International consensus on (ICON) pediatric asthma

Asthma is the most common chronic lower respiratory disease in childhood throughout the world. Several guidelines and/or consensus documents are available to support medical decisions on pediatric asthma. Although there is no doubt that the use of common systematic approaches for management can considerably improve outcomes, dissemination and implementation of these are still major challenges. Consequently, the International Collaboration in Asthma, Allergy and Immunology (iCAALL), recently formed by the EAACI, AAAAI, ACAAI, and WAO, has decided to propose an International Consensus on (ICON) Pediatric Asthma. The purpose of this document is to highlight the key messages that are common to many of the existing guidelines, while critically reviewing and commenting on any differences, thus providing a concise reference. The principles of pediatric asthma management are generally accepted. Overall, the treatment goal is disease control. To achieve this, patients and their parents should be educated to optimally manage the disease, in collaboration with healthcare professionals. Identification and avoidance of triggers is also of significant importance. Assessment and monitoring should be performed regularly to re-evaluate and fine-tune treatment. Pharmacotherapy is the cornerstone of treatment. The optimal use of medication can, in most cases, help patients control symptoms and reduce the risk for future morbidity. The management of exacerbations is a major consideration, independent of chronic treatment. There is a trend toward considering phenotype-specific treatment choices; however, this goal has not yet been achieved.

FZD7 has a critical role in cell proliferation in triple negative breast cancer

Breast cancer is genetically and clinically heterogeneous. Triple negative breast cancer (TNBC) is a subtype of breast cancer that is usually associated with poor outcome and lack of benefit from targeted therapy. We used microarray analysis to perform a pathway analysis of TNBC compared with non-triple negative breast cancer (non-TNBC). Overexpression of several Wnt pathway genes, such as frizzled homolog 7 (FZD7), low density lipoprotein receptor-related protein 6 and transcription factor 7 (TCF7) was observed in TNBC, and we directed our focus to the Wnt pathway receptor, FZD7. To validate the function of FZD7, FZD7shRNA was used to knock down FZD7 expression. Notably, reduced cell proliferation and suppressed invasiveness and colony formation were observed in TNBC MDA-MB-231 and BT-20 cells. Study of the possible mechanism indicated that these effects occurred through silencing of the canonical Wnt signaling pathway, as evidenced by loss of nuclear accumulation of β-catenin and decreased transcriptional activity of TCF7. In vivo studies revealed that FZD7shRNA significantly suppressed tumor formation, through reduced cell proliferation, in mice bearing xenografts without FZD7 expression. Our findings suggest that FZD7-involved canonical Wnt signaling pathway is essential for tumorigenesis of TNBC, and thus, FZD7 shows promise as a biomarker and a potential therapeutic target for TNBC.

MeDALL (Mechanisms of the Development of ALLergy): an integrated approach from phenotypes to systems medicine

The origin of the epidemic of IgE-associated (allergic) diseases is unclear. MeDALL (Mechanisms of the Development of ALLergy), an FP7 European Union project (No. 264357), aims to generate novel knowledge on the mechanisms of initiation of allergy and to propose early diagnosis, prevention, and targets for therapy. A novel phenotype definition and an integrative translational approach are needed to understand how a network of molecular and environmental factors can lead to complex allergic diseases. A novel, stepwise, large-scale, and integrative approach will be led by a network of complementary experts in allergy, epidemiology, allergen biochemistry, immunology, molecular biology, epigenetics, functional genomics, bioinformatics, computational and systems biology. The following steps are proposed: (i) Identification of 'classical' and 'novel' phenotypes in existing birth cohorts; (ii) Building discovery of the relevant mechanisms in IgE-associated allergic diseases in existing longitudinal birth cohorts and Karelian children; (iii) Validation and redefinition of classical and novel phenotypes of IgE-associated allergic diseases; and (iv) Translational integration of systems biology outcomes into health care, including societal aspects. MeDALL will lead to: (i) A better understanding of allergic phenotypes, thus expanding current knowledge of the genomic and environmental determinants of allergic diseases in an integrative way; (ii) Novel diagnostic tools for the early diagnosis of allergy, targets for the development of novel treatment modalities, and prevention of allergic diseases; (iii) Improving the health of European citizens as well as increasing the competitiveness and boosting the innovative capacity of Europe, while addressing global health issues and ethical issues.

