Adjuvant Docetaxel in Node-Negative Breast Cancer Patients: A Randomized Trial of AGO-Breast Study Group, German Breast Group, and EORTC-Pathobiology Group

BACKGROUND

In node-negative breast cancer (NNBC), a high risk of recurrence is determined by clinico-pathological or tumor-biological assessment. Taxanes may improve adjuvant chemotherapy.

METHODS

NNBC 3-Europe, the first randomized phase-3 trial in node-negative breast cancer (BC) with tumor-biological risk assessment, recruited 4146 node-negative breast cancer patients from 2002 to 2009 in 153 centers. Risk assessment was performed by clinico-pathological factors (43%) or biomarkers (uPA/PAI-1, urokinase-type plasminogen activator/its inhibitor PAI-1). High-risk patients received six courses 5-fluorouracil (500 mg/m²), epirubicin (100 mg/m²), cyclophosphamide (500 mg/m²) (FEC), or three courses FEC followed by three courses docetaxel 100 mg/m² (FEC-Doc). Primary endpoint was disease-free survival (DFS).

RESULTS

In the intent-to-treat population, 1286 patients had received FEC-Doc, and 1255 received FEC. Median follow-up was 45 months. Tumor characteristics were equally distributed; 90.6% of tested tumors had high uPA/PAI-1-concentrations. Planned courses were given in 84.4% (FEC-Doc) and 91.5% (FEC). Five-year-DFS was 93.2% (95% C.I. 91.1-94.8) with FEC-Doc and 93.7% (91.7-95.3) with FEC. Five-year-overall survival was 97.0% (95.4-98.0) for FEC-Doc and 96.6% % (94.9-97.8) for FEC.

CONCLUSIONS

With adequate adjuvant chemotherapy, even high-risk node-negative breast cancer patients have an excellent prognosis. Docetaxel did not further reduce the rate of early recurrences and led to significantly more treatment discontinuations.

How should the respiration rate be counted in cattle?

Respiration rate (RR) is a proficient indicator to measure the health status of cattle. The common method of measurement is to count the number of respiratory cycles each minute based on flank movements. However, there is no consistent method of execution. In previous studies, various methods have been described, including counting flank movements for 15 s, 30 s or 60 s as well as stopping the time for 5 or 10 breaths. We assume that the accuracy of the aforementioned methods differs. Therefore, we compared their precision with an RR sensor, which was used as the reference method in this study. Five scientists from the fields of agricultural science and veterinary medicine quantified the flank movement according to each of the five methods mentioned above. The results showed that with an average RR of 30 breaths per minute (bpm), all methods showed a high correlation to the values of the RR sensor. However, counting breaths for 60 s had the highest level of conformity with the RR sensor (Lin`s concordance correlation coefficient: 0.96) regardless of the level of RR. With rising RR, the inaccuracy increased significantly for the other four investigated methods, especially when counting 5 and 10 breaths. Therefore, we would recommend that counting for 60 s should be used as the standard method for future studies due to its high precision regardless of the level of RR.

Gene Expression-Based Prediction of Neoadjuvant Chemotherapy Response in Early Breast Cancer: Results of the Prospective Multicenter EXPRESSION Trial

PURPOSE

Expression-based classifiers to predict pathologic complete response (pCR) after neoadjuvant chemotherapy (NACT) are not routinely used in the clinic. We aimed to build and validate a classifier for pCR after NACT.

PATIENTS AND METHODS

We performed a prospective multicenter study (EXPRESSION) including 114 patients treated with anthracycline/taxane-based NACT. Pretreatment core needle biopsies from 91 patients were used for gene expression analysis and classifier construction, followed by validation in five external cohorts (n = 619).

RESULTS

A 20-gene classifier established in the EXPRESSION cohort using a Youden index-based cut-off point predicted pCR in the validation cohorts with an accuracy, AUC, negative predictive value (NPV), positive predictive value, sensitivity, and specificity of 0.811, 0.768, 0.829, 0.587, 0.216, and 0.962, respectively. Alternatively, aiming for a high NPV by defining the cut-off point for classification based on the complete responder with the lowest predicted probability of pCR in the EXPRESSION cohort led to an NPV of 0.960 upon external validation. With this extreme-low cut-off point, a recommendation to not treat with anthracycline/taxane-based NACT would be possible for 121 of 619 unselected patients (19.5%) and 112 of 322 patients with luminal breast cancer (34.8%). The analysis of the molecular subtypes showed that the identification of patients who do not achieve a pCR by the 20-gene classifier was particularly relevant in luminal breast cancer.

CONCLUSIONS

The novel 20-gene classifier reliably identifies patients who do not achieve a pCR in about one third of luminal breast cancers in both the EXPRESSION and combined validation cohorts.

Combined IMIG and immune Ig attenuates inflammatory colitis in mice

BACKGROUND

Using a combination of homologous and heterologous (mouse/human) polyclonal anti-idiotypic Igs and immune Igs in BALB/c mice we have previously reported attenuation of allergic type responses following OVA immunization. We have now investigated attenuation of an inflammatory colitis in C57BL/6 mice receiving dextran sodium sulfate (DSS) in their drinking water, using additional treatment of DSS-exposed mice with combined human Igs, commercial IVIG (given IM, hence hereafter IMIG) as a source of pooled anti-idiotype Ig, and human anti-Tet as immune Ig.

