Impact of HER2 Status on Risk of Sentinel Node Metastasis: An Independently Validated Multivariable Model

Purpose The presence of axillary lymph node metastases is dictated by tumor biology and is a strong prognostic indicator in breast cancer. We have previously published a user-friendly nomogram that provides a risk estimate for sentinel lymph node (SLN) metastasis in women with breast cancer (Bevilacqua et al. 2007, J Clin Oncol 25: 3670). At that time, HER2 testing was not uniformly performed, but is now standard of care. The purpose of this study was to determine if the addition of HER2 status or grouping of patients by molecular subtype improves the prediction of SLN metastasis.Patients and Methods: The ability of clinical and pathologic features to predict the presence of SLN metastasis in patients presenting with clinically node negative invasive breast cancer, was assessed with multivariable logistic regression (MVA) for 4723 sequential SLN biopsy procedures with known ER, PR, and HER2 from 1996 to 2004. HER2 status was defined as positive if IHC=3+ and/or FISH≥2. The modeling (n=3297) and validation (n=1426) groups were identified by simple random sampling. Two models were created using the modeling population: one included ER, PR, and HER2 as separate variables and one combined these markers into 4 subtypes defined as: Luminal A-like=ER or PR +, HER2 −; Luminal B-like=ER or PR +, HER2 +; HER2-like=ER and PR −, HER2 +; Basal-like=ER and PR −, HER2 −. The validation group was used to assess the calibration (intercept, slope, Emax, Eavg) and discrimination (AUC, area under the receiver operating curve) of the models.Results: In addition to age, tumor size, tumor type, lymphovascular invasion, tumor location, and multifocality, subtype was found to be an independent predictor of SLN metastasis on MVA (p=0.003). The Basal-like subtype was associated with a significantly lower risk of SLN metastasis (compared with referent Luminal A-like subtype, OR=0.58). HER2 alone was not found to be an independent predictor of SLN metastasis (p=0.56), while ER and PR remained significant (p=.05, p=.02). Compared to our previous model without HER2, the AUC was slightly decreased by the addition of either HER2 or subtype into the model, but the calibration was slightly improved (Table 1). DiscriminationCalibrationModelAUCInterceptSlopeEmaxEavgPrevious Model0.735- 0.0440.8690.0390.020Mew model with HER20.733- 0.0030.8890.0270.019New model with subtype0.731- 0.0010.8870.0270.020Table 1: Discrimination and calibration measures comparing the new model (with HER2 alone or subtype) with the previously published model (without HER2 or subtype).Conclusion: The addition of subtype, defined by combining HER2 status with ER and PR, slightly increases the calibration of the new model but does not increase its discrimination compared to the previous model. Breast tumor subtype is a significant independent predictor of risk of SLN metastasis, with basal-like subtype having a lower risk of SLN metastasis.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1004.

Depressive relapse during lithium treatment associated with increased serum thyroid-stimulating hormone: results from two placebo-controlled bipolar I maintenance studies

OBJECTIVE

To assess the relationship between depressive relapse and change in thyroid function in an exploratory post hoc analysis from a controlled maintenance evaluation of bipolar I disorder.

METHOD

Mean thyroid-stimulating hormone (TSH) and outcome data were pooled from two 18-month, double-blind, placebo-controlled, maintenance studies of lamotrigine and lithium monotherapy. A post hoc analysis of 109 subjects (n = 55 lamotrigine, n = 32 lithium, n = 22 placebo) with serum TSH values at screening and either week 52 (+/-14 days) or study drop-out was conducted.

RESULTS

Lithium-treated subjects who required an intervention for a depressive episode had a significantly higher adjusted mean TSH level (4.4 microIU/ml) compared with lithium-treated subjects who did not require intervention for a depressive episode (2.4 microIU/ml).

CONCLUSION

Lithium-related changes in thyroid function are clinically relevant and should be carefully monitored in the maintenance phase of bipolar disorder to maximize mood stability and minimize the risk of subsyndromal or syndromal depressive relapse.

