P3-01-12: Prognostic Impact of RANK, RANKL and OPG Gene Expression in ER Positive Primary Breast Cancer

Background

The cell surface receptor RANK (receptor activator of NFκB), its ligand (RANKL) and the decoy receptor of RANKL osteoprotegerin (OPG) play an important functional role in bone physiology and in bone metastasis by regulating osteoclasts. Just recently it was shown that tumor-infiltrating lymphocytes can stimulate breast cancer metastases through RANK-RANKL signalling.

Material and methods: We analyzed gene expression of RANK, RANKL and OPG in a combined Affymetrix dataset of 307 ER positive breast cancers from our institutions which were either untreated of treated with chemotherapy. Kaplan Meier analysis of disease free survival and Cox regression analysis was applied to examine the prognostic value of the different markers.

Results: We observed no significant difference in survival when samples were analyzed according to either RANK or RANKL mRNA expression. In contrast when samples were stratified in quartiles of OPG expression a positive linear relationship of survival with the expression of OPG was observed. Moreover since OPG demonstrated a bimodal type of expression a cutoff value can be derived from the expression data. Using this cutoff value a hazard ration of 2.14 (95% CI 1.27−3.61; P=0.004 for low OPG expression was detected. OPG expression correlated with lower proportion of grade 3 tumors (15.7% vs 27%; P=0.022) and a higher proportion of PgR positive samples (86.2% vs 71.4%; P=0.002). No significant differences were observed for lymph node status, age, tumor size and HER2 status. In multivariate analysis only lymph node status remained significant while OPG, Ki67, age, grade, and PgR only displayed a trend towards significance.

Conclusion: Expression of osteoprotegerin seems to correlate with good prognosis in ER postive breast cancer. These data are in line with in vitro studies demonstration that OPG inhibits RANKL induced migration of tumor cells.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-01-12.

PD03-02: Prognostic and Predictive Predictors for Triple Negative Breast Cancer

Background: Both the prognosis and the therapeutic options in triple negative breast cancer (TNBC) are rather limited. Current prognostic gene expression profiles for breast cancer mainly reflect proliferation status and are most useful in ER-positive cancers. The identification of prognostic gene signatures from TNBC cohorts in previous studies was hindered due to relatively small sample sizes.

Materials and Methods: All currently available TNBC gene expression datasets generated on Affymetrix U133 gene chips were assembled. To minimize inter-laboratory variation we analyzed only highly comparable arrays and data set-biased genes were filtered. Supervised analysis was applied to identify a prognostic signature from a finding cohort of 394 TNBC and validation was performed in an independent cohort of 261 TNBC. The genes from the prognostic predictor were analyzed for their correlation to known molecular phenotypes among TNBC.

Results: Two supervised prognostic signatures consisting of 264 and 26 probesets, respectively, were obtained when applying different cutoffs for false discovery rates of 25% and < 3.5% in the finding cohort. In multivariate analysis in the independent validation cohort hazard ratios of 4.03 (95% CI 1.71−9.48; P=0.001) and 4.08 (95% CI 1.79−9.28; P=0.001), respectively, were obtained for the two signatures. When compared to 16 metagenes for previously described molecular phenotypes in TNBC the prognostic signatures displayed highest correlation to metagenes for IL-8/inflammation, VEGF/angiogenesis, and Histones. A subset of genes in the 264-probeset signature was inversely associated with a poor prognosis (29/264=11.0%). Most of these “good prognosis” genes are correlated with immune cell metagenes (21/29=72.4%). In contrast both identified supervised prognostic signatures did not correlate to previously published prognostic signatures (recurrence score, genomic grade index, Amsterdam signature, wound response signature, 7-gene immune response module, stroma derived prognostic predictor, and a medullary like signature). Regarding the response of TNBC to neoadjuvant chemotherapy the predictive value of the B-cell metagene was superior to the 264- and 26-probeset signatures. However combination of the B-cell metagene and the signatures increased the AUC in ROC-analysis from 0.606 to 0.656. Conclusions: The use datasets consisting only of TNBC allows identification supervised prognostic signatures for TNBC which are unrelated to previously known prognostic signatures.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD03-02.

Use of microarray analysis of differentially expressed genes in luminal B subtype of breast cancers to evaluate NHERF1 as a marker of endocrine resistance

11015

Background: In vitro and in vivo data demonstrate that the expression of estrogen receptor (ER) in breast cancer is mainly associated with low proliferation. Gene expression profiling has recently been used to identify a group of high proliferating estrogen receptor positive breast cancers (the luminal B subtype), which are associated with a prognosis that is even worse than that of high proliferating estrogen receptor negative tumors. The analysis of those tumors might provide valuable information about breast cancer biology and could be helpful for adjuvant or neoadjuvant treatment decisions.Methods and Results: We analyzed microarray data from breast cancer specimens to gain insight into genes which play a role in estrogen receptor signalling. Genes were identified showing strong expression in high proliferating ER-positive tumors but no expression in either Ki67-/ER+ or Ki67+/ER- samples. Among these genes the Na+/H+ exchanger regulatory factor NHERF1 was found. We assessed the clinical relevance of NHERF1 transcript levels using a total of 2469 breast cancers. Analysis indicates that enhanced NHERF1 expression is associated with metastatic progression and poor prognosis of breast cancer patients. We found no correlation between NHERF1 and the nodal status as well as age, but positive correlations for tumor size (P<0.001), grade (P<0.001) and erbb2 (P=0.033). Weak NHERF1 expression correlated with longer disease free survival (DFS) in grade 1 and 2 tumors, but not in grade 3 breast cancers. Since NHERF1 expression is strongly linked to the presence of ER, the predictive value for endocrine treatment was analyzed. For samples with weak or none NHERF1 expression a treatment benefit was observed (P=0.007). While untreated patients display a 10 yr DFS rate of 67.2 ± 3.8%, endocrine treatment resulted in 80.1 ± 4.0%. In contrast no differences in disease free survival were found for corresponding NHERF1 expressing breast cancers. Conclusions: Our data indicate that expression of NHERF1 defines a state of differentiation, where breast cancer cells are refractory to endocrine treatment.

No significant financial relationships to disclose.

