recurrence in patients with breast cancer. This result provides the clinical evidence, in accordance with existing biological data, that COX-2 inhibitor use in breast cancer patients may be inversely associated with tumor recurrence. However, prospective randomized trials are required to validate our finding.

Abstract P6-15-13: Biologic Activity of a Novel Heat Shock Protein 90 Inhibitor, PF-4928473, in Human Breast Cancer Cell Lines

Background: Heat shock protein 90 (HSP90) is a key molecular chaperone involved with the post-translational folding and maturation of various cellular proteins, including Raf, Src, ER, EGFR, HER2/ErbB2, IGFR, and VEGFR. Therefore, targeting HSP90 represents an attractive strategy for modulating aberrant oncogenic signal transduction in human malignancies. In the present study, we investigate the anti-cancer activity of PF-4928473, a novel small molecule inhibitor of HSP90, in a diverse panel of human breast cancer cell lines in vitro.

Methods: 49 breast cancer cell lines (representing 10 luminal, 18 HER2- amplified, 18 non-luminal, 3 immortalized subtypes), including two HER2- amplified lines with conditioned trastuzumab and lapatinib resistance (SKBR3 parental), were assessed. Cell proliferation assays with two-fold drug dilutions over 9 concentrations were performed over 6 days to determine growth-adjusted IC50 and IC100 values, the latter as a surrogate of in vitro drug lethality. Flow-cytometry was performed in a selected subset of 21 cell lines to assess effects on cell cycle and apoptosis after 48 hours and 5 days of drug exposure, respectively. Western blot analysis evaluated the biochemical effects of HSP90 drug inhibition. Results: In our panel, IC50s ranged from 8 (±1) nM to 525 (±2) nM, with 45 cell lines exhibiting IC50s ≥50 nM. Differential drug sensitivity was observed with HER2-amplified lines, with 15 of 18 demonstrating IC50s ≥28 nM. For SKBR3-trastuzumab and -lapatinib-resistant lines, IC50s were 13 (±1) nM and 21 (±2) nM, respectively. IC100s ranged from 9 (±3) nM to > 1000 nM. 17 of 18 HER2-amplified lines had IC100s between 9 (±3) nM and 69 (±1) nM, including SKBR3-trastuzumab and -lapatinib-resistant lines at 31 (±2) nM and 66 (±2) nM, respectively. Flow cytometry with 50 nM of PF-4928473 revealed moderate early apoptotic effects in cell lines with IC50s < 30 nM, encompassing the majority of HER2-amplified lines. Mild effects on cell cycle, primarily G0/G1 arrest, were observed in 8 lines at 50 and/or 100 nM. Western blots of representative cell lines at 50 and 100 nM of PF-4928473 identified downregulation of p-AKT and p-ERK in the HER2-amplified SKBR3 line (IC50: 19 ±4 nM), vs. relative lack of effect for the non-luminal MDA-MB-468 (IC50: 24 ±5 nM) and luminal KPL-1 (IC50: 68 ±2 nM) lines. Upregulation of HSP70, a known biomarker associated with HSP90 inhibition, was observed at 12 hours post-drug exposure regardless of cell sensitivity. Further biochemical studies are ongoing.

Conclusions: PF-4928473 demonstrated low nanomolar in vitro anti-proliferative activity, lethality, and apoptosis in a wide panel of human breast cancer cell lines, including trastuzumab and lapatinib-resistant lines. Biological effects were most pronounced in HER2-amplified lines, in keeping with HER2 as a known protein client of HSP90. Based on these results, further translational evaluation of HSP90 inhibitors in this population merits consideration.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-15-13.

Adult idiopathic jejuno-ileal intussusception

This 67-year-old woman, with numerous previous abdominal operations, presented to her general practitioner 3 years ago with generalised abdominal pain and diarrhoea. With unremarkable haematology tests and a CT scan at that time she was given the diagnosis of irritable bowel syndrome. During the next 3 years her symptoms continued intermittently and now associated with vomiting and weight loss. This time both a barium follow-through followed by a CT scan demonstrated a small bowel intussusception. A laparotomy was done but surprisingly no intussusception was found, only a single adhesional band which was divided. She was discharged 5-days postoperative but re-admitted 3 days later with abdominal discomfort, bloating and vomiting. A repeat CT scan again showed the presence of a small bowel intussusception and a second laparotomy was performed, this time demonstrating a jejuno-ileal intussusception which was reduced and resected with primary anastomosis. Her postoperative course was without incidents.

Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor Blockers May Reduce Breast Cancer Recurrence

There have been epidemiologic and biochemical findings alluding to the role of angiotensin converting enzyme inhibitors(ACEIs) and angiotensin receptor blockers(ARBs) in reducing the risk of developing cancer. To date, there exists no study that reported any relationship between their use and the risk of cancer recurrence. Thus, we investigated the associations between the use of ACEI/ARB and the risk of tumor recurrence among breast cancer patients without any evidence of disease.We reviewed the medical records of female patients diagnosed with stage II/III breast cancer in Albert Einstein Medical Center between 1999 and 2005 and later reached no evident disease (NED) stage after curative therapy. Follow up period was from 1999 to 2008 with mean and maximum being 4.4 years and 9.8 years, respectively. ACEI/ARB user was defined as patients taking the medication in NED stage for at least 6 months. Multivariate analyses were performed using logistic regression and Cox proportional hazard model.Of 707 cancer patients and of 335 cancer patients with hypertension, 164, representing 23.3% of total and 49.0% of those with hypertension were prescribed ACEI/ARB. ACEI/ARB use was associated with older age (P<0.001), postmenopausal status (P<0.001), and diabetes (P<0.01). Fourteen percent (23/164) of ACEI/ARB users developed cancer recurrence, while 23.3% (125/541) of nonusers developed a recurrence (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.33-0.97; P=0.01). Kaplan-Meier survival analysis revealed that ACEI/ARB use was related to disease-free survival benefit (log-rank test P<0.01). Five year disease-free survival for ACEI/ARB users was 0.85 compared with 0.76 for nonusers (P<0.01). Adjusting for statistically significant variables above, ACEI/ARB use was associated with reduced risk of developing recurrence not only in all breast cancer patients but also when they were compared to a subset of the nonusers who had hypertension (AHR, 0.41; 0.23-0.80; P<0.01). While ACEI/ARB use was not associated with reduced mortality in all breast cancer patients (AHR, 1.01; 95% CI: 0.61-1.65; P=0.36; log-rank test P=0.52), it was when compared to the subset of patients with hypertension (AHR, 0.43; 95% CI, 0.25-0.68; P<0.01; log-rank test P<0.01).The use of ACEI/ARB is related to reduced risk of developing recurrence in patients with breast cancer. This result provides clinical evidence, in accordance with existing biochemical and epidemiologic data, that antagonizing angiotensin system is inversely associated with tumor recurrence. However, prospective randomized trials are needed to validate this finding.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3121.

A polypoid gastric heterotopia of jejunum diagnosed by capsule endoscopy

A 36-year-old lady presented with symptoms of intermittent small bowel obstruction caused by a polyp in the jejunum. CT scan and small bowel enema failed to demonstrate this polyp, and required a small bowel capsule endoscopy to finally reach a diagnosis. The objective of this report is to highlight the role of capsule endoscopy as a diagnostic tool in the small bowel pathology and to report a case of a polypoid gastric heterotopia of jejunum.

The incidence and outcome of incidental breast lesions detected by computed tomography

INTRODUCTION

In the UK, the majority of breast cancers are diagnosed through symptomatic breast clinics and the breast screening programmes. With increased use of computed tomography (CT) to assess various pathologies, breast lesions are picked up incidentally. The aim of this study was to investigate the incidence and outcomes of breast lesions detected incidentally on CT scans.

PATIENTS AND METHODS

A retrospective study was conducted to assess the incidence and outcome of incidentally found breast lesions, which were detected on chest CT scans that were conducted for other pathologies during the period from February 2007 to October 2008.

RESULTS

A total of 432 chest CT scans were performed over 18 months. Thirty-three (7.63%) patients were found to have an incidental breast lesion. The mean age was 73 years (range, 50-86 years). Of these, 17 (52%) were benign, eight (24%) were primary breast cancer and the remaining eight (24%) had no definite pathology. The detection rate of breast cancer was 1.85%.