METHODS

Acute or chronic colitis was induced by DSS in groups of C57BL/6 mice. Mice also received weekly immunotherapy with im injections of polyclonal immune Ig, polyclonal anti-idiotype Ig, or the combined Igs, for a total of 5 injections, beginning with DSS treatment or after 2 cycles of DSS. Weight loss and mortality were monitored daily, and the extent of colitis was determined further using colonic length measurement, and by ELISA measurement of inflammatory cytokines in supernatants from colonic explant cultures.

RESULTS

Mice developed colitis in both the acute and chronic models with loss of body weight, shortened colon lengths, and increased expression of inflammatory cytokines in colonic tissue. Loss of body weight, and inflammatory cytokine production, was attenuated only in chronic colitis, and only after combined IMIG and immune Ig treatment, and not in groups receiving only IMIG or immune Ig alone.

CONCLUSION

Heterologous combinations of polyclonal IMIG and immune Ig can attenuate inflammatory colitis in mice. Given the described efficacy of this treatment for allergic desensitization, we hypothesize this methodology may have widespread clinic utility.

Mechanism(s) of prolonged attenuation of allergic responses after modulation of idiotypic regulatory network

BACKGROUND

We showed previously that allergic reactivity to ovalbumin (OVA) could be regulated in mice following perturbation of immune networks using combinations of an immune Ig along with anti-idiotypic Ig. We have explored features of this regulation including: its persistence after cessation of administration of combined Igs; the ability of heterologous Igs to produce immunoregulation; a role for Treg induction in regulation; and the ability to attenuate responses in mice pre-sensitized to an allergic stimulus.

METHODS

BALB/c mice were sensitized to OVA. Mice also received 5 weekly injections of immune Ig or anti-idiotype Ig (at separate sites) from either homologous (mouse) or heterologous (human) sources. In the latter case pooled IVIG (given IM, hence hereafter IMIG) was used as a source of anti-idiotype Ig, and human anti-Tet as immune Ig. Injections of the Ig were given from the time of OVA sensitization (to attenuate development of immunity), or after pre-sensitization of mice (to attenuate existing allergic responses). All mice were assayed for development of OVA-specific serum IgE and IgG, as well as the production of OVA-induced IL-2, IL-4, IL-13, IL-31 and IL-33 in splenocytes cultured for 72 h. In studies examining possible mechanism(s) responsible for inhibition of immunity mice received, in addition to the Ig treatments described, infusion of depleting anti-CD4, and/or anti-CD8 antibodies, or a mAb to TNFSFR25, known to expand Tregs implicated in regulation of Allo immunity.

RESULTS

Combinations of both heterologous and homologous immune Igs and anti-idiotype Igs attenuated OVA allergic responses in both naïve and pre-sensitized mice. This attenuation persisted in mice greater than 14 weeks after cessation of treatment with the Igs used. Finally, depletion of either CD4 or CD8 cells ameliorated the suppressive effect seen, while the combination of anti-CD4 and anti-CD8 essentially abolished suppression. Suppression was further enhanced by anti-TNFSFR25 mAb.

CONCLUSIONS

We conclude that the combine Ig treatment protocols used produced a long-lasting suppression of allergic immunity, even in pre-sensitized animals. The effects seem to depend upon induction and expansion of Tregs and represents a novel approach to treatment of allergic disease in humans and other animals.

Kinetics of Various 99mTc-Sn-Pyrophosphate Compounds in the Rat

The bone-seeking 99mTc-Sn-pyrophosphate compound (compound A) was diluted both in vitro and in vivo and proved to be unstable both in vitro and in vivo. However, stability was much better in vivo than in vitro and thus the in vitro stability of compound A after dilution in various mediums could be followed up by a consecutive evaluation of the in vivo distribution in the rat. After dilution in neutral normal saline compound A is metastable and after a short half-life it is transformed into the other 99mTc-Sn-pyrophosphate compound A is metastable and after a short half-life in bone but in the kidneys. After dilution in normal saline of low pH and in buffering solutions the stability of compound A is increased. In human plasma compound A is relatively stable but not in plasma water. When compound B is formed in a buffering solution, uptake in the kidneys and excretion in urine is lowered and blood concentration increased.

It is assumed that the association of protons to compound A will increase its stability at low concentrations while that to compound B will lead to a strong protein bond in plasma. It is concluded that compound A will not be stable in vivo because of a lack of stability in the extravascular space, and that the protein bond in plasma will be a measure of its in vivo stability.

Die Methode der radiokardiographischen Funktionsanalyse

Es wurde die Methode der „radiokardiographischen Funktionsanalyse” im einzelnen beschrieben. Das Prinzip der Methode basiert auf der Messung der Radioaktivität von außen über dem Herzen nach Gleichverteilung des radioaktiven Indikators im Blut. Hierzu wird der zeitliche Verlauf der Radioaktivität über 160 Herzaktionen registriert. Dadurch läßt sich die Strahlendosis klein halten bei Erlangung eines repräsentativen Mittelwertes für die Herzaktion. Durch die Registrierung der Meßdaten erhält man gleichzeitig mehrere Parameter, die zur Beurteilung der Herzfunktion herangezogen werden können. Die Bedeutung der einzelnen Parameter wurde ausführlich diskutiert.