T cell marker metagene predicts a favourable prognosis in estrogen receptor negative and Her2 positive breast cancers

Abstract #1048

Background: Lymphocyte infiltration (LI) is often seen in breast cancer and has been suggested as a marker of host antitumor immune response but its importance remains controversial. A positive correlation of Her2 amplification/overexpression and LI has been described which was associated with a more favorable outcome. In rapidly proliferating tumors LI is a good prognostic indicator correlating with lymph node negativity, smaller tumor size, lower grade. However the impact of monocytes, B- and T-lymphocytes on prognosis are still a matter of debate.&#x2028; Material and Methods: A database of 2110 primary invasive breast cancer samples from 14 microarray datasets was established. Only Affymetrix HG-U133A microarrays were included for full comparability. Feature reduction was achieved by generating metagenes from genes with strong correlation in unsupervised clustering. The relationship of the five major metagenes with different cell types in the sample as well as differentiation programs/pathways associated with specific expression profiles was analyzed.&#x2028; Results: A large cluster of approximately 600 genes with functions in immune cells was consistently obtained in all datasets. The redundant information from several ProbeSets allowed the construction of robust metagenes which can be used as surrogate markers for the amount of different immune cell types in the breast cancer sample. However, rather complex relationships of these immunological metagenes with standard parameters of the tumors were observed. When different subgroups of tumors were analyzed for disease free survival the IgG metagene as a surrogate marker for B cells had no significant prognostic value. In contrast high expression of the T cell surrogate marker (LCK metagene) was beneficial among all subgroups of ER-negative tumors. Moreover a positive prognostic value of LCK metagene expression was also revealed for those ER-positive tumors with a Her2 overexpression. In addition a trend for a better response to neoadjuvant chemotherapy was detected for those ER negative tumors associated with lymphocyte infiltration as deduced from high expression of both IgG and LCK metagenes.&#x2028; Conclusions: Tumor associated lymphocytes could represent an anti tumor response but on the other hand they might promote tumor progression by shifting the cytokine milieu toward angiogenic factors, inflammatory cytokines and matrix metallo-proteinases. Thus it is crucial to precisely define the specific subtypes of immune cells which are associated with the tumor. Our results demonstrate that this task can be accomplished by a detailed analysis of the expression of metagenes. These surrogate markers define subgroups of tumors with different prognosis.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1048.

Prenatal ultrasound assessment and fetal heart monitoring: analysis of dizygotic twins discordant for body stalk anomaly in the third trimester of pregnancy

We describe a case of dizygotic twin pregnancy which was referred to our centre because of a discordant anomaly of one of the twins. The ultrasound examination revealed a large extra-abdominal mass (liver and bowel) with micromelia, severe kyphoscoliosis and a short umbilical cord of the second dizygotic discordant twin. These ultrasound findings were diagnosed as body stalk anomaly. Body stalk anomaly in twins is extremely rare. This is, to our knowledge, one of the few documented cases reported on dizygotic twins discordant for this anomaly. This finding, in association with a decrease of amniotic fluid volume, may be attributed to early amniotic membrane rupture as the primary event in the pathogenesis of body stalk anomaly.

Risikofaktoren der Rezidivhäufigkeit von vulvären intraepithelialen Neoplasien Grad III (VIN III)

OBJECTIVE

The incidence of vulvar intraepithelial neoplasia (VIN) has increased in the last decades. The therapy of VIN is the in toto resection. Still some patients develop VIN recurrence. The aim of this retrospective study is the identification of risk factors for VIN recurrence.

MATERIAL AND METHODS

68 Patients with VIN III has been examined in an univariate and multivariate analysis for the following parameters (follow-up: median 27 months): age, HPV, HIV, multicentricity, resection margins (1-4 mm, 5-9 mm, > or = 10 mm).

RESULTS

In the univariate analysis positive HPV and HIV status correlated with VIN recurrence. Also resection margins < 5 mm showed a significant correlation with VIN recurrence. Multivariate analysis demonstrated that HPV, HIV and resection margins < 5 mm are independent risk factors. No statistically association was found for age and multicentricity.

CONCLUSION

The aim of VIN therapy must be the total resection with a negative resection margin of > or = 5 mm. HPV- and/or HIV-positive patients have a significantly higher risk for VIN recurrence and need therefore an intensive follow up.

Gene expression profiling of breast cancer patients treated with docetaxel, doxorubicin, and cyclophosphamide within the GEPARTRIO trial: HER-2, but not topoisomerase II alpha and microtubule-associated protein tau, is highly predictive of tumor response

Gene expression analysis in breast cancer patients undergoing neoadjuvant chemotherapy is an interesting tool for identification of gene signatures and new markers to predict tumor response. However, the detection of predictive markers strongly depends on the drugs used in the specific therapeutic setting. There is growing evidence that topoisomerase II-alpha (TOPO IIalpha) is a marker for anthracycline-, and microtubule-associated protein tau (MAPT) for taxane sensitivity. HER-2 has been described as a marker of both anthracycline and taxane sensitivity. We performed gene expression profiling of 50 patients within the GEPARTRIO study, an anthracycline and taxane neoadjuvant chemotherapy trial. Here we investigate the predictive value of TOPO IIalpha, MAPT and HER-2 mRNA expression for pathological complete response (pCR) in this setting. Interestingly, HER-2 gene expression was strongly predictive of pCR (P=0.017) as well as overall response (P=0.037) and clinical complete response (cCR, P=0.050). In contrast, for both TOPO IIalpha and MAPT no correlation with pCR was observed in our sample group.

Zervixkarzinom-Früherkennung bei HIV-positiven Frauen - Ist eine Verlängerung des Screeningintervalls sinnvoll?

OBJECTIVE

Cervical cancer screening guidelines stated recently that the screening interval of healthy women can be extended up to 3 years. Can those recommendations be applied for high risk populations?

MATERIAL AND METHODS

In a prospective setting 305 HIV-positive women have been enrolled in this analysis between September 2000 and December 2003. Patients have been characterized according to HPV (human papilloma virus) prevalence, CIN (cervical intraepithelial neoplasia) incidence and CD4 cell count.