CONCLUSIONS

CT is emerging as an important contributor to the detection of occult breast lesions. Radiological awareness of incidental breast lesions is important so that appropriate referral to a specialised breast unit is made.

META060 inhibits multiple kinases in the NF-kappaB pathway and suppresses LPS--mediated inflammation in vitro and ex vivo

OBJECTIVE

We investigated whether a novel candidate META060 targeted the inflammatory signal transduction without affecting constitutive COX-2 enzymatic activity in lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophages. We also investigated its bioavailability in humans and its anti-inflammatory effect ex vivo.

METHODS

We measured prostaglandin E(2), nitric oxide, TNFalpha and IL-6 by ELISA, COX-2 protein by Western blot, NF-kappaB nuclear binding by electrophoretic mobility shift assays, and NF-kappaB activation by luciferase assay. Kinase inhibitions were measured by cell-free assays. Bioavailability was tested in 4 human subjects consuming 940 mg META060. LPS-activated TNFalpha and IL-6 were measured in peripheral blood mononuclear cells (PBMC) isolated from 1 subject up to 6 hours post administration.

RESULTS

META060 dose-dependently inhibited prostaglandin E(2) and nitric oxide formation, COX-2 abundance, and NF-kappaB activation. In cell-free assays, META060 inhibited multiple kinases in the NF-kappaB signaling pathway, including BTK, PI3K, and GSK3. META060 was detected in the plasma of the subjects; isolated PBMC were resistant to LPS-stimulated TNFalpha and IL-6 production.

CONCLUSION

Without inhibiting COX-2 enzyme, META060 reduces the inflammation by inhibiting multiple kinases involved in NF-kappaB pathway, and may have potential as a safe anti-inflammatory therapeutic.

HIV-1 clade C infection and progressive disruption in the relationship between cortisol, DHEAS and CD4 cell numbers: a two-year follow-up study

BACKGROUND

It is well established that there is mutual interaction between the neuroendocrines and immune systems and that the disturbance in any one system could affect the function of the other. While there is a large body of evidence suggesting negative impact of human immunodeficiency virus type 1B (HIV-1B) infection on both immune and neuroendocrine systems, the consequence of HIV-1 clade C infection (with structural differences from HIV-1B virus) on these systems is not clearly understood.

METHODS

We carried out a 2-year longitudinal study on plasma profile of adrenocorticosteroids, including cortisol and DHEAS and their relationship with declining CD4+ cell counts in neurologically asymptomatic HIV-C infected individuals (N=84) in order to understand the impact of HIV-1 clade C infection on adrenocortical dysfunction and its relationship with the progressive decline in the cell mediated immunity.

RESULTS

We found that while plasma cortisol levels increased significantly at baseline in HIV-1C infected individuals compared to those in HIV-negative controls (HIV-1C+, 9.83+/-0.39 vs controls, 8.04+/-0.45; p<0.01), there was a significant decrease in DHEAS in HIV-1C+ individuals, compared to that in HIV-negative controls (81.02+/-4.9 vs 185.1+/-12.03, p<0.001), and consequently a significant increase in cortisol:DHEAS ratio in HIV-1 clade C infected persons (0.19+/-0.002 vs control 0.058+/-0.006; p<0.001). Moreover, in HIV-1C infected individuals, there was a strong positive correlation between DHEAS and CD4 cells (r=0.2; p<0.05), and a strong negative correlation between cortisol, as well as cortisol:DHEAS ratio and CD4 cells (r=-0.25; p<0.01; and r=-0.31; p<0.001, respectively).

CONCLUSIONS

These findings suggest the persistent and progressive adrenocortical dysfunction during the asymptomatic phase of HIV infection, and that the evaluation of increase in plasma cortisol, a decrease in DHEAS, and an increase in cortisol:DHEAS ratio may serve as important biomarkers preceding the impending down regulation of CD4 cell counts and progressive decline in the immune system function in HIV-1C infection. Furthermore, these findings may indicate the dysregulation of 3beta-hydroxysteroid dehydrogenase (3beta-HSD) activity, the enzyme involved in the biosynthesis of cortisol and DHEA through the pregnenolone-progesterone pathway, and that it may offer an opportunity for drug discovery targeting re-regulation of 3beta-HSD activity for potential therapeutic application in HIV-1C infection.