Abstract P2-09-17: Limited Gene Expression Profiling as Predictor of Response to Neoadjuvant Chemotherapy (NCT) with Docetaxel, Doxorubicin, Cyclophosphamide (TAC), or AC and Nab-Paclitaxel and Carboplatin +/− Trastuzumab in Patients (pts) with Locally Advanced (LABC) Stage II-III and Inflammatory Breast Cancer (IBC)

Background: Pathologic complete response (pCR) following neoadjuvant therapy (NCT) may predict for improved survival. Hence, more effective and individualized/targeted NCT regimens in conjunction with molecular markers that predict for both response and/or resistance are needed. Materials and Methods: 119 evaluable pts (121 enrolled) with stages II/III LABC/IBC were prospectively randomized to receive 6 cycles of docetaxel 75 mg/m2, doxorubicin 50 mg/m2, cyclophosphamide 500 mg/m2 with filgrastim support (TAC, arm A) versus a novel regimen of A 60 mg/m2 and C 600 mg/m2 given every 2 weeks x 4, followed by 3 weekly doses of carboplatin (AUC 2) and nab-paclitaxel 100 mg/m2 repeated as 28 day cycles x 3 (arm B). Pts with HER2 overexpressing (HER2+) BC received NCT similar to arm B, but with the addition of 12 weekly doses of trastuzumab given together with carboplatin and nab-paclitaxel (arm C). Core biopsies were performed prior to NCT and samples from 10 micron thick slides of formalin-fixed and paraffin-embedded (FFPE) breast cancer tissue were microdissected, and RNA was extracted for assessment of gene expression by RT-PCR for a panel of genes involved in cell proliferation, tumor suppression, DNA repair, and apoptosis. The following genes were evaluated: HER2/neu, IGF-1R, JAK2, STAT3, EGFR, BRCA1 and 2, PARP1, ERCC1, Topoisomerase 2-alpha, BBC3 (PUMA), p21, p27, IRF1, Beta-catenin, and SPARC, with actin as control. Responses were separated as complete or other response, and the Wilcoxon test was applied. Results: Neoadjuvant response assessment and sufficient amount of RNA following microdissection of primary tumor slides were available in 66/121 pts (55%). These 66 pts had similar characteristics to the entire cohort of enrolled pts. The median age was 51 yrs (range 30-69), and pts were treated for stage II/III BC (N=32, N=34, respectively, with 10 IBC cases). 37 pts were treated on Arms A and B (HER2- cohorts), and 29 on arm C (HER2+ cohort). pCR rates were 5/37 (14%) in groups A and B (of this set) combined, and 14/29 (48%) in group C (HER2+). For all arms/pts combined, overexpression of HER2, EGFR, and BRCA2, and low expression of p27, and IGFR1 were observed in pts with pCR, in comparison to pts not achieving pCR (P<0.05). When the analysis was restricted to HER2 negative cases (Arms A and B), BRCA2, JAK2 overexpression, and low expression of IGF1R were associated with pCR (P<0.05). Conclusion: Limited gene array analysis from microdissected FFPE specimens procured prior to NCT is feasible, and there is sufficient evidence in this limited data set to suggest that the specifc gene expression levels tested may play an important role in determining response to NCT both in HER2+ and HER2-, locally advanced, and inflammatory breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-09-17.

Abstract PD04-09: Multiple Biomarker Expression in Circulating Tumor Cells from Metastatic Breast Cancer Patients

Background: Numeration of circulating tumor cells, CTCs, from metastatic breast cancer (MBC) patients (pts) is predictive of outcome. Biomarker characterization of CTCs may be a useful adjunctive guide for personalized targeted and systemic treatment (Rx) selection.

