Placental vascular pathology findings and pathways to preterm delivery

The authors examined the associations between placental vascular findings and preterm delivery in 1,053 subcohort women (239 preterm, 814 term) from a Michigan pregnancy cohort study (1998-2004). Twenty-nine placental vascular variables from microscopic examinations were grouped into 5 constructs: 3 maternal constructs-obstructive lesions (MV-O), bleeding/vessel integrity (MV-I), and lack of physiologic conversion of maternal spiral arteries (MV-D)--and 2 fetal constructs--obstructive lesions (FV-O) and bleeding/vessel integrity (FV-I). Construct-specific scores were created by adding the number of positive findings and deriving a dichotomous variable to approximate the top quintile ("high") and bottom 4 quintiles ("not high") within each construct. In multivariate polytomous logistic regression models, medically indicated preterm delivery at <35 weeks was significantly associated with high scores for each of the vascular constructs; adjusted odds ratios ranged from 2.4 to 5.4. Spontaneous preterm delivery at 35-36 weeks was significantly associated with a high score on any 1 of 3 constructs: MV-I, MV-D, and FV-I. Spontaneous preterm delivery at <35 weeks was significantly associated with a high score on 2 or more of 3 constructs: MV-I, MV-D, and FV-I; adjusted odds ratios ranged from 4.1 to 7.4. These results support a role for various placental vascular lesions in medically indicated and spontaneous preterm delivery.

Biologically-Inspired Patterned and Coated Adhesives for Medical Devices

The challenge of having a medical device robustly and reversibly adhere to a tissue in a minimally-invasive way during a clinical procedure is significant and has yet to be solved. Materials that could perform this adhesion would be valuable for use in a wide array of devices, including wired and wireless endoscopes for gastrointestinal interventions; cardiovascular devices such as mobile robots that transverse the heart surface or fixation devices for open heart surgery; and for adhering craniectomy devices to the skull during decompressive treatment. Fibrillar patterned adhesives inspired by the micro- and nano-scale structures on the feet of geckos have been widely studied and synthesized and have shown great potential for reversible adhesion in dry environments. Preliminary work has also been conducted to enhance the adhesion of these materials in wet conditions by coating them with polymers that include dopamine methacrylamide (DMA), a synthetic sticky polymer inspired by the material found naturally in the holdfasts of mussels. These coated materials demonstrated wet adhesion enhancement at the nano-scale, but not at the macro-scale and not when compared to unpatterned materials. In this work, we take previously-developed gecko-inspired patterned arrays of fibers with mushroom-shaped tips which have demonstrated enhanced adhesion with respect to unpatterned materials in dry conditions and coat them with these same synthetic mussel-inspired polymers to enhance adhesion in fully-submerged wet environments. DMA-containing polymers were synthesized through a multistep process and applied to an array of micro-scale polyurethane fibers by stamping. Material samples were tested in a custom-built adhesion measurement system in contact with a 6 mm glass hemisphere in both dry and wet conditions. Flat DMA-stamped samples demonstrated as much as 7 times enhancement over uncoated samples, while patterned, coated samples demonstrated as much as 23 times adhesion enhancement. The sample also maintained 65% of its adhesive ability over 100 test cycles. These materials are the first to demonstrate reversible fibrillar adhesion in wet conditions at the macro-scale with respect to both unpatterned and uncoated materials on non-flat surfaces using intermolecular forces instead of suction forces. Versatile reversible materials capable of adhering to non-flat surfaces in wet conditions should continue to be studied for their value for a wide array of medical device applications.

Efficacy results from the ToGA trial: A phase III study of trastuzumab added to standard chemotherapy (CT) in first-line human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (GC)