Complexing of Reduced Technetium and Tin (II) by Chelating Phosphate Compounds

Complexing of reduced 99mTc, "Tc and of 113Sn(II) by pyrophosphate was studied, using the in vivo distribution in the rat as an indicator for complex formation. 99mTc-pyrophosphate was only formed at very low technetium concentrations, otherwise colloid formation occurred. Reduced 99mTc in trace amounts and 113Sn(II) complexed equimolarly with pyrophosphate were concentrated in bone and excreted in urine in comparable amounts. The in vivo distribution of 32P- orthophosphate and -pyrophosphate was characterized by a considerable uptake in the liver and a poor urinary excretion. The distribution patterns of 32P-pyrophosphate, complexed equimolarly with tin(II), remained unchanged. Despite these findings it is concluded that real chelates are formed, since non-complexed reduced 99mTc was not concentrated in bone. Two variants of reduced technetium could be discerned: a 99mTc-kidney agent and a 99mTc protein-bound agent. Some evidence was found that reduced technetium may change its oxidation state, but it seems much more likely that both agents are technetium(IV) compounds. It is suggested that the kidney agent is hydrated technetium dioxide whereas the protein- bound agent is a charged technetium(IV) compound. Only hydrated technetium dioxide is obviously complexed by chelating phosphate compounds.

Kinetics of Various 99mTc-Sn-Pyrophosphate Compounds in the Rat

The kinetic data of two different 99mTc-Sn-pyrophosphate compounds (compound A and B) were evaluated in non-adult rats. Only compound A concentrated in bone. Both compounds dispersed rapidly in the intravascular as well as the extravascular space. The plasma protein bond of both compounds increased with time after injection and impaired both the renal clearance of both compounds and the bone clearance of compound A. The renal clearance of both compounds was somewhat above that of 5 1Cr-EDTA. It is concluded that compound A and B is mainly excreted by glomerular filtration. About one fourth of the glomerular filtrate of compound B is reabsorbed and accumulated by the tubular cells.

Untersuchungen zur Monozytopoese bei malignen Erkrankungen und unter B CG-Immunstimulation mit Hilfe des DNA-Markers 3H-Thymidin

Bei Patienten mit Morbus Hodgkin, Non-Hodgkin-Lymphom, Mycosis fungoides, Mammakarzinom oder malignem Melanom wurde die monozytopoetische Proliferationsaktivität im Knochenmark und Blut untersucht. Bei allen Patienten wurde die Studie vor der Behandlung durchgeführt. Bei einem Teil der Patienten erfolgte eine nochmalige Untersuchung nach der Operation und der prophylaktischen Immunstimulation mit BCG. Bei allen Patienten mit unbehandeltem Malignom lag eine mehr oder weniger ausgeprägte Stimulation der Monozytopoese vor. Bei der postoperativ durchgeführten prophylaktischen Behandlung mit BCG konnte vorübergehend eine Zunahme der Proliferationsaktivität der Monozytopoese beobachtet werden. Nach der vierten BCG-Immunstimulation fielen die Werte jedoch in den Normbereich ab. Die Ergebnisse machen deutlich, daß bei Patienten mit Malignomen ein erhöhter Monozytenbedarf vorliegt. Eine Immunstimulation mit BCG in der von uns durchgeführten Weise steigert die Proliferationsaktivität der Monozytopoese. Dieser Effekt ist jedoch vorübergehend.

Untersuchungen zur Bestimmung der Erythrozyten-überlebenszeit und des Abbauortes der Erythrozyten bei Gesunden mit Hilfe der Cr51-Markierung in vitro und in vivo

Bei gesunden Versuchspersonen wurde eine Radiochrommarkierung der Erythrozyten in vitro und in vivo durchgeführt und der Aktivitätsverlauf im Blut, sowie über Herz, Milz und Leber beobachtet. Die dabei gewonnenen Normalwerte und die prinzipiellen Unterschiede der beiden Methoden werden vor allem in Hinblick auf ihre Anwendung in der klinischen Diagnostik besprochen.

[Safe treatment of acute hyperkalemia : The 1:4 and other principles]

Acute hyperkalemia is a dangerous electrolyte disorder, which must be treated immediately. It can lead to cardiac arrhythmia and death due to alterations in cell membrane potentials. The resulting alterations in the electrocardiogram (ECG) are multifarious and need to be rapidly recognized. Treatment consists of various stages. In addition to membrane stabilization, which is always necessary, potassium must be displaced into the intracellular space and then eliminated from the body. A commonly applied method for displacement of potassium into the intracellular space involves the administration of insulin-glucose mixtures, which is associated with many complications. In the clinical routine many prescription variations are applied, which do not always appear to be ideal with respect to the individual risk-benefit ratio. A practically useful and easily memorized insulin-glucose mixture has a relationship of 1IU insulin to 4g glucose. The therapeutic elimination from the body is carried out using an enhanced diuresis or the utilization of renal replacement procedures. Special attention must be paid to the continous monitoring of potassium and blood sugar levels. After overcoming the acute situation, attention must be paid to treatment of the underlying disorder and if necessary to readjustment of the long-term medication of the patient.

Olive oil in the prevention and management of type 2 diabetes mellitus: a systematic review and meta-analysis of cohort studies and intervention trials

Background/Objectives:

Olive oil (OO) as food is composed mainly of fatty acids and bioactive compounds depending from the extraction method. Both had been discussed as health promoting with still open questions. Thus, we conducted a meta-analysis to illustrate the impact of this food on type 2 diabetes (T2D) by investigating the association between OO intake and risk of T2D, and the effect of OO intake in the management of T2D.