PD 0332991, a selective CDK 4/6 inhibitor, preferentially inhibits proliferation of luminal ER+ breast cancer cells and acts synergistically with tamoxifen and trastuzumab in vitro

Abstract #5064

Background: Cell cycle dysregulation is a common molecular finding in malignancy and the cyclin-D kinases (CDK) represent an attractive target in this pathway. PD 0332991 (Pfizer Inc.) is an orally active potent and highly selective inhibitor of CDK 4 and CDK6 kinases with the ability to block pRb phosphorylation at serine 780 and 795 in the low nanomolar range. To identify predictors of response to PD 0332991, we determined the in vitro sensitivity to PD 0332991 of a large panel of molecularly characterized breast cancer cell lines, and then used baseline expression profiles to determine genes associated with response. Methods: 44 human breast cancer cell lines representing the known molecular subgroups of breast cancer (i.e. luminal, HER2, basal, etc) and 3 immortalized breast lines were treated in duplicate with PD 0332991 using two-fold dilutions over 12 concentrations. Dose response curves were generated using a cell count assay to calculate the IC50 across the panel. These data were then analyzed against baseline gene expression data (Agilent microarray) to identify genes associated with sensitivity and resistance to PD 0332991. ANOVA analysis identified genes associated with response and/or resistance to PD 0332991. Western blot analysis was performed analyzing the effects of PD 0332991 on pRb phosphorylation. Cell cycle analysis was performed using NIM-DAPI staining and flow-cytometry. In addition, combination studies were performed to analyze the interaction between PD 0332991 and tamoxifen and trastuzumab. These data were analyzed using Calcusyn software to generate a combination index (CI) to define the interaction as additive (CI=1), synergisitc (CI&lt;1), or antagonistic (CI&gt;1). Results: Cell lines representing the luminal ER+ subtype (including HER2 amplified) were most sensitive to inhibition by PD 0332991 and non-luminal/basal (triple-negative) were most resistant. ANOVA analysis identified 563 differentially expressed genes between the sensitive and resistant groups. While, several of these genes are associated with breast cancer subtype, pRb was elevated and CDKN2A (p16) was decreased in the most sensitive lines. Cell lines treated with PD 0332991 showed clear G0/G1 arrest and a decrease in S-phase fraction in sensitive but not in resistant cell lines. In addition, Western blot showed that pRb phosphorylation is blocked in a time dependent manner. Finally, the combination of tamoxifen and PD 0332991 was strongly synergistic in three ER+ cell lines evaluated and appeared synergistic with trastuzumab as well. Conclusion: These studies suggest that a subgroup of breast cancers may be more likely to benefit from treatment with the PD 0332991 CDK4/6 inhibitor than others. This group represents ER+ luminal breast cancer and is associated with elevated pRb and low p16. The combination of PD 0332991 and tamoxifen and trastuzumab shows promising biologic activity in ER+ and HER2 amplified breast cancer cell lines, respectively.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5064.

Statistical optimization of medium components for extracellular protease production by an extreme haloarchaeon, Halobacterium sp. SP1(1)

AIMS

Optimization of medium components for extracellular protease production by Halobacterium sp. SP1(1) using statistical approach.

METHODS AND RESULTS

The significant factors influencing the protease production as screened by Plackett-Burman method were identified as soybean flour and FeCl(3). Response surface methodology such as central composite design was applied for further optimization studies. The concentrations of medium components for higher protease production as optimized using this approach were (g l(-1)): NaCl, 250; KCl, 2; MgSO(4), 10; tri-Na-citrate, 1.5; soybean flour, 10 and FeCl(3), 0.16. This statistical optimization approach led to production of 69.44 +/- 0.811 U ml(-1) of protease.

CONCLUSIONS

Soybean flour and FeCl(3) were identified as important factors controlling the production of extracellular protease by Halobacterium sp. SP1(1). The statistical approach was found to be very effective in optimizing the medium components in manageable number of experimental runs with overall 3.9-fold increase in extracellular protease production.

SIGNIFICANCE AND IMPACT OF THE STUDY

The present study is the first report on statistical optimization of medium components for production of haloarchaeal protease. The study also explored the possibility of using extracellular protease produced by Halobacterium sp. SP1(1) for various applications like antifouling coatings and fish sauce preparation using cheaper raw material.