LBA4509

Background: Advanced GC is an incurable disease; new and less toxic treatments are needed. HER2 overexpression has been reported in 6–35% of stomach and gastroesophageal tumors. Trastuzumab (H; Herceptin), a monoclonal antibody against HER2, has shown survival benefits when given with CT in patients (pts) with HER2-positive early and metastatic breast cancer. The ToGA study is the first randomized, prospective, multicenter, phase III trial to study the efficacy and safety of H in HER2- positive GC. Methods: Pts with HER2-positive gastroesophageal and gastric adenocarcinoma (locally advanced, recurrent, or metastatic) were randomized to receive H+CT (5-fluorouracil or capecitabine and cisplatin) q3w for 6 cycles or CT alone. H was given until disease progression. The primary end point was overall survival (OS); secondary end points included overall response rate (ORR), progression-free survival, time to progression, duration of response, and safety. An interim analysis was planned at 75% of deaths and the Independent Data Monitoring Committee recommended releasing the data as the pre-specified boundary was exceeded and median follow-up of pts was 17.1 months. Results: Tumors from 3,807 pts were centrally tested for HER2 status: 22.1% were HER2 positive (abstract #4556). 594 pts were randomized 1:1 at sites in Europe, Latin America, and Asia. Baseline characteristics were well balanced across arms. Median OS was significantly improved with H+CT compared to CT alone: 13.5 vs. 11.1 months, respectively (p=0.0048; HR 0.74; 95% CI 0.60, 0.91). ORR was 47.3% in the H+CT arm and 34.5% in the CT arm (p=0.0017). Safety profiles were similar with no unexpected adverse events in the H+CT arm. There was no difference in symptomatic congestive heart failure between arms. Asymptomatic left ventricular ejection fraction decreases were reported in 4.6% of pts in the H+CT arm and 1.1% in the CT arm. Conclusions: This first randomized trial investigating anti-HER2 therapy in advanced GC showed that H+CT is superior to CT alone. The OS benefit indicates that H is a new, effective, and well-tolerated treatment for HER2-positive GC.

[Table: see text]

Clinical outcome of sequential chemotherapy in metastatic and/or recurrent gastric cancer

e15521

Background: Little is known about data on subsequent chemotherapy (CTx) following 1st-line CTx in stage IV gastric cancer. The purpose of this study was to analyze the natural history of stage IV gastric cancer with sequential CTx Methods: A total of 532 patients (pts) with unresectable gastric adenocarcinoma were studied. They were managed with a strategy of maximal administration of CTx only if pts’ general conditions were allowed. Response evaluation was performed by RECIST every 2 cycles. Response of unmeasurable lesions was dichotomized only into stable disease or progressive disease. Results: When pts were divided into CTx group (460 of 532, 87%) and best supportive care group (BSC; 72 of 532, 13%) resulting from poor performance/pt's refusal/comorbidity (31/23/18), the former had younger age (p = 0.046), better performance (p < 0.001), and less advanced metastatic sites (p = 0.001) than the latter. Median overall survivals from diagnosis of unresectable cancer were 12.0/13.3/2.5 months for overall/CTx/BSC, respectively. 87%/47%/23% of the whole pts received 1st/2nd/3rd-line CTx, respectively. Median number of regimens delivered was 2. Maximally 5th-line CTx was given to 15 pts (3%). Response and disease control rates were 21.7%/12.5%/11.8% and 79.4%/56.3%/49.4% for 1st/2nd/3rd lines, respectively. Median progression-free and overall survivals from CTx were 5.5/3.4/2.5 months and 12.1/7.9/5.5 months for 1st/2nd/3rd lines, respectively. The most common cause of discontinuation of CTx was disease progression (68%/74%/70%) followed by pt's refusal (22%/13%/12%) for 1st/2nd/3rd lines, respectively. Prognosticators were performance status, histology, metastatic site, and CTx before 1st or 2nd line. Conclusions: When pts with unresectable gastric cancer were managed with a strategy of maximal administration of CTx, a considerable number of pts could receive 2nd or 3rd line CTx, showing modest activity. Performance status and metastatic site were consistent prognosticators even if lines changed. Our data on the natural history of stage IV gastric cancer with sequential CTx may suggest that clinical trials can be performed in a 2nd or 3rd line setting as well.

No significant financial relationships to disclose.

Efficacy results from the ToGA trial: A phase III study of trastuzumab added to standard chemotherapy (CT) in first-line human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (GC)

LBA4509

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

[Table: see text]

Pathological features of advanced gastric cancer (GC): Relationship to human epidermal growth factor receptor 2 (HER2) positivity in the global screening programme of the ToGA trial