Subjects/Methods:

Searches were performed in PubMed, Cochrane Library and google scholar. First, we conducted a random effect meta-analysis of prospective cohort studies and trials investigating the association between OO and risk of T2D. Second, a meta-analysis was performed to detect the effects of olive oil on glycemic control in patients with T2D.

Results:

Four cohort studies including 15 784 T2D cases and 29 trials were included in the meta-analysis. The highest OO intake category showed a 16% reduced risk of T2D (RR: 0.84; 95% CI: 0.77, 0.92) compared with the lowest. However, we observed evidence for a nonlinear relationship. In T2D patients OO supplementation resulted in a significantly more pronounced reduction in HbA1c (MD: −0.27% 95% CI: −0.37, −0.17) and fasting plasma glucose (MD: −0.44 mmol l⁻¹; 95% CI −0.66, −0.22) as compared with the control groups.

Conclusions:

This meta-analysis provides evidence that the intake of OO could be beneficial for the prevention and management of T2D. This conclusion regards OO as food, and might not been valid for single components comprising this food.

c-met is overexpressed in type I ovarian cancer: Results of an investigative analysis in a cohort of consecutive ovarian cancer patients

The tyrosine kinase c-met alters signaling cascades such as the BRAF-MAPK and PI3K-PKB pathways. These alterations are involved in the carcinogenesis of type I but not type II ovarian cancer (OC). Therefore, the present study investigated the patterns of c-met expression in a cohort of consecutive patients with OC. c-met expression was determined by immunohistochemical analysis. Differences in c-met overexpression among subgroups of established clinicopathological features, including age, histological subtype, tumor stage, histological grading, post-operative tumor burden and completeness of chemotherapy, were determined by χ² test. Cox regression analyses were performed to determine the prognostic effect of c-met. Survival rates were estimated using the Kaplan-Meier method. A total of 106 patients were enrolled into the study. c-met was overexpressed in 20.8% of the entire cohort; 35.7% of patients with type I OC and 8.6% of patients with type II OC showed overexpression (P=0.001). However, c-met overexpression was not associated with any other established clinicopathological features (all P-values >0.05). Univariate Cox regression analysis showed that overexpression of c-met was associated neither with progression-free survival (PFS) nor with disease-specific survival (DSS) (P=0.835 and P=0.414, respectively). Kaplan-Meier plots also failed to demonstrate an effect of c-met on the 5-year PFS and DSS rates (P=0.938 and P=0.412, respectively). These findings support the hypotheses that the overexpression of c-met is associated with type I but not type II OC, and that overexpression of c-met does not affect the prognosis of OC.

Comparison of prognostic and predictive impact of genomic or central grade and immunohistochemical subtypes or IHC4 in HR+/HER2- early breast cancer: WSG-AGO EC-Doc Trial

INTRODUCTION

Potential prognostic and predictive markers in early, intermediate-risk breast cancer (BC) include histological grade, Ki-67, genomic signatures, e.g. genomic grade index (GGI), and intrinsic subtypes. Their prognostic/predictive impact in hormone receptor (HR: ER and/or PR) positive/HER2- BC is controversial. WSG-AGO EC-Doc demonstrated superior event-free survival (EFS) in patients with 1-3 positive lymph node receiving epirubicin/cyclophosphamide-docetaxel (EC-Doc) versus 5-fluoruracil/epirubicin/cyclophosphamide (FEC).

METHODS

In a representative trial subset, we quantify concordance among factors used for clinical chemotherapy indication. We investigate the impact of central histology (n = 772), immunohistochemistry for intrinsic subtyping and IHC4, and dichotomous (GG) or continuous (GGI) genomic grade (n = 472) on patient outcome and benefit from taxane chemotherapy, focusing on HR+/HER2- patients (n = 459).

RESULTS

Concordance of local grade (LG) with central (CG) or genomic grade was modest. In HR+/HER2- patients, low (GG-1: 16%), equivocal (GG-EQ: 17%), and high (GG-3: 67%) GG were associated with respective 5-year EFS of 100%, 93%, and 85%. GGI was prognostic for EFS within all LG subgroups and within CG3, whereas IHC4 was prognostic only in CG3 tumors.In unselected and HR+/HER2- patients, CG3 and luminal-A-like subtype entered the multivariate EFS model, but not IHC4 or GG. In the whole population, continuous GGI entered the model [hazard ratio (H.R.) of 75th versus 25th = 2.79; P = 0.01], displacing luminal-A-like subtype; within HR+/HER2- (H.R. = 5.36; P < 0.001), GGI was the only remaining prognostic factor.In multivariate interaction analysis (including central and genomic grade), luminal-B-like subtype [HR+ and (Ki-67 ≥20% or HER2+)] was predictive for benefit of EC-Doc versus FEC in unselected but not in HR+/HER2- patients.

CONCLUSION

In the WSG-AGO EC-Doc trial for intermediate-risk BC, CG, intrinsic subtype (by IHC), and GG provide prognostic information. Continuous GGI (but not IHC4) adds prognostic information even when IHC subtype and CG are available. Finally, the high interobserver variability for histological grade and the still missing validation of Ki-67 preclude indicating or omitting adjuvant chemotherapy based on these single factors alone.