Preliminary results from a phase II study of ARQ 197 in patients with microphthalmia transcription factor family (MiT)-associated tumors

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Background: ARQ 197 is a selective, non-ATP competitive inhibitor of c-Met, a receptor tyrosine kinase implicated in tumor cell migration, invasion, and proliferation. The drug has demonstrated a favorable safety profile and preliminary anti-cancer activity in three phase 1 studies. MiT tumors include clear cell sarcoma (CCS), alveolar soft part sarcoma (ASPS), and translocation-associated renal cell carcinoma (TLA RCC) and are linked biologically by a shared activated transcriptional mechanism which directly upregulates c-Met. Tumors with this type of chromosomal abnormality are generally resistant to all approved therapies and, in the absence of complete surgical resection, prove invariably fatal. Methods: This is a multi-center, single arm, two-stage phase 2 trial in patients (pts) 13 years of age or older with MiT tumors. Initially pts received 120 mg ARQ 197 orally twice daily (bid). The protocol was amended in August 2008 to increase the dose to 360 mg bid. If either a complete response (CR) or a partial response (PR) were to be observed in the 23 pts in stage 1, the study would be advanced to stage 2 where 16 additional patients will be enrolled. Tumor responses are measured in 8-week intervals per RECIST criteria. Results: To date, 28 pts (19 females, 9 males; median age = 21; 7 CCS, 17 ASPS, 4 RCC) have been treated. One pt with CCS demonstrated a confirmed PR, 15 pts (10 ASPS, 2 CCS, 3 RCC) demonstrated stable disease (SD) for durations up to 29+ weeks, and 4 pts progressed. An overall response rate of 5% and a disease control rate (CR+PR+SD) of 80% were demonstrated among 20 pts who were evaluable for efficacy. The most common drug-related adverse events (AEs) have been fatigue (35.7%), nausea (35.7%), vomiting (21.4%), decreased hemoglobin (10.7%). and cough (10.7%). To date, only 3 drug-related Grade 3 or 4 AEs have been reported including anemia (2) and decreased neutrophil count (1). No drug-related serious AEs or deaths have been reported. Conclusions: To date, ARQ 197 has demonstrated an extremely favorable safety profile and preliminary evidence of anti-cancer activity in these young pts. The criterion for advancing the study from stage 1 to stage 2 has been met. Stage 2 enrollment is ongoing. Updated data on both dose levels will be presented.

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Study of quadrant high-dose intraoperative radiation therapy for early-stage breast cancer

BACKGROUND

Partial breast irradiation has been tested in limited pilot studies and shown to provide acceptable cosmesis, minimal toxicity and adequate local control. The aim of this study was to determine the feasibility of using quadrant high-dose intraoperative radiation therapy (IORT) for the treatment of early-stage breast cancer.

METHODS

Fifty-two women with early-stage breast cancer were treated with breast-conserving therapy and IORT between October 2002 and January 2006. The first 18 women received a radiation dose of 20 Gy. The protocol was then amended and the remaining 34 women were treated with 18 Gy. Each patient was evaluated after surgery, and at 3, 6 and 12 months; complications, toxicity and cosmetic outcomes were recorded by the breast surgeon.

RESULTS

Women treated with 18 Gy appeared to have a more favourable cosmetic outcome compared with the earlier treatment group. At last follow-up, none of the women treated on the protocol had a breast recurrence.

CONCLUSION

Experience suggests that this IORT technique is feasible, although further follow-up is necessary to assess its therapeutic value.

Banff schema for grading pancreas allograft rejection: working proposal by a multi-disciplinary international consensus panel

Accurate diagnosis and grading of rejection and other pathological processes are of paramount importance to guide therapeutic interventions in patients with pancreas allograft dysfunction. A multi-disciplinary panel of pathologists, surgeons and nephrologists was convened for the purpose of developing a consensus document delineating the histopathological features for diagnosis and grading of rejection in pancreas transplant biopsies. Based on the available published data and the collective experience, criteria for the diagnosis of acute cell-mediated allograft rejection (ACMR) were established. Three severity grades (I/mild, II/moderate and III/severe) were defined based on lesions known to be more or less responsive to treatment and associated with better- or worse-graft outcomes, respectively. The features of chronic rejection/graft sclerosis were reassessed, and three histological stages were established. Tentative criteria for the diagnosis of antibody-mediated rejection were also characterized, in anticipation of future studies that ought to provide more information on this process. Criteria for needle core biopsy adequacy and guidelines for pathology reporting were also defined. The availability of a simple, reproducible, clinically relevant and internationally accepted schema for grading rejection should improve the level of diagnostic accuracy and facilitate communication between all parties involved in the care of pancreas transplant recipients.