4556

Background: HER2 positivity is thought to be a negative prognostic factor in GC, correlating with poor survival rates. Reported HER2-positivity rates in GC have varied widely (6–35%). The ToGA trial is evaluating the addition of trastuzumab (Herceptin) to chemotherapy in HER2-positive advanced GC. It is the first randomised Phase III trial to provide prospective information on HER2-positivity rates in GC. Enrollment is complete, with 3,883 patients screened in 24 countries. The pathological features of GC and the relationship with HER2 positivity will be examined. Methods: Advanced GC tumour samples were centrally screened by immunohistochemistry (IHC; HercepTest) and fluorescence in situ hybridisation (FISH; PharmDx) in parallel. A HER2-scoring system modified from the protocol in breast cancer (BC) was used: a score of IHC 3+ and/or FISH positive was defined as HER2 positive. Results: Final data showed an overall HER2-positivity rate of 22.1% evaluated from 3807 patients. The HER2-positivity rate was similar between Europe (23.6%) and Asia (23.5%). HER2-positivity rates were higher in gastro-oesophageal junction (GEJ) than stomach cancer (33.2% vs 20.9%; p<0.001) and in intestinal than diffuse/mixed cancer (32.2% vs 6.1%/20.4%; p<0.001). This is reflected in above-average HER2-positivity rates in countries with the highest GEJ:stomach cancer ratios (France 0.56 [HER2 positivity 26.9%]; Germany 0.53 [23.7%]; UK 0.33 [25.8%]) and intestinal:diffuse cancer ratios (UK 3.4 [HER2 positivity 25.8%]; Australia 2.6 [32.8%]; Japan 2.8 [27.8%]). The modified HER2-scoring system showed concordance between IHC and FISH results of 87.5%. In BC most IHC 0/1 samples are FISH negative but, in ToGA, the frequency of IHC 0/1 samples testing FISH positive was almost as high as IHC 2/FISH-positive samples (23% vs 26%). Conclusions: The overall HER2-positivity rate in advanced GC in ToGA is 22.1%. Variations in tumour location and type mostly explain the difference in HER2-positivity rates between countries. Efficacy data will enable further evaluation of the clinical significance of HER2 IHC and FISH scoring patterns.

[Table: see text]

Prognostic impact of the NFKB1 insertion/deletion promoter polymorphism on survival in patients with surgically resected gastric cancer

e15638

Background: The present study analyzed the functional insertion/deletion polymorphism in the promoter region of NKFB1 gene and their impact on the prognosis for patients with gastric adenocarcinoma. Methods: Five hundred and three consecutive patients with surgically resected gastric adenocarcinoma were enrolled in the present study. The genomic DNA was extracted from paraffin-embedded tissue and the -94 insertion/deletion ATTG polymorphism of NFKB1 determined using a PCR- RFLP assay. Results: The NFKB1 promoter gene polymorphism was successfully amplified in 97.8% of the cases. There were no sexual differences in relation to the genotype and allele. No correlation was observed between the frequency of the genotype or allele and the T, N, or M stage. The multivariate survival analysis showed no association between the NFKB1 -94 insertion/deletion promoter polymorphism and the disease-free survival or overall survival of the patients with gastric cancer. Conclusions: The functional NFKB1 promoter polymorphism was not found to be a prognostic marker for Korean patients with surgically resected gastric adenocarcinoma.

No significant financial relationships to disclose.

Predictive factors associated with clinical outcome and safety in Korean patients with metastatic renal cell carcinoma treated with sunitinib

e16111

Background: Sunitinib has become a standard treatment for metastatic renal cell carcinoma (RCC). The research for identifying patients who are more likely to benefit from this agent is quite limited, especially in Asian patients. Methods: In total, 81 histologically proven metastatic RCC patients who were treated with sunitinib were reviewed between Jan 2006 and Dec 2008. Tumor response was evaluated according to the RECIST criteria, and safety was assessed by NCI-CTC (version 3.0). Primary endpoint was progression-free survival (PFS) and secondary endpoints included overall survival (OS), overall response rate (ORR), disease control rate (DCR), and toxicities. Clinical features associated with clinical outcome were identified by univariate analysis; then, a stepwise modeling approach based on Cox's proportional hazards regression was used to identify independent prognostic factors to these endpoints. Results: Median age was 58 years (range, 29 to 73), and 33 patients received sunitinib as first-line systemic treatment. Clear cell type was predominant (85%). Patient distribution was 12% for favorable, 78% for intermediate, and 10% for poor group according to the MSKCC risk group. With the median follow-up of 26 months, median PFS was 16 months (95% CI, 8 –24) and median OS was 24 months (95% CI, 18 –30). ORR was 30% (95% CI, 19–40%) and DCR was 80% (95% CI, 70–89%). The most common grade 3/4 adverse events of sunitinib was thrombocytopenia (32%). Other severe toxicity included neutropenia (21%), anemia (19%), leucopenia (14%), fatigue (10%), stomatitis (10%). In multivariate analysis, the previous exposure to immunotherapy was related to longer PFS (P<.012). Performance status (ECOG 0–1) and corrected Ca level (8.5∼10.5 mg/dl) were associated with favorable ORR (P=.038) and DCR (p=0.008), respectively. Predictive factors for grade 3/4 thrombocytopenia were corrected Ca level (P=.018), poor MSKCC risk group (P=.025), and low WBC count (<4500/ul, P=.041). Conclusions: Compared to western reports, our data demonstrated comparable clinical efficacy in Asian patients, but different safety profile, especially in hematologic toxicities. This approach provides a tailored approach to predictive factors for targeted agents.