TRIAL REGISTRATION

The WSG-AGO/EC-Doc is registered at ClinicalTrials.gov, NCT02115204.

Abstract P2-08-07: Prognostic significance of immune checkpoint receptors in node-negative breast cancer

Background: Immune checkpoint blockade is increasingly discussed in breast cancer. We examined the prognostic significance of the immune checkpoint receptors cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) and programmed cell death protein 1 (PD-1) in node-negative breast cancer.

Methods: Microarray based gene-expression data for CTLA-4 (221331_x_at) and PD-1 (207634_at) were analysed in four previously published cohorts (Mainz, Rotterdam, Transbig, Yu) of node-negative breast cancer patients not treated with adjuvant therapy (n=824). A meta-analysis of previously published cohorts was performed using a random effects model. Prognostic significance of CTLA-4 as well as PD-1 for metastasis-free survival (MFS) was examined in the whole cohort and in different molecular subtypes: luminal (ER+/HER2-), basal-like (ER-/HER2-) and HER2+. Independent prognostic relevance was analysed using multivariate Cox regression.

Results: Higher RNA expression of CTLA-4 was related to better MFS in a meta-analysis of the whole cohort (HR 0.58, 95% CI 0.38-0.88, P=0.0102). Prognostic significance was most pronounced in the HER2+ positive molecular subtype (HR 0.23, 95% CI 0.08-0.65, P=0.0062) as compared to luminal (HR 0.68, 95% CI 0.39-1.18, P=0.1744) and basal-like (HR 0.53, 95% CI 0.25-1.15), P=0.1087) carcinomas of the breast. PD-1 RNA expression, however, was not associated with outcome in the whole cohort of patients (HR 0.88, 95% CI 0.32-2.43, P=0.1853). A trend for improved survival was noticed in basal-like breast cancer (HR 0.40, 95% CI 0.15-1.08, P=0.0701). Neither luminal (HR 0.81, 95% CI 0.28-2.36, P=0.2122) nor HER2+ (HR 0.85, 95% CI 0.27-2.68, P=0.7759) patients showed an association of PD-1 with MFS. CTLA-4 showed independent prognostic significance (HR 0.393, 95% CI 0.224-0.688, P=0.001) in multivariate analysis. In addition to CTLA-4, only histological grade of differentiation (HR 2.335, 95% CI 1.490-3.660, P&lt;0.0001) and tumor size (HR 1.924, 95% CI 1.260-2.937, P=0.002), but neither PD-1 nor age nor HER2 status nor hormone receptor status retained an independent prognostic association with MFS.

Conclusions: The immune checkpoint receptor CTLA-4 has independent prognostic significance in node-negative breast cancer. Higher expression of CTLA-4 is associated with improved outcome. The prognostic impact of CTLA-4 differs between molecular subtypes and is most pronounced in HER2+ breast cancer.

Citation Format: Schmidt M, van de Sandt L, Heimes A-S, Battista M, Lebrecht A, Almstedt K, Hoffmann G, Rahnenführer J, Hengstler JG. Prognostic significance of immune checkpoint receptors in node-negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-07.

Detection of Subpubic Tumor Causing Bladder Outlet Obstruction by 3D Perineal Ultrasound

This case report shows that 3D perineal ultrasound can be superior to clinical examination and routine 2D perineal ultrasound in the detection of an unusual subpubic tumor. A 73-year-old female patient was referred to our urogynecological outpatient unit complaining of over-active bladder symptoms and voiding dysfunction for 3 years. Gynecological examination found no signs of pelvic organ prolapse or abnormality in the vaginal cavity. Routine 2D perineal ultrasound showed substantial residual urine (ca. 300 ml on catheter) and limited bladder neck mobility, but no signs of pelvic organ prolapse. Use of standardized 3D perineal ultrasound revealed a 24 × 26 × 32 mm spherical, hypoechoic tumor below the pubic symphysis between the distal urethra and the pubic bones. This structure was mistaken for the pubic symphysis in the midline on 2D ultrasound performed earlier. At surgery, the tumor was completely excised through a vaginal incision between the urethra and the pubic symphysis. After an uneventful postoperative recovery the patient developed de-novo stress urinary incontinence, which was corrected successfully by the insertion of a retropubic tension-free suburethral sling after an interval of 8 weeks. After a further follow-up of 8 weeks the patient reported well-being, urinary continence and no voiding dysfunction; no abnormalities were found on examination. In conclusion, 3D perineal ultrasound is a useful additional tool for the diagnostic workup of bladder outlet obstruction.