RESULTS

41 % of all HIV-positive women were HPV positive (oncogene subtypes). In patients with diminished CD4 cells the HPV prevalence increased to 60 % (54/90). CIN was found in 27 % (83/305) women. CIN was more frequent by HPV-positive women with a CD4 cell count < 200 mm (3) (52 %, 38/72). The CIN incidence was also high in HIV-positive women with negative HPV infection and diminished CD4 cell count (39 %, 7/18 vs.7 %, 11/161).

CONCLUSIONS

The current cervical cancer screening guidelines are not helpful in HIV-positive women. The CIN incidence is significantly higher as in the HIV-positive population. For this reason this high risk population as e. g. HIV-infected women need an intensive care of diagnostic tools and short screening intervals to detect CIN.

[Identification of preeclampsia by cDNA-gene expression profiling in human placentas and serum -- a pilot study]

OBJECTIVE

Preeclampsia is associated with significant maternal and fetal morbidity and mortality. The etiology remains unclear. For the accurate diagnosis and the prevention of preeclampsia it seems to be important to find a diagnostic tool that identifies risk patients before symptoms occur. With a new approach, the cDNA-Array analysis, human placentas and blood from preeclamptic and healthy pregnant women were examined for differentially expressed genes to find typical genes expression profiles.

MATERIAL AND METHODS

In this pilot study, cDNA array analysis with a 19 200 gene array of placenta and blood samples from three preeclamptic patients have been performed to classify this samples based on expression patterns.

RESULTS

Comparing normal placenta and blood from healthy delivered women (n = 4), a subset of 200 genes repeatedly found to be differentially expressed in preeclampsia. The placenta and blood samples from preeclampsia were accurately grouped by their individual gene expression patterns.

CONCLUSIONS

These results suggest that the use of cDNA array is a tool to identify gene expression patterns in preeclampsia. With this set of differentially expressed genes in conjunction with sample clustering algorithms the identification of preeclampsia in placenta or blood samples is possible.

[Management of abnormal uterine bleeding]

Bleeding disorders are one of the most frequent gynecological problems. The causes of bleeding disorders, and their frequency in particular, vary depending on the age of the woman affected. In premenopause and perimenopause, the most frequent causes are hormonal, in up to 90 % of cases, as well as organic changes in the uterus such as myomas, adenomyosis uteri, or endometrial polyps, in up to 70 % of cases. Coagulation defects cause increased bleeding, particularly in girls and young women, with no other recognizable cause. The treatment of bleeding disorders is causally based, although if the woman does not wish to have children, the therapeutic algorithm in many cases leads to similar symptomatic measures. The following therapeutic approaches, listed in order of increasing efficacy, are mainly used in the treatment of increased bleeding: gestagen, estrogen-gestagen combination, levonorgestrel (Mirena) and endometrial ablation or myoma enucleation, with comparable success rates, and finally hysterectomy. Embolization of the uterine artery in myomas or adenomyosis uteri, nonsteroidal anti-inflammatory drugs, and antifibrinolytic agents represent alternatives that may be useful in individual cases. The paper provides an overview of the various causes, useful diagnostic measures, and treatment options in uterine bleeding disorders.

[Integrin expression in eutopic and ectopic endometrium]

The significance of retrograde menstruation as a risk factor for endometriosis has been confirmed by numerous clinical observations. Integrins mediate both cell-cell and cell-matrix adhesion, and it is therefore suspected that integrins are involved in the development of endometriosis. Using immunohistochemistry, integrin expression in eutopic and ectopic endometrium is examined in endometriosis patients and control individuals. In nearly all cases, the glandular epithelial cells in the endometrium showed expression of alpha (2-), alpha (3)-, alpha (6)- and alpha (v)- integrin and a low percentage of expression of alpha (1)-, alpha (4)-, and alpha (5)-integrin. In comparison with eutopic endometrium, ectopic endometrium shows reduced expression of alpha (2)- and alpha (v)-integrin. Since no differences in alpha (2)- and alpha (v)-integrin expression were observed in eutopic endometrium between endometriosis patients and control individuals, it may be suspected that the reduced expression of these in ectopic endometrium is explained by influences in the altered environment -- e. g., in the peritoneal fluid -- on the ectopic endometrium.

Gene Expression Profiles of Breast Cancer Obtained from Core Cut Biopsies Before Neoadjuvant Docetaxel, Adriamycin, and Cyclophoshamide Chemotherapy Correlate with Routine Prognostic Markers and Could Be Used to Identify Predictive Signatures

BACKGROUND

Neoadjuvant administration of chemotherapy provides a unique opportunity to monitor response to treatment in breast cancer and assesses response exactly. Global gene expression profiling by microarrays has been used as a valuable tool for the identification of prognostic and predictive marker genes. Even though this technology is now wide spread and relatively standardized, there are only few data available which compare established parameters with expression values to determine reliability of this method. Therefore we analyzed gene expression data of pretreatment biopsies of breast cancer patients and compared them with the results of the immunohistochemical receptor expression for ER/ PR and Her-2, as well as FISH testing for HER-2 amplification. We analyzed the change of expression of these markers before and after neoadjuvant chemotherapy. Furthermore we evaluated the predictive significance of prognostic gene signatures as described by Sorlie, van't Veer and Ahr for response to neoadjuvant chemotherapy.

METHODS

Pretherapeutic core biopsies were obtained from 70 patients undergoing neoadjuvant TAC chemotherapy within the GEPARTRIO-trial. Samples were characterized according to standard pathology including ER, PR and HER2 IHC and amount of cancer cells. Only biopsies with more than 80 % tumor cells were considered for further examination. RNA was isolated and expression profiling performed using Affymetrix Hg U133 Arrays (22 500 genes). GeneData's Expressionist software was used for bioinformatic analyses.

RESULTS

More than two thirds of the biopsies yielded sufficient amounts (> 5 microg) of RNA for expression profiling and high quality data were obtained for 50 samples. Unsupervised clustering broadly revealed a correlation with hormone receptor status. When ER-alpha, PR and HER2 as analyzed by immunohistochemistry were compared to the corresponding mRNA data from gene chips more than 90 % concordance was observed. We could observe a switch of receptor expression for ER, PR or HER-2 from positive to negative and vice versa in 16/35 cases (45.7 %) and 5/22 cases (22.7 %) respectively. The prognostic marker sets of Sorlie, van't Veer and Ahr could not discriminate responders from non-responders in our patient group.