Method: A multimarker assay was used to simultaneously quantify expression of HER2, ER and ERCC1. A fast laser scanning instrument was used for sensitive location of CTCs on large glass substrates. CTCs are identified using automated digital microscopy by morphology, the presence of cytokeratin and a nucleus, and the absence of CD45. At the COHCC pts with newly diagnosed/progressing MBC were accrued. Blood samples (10 ml) were procured prior to initiating systemic Rx and at subsequent 3 month intervals and sent to PARC for analysis. Cell lines with expression of each marker were used for normalization of the cell intensities. Sample scores were derived from the percentage of CTCs expressing the marker and the average expression level.

Results: The multiple-marker assay was done on CTCs at repeat time points and results were compared to findings from the original primary BCs (P) and biopsied metastases (M) in 30 and 20 MBC pts respectively. While P and M tissue scores were concordant for HER2, the CTC score was discordant in 58% of the samples; HER2 expression changed during Rx in 19% of pts. While the status for ERCC1 was discordant between P and M tissue in 13% of the pts, CTCs scores were discordant with P and M tumors in 63% and 67% of the patients respectively, and CTC expression status changed during Rx in 15% and 7% of pts respectively. While the status for ER was discordant between P and M tissue in 15% of the pts, CTC scores were discordant from the P and M tumors in 42% and 71% of pts respectively, and CTC ER status changed in 7% and 17% respectively of pts during Rx.

Conclusions: Significant discordances in expression level of ER, HER2 andERCC 1 was observed between CTCs, and both primary and metastatic BC tissue. Changes in CTC expression patterns were also observed during the course of Rx for all three markers. Correlation of CTC biomarker expression patterns and changes with response to Rx therapy is ongoing to validate medical significance. Multimarker testing may ultimately lead to improvements in personalized Rx for pts with MBC.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD04-09.

The natural history of allergic rhinitis in childhood

The distinction between 'seasonal' and 'perennial' allergic rhinitis (AR) is not always adequate. The 'Allergic Rhinitis and its Impact on Asthma' (ARIA) work group suggested a new classification for AR based on severity and duration of symptoms. Our primary aim was to describe the natural history and burden of AR according to the new ARIA criteria in a population-based birth cohort study of children up to 13 yr. We defined symptoms as 'severe' (impairment of daily activities) or 'mild' (no impairment) and 'persistent' (duration > 1 month) or 'intermittent' (<or=1 month) using annual questionnaires. Serum immunoglobulin E to five common aero-allergens was determined at six time points. We analyzed complete follow-up data from 467 children (54% boys). The 12-month prevalence of AR quadrupled from 6% (at age 3 yr) to 24% (at age 13 yr) in children with non-allergic parents and more than tripled from 13% (3 yr) to 44% (13 yr) in children with at least one allergic parent. Half or more of the children with AR had 'severe persistent' symptoms. At age 13, these children were significantly more often sensitized than those with 'mild persistent' disease: 91% vs. 70% (p = 0.015). Sensitization to aero-allergens (adjusted OR 18.9; 95%CI 9.3-38.4) and having 2 parents with allergy (3.1; 1.1-9.3) were significantly associated with AR. According to the ARIA criteria, the impact of AR seems to be substantial; the vast majority of affected children suffered persistently for periods of 2 months or more annually, and most of the children with persistent AR were impaired in their daily activities.

Basal-, Luminal-, and HER2- Molecular Subtype, and the MammaPrint 70-Gene Signature as Predictors of Response to Neoadjuvant Chemotherapy (NCT) with Docetaxel, Doxorubicin, Cyclophosphamide (TAC), or AC and Nab-Paclitaxel and Carboplatin +/- Trastuzumab in Patients (Pts) with Stage II-III and Inflammatory Breast Cancer (BC)