[Surface Cleaning and Disinfection in the Hospital. Improvement by Objective Monitoring and Intervention]

Background and Objective: An assessment of cleaning and disinfection in hospitals by the use of objective surveillance and review of mandatory corrective measures was undertaken. Methods: A prospective examination of the cleaning and disinfection of surfaces scheduled for daily cleaning in 5 general care hospitals by use of an ultraviolet fluorescence targeting method (UVM) was performed, followed by structured educational and procedural interventions. The survey was conducted in hospital wards, operating theatres and intensive care units. Cleaning performance was measured by complete removal of UVM. Training courses and reinforced self-monitoring were implemented after the first evaluation. 6 months later, we repeated the assessment for confirmation of success. Results: The average cleaning performance was 34% (31/90) at base-line with significant differences between the 5 hospitals (11-67%). The best results were achieved in intensive care units (61%) and operating theatres (58%), the worst results in hospital wards (22%). The intervention significantly improved cleaning performance up to an average of 69% (65/94; +34.7%; 95% confidence interval (CI): 21.2-48.3; p<0.05), with differences between the hospitals (20-95%). The largest increase was achieved in hospital wards (+45%; CI 29.2-60.8; p<0.05). Improvements in operating theatres (+22.9%; CI 10.9-56.7) and intensive care units (+5.6%; CI 25.8-36.9) were statistically not significant. Conclusions: The monitoring of cleaning and disinfection of surfaces by fluorescence targeting is appropriate for evaluating hygiene regulations. An intervention can lead to a significant improvement of cleaning performance. As part of a strategy to improve infection control in hospitals, fluorescence targeting enables a simple inexpensive and effective surveillance of the cleaning performance and corrective measures.

Abstract P6-08-20: Prognostic significance of the interferon metagene in node-negative breast cancer depends on the molecular subtype

Background: Interferons are crucial for adaptive immunity and play an important role as central coordinators of tumor-immune system interactions. We examined the subtype specific prognostic significance of an interferon (IFN) metagene in node-negative breast cancer.

Methods: Using microarray based gene-expression data, we identified co-regulated genes related to biological processes. After hierarchical clustering, we defined an interferon (IFN) metagene which was composed of 36 interferon-stimulated genes. The subtype specific prognostic role of the IFN metagene was analysed in four previously published cohorts (Mainz, Rotterdam, Transbig, Yu) of node-negative breast cancer patients not treated with adjuvant therapy (n=824). A meta-analysis of previously published cohorts was performed using a random effects model. Prognostic significance of the IFN metagene for metastasis-free survival (MFS) was examined in different molecular subtypes: luminal A (ER+/HER2-/aurora kinase A [AURKA]low, luminal B (ER+/HER2-/AURKAhigh), basal-like (ER-/HER2-), and HER2+.

Results: Prognostic significance of the IFN metagene was restricted to the HER2+ positive molecular subtype (HR 0.50, 95% CI 0.28-0.88, P=0.0056). Prognostic effects were not seen in luminal A (HR 1.00, 95% CI 0.65-1.53, P=0.8819), luminal B (HR 1.00, 95% CI 0.76-1.32, P=0.9770) or basal-like (HR 0.87, 95% CI 0.66-1.15, P=0.3282) carcinomas of the breast.

Conclusions: The prognostic significance of the interferon metagene in node-negative breast cancer is subtype specific and confined to the HER2+ molecular subtype. A higher expression of the IFN metagene is associated with improved outcome in HER2+ breast cancer.

Citation Format: Marcus Schmidt, Leonie van de Sandt, Karolina Edlund, Isabel Sicking, Marco Battista, Anne-Sophie Heimes, Antje Lebrecht, Gerald Hoffmann, Mathias Gehrmann, Jörg Rahnenführer, Jan G Hengstler. Prognostic significance of the interferon metagene in node-negative breast cancer depends on the molecular subtype [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-20.

Meniere's disease: a neuropsychological study II

23 Meniere patients were examined with an extensive battery of neuropsychological tests. In a previous investigation the authors had demonstrated that patients with a long duration of Meniere's disease had psychological disturbances, presumably localized in the nondominant hemisphere. In the present investigation the patients had a short duration of the disease, and we were unable to reproduce the psychological disturbances. It is concluded that the central changes in the nondominant hemisphere function develop over a long period of time. It is hoped for that further neuropsychological investigations of Meniere patients can give more information of what is primary in Meniere's disease: peripheral sensory or central neurological changes.

Effects of leucine-rich protein supplements on anthropometric parameter and muscle strength in the elderly: a systematic review and meta-analysis

OBJECTIVE

The primary objective of the present systematic review and meta-analysis was to synthesize the available literature relating to leucine supplementation in the elderly with respect to its effects on anthropometrical parameters and muscle strength. The secondary aim was to perform a selective subgroup analysis when possible differentiating between healthy and sarcopenic subjects.

METHODS

Literature search was performed using the electronic databases MEDLINE, EMBASE, SportDiscus, and the Cochrane Central Register of trials with restrictions to randomized controlled trials or studies following a cross-over design. Parameters taken into account were body weight, body mass index, lean body mass, fat mass, percentage of body fat, hand grip strength, and knee extension strength. Moreover, biomarkers of glucose metabolism (fasting glucose, fasting insulin, albumin, and HOMA index) were extracted when possible. For each outcome measure of interest, a meta-analysis was performed in order to determine the pooled effect of the intervention in terms of weighted mean differences between the post-intervention (or differences in means) values of the leucine and the respective control groups. Data analysis was performed using the Review Manager 5.2.4. software.

RESULTS

A total of 16 studies enrolling 999 subjects met the inclusion criteria. Compared with control groups, leucine supplementation significantly increased gain in body weight [mean differences 1.02 kg, 95%-CI (0.19, 1.85), p=0.02], lean body mass [mean differences 0.99 kg, 95%-CI (0.43, 1.55), p=0.0005], and body mass index [mean differences 0.33 kg/m2, 95%-CI (0.13, 0.53), p=0.001], when compared to the respective control groups. With respect to body weight and lean body mass, leucine supplementation turned out to be more effective in the subgroup of study participants with manifested sarcopenia. All other parameters under investigation were not affected by leucine supplementation in a fashion significantly different from controls.