CONCLUSIONS

Our results demonstrate that reliable expression profiles can be achieved by using limited amounts of tissue obtained during neoadjuvant chemotherapy. Microarray data capture conventional prognostic markers but might contain additional informative gene sets correlated with treatment outcome. Prognostic marker sets are not suitable to predict tumor response in the neoadjuvant setting, suggesting the necessity of class prediction methods to identify marker sets predictive for the type of therapy used.

[Management of HIV-positive pregnancies -- results from a retrospective study]

OBJECTIVE

The management of HIV-positive pregnancies was investigated in conjunction to pre-, peri and postpartal complications and the HIV transmission rate.

PATIENTS AND METHODS

Retrospective study of 88 HIV-positive patients who were delivered at the Dept. of Obstetrics and Gynaecology during 1.1.1997-31.12.2001.

RESULTS

HIV-positive patients showed significantly more prepartal complications, compared to control group. Low CD4-cell count (< or = 200/microl) or high viral load (> 10 000 HIV-copies/ml) was not associated with increased risk for transmission relevant complications. The overall HIV-transmission rate was 3.4 % (3/89 newborns; with ART 2.5 % [2/85], without ART 33.3 % [1/3]). The transmission rate increased with complications during pregnancy (7.7 % [2/26] vs. 1.6 % [1/61]). Newborns delivered < or = 35 (th) week of gestation showed a transmission rate of 5.3 % compared to 2.9 % of newborns delivered after the 35 (th) week of gestation. 98 % of the patients were delivered by cesarean section (primary: n = 71, prior: n = 15), spontaneously: n = 2). 97 % of patients (85/88) were treated with antiretroviral therapy (ART). No differences were found in the postpartal complication rate of HIV-positive to -negative patients. None of the newborns was breast fed.

CONCLUSIONS

Treatment of this risk-pregnancies in HIV experienced centers significantly reduces the risk of HIV transmission.

Predictive value of impaired uterine transport function assessed by negative hysterosalpingoscintigraphy (HSSG)

BACKGROUND

Hysterosalpingoscintigraphy (HSSG) has given insight into the dynamics of rapid sperm transport inside the female genital tract.

RESULTS

While there is an increase of an ipsilateral transport on the side bearing the dominant follicle in 70% of the subjects in the periovulatory phase, 15% of the patients do not demonstrate transport to the fallopian tubes (negative HSSG). In these patients the pregnancy rate achieved spontaneously or by intrauterine insemination is significantly reduced compared to the patients who showed an intact transport mechanism confirmed by positive HSSG. On the other hand, by means of assisted reproductive techniques (ART), pregnancy rates were higher in the group of patients showing negative HSSG (P < 0.0005).

CONCLUSIONS

Our data clearly indicate that HSSG is a helpful method to evaluate the integrity of the utero-tubal transport mechanism. As pregnancy rates remain low in patients with negative HSSG, this result should be considered as an indication for IVF-treatment even in patients with patent fallopian tubes and normozoospermia of the partner.

An�sthesiologische Versorgung von HIV-positiven Schwangeren zur elektiven Sectio caesarea

OBJECTIVE

Worldwide, 50 million people are infected with the human immunodeficiency virus (HIV), and 43% are women. Perinatal vertical transmission of HIV accounts for most new pediatric cases. Elective Cesarean delivery, combined antiretroviral therapy perioperatively and abandonment of breast-feeding postoperatively reduces vertical HIV transmission. However, the incidence of maternal and neonatal morbidity perioperatively is relatively unknown. The goal of the present study was to prospectively record perioperative maternal and neonatal complications in the largest HIV positive collective undergoing elective Cesarean section with spinal anesthesia published to date.

METHODS

From 1999-2001, 54 HIV positive parturients were enrolled in this study. All parturients received IV zidovudine therapy (2 mg/kg body weight) perioperatively. Spinal anesthesia was performed using 60 mg of 4% hyperbaric mepivacaine plus 5 microg sufentanil intrathecally. Sensory, analgesic and motor block characteristics, the incidence of maternal hypotension, postoperative maternal complications as well as neonatal outcome were recorded.

RESULTS

Short-term hypotension occurred in 65% of the parturients. Intraoperatively, one parturient died following amniotic fluid embolism. In 17% of the parturients, postoperative complications headed by wound healing impairment, bronchitis and pneumonia requiring prolonged antibiotic therapy were observed. To date, after a minimum observation period of 8 months, only one infant (1.8%) is HIV positive.

CONCLUSION

Intrathecal mepivacaine combined with sufentanil in HIV positive parturients undergoing elective Cesarean section is an appropriate anesthetic option. Postoperative maternal morbidity was 17%. Neonatal outcome showed no evidence of neonatal depression.

Mepivacaine for Spinal Anesthesia in Parturients Undergoing Elective Cesarean Delivery: Maternal and Neonatal Plasma Concentrations and Neonatal Outcome

OBJECTIVE

Worldwide, long-acting bupivacaine is most commonly used for spinal anesthesia in parturients undergoing elective Cesarean delivery. However, advances in surgical technique and shorter duration of surgery make short-acting local anesthetic like mepivacaine appropriate, particularly if combined with opioids to enhance postoperative maternal pain relief.

MATERIAL AND METHODS

We assessed the effect of 4% hyperbaric mepivacaine (60 mg) plus 10 microg fentanyl for spinal anesthesia in 11 parturients undergoing elective Cesarean delivery. Sensory, motor and analgesic block characteristics, neonatal outcome (Apgar scores, umbilical cord blood analysis, neurologic and adaptive capacity score) as well as fetal and maternal mepivacaine plasma concentrations at delivery were determined (HPLC/UV).