No significant financial relationships to disclose.

Does hormone receptor (HR) positivity affect the prognosis in breast cancers with human epidermal growth factor receptor 2 (HER2) overexpression?

e22091

Background: Biologically, there is an unclear issue about the role of HR positivity in HER2 positive breast cancer. These HER2(+)/ HR(+) pts were grouped into luminal B type apart from HER2(+)/ HR(-) pts in molecular profiling. However, from the clinical point of view, these pts have been categorized and been treated as either the only HER2(+) disease regardless of HR status or vice versa. Thus, we investigated the impact of HR status on clinical outcomes in HER2-overexpressed breast cancers. Methods: We retrospectively reviewed medical charts of HER2-positive breast cancer pts who underwent curative surgical resection from 1996 to 2001 in the Severance hospital, Korea. Demographic comparisons were performed by Chi-square tests. Tumor size, nodal stage, TNM stage, HR status, and adjuvant tamoxifen use were included in the Cox proportional hazards model. Results: Among the total 174 HER2-positive pts, HR (n=93) was positive in 53.5% (n = 93) and HR-positive tumors were more likely to be premenopausal (73% v 52%; P=0.01) and well- differentiated (grade 1or 2; 77% v 62%; P=0.04). There were no significant differences according to HR status in terms of tumor size, nodal stage, TNM stage, operation methods, and chemotherapy regimen. In these HER2-positive pts, the 5-year disease free survival (DFS) was longer in HR(+) pts than in HR(-) pts (DFS; 82.9% v 61.5%; P= 0.01). In a subset analysis, the 5-year DFS of HER2(+)/ER(+) pts without adjuvant tamoxifen (n=26) was not different from that of HER2(+)/ ER(-) pts (DFS; 57.7% v 61.5%; P= 0.32). However, the 5-year DFS of HER2(+)/ ER(+) pts with adjuvant tamoxifen was significantly prolonged compared with that of HER2(+)/ ER(-) pts (DFS; 91.5% v 61.5%; P< 0.001). In a multivariate analysis of DFS, tumor size and adjuvant tamoxifen use significantly affected DFS with an adjusted hazard ratio of 2.56 (95% CI, 1.2–4.9; P= 0.01) and 6.58 (95% CI, 2.8–20.3; P< 0.001), respectively. Conclusions: In an analysis of HER2-overexpressed breast cancer, the presence of HR itself did not affect the prognosis. However, most of the survival benefit seems to be driven from adjuvant tamoxifen therapy not the HR status itself.

No significant financial relationships to disclose.

Development of an advanced water treatment system for wastewater reuse

The aim of this research was to develop an optimal reuse system applying various types of advanced oxidation processes such as titanium dioxide (TiO2), ozone (O3) and electro-coagulation/oxidation methods. This system is suitable for improving the treatment efficiency of difficult wastewaters, and for the efficient reuse of wastewater. The connecting systems were divided into various types to investigate the stability and treatment efficiency according to the kinds of waste load. Different treatment sequences were examined taking into consideration the characteristics and economical efficiency. In the case of electro-coagulation/oxidation + ozone system, the mean treatment efficiency in terms of BOD5, CODCr and SS removal was 98.7%. The effluent concentration was 50.2 mg l(-1), 38.3 mg l(-1), 30.4 mg l(-1), respectively. In considering the economical efficiency and commercial use, around an eighth of the treatment expenses and around a fifth of the maintenance expenses could be saved compared with existing water treatment systems. The initial construction expenses could be reduced by a third to a fifth. Therefore, if a proper implementation of this research is carried out in relation to site conditions and the purpose of the water reuse, the water reuse rate will be higher and water resources can be protected.