CONCLUSIONS

It is concluded that leucine supplementation was found to exert beneficial effects on body weight, body mass index, and lean body mass in older persons in those subjects already prone to sarcopenia, but not muscle strength. However, due to the heterogeneity between the trials included in this systematic review, further studies adopting a homogenous design with respect to participant characteristics duration as well as the kind and amount of daily supplement in use are required.

Prevalence of Levator Ani Defects in Urogynecological Patients

Introduction: Defects of the levator ani muscle complex could represent a pathophysiological link between vaginal birth trauma and urogynecological symptoms many years later. The aim of our study was to determine the prevalence of levator ani muscle defects using 3D or 4D ultrasound and palpation in urogynecological patients. Material and Methods: Urogynecological patients were retrospectively investigated using 3D or 4D ultrasound. Clinical examination consisted of palpation and 3D or 4D imaging of the levator ani muscle. Results: A total of 319 women were included in the analysis. Mean age was 64.9 years, average parity was 2.1. Stress incontinence was present in 50.8 %, overactive bladder symptoms in 69.3 % and pelvic organ prolapse in 42.3 % of patients. A levator ani defect was found on ultrasound in 76 patients (23.8 %) and on palpation in 64 women (20.0 %). In the group of patients with pelvic organ prolapse, levator ani defects were found in 32.6 % of patients using ultrasound and in 26.7 % of patients using palpation. The odds ratio (OR) for levator ani defects in women with pelvic organ prolapse was 2.3 (95 % CI [CI: confidence interval]: 1.36-3.88], p = 0.002). Conclusion: In a cohort of urogynecological patients seen at a tertiary urogynecological unit, the prevalence of levator ani defects was significantly higher in women with pelvic organ prolapse compared to women with stress incontinence or urge symptoms.

Prognostic influence of pre-operative C-reactive protein in node-negative breast cancer patients

The importance of inflammation is increasingly noticed in cancer. The aim of this study was to analyze the prognostic influence of pre-operative serum C-reactive protein (CRP) in a cohort of 148 lymph node-negative breast cancer patients. The prognostic significance of CRP level for disease-free survival (DFS), metastasis-free survival (MFS) and overall survival (OS) was evaluated using univariate and multivariate Cox regression, also including information on age at diagnosis, tumor size, tumor grade, estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status, proliferation index (Ki67) and molecular subtype, as well as an assessment of the presence of necrosis and inflammation in the tumor tissue. Univariate analysis showed that CRP, as a continuous variable, was significantly associated with DFS (P = 0.002, hazard ratio [HR] = 1.04, 95% confidence interval [CI] = 1.02-1.07) and OS (P = 0.036, HR= 1.03, 95% CI = 1.00-1.06), whereas a trend was observed for MFS (P = 0.111). In the multivariate analysis, CRP retained its significance for DFS (P = 0.033, HR= 1.01, 95% CI = 1.00-1.07) as well as OS (P = 0.023, HR= 1.03, 95% CI = 1.00-1.06), independent of established prognostic factors. Furthermore, large-scale gene expression analysis by Affymetrix HG-U133A arrays was performed for 72 (48.6%) patients. The correlations between serum CRP and gene expression levels in the corresponding carcinoma of the breast were assessed using Spearman's rank correlation, controlled for false-discovery rate. No significant correlation was observed between CRP level and gene expression indicative of an ongoing local inflammatory process. In summary, pre-operatively elevated CRP levels at the time of diagnosis were associated with shorter DFS and OS independent of established prognostic factors in node-negative breast cancer, supporting a possible link between inflammation and prognosis in breast cancer.

Adjuvant treatment decisions for patients with endometrial cancer in Germany: results of the nationwide AGO pattern of care studies from the years 2013, 2009 and 2006

PURPOSE

In 2013, 2009 and 2006, the Arbeitsgemeinschaft Gynäkologische Onkologie evaluated the therapeutic approaches for endometrial carcinoma and the adherence to their guideline in Germany. Here, the adjuvant treatment decisions were presented.

METHODS

A questionnaire was developed and sent to all 682 German gynecological departments in 2013 (775 in 2009 and 500 in 2006, respectively). The results of the questionnaires were compared with the recommendations of the guideline and with each other using Fisher's exact test.

RESULTS

Responses were available in 40.0 % in 2013, 33.3 % in 2009 and 35.8 % in 2006. Participants recommended external beam radiotherapy (EBRT) in 13 out of 16 requested stages and vaginal brachytherapy (VBT) in only 10 out of 16 requested stages as suggested by the guideline. Comparing the results of 2013 with 2009, less participants used EBRT and VBT in 7 out of 16 and in 6 out of 16 requested stages, respectively. Conversely, more participants offered adjuvant chemotherapy (CT) in 2013 (90.4 %) compared to 61.9 % in 2009 (p < 0.001) and 48.8 % in 2006 (p < 0.001), respectively. However, the stage-adjusted recommendations of CT were not in line with the guideline in 11 out of 15 requested stages. In total, 77.3 % of the participants use a multiple drug schedule with a platinum and a taxane compound.

CONCLUSIONS

The results suggest non-adherence to the guideline concerning the stage-adjusted use of VBT and CT in endometrial carcinoma. These findings emphasize great uncertainties and the need of more clarifying trials. Furthermore, a shift from radiotherapy toward CT is observable.