RESULTS

Motor block (Induction-Bromage 0) duration lasted 113 +/- 20 min. Effective analgesia (VAS < or = 40) was 128 +/- 35 min. Maternal and fetal mepivacaine free plasma concentration were 0.18 +/- 0.05 microg/ml and 0.10 +/- 0.03 microg/ml, respectively. The fetal to maternal (UV/MV)-ratio for mepivacaine free plasma concentration was 0.56. Apgar scores, NACScores and the umbilical blood analysis showed no evidence of neonatal depression.

CONCLUSIONS

Particularly with short duration of surgery (21 +/- 5 min) intrathecal mepivacaine combined with fentanyl offers a favorable clinical alternative in parturients undergoing elective Cesarean delivery.

Ovarian cancer antigen CA 125 influences adhesion of human and mammalian cell lines in vitro

Despite the widespread use of CA 125 for diagnostic and therapeutic evaluation of ovarian cancer function, the molecular nature of CA 125 is only poorly understood. It has been shown that CA 125 enhances the invasiveness of a benign endometriotic cell line in vitro. The invasiveness of cells is controlled by proteolytic activity, cell motility and cell adhesion. Therefore, we determined the influence of CA 125 on the cell adhesion of human carcinoma cell lines in vitro. In all tested human and mammalian cell lines (HECIA, AN3-CA, RL95-2, SK-OV-3, OAW-42, PA-1, HeLa, MCF7, T-47D, A-673, RT112, EJ28, EEC 145, CHO, MDBK, MDCK. LLC-PK1) the cell adhesion in vitro was significantly impaired by CA 125 in a time-dependent manner. Treatment of cells with trypsin diminished the effect of CA 125 on cell adhesion for two hours. By inhibition of protein synthesis with cycloheximide (2 microg/ml) the influence of trypsin on the anti-adhesive effect of CA 125 was significantly prolonged. The results suggest that the ovarian cancer antigen CA 125 influences cell adhesion in vitro.

[Disturbed utero-tubal transport in hysterosalpingoscintigraphy as a predictive functional test for IVF therapy]

Hysterosalpingoscintigraphy (HSSG) is a simple method to evaluate the transport function of uterus and fallopian tubes. There is a quick uptake of radionuclides into the uterus and a transport to the side bearing the dominant follicle in 70 % of the patients in the late follicular phase of the cycle. Uptake and transport of the immotile radionuclides imitate the directed sperm transport through the female genital tract at the time of ovulation. 214 of 796 infertility patients with proven patency of fallopian tubes (27 %) showed only an uptake of the particles without a transport towards the fallopian tubes (negative HSSG). In these patients no spontaneous pregnancy occurred and pregnancy rate remained low by the means of timed intercourse or insemination. Indeed, the pregnancy rate (8.4 %) was significantly lower compared with the patients who became pregnant by timed intercourse, insemination or spontaneously and had a positive HSSG before (15 %; p=0.001). However, the pregnancy rate that could only be achieved by methods of ART was significantly higher in the group of patients with negative HSSG (57 % vs. 25 %, p=0.05). Our data suggest that HSSG is a new method to evaluate the integrity of the inner genital tract's transport function, especially in patients suffering from idiopathic infertility. Impaired transport function (negative HSSG) should be considered as an indication for IVF-treatment.

[Isolated decrease of haptoglobin during pregnancy: diagnosis by chance or pathological? ]

Haptoglobin is an acute-phase-protein, which is important in many diseases like infections, trauma and neoplasma. An increase in haptoglobin is induced by cytocines like IL-6 und IL-1. The normal range for plasmatic haptoglobin is 50-220 mg/dl. During pregnancy the most likely diagnosis is the HELLP- Syndrome (hemolysis, elevated liver enzymes and low platelets), followed by rare diagnoses like viral hepatitis or favism. We report about a 31-year-old III-gravida 0-para at 31 weeks of gestation with a decrease of haptoglobin over a period of 6 weeks (cut off: < 13 mg/dl) and without any clinical signs of preeclampsia. Liver enzymes were constantly slightly elevated without any progress, other laboratory test results were normal. The patient had a caesarean section at 37 weeks of gestation. Serum haptoglobin returned to normal values within three days after delivery. The reason for the decrease of haptoglobin in our case remains uncertain. Further studies need to focus on the differential diagnosis of a decrease of haptoglobin as well as an isolated decrease of haptoglobin during pregnancy and on the valid ranges of the different haptoglobin subtypes.

Molecular classification of breast cancer patients by gene expression profiling

For many tumors, pathological subclasses exist which have to be further defined by genetic markers to improve therapy and follow-up strategies. In this study, cDNA array analyses of breast cancers have been performed to classify tumors into categories based on expression patterns. Comparing purified normal ductal epithelial cells and corresponding tumour tissues, the expression of only a small fraction of genes was found to be significantly changed. A subset of genes repeatedly found to be differentially expressed in breast cancers was subsequently employed to perform a classification of 82 normal and malignant breast specimens by cluster analysis. This analysis identifies a subgroup of transcriptionally related tumours, designated class A, which can be further subdivided into A1 and A2. Correlation with classical clinicopathological parameters revealed that subgroup A1 was characterized by a high number of node-positive tumours (14 of 16). In this subgroup there was a disproportionate number of patients who had already developed distant metastases at the time of diagnosis (25% in this subgroup, compared with 5% among the rest of the samples). Taken together, the use of these differentially expressed marker genes in conjunction with sample clustering algorithms provides a novel molecular classification of breast cancer specimens, which facilitates the identification of patients with a higher risk of recurrence.

[Amniotic fluid embolism as an obstetric emergency--description of the syndrome and a case with fatal outcome]

Amnotic fluid embolism is an incompletely understood obstetric emergency presenting with the acute onset of hypoxia, hypotension and severe coagulopathy. Up to 86% of the cases are fatal, maternal death occurs within the first hour of symptom onset in 50% of the patients. This report describes the case of a 29-year-old, HIV-positive patient undergoing elective cesarean section who died despite immediate onset of cardiopulmonary resuscitation. The epidemiology of amniotic fluid embolism, clinical presentation, differential diagnosis, pathology and possible treatment are discussed.