Symptoms of depression and cognitive functioning in older American Indians

Depression and lower cognitive functioning are common conditions in older populations. While links between psychopathology and neuropsychological performance have been studied in the white majority population, little is known about such links in the American Indian population. American Indians aged 60 and older (n=140) completed structured interviews that included a depression screener and two cognitive screening measures, the Mini-Mental State Examination (MMSE) and the Mattis Dementia Rating Scale (MDRS). Participants had mean values of 26.7/30 on the MMSE and 125.8/144 on the MDRS. The depression screen was not associated with the MMSE or MDRS total scores. However, older American Indians who screened positive for depression scored lower than did those American Indians who screened negatively for depression (27.7 versus 29.8 respectively) on the MDRS conceptualization subscale after adjusting for sociodemographic and health variables. The combined effects of psychopathology and cognitive impairment are likely to adversely impact the health and welfare of American Indians and their families. More research is needed to provide a better understanding of the relationship between psychopathology and cognition that will help inform clinical treatment for psychopathology in older ethnic minorities.

Heritability of flow-mediated dilation: a twin study

BACKGROUND

Endothelial dysfunction assessed by brachial artery flow-mediated dilation (FMD) is a marker for early atherosclerotic vascular disease and future cardiovascular events.

OBJECTIVE

To estimate the heritability of brachial artery FMD using a twin design.

METHODS

We estimated the heritability of FMD using 94 middle-aged male twin pairs. FMD was measured by ultrasound, and traditional coronary heart disease risk factors were measured. Genetic modeling techniques were used to determine the relative contributions of genes and environment to the variation in FMD.

RESULTS

The mean age of the twin participants was 54.9 +/- 2.8 years. The mean FMD was 0.047 +/- 0.030. The intraclass correlation coefficient was higher in MZ twins [0.38, 95% confidence interval (CI) 0.32-0.43] than in DZ twins (0.19, 95% CI 0.11-0.26), suggesting a role of genetic influence in FMD variation. Structural equation modeling showed that both genetic and unique environmental factors contributed significantly to the variation in FMD. The crude FMD heritability was 0.37 (95% CI 0.15-0.54). After adjustment for traditional cardiovascular risk factors, including age, total cholesterol, blood pressure, and body mass index, the heritability of FMD was 39% (95% CI 0.18-0.56). The remaining variation in FMD could be explained by individual-specific environment.

CONCLUSION

This is the first study using twins to estimate the relative contributions of genetics and environment to the variation in FMD in a US population. Our results demonstrate a moderate genetic effect on brachial artery FMD, independent of traditional coronary risk factors. Our data also highlight the importance of unique environment on the variability in FMD.

Sirolimus in chronic allograft nephropathy in pediatric recipients

CAN is a common cause of late graft loss. Nephrotoxicity due to CNIs is known to contribute to CAN. We retrospectively evaluated the efficacy and safety of SRL in pediatric renal Tx recipients showing CAN in their allograft biopsy. Twenty-one patients aged 10.4 +/- 4.6 yr at Tx time receiving CNIs as primary immunosuppression were converted to SRL at 58.9 +/- 49.1 months after Tx, due to progressive decline of renal function and biopsy proven CAN. Mean follow-up after switch was 19.7 +/- 9.5 months. All patients received CsA as part of the immunosuppressive regimen, at a mean dose 4.4 +/- 1.2 mg/kg/day. Mean daily dose of SRL three month after conversion was 2.6 +/- 0.8 mg/body surface area/day and the mean through levels where 6.9 +/- 2.5 ng/mL. Graft biopsies showed Grade I CAN in 12 children and Grade II CAN in nine. After SRL introduction, there were neither acute rejection episodes nor graft losses. GFR improved at three months and was sustained thereafter only in children with Grade I CAN. Post-Tx time at conversion was the only significant variable between patients who had Grade I CAN and Grade II CAN (33.6 +/- 33.3 vs. 92.7 +/- 47.5 months, p = 0.003). Nine patients had no AEs, six patients had nine SAE: five diarrhea, one herpes zoster, one pancreatic pseudo cyst, one pneumonia, and one Influenza A infection; 11 patients had 13 AEs: six oral aphthous ulcers, three urinary tract infections, two herpes simplex, one lymphedema, and one nephrotic proteinuria. Significant improvement of GFR occurred in Grade I CAN group at three months from conversion and was sustained during follow-up. Those who had Grade II CAN experienced no change in GFR. The incidence of AEs and SAE is of concern and further studies are necessary to assess their relevance.

Self-everting ileostomy

OBJECTIVE

Self-everting ileostomy.

METHOD

After delivering the small bowel through the trephine wound the bowel is opened and with time the mucosa migrates to the skin edge forming a spouted ileostomy.

RESULTS

Five patients underwent the self-everting ileostomy with no stomal complications experienced. The end result is indistinguishable from a primarily sutured stoma.

CONCLUSION

The self-everting ileostomy can be a useful technique to get out of a difficult situation.