Background: Pathologic complete response (pCR) and minimal residual cancer burden (RCB scores of 0 [pCR]-1[near CR]) after NCT may predict for improved survival (Symmans et al. J Clin Oncol 25:4414-22, 2007). Hence, improved NCT regimens in conjunction with molecular markers that predict for both response and/or resistance are needed. Materials and Methods: 115 pts with stages II-III BC were to be prospectively randomized to receive 6 cycles of docetaxel 75 mg/m2, doxorubicin 50 mg/m2, cyclophosphamide 500 mg/m2 with filgrastim support (TAC, arm A) versus a novel regimen of A 60 mg/m2 and C 600 mg/m2 given every 2 weeks x 4, followed by 3 weekly doses of carboplatin (AUC 2) and nab-paclitaxel 100 mg/m2 repeated as 28 day cycles x 3 (arm B). Pts with HER2 + BC received NCT similar to arm B, but with the addition of 12 weekly doses of trastuzumab given together with carboplatin and nab-paclitaxel (arm C). Core biopsies were performed prior to NCT and were preserved fresh frozen. 70-gene (MammaPrint™) profiling and 80-gene profiling (van de Vijver et al. NEJM 347:1999-2009, 2002) to categorize all tumors for basal-, HER2-, and luminal subtypes were carried out. We set out to assess the predictive value of Mammaprint scores (poor vs. good), as well as basal, vs. luminal, vs. HER2 molecular subtype profiling, for response to treatment on arms A vs. B vs. C. Responses were dichotomized as complete or near complete response (Symmans RCB scores of 0-1) vs. suboptimal response (RCB score &gt; 1). Results: Sufficient amount of BC tissue and good quality RNA for gene array assessment were procured in 64% of the first 90 patients who have undergone pre-treatment core biopsies, and then proceeded to NCT, followed by definitive surgery. Here we report on the first 50 pts with complete set of data analyzed. The median age was 50 years (range:31-69). Pts were treated for stage II (49%) and III locally advanced (41%), and inflammatory BC (10%). By gene profiling, 28% of the tumors were HER2-type (vs. 38% by IHC 3+, or FISH, representing all pts treated on arm C), 26% basal-type, 42% luminal-type, and 4% borderline luminal-type. Poor-prognosis signature by the 70-gene (MammaPrint) assay was observed in 74% of pts: 92% of HER2-type, 100% of basal-type, and 52% of luminal-type tumors were characterized as poor-risk by the 70-gene assay. Following NCT, Symmans RCB scores of 0-1 were observed in 71% of pts with HER2-type, in 38% with basal-type, and 28% of pts with luminal-type molecular subtype characteristics. Conclusion: BC with HER2- and basal-molecular subtypes are more likely to respond to NCT and is frequently associated with poor-risk characteristics as determined by the 70-gene assay. The complete analysis of correlations among response to specific sets of NCT, molecular subtype, and 70-gene assay results in the entire pt population will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2026.

Multiple Biomarker Expression in Circulating Tumor Cells (CTCs) from Metastatic Breast Cancer (MBC) Patients (Pts)

Background: Numeration of CTCs from MBC pts is predictive of outcome. Quantitative changes in CTC-s are currently tested for their potential to monitor therapy (Rx). Biomarker characterization of CTCs may be a useful adjunctive guide for Rx selection. Method: At the COHCC between 5/1/2008 and 4/31/09, consecutively treated pts with newly diagnosed/or progressing MBC were accrued. Blood samples (10-40 ml) were procured prior to or during systemic Rx, and were sent to PARC for analysis. A novel high-speed scanning instrument located CTCs from cytokeratin (CK) labeling enabling high resolution images to be selectively acquired using digital microscopy. From these images, CTCs were identified by CK, DAPI (nuclear marker) and CD45, and protein expression levels were determined for HER2, ER, ERCC1 and EGFR. Cell lines with expression of each marker were used for normalization of the cell intensities, and a scoring system was used to account for relative number and expression levels of markers on the CTCs. Results: Of 21pts tested 81% were found to have detectable CTCs. CTCs were further analyzed from 13 such pts, some of whom had multiple specimens. Expression of EGFR and ERCC1 were detected in 77% and 92% of specimens tested. Expression of HER2 was detected in 47% and ER in 91% in samples tested. Discordance rates for the expression of the above 4 markers on the primary tumors vs. CTC were measured either before, during systemic treatment, or at progression on therapy. We observed significant discordance rates for all markers tested:ER 36%; ERCC1:20%; EGFR:60%; and HER2: 50%, respectively. Conclusions: Multiplex tumor marker testing of CTCs from pts with MBC is feasible. Following additional validation of expression patterns and the high discordance rates observed between CTCs and primary or metastatic tumor sites, prospective trials incorporating CTC expression into personalized treatment strategies may be justified.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3007.