Cervical intraepithelial neoplasia in human immunodeficiency virus-positive patients

Cervical intraepithelial neoplasia (CIN) is common in patients positive for human immunodeficiency virus (HIV). The questions are whether the management of CIN in these patients should be different from that of HIV-negative women, whether there are any prognostic factors to indicate the course of CIN, and whether the latter is influenced by antiretroviral therapy. A total of 267 HIV-seropositive women were counseled and examined in our colposcopic clinic. Of that number, 53 patients died during the observation period; 74% of these patients were immunosuppressed (CD4 count < 200 cells/mm3), and 45% were given diagnoses of CIN. The incidence of CIN was significantly higher in patients with CD4 less than 200 cells/mm3. Neither the route of HIV infection nor the HPV status nor smoking habits correlated with CIN. CIN relapse was histologically confirmed in 28% of patients who underwent complete surgical removal. Immune status plays an important role in HIV-positive women not only with respect to survival but with respect to CIN.

Expression of p16 and lack of pRB in primary small cell lung cancer

The retinoblastoma protein (pRB), p16, and cyclin D1 are major components of the RB pathway, which controls the G1 checkpoint of the cell cycle. Proper regulation of this pathway is crucial for normal cell proliferation. Abnormal forms of these proteins have been found in various types of malignant tumours. In the present report, immunohistochemical techniques were applied to study the expression of pRB, p16, and cyclin D1 in 161 samples of primary small cell lung cancer (SCLC) and 20 samples of non-small cell lung cancer (NSCLC). While pRB and cyclin D1 staining was negative in 161 specimens of SCLC, expression of p16 was observed in 153 samples. In contrast to SCLC, 16 out of 20 NSCLC cases exhibited pRB expression and 15 showed cyclin D1 expression, but only very weak p16 staining was found in five samples. These observations could provide additional criteria for the distinction between SCLC and NSCLC. Furthermore, these findings, based on primary tissues, implicate different mechanisms in the tumourigenesis of SCLC and NSCLC.

Cross-reactive staining of normal bone-marrow cells by monoclonal antibody 2E11

The monoclonal antibody (MAb) 2E11 is commonly used for detection of microdisseminated epithelial cells in bone marrow of cancer patients. Surprisingly, in an earlier report 2E11 was shown to bind to mononuclear cells in bone marrow in 61% of healthy donors. In the present study we tested whether this cross-reaction with non-epithelial bone-marrow cells can be characterized further. In addition, we analyzed the influence of 2E11 concentration on the staining of mononuclear cells. We performed immunocytochemical double stainings of bone-marrow aspirations from breast-cancer patients using 2E11/A45-B/B3 (MAb against cytokeratin 8, 18, 19) and 2E11/CD45 (MAb against CD45-leukocyte common antigen), while tumor cell lines MCF-7 and K526 as well as bone marrow from breast-cancer patients were treated with different concentrations of 2E11. A portion of 2E11-positive cells was characterized as hematopoietic cells by CD-45-binding, while others were identified as epithelial cells by A45-B/B3-binding. We defined a concentration of 2E11 to immunolabel epithelial cells and distinguish hematopoietic cells. Higher concentrations of 2E11 enhance staining of hematopoietic cells, to match that of epithelial cells. We conclude that 2E11 shows cross-reactivity to epitopes displayed by hematopoietic cells. However, specific staining of epithelial cells can be achieved. As long as there is no antibody available which is highly specific for epithelial cells, detection of microdisseminated tumor cells in bone marrow by antigen-antibody reaction should be verified morphological criteria.

Immunocytochemical and molecular strategies for the detection of micrometastases in patients with solid epithelial tumours: a review

This review focuses on diagnostic approaches to identify patients with minimal residual epithelial cancer. Epithelial malignancies are the most common forms of cancer in Western industrialized countries. The failure to reduce the mortality of patients with epithelial tumours is probably a result of the early dissemination of cancer cells to secondary sites, which is usually missed by conventional diagnostic procedures used for tumour staging. Therefore, over the past 10 years, sensitive assays have been developed to detect individual carcinoma cells disseminated to regional lymph nodes or distant organs. Among the distant organs, the bone marrow has been identified as the most important site for the detection of haematogeneously spread cancer cells. With regard to detection techniques, most investigators have used either immunocytochemical assays with a variety of 'epithelial-specific' cytoskeleton and membrane antigens, or molecular methods based on the polymerase-chain reaction. At present, almost all data on the prognostic significance of micrometastatic cells in bone marrow are based on immunocytochemical analyses, whereas the promising new molecular assays still need to be validated in clinical trials.

Cytology of ascitic fluid in a patient with metastasizing malignant Brenner tumor of the ovary. A case report

BACKGROUND

Transitional cell ("Brenner") tumors represent about 2% of all ovarian neoplasms. Brenner tumors are almost always benign. Malignant Brenner tumors of the ovary resemble urothelial carcinomas and are extremely rare.

CASE

A 77-year-old, white female presented with malignant Brenner tumor in both ovaries as well as lung and abdominal metastases. The cytology of the ascitic fluid revealed many activated mesothelial cells and three-dimensional cell clusters arranged in a papillary pattern. The round to oval nuclei displayed mild anisokaryosis and hyperchromasia but had a quite evenly dispersed opaque or finely granular nucleoplasm. Enfoldings of the nuclear membrane gave them the appearance of so-called coffee bean nuclei. The cytoplasm stained light bluish.

CONCLUSION

Knowledge of the cytologic features of ascitic fluid might allow a preoperative diagnosis of malignant, or at least proliferating, ovarian Brenner tumor.

[Blind prophylactic antibiotic administration in premature rupture of fetal membranes]

In a retrospective study based on patients treated at the Department of Gynecology and Obstetrics of the University of Cologne during 1984-1993, we tested whether antepartal prophylactic application of antibiotics in patients with premature rupture of membranes (PROM) decreases the frequency of maternal or fetal infections. With raising intervals between PROM and birth exceeding 24 hours, the frequency of maternal/fetal infections raised in the total study population (n = 940). The maternal infection rate increased from 4% to 11% and the frequency of fetal sepsis from 4% to 19% with a PROM to birth interval exceeding 24 hours. In the group of patients with prophylactic application of antibiotics the frequency of maternal or fetal infections was not lower than in the group without antibiotics. This holds true for the total study population as well as for subgroups with different gestational ages. In the total study population 12% of antibiotics-treated patients and 22% of their newborns had peripartal infections, whereas in the untreated population 3% of the mothers and 4% of the newborns showed signs of infection. The prophylactic application of antibiotics raises significantly the latency period in combination with or without tocolysis in PROM during 25. and 37. week of gestation.

[Value of immunohistochemical determination of receptors, tissue proteases, tumor suppressor proteins and proliferation markers as prognostic indicators in primary breast carcinoma]

OBJECTIVE

We tested whether immunohistochemical detection of oestrogen and progesterone receptor (ER, PR), the oestrogen-dependent protein pS2, the growth hormone receptors p 185neu and EGF-R, the tumour suppressor protein p53, the tissue proteases Cathepsin D and Urokinase, and the proliferation marker PCNA are of prognostic relevance in breast cancer patients.

METHODS

Expression of the proteins listed above was evaluated in formalin-fixed and paraffin-embedded sections of 311 primary breast cancer specimens using modified Avidin-Biotin-Complex methods. Results were correlated to clinical and morphological parameters (age, menopausal status, nodal status, tumour size, tumour grade), and clinical course of disease (complete follow-up in 301 women, median observation time 62 months) utilising univariate and multivariate statistical analyses.

RESULTS

If univariate analyses and multivariate regression analyses according to the Cox-model were applied, only Cathepsin D correlated to an elevated risk for recurrence in nodally negative patients (n = 135). In nodally positive women (n = 161), increasing tumour size, tumour grade, lack of ER and PR, expression of p185neu, p53, and PCNA indicated a significantly increased relative risk.

CONCLUSIONS

Immunohistochemistry allows the detection of parameters which may indicate prognosis in subgroup of breast cancer patients.

Comparative prognostic value of Cathepsin D and urokinase plasminogen activator, detected by immunohistochemistry, in primary breast carcinoma

The lysosomal protease Cathepsin D and the serine protease urokinase plasminogen activator (uPA) are suspected to indicate poor prognosis in primary breast carcinoma. We tested Cathepsin D and uPA immunohistochemically in 281 surgical specimens of primary ductal infiltrating breast carcinomas. Staining was evaluated, taking intracytoplasmic immunoreactions into account, in tumour cells and tumour infiltrating macrophages. Positivity was established in 48.4% and 58.0% of tissue samples for cathepsin D and uPA respectively (co-expression: 67.6%). In patients with cathepsin D- or uPA-positive tumours, relapses were more frequent and disease-free survival was shorter irrespective of nodal status, receptor status or menopausal status, (median observation time 74 months). However, this trend was statistically significant only for cathepsin D. With stepwise cox regression analysis, borderline significance (p = 0.07) was calculated for cathepsin D only in node-negative patients. The combination of cathepsin D with uPA measurements did not enhance its prognostic value. Immunohistochemical detection of Cathepsin D could potentially be used to identify patients with poor prognosis in the group of node negative breast cancer patients.

Prognostic value of cathepsin D in breast cancer: comparison of immunohistochemical and immunoradiometric detection methods

AIM

To test whether immunoradiometric or immunohistochemical detection of lysosomal protease cathepsin D in breast cancer is more predictive of outcome.

METHODS

Tumour tissues from 270 primary breast cancer patients were evaluated for the expression of cathepsin D using immunohistochemistry (IH; paraffin embedded tissues) and an immunoradiometric assay (IRMA; cytosol from frozen tissues). Immunohistochemical scores were based on immunoreaction in tumour cells and tumour associated macrophages.

RESULTS

IRMA values (cut off 40 fmol/mg cell protein) correlated significantly with IH values. Recorded incidences of positive immunoreaction in tumour cells using two different cut off values were 52% and 35%, respectively. Macrophages stained positive in 31% of tissues. Combined evaluation of tumour cells and macrophages resulted in positivity rates of 59% and 48%, respectively. Node status was the only variable found to correlate with cathepsin D expression. IH results correlated significantly with clinical outcome (median observation time 68 months) in node negative patients (n = 120) but not in node positive patients (n = 145). Cathepsin D positivity as measured by IRMA was not related to clinical outcome in either group. On multivariate analysis in the node negative group, IH detection of cathepsin D appeared to be the only independent factor indicating prognosis. For node positive patients, tumour grade, size, and receptor status were of prognostic relevance.

CONCLUSIONS

Because of the simple methodology and the minimal amount of tissue used for analysis, immunohistochemistry was preferred to immunoradiometry for cathepsin D measurement; it also provided more predictive data with respect to prognosis.

[Prognostic value of immunohistochemical determination of urokinase plasminogen activator in primary breast cancers]

There is ample evidence that the protease urokinase plasminogen activator (uPA) plays a role in invasion and spread of tumours. Several publications suggest its biochemical measurement in tumour cytosols to be of prognostic significance in breast carcinomas. Our study set out to determine whether the immunohistochemical detection of uPA in formalin-fixed, paraffin-embedded primary breast cancer tissues is of prognostic relevance. We tested 269 surgical specimens of primary ductal infiltrating carcinoma immunohistochemically using a modified avidin-biotin method. Some 57% of carcinoma specimens yielded specific positive staining in tumour cells. Detection of uPA correlated to tumour grade (P = 0.04), and to the detected level of the proliferation marker PCNA (P = 0.002), but not to patients' age or menopausal status, tumour size, nodal or steroid receptor status (P > 0.05). At median 68 months' follow-up, 34% of patients had experienced tumour relapse and 28% had died from cancer. Clinical course was correlated significantly to tumour size, tumour grade, nodal and steroid hormone receptor status (P < 0.05). Immunohistochemical detection of uPA, however, could not be demonstrated to be of any prognostic significance with regard to relapse-free or overall survival (P > 0.05) in the total study group or in the N0 (n = 120) and N + (n = 144) subgroups, regardless of whether univariate or multivariate analysis was applied.