Dynamic evolution of serum immunoglobulin E to airborne allergens throughout childhood: results from the Multi-Centre Allergy Study birth cohort

BACKGROUND

Allergic rhinoconjunctivitis and asthma evolve dynamically throughout childhood. Yet, data on the evolution of serum levels of IgE antibodies against airborne allergens throughout the first decade of life are scarce.

OBJECTIVE

To describe the patterns of new and persistent sensitization against airborne allergens including remission from birth to 10 years of age and the long-term clinical outcomes up to the age of 13 years.

METHODS

In 273 children from the Multi-Centre Allergy Study, a German birth cohort, IgE levels were determined against airborne allergens (Dermatophagoides pteronyssinus, cat and dog dander, birch and grass species pollens) at 2, 5, 7, and 10 years of age (ImmunoCAP, Phadia); allergic rhino-conjunctivitis and asthma were ascertained at the 13 years of age through a standardized questionnaire (International Study of Asthma and Allergies in Childhood).

RESULTS

The prevalence of sensitization to each allergen increased steadily throughout childhood, and a hierarchy of sensitization prevalence (grass>birch>mites>cat>dog) was maintained from 5 years of age onwards. A mono-sensitization state was relatively short (measurable half-life=3 years) as additional sensitizations were acquired frequently, and relatively soon after the first one. Remission of weak sensitization (UNICAP classes 1-2) was also quite frequent, especially before 5 years of age. By contrast, stronger IgE responses (>3.5 kU/L) were invariably persistent. Early sensitization was associated with a higher tendency for poly-sensitization at 10 years of age and allergic rhino-conjunctivitis and/or asthma at 13 years of age.

CONCLUSIONS

IgE responses against airborne allergens undergo dynamic changes throughout childhood, with a high frequency of new sensitization or remission. The long-term persistence and the clinical impact of IgE responses are affected by the intensity of IgE sensitization and the age of its onset.

Longitudinal trends of total and allergen-specific IgE throughout childhood

BACKGROUND

The development and the quantitative relationship between allergen-specific IgE (S-IgE) responses and total IgE (T-IgE), during childhood and adolescence have not been described and understood in detail. The objective of this study was to describe and compare the longitudinal trends of serum levels of S-IgE and T-IgE during childhood.

METHODS

We analysed data from participants in the MAS birth cohort study at 2, 5, 7 and 10 years of age (n = 273) and at 1, 3, 5, 6, 7, 10 and 13 years (n = 84). Total-IgE and the overall level of specific-IgE against nine locally relevant airborne and food allergens were determined by FEIA (ImmunoCAP). Allergic rhino-conjunctivitis and asthma were ascertained by questionnaires.

RESULTS

Longitudinal patterns of T-IgE levels from age 1 to 13 years were highly heterogeneous (declining, flat or increasing with different profiles). From 5 years of age, logarithmic (log(10)) transformed values of T-IgE and of S-IgE levels tend to follow a parallel trend, so that their relation remained constant throughout school age. A flat trend of T-IgE vs a constantly increasing trend of T-IgE was associated with a low or, respectively, high rate of wheezing at 13 years of age.

CONCLUSIONS

Beginning at the age of 5 years, total serum IgE levels in children from an industrialized country evolved in parallel with overall S-IgE levels. Therefore, variations in T-IgE levels at school age closely reflect variations in overall S-IgE levels. Further studies are required to strengthen the biological and clinical implication of this novel finding.

Multiple biomarker expression in circulating tumor cells (CTCs) from locally advanced/inflammatory (LA/IBC) and metastatic breast cancer (MBC) patients (pts)

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Background: Numeration of CTCs from MBC pts is predictive of outcome. Quantitative changes in CTC-s are currently tested for their potential to monitor therapy (Rx). Biomarker characterization of CTCs may be a useful adjunctive guide for Rx selection. Methods: At the COHCC between May 1, 2008 and December 31, 2008, consecutively treated pts with LABC/IBC, or with newly diagnosed/progressing MBC were accrued. Blood samples (20–30 mL) were procured prior to initiating neoadjuvant (neo)Rx (LABC and IBC patients) or systemic Rx (MBC), and were sent to PARC for analysis. A novel high-speed scanning instrument located CTCs from cytokeratin (CK) labeling enabling high resolution images to be selectively acquired using digital microscopy. From these images, CTCs were identified by CK, DAPI (nuclear marker) and CD45, and protein expression levels were determined for HER-2, estrogen receptor (ER), Excision repair cross-complementation group 1 (ERCC1), and EGFR. Cell lines with expression of each marker were used for normalization of the cell intensities, and a scoring system was used to account for relative number and expression levels of markers on the CTCs. Results: Twenty-seven pts with LABC, 4 pts with IBC, and 11 pts with MBC were enrolled. We have observed CTCs prior to initiating neoRx in all pts with IBC relative to 39% of all LABC/IBC cases, and in 57% of pts (n:14) with HER-2+ primary BC versus 24% (n = 17) with HER-2- BC . ER status, size, or grade did not predict for CTC detection. Numeration of CTCs was seen in 45% of pts with MBC. Expression of EGFR and ERCC1 was detected in 3 of 4, and 2 of 4 tested CTC samples from MBC cases. Expression of HER-2 and ER was observed on 1 of 3 and 3 of 4 CTC samples; there was discrepancy between the CTC expression profile and HER-2 and ER status of the primary BC in one case each. Conclusions: Detecting multiple markers in CTCs from pts with MBC is feasible, and similar testing in LABC/IBC patients is needed. Such multiplex testing may allow for more personalized Rx for pts with LABC/IBC and MBC.

No significant financial relationships to disclose.

A pilot study to compare FXR expression in normal and malignant tissue in receptor-positive early-stage breast cancer

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Background: Farnesoid X receptor (FXR), a nuclear receptor, is a ligand dependent transcriptional factor regulating cholesterol and carbohydrate metabolism. Recently, FXR was shown to have a contributing role in colorectal cancer. We hypothesize that FXR expression changes from normal to premalignant to malignant tissue in patients with breast cancer. Methods: We identified 16 paired formaldehyde fixed, paraffin embedded tissue (normal, premalignant, and malignant) from patients with receptor positive, early stage breast cancer. Clinical information was extracted from a prospective database initiated in 2006 under institutional approval. Immunohistochemical staining of FXR using a validated polyclonal antibody was completed with appropriate positive and negative controls. The slides were graded independently by two investigators using an agreed upon scale to detect the percentage of positively stained cells to the nearest 10th percentile. Statistical analysis was performed by ANOVA and Student's t-test. A p-value of 0.05 was considered significant in all analyses. Results: Normal tissue and invasive cancer was identified in all 16 patient specimens. Of the 16 invasive cancers, 12 were ductal and 4 were lobular. 8/16 (50%) of the specimens also contained non-invasive cancer. 5/16 patients (31%) had N1 disease. FXR expression did not correlate with grade, histology, stage, or lymph node status. However, FXR expression increases with malignant transformation of the breast cancer cell. The mean percentage of cells staining positive for FXR in normal breast tissue was 58%, non-invasive 72% and invasive 79%. FXR staining in normal breast tissue was significantly less when compared to both invasive and noninvasive cancer (p< 0.007). Conclusions: FXR expression is upregulated in breast cancer when compared with expression in normal tissue and appears to progressively increase along the continuum of malignancy. Our pilot study results warrant further evaluation into FXR as a predictive biomarker for breast cancer, given the ability to target FXR via development of non-toxic oral ligands.

No significant financial relationships to disclose.