P53 protein in 204 patients with primary breast carcinoma--immunohistochemical detection and clinical value as a prognostic factor

In a retrospective study, 204 formalin-fixed and paraffin-embedded biopsies of primary breast carcinomas were tested immunohistochemically for the expression of p53 protein (PAb 1801). 38% of the carcinomas were positive with respect to p53. The expression of p53 correlated significantly with the loss of tumor differentiation (P = 0.013), but not with menopausal status, patients' age, tumor size, axillary lymph node involvement or hormone receptor status. The influence of p53 expression on prognosis was evaluated in 197 patients (T1-4 N0-2 M0, median observation time 72 months). Detection of p53 protein was associated with a significantly longer disease-free survival in node-positive women (P = 0.03). However, p53 protein did not prove to be a prognostic factor in node-negative patients. The results demonstrate the prognostic value of p53 expression in breast cancer which appears to be limited to patients with node-positive tumors.

[Immunohistochemical detection of pS2 protein in paraffin sections of breast carcinoma tissue. Comparison with results of an immunoradiometry assay]

The synthesis of pS2 protein is induced through estrogen-dependent transcription of the pS2 gene. The presence of the pS2 protein in breast cancer is thought to be as valuable as receptor status, or even more so, in predicting the response to hormonal therapy. Furthermore, pS2 appears to be a prognostic factor for primary breast cancer. In 162 cases of primary breast cancer, pS2 was tested by immunohistochemical procedures on formalin-fixed and paraffin-embedded tissues. Staining was evaluated semi-quantitatively using an immunoreactive score (IRS). The concentrations of pS2 in tumor cytosol were determined using an immunoradiometric assay. Positive staining for pS2 (IRS > or = 2) was seen in 27% of the tumors. Comparison of immunohistochemical and biochemical detection (26% of tumors had pS2 cytosol concentrations above the cut-off value of 26 ng/mg cell protein) revealed an 81% concordance rate (r = 0.76; P < 0.0001). Univariate analysis showed no significant correlation of immunohistochemical pS2 detection and age or menopausal status of patients, tumor size, tumor grade or nodal status. However, the immunohistochemical pS2 status correlated significantly with the immunohistochemical detection of the estrogen (ER; P < 0.001) and progesterone receptor status (PR; P < 0.0001). pS2-positive tumors were ER-positive in 66% of cases and PR-positive in 73%; 89% of pS2-positive tumors were positive for ER and/or PR. The incidence of immunohistochemical pS2 detection was 41% in the group of steroid receptor positive carcinomas (ER- and/or PR-positive) in contrast to 7% in steroid receptor negative tumors (ER- and PR-negative).

Immunohistochemical detection of epidermal growth factor receptor lacks prognostic significance for breast carcinoma

OBJECTIVE

We sought to determine whether the immunohistochemical detection of epidermal growth factor receptor (EGF-R) in primary cancer tissues is of prognostic significance in patients with breast carcinoma.

METHODS

Paraffin-embedded tissues from 244 study subjects with primary breast carcinomas were tested immunohistochemically for the presence of EGF-R and were compared in a retrospective study with clinical outcome.

RESULTS

Epidermal growth factor receptor was detected in the tumors of 49 (20.1%) of the 244 study subjects. The incidence of EGF-R detection was comparable in subjects with disease-free lymph nodes (T1-4, N0, M0, n = 111; EGF-R present 22.5%) or those whose nodes contained carcinoma (T1-4, N+, M0, n = 133; EGF-R present 18.9%). No reliable correlation was found in either group between EGF-R detection and clinical, functional, or morphologic prognostic indicators that included age, menopausal status, tumor size, tumor grade, nodal status, and hormone receptor status. Relapse-free survival and overall survival (median observation time 62.5 months) did not differ between patients with EGF-R-positive or EGF-R-negative breast carcinoma specimens.

CONCLUSIONS

In our experience, the immunohistochemical determination of EGF-R in routine formalin-fixed, paraffin-embedded tumor specimens fails to provide useful information concerning the prognosis of patients with primary breast carcinoma.

[Psychological disease adjustment in breast cancer patients]

In a prospective follow-up study, attention was focused on adjustment to disease in breast cancer patients one year after diagnosis. Prebioptic data was collected in the original patient group consisting of 95 women with mammary tissue findings that required clarification. Twenty-nine women with histological confirmation of breast cancer and 37 patients of the control group with benign histological findings were recontacted after an interval of one year. Data was collected by means of psychological test questionnaires (STAI, SVF, FPI, CIP-DS), the patients with breast cancer were given an additional problem-oriented questionnaire about coping with disease, compiled by the author. Most denied having disease-related fears-progression of the disease, premature death; instead, marked sleep disturbances, regularly, recurring nightmares, and depressed states of mind characterized the psychosomatic correlate of the mental burden. The psychological consequences of cancer are related to some extent to the stage of tumour growth at the time of diagnosis; the process of social reintegration appears to be facilitated in women whose biopsy operation did not involve removal of a breast. An clear characterization of breast cancer patients could not be established using psychological testing procedures one year after diagnosis of the disease.

[Premature rupture of fetal membranes: problems and obstetric management]

The treatment of a premature rupture of the foetal membrane (prom) has up to now been a subject of controversy. Depending on the stage of gestation, the prompt birth ensuing as a result of prom, involves the risk of immaturity of the child. Conservative waiting by contrast, exposes mother and child to a potential risk of infection. The retrospective study presented, summarises the strategies for treating prom used at the Cologne University Department of Obstetrics and Gynaecology during the period from 1984 to 1989, and attempts to develop from these data proposals for the treatment of prom. With an increase in latency of over 24 hours between prom and delivery, the maternal and neonatal rate of infection also increased significantly. An effective result of a prophylaxis with antibiotics could only be shown in the reduction of incidence of infection in the mother. An effect on the neonatal rate of infection could not be seen. Inducing prepartually lung-maturity with glucocorticoides or ambroxol resulted in a significant decrease of the RDS-rate in new born children up to the 34th week of gestation. Beyond the 34th week of gestation, this effect could not be found. Whereas after completion of the 37th week of gestation, the preferred treatment used by doctors is allowing the shortest possible time of latency between prom and delivery, the expected pulmonary immaturity before the 34th week of gestation has to be treated by prolonging the pregnancy and inducing pulmonary maturity under antibiotic prophylaxis and at the same time controlling infection.(ABSTRACT TRUNCATED AT 250 WORDS)