Survival after neoadjuvant chemotherapy with or without bevacizumab or everolimus for HER2-negative primary breast cancer (GBG 44-GeparQuinto)†

BACKGROUND

The GeparQuinto study showed that adding bevacizumab to 24 weeks of anthracycline-taxane-based neoadjuvant chemotherapy increases pathological complete response (pCR) rates overall and specifically in patients with triple-negative breast cancer (TNBC). No difference in pCR rate was observed for adding everolimus to paclitaxel in nonearly responding patients. Here, we present disease-free (DFS) and overall survival (OS) analyses.

PATIENTS AND METHODS

Patients (n = 1948) with HER2-negative tumors of a median tumor size of 4 cm were randomly assigned to neoadjuvant treatment with epirubicin/cyclophosphamide followed by docetaxel (EC-T) with or without eight infusions of bevacizumab every 3 weeks before surgery. Patients without clinical response to EC ± Bevacizumab were randomized to 12 weekly cycles paclitaxel with or without everolimus 5 mg/day. To detect a hazard ratio (HR) of 0.75 (α = 0.05, β = 0.8) 379 events had to be observed in the bevacizumab arms.

RESULTS

With a median follow-up of 3.8 years, 3-year DFS was 80.8% and 3-year OS was 89.7%. Outcome was not different for patients receiving bevacizumab (HR 1.03; P = 0.784 for DFS and HR 0.974; P = 0.842 for OS) compared with patients receiving chemotherapy alone. Patients with TNBC similarly showed no improvement in DFS (HR = 0.99; P = 0.941) and OS (HR = 1.02; P = 0.891) when treated with bevacizumab. No other predefined subgroup (HR+/HER2-; locally advanced (cT4 or cN3) or not; cT1-3 or cT4; pCR or not) showed a significant benefit. No difference in DFS (HR 0.997; P = 0.987) and OS (HR 1.11; P = 0.658) was observed for nonearly responding patients receiving paclitaxel with or without everolimus overall as well as in subgroups.

CONCLUSIONS

Long-term results, in opposite to the results of pCR, do not support the neoadjuvant use of bevacizumab in addition to an anthracycline-taxane-based chemotherapy or everolimus in addition to paclitaxel for nonearly responding patients.

CLINICAL TRIAL NUMBER

NCT 00567554, www.clinicaltrials.gov.

Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials

BACKGROUND

High adherence to a Mediterranean diet (MD) is associated with reduced all-cause and cardiovascular mortality risk. To our knowledge, there is no systematic review and meta-analysis of randomized controlled trials that has compared the effects of an MD on outcomes of endothelial function and inflammation.

METHODS AND RESULTS

Literature search was performed using the electronic databases MEDLINE, EMBASE, and the Cochrane Trial Register. Inclusion criteria were: randomized controlled trials, 19 + years of age, and minimum intervention period of 12 weeks. Study specific weighted mean differences (WMD) were pooled using a random effect model. Seventeen trials including 2300 subjects met the objectives. MD regimens resulted in a significantly more pronounced increase in flow mediated dilatation [WMD: 1.86%, 95% CI 0.23 to 3.48, p = 0.02; I(2) = 43%], and adiponectin [WMD: 1.69 μg/ml, 95% CI 0.27 to 3.11, p = 0.02; I(2) = 78%], while high-sensitive C reactive protein [WMD: -0.98 mg/l, 95% CI -1.48 to -0.49, p < 0.0001; I(2) = 91%], interleukin-6 [WMD: -0.42 pg/ml, 95% CI -0.73 to -0.11, p = 0.008; I(2) = 81%], and intracellular adhesion molecule-1 [WMD: -23.73 ng/ml, 95% CI -41.24 to -6.22 p = 0.008; I(2) = 34%] turned out to be significantly more decreased.

CONCLUSION

The results of the present meta-analysis provide evidence that an MD decreases inflammation and improves endothelial function.

Nationwide analysis on surgical procedures for patients with endometrial cancer in Germany: results of the AGO pattern of care studies from the years 2013, 2009, and 2006

PURPOSE

In 2013, 2009, and 2006, the Arbeitsgemeinschaft Gynäkologische Onkologie evaluated the therapeutic approaches and the adherence to their guidelines for endometrial carcinoma (EC) in Germany. Here, we present the results concerning the surgical procedures.

METHODS

A questionnaire was developed and sent to 682 German gynecological departments in 2013 (775 in 2009 and 500 in 2006). The results were compared with the recommendations of the guideline and with each other.

RESULTS

Responses were available in 40.0 % in 2013, 33.3 % in 2009, and 35.8 % in 2006, respectively. Pelvic lymphadenectomy (LAN) was performed in accordance with the guidelines with some exceptions in 2013, 2009, and 2006, whereas paraaortic LAN was performed in accordance with the guideline only in 2009. Histological high-risk subtypes of EC received pelvic and paraaortic LAN in 2013, 2009, and 2006 in accordance with the guidelines with small exceptions. LAN for Patients, who were postoperatively upstaged or upgraded, was not conducted in accordance with the guidelines in 2013, 2009, and 2006. In 2013, 84.6 % of the participants offered the laparoscopic approach (LSA) for hysterectomy and bilateral salpingo-oophorectomy, 63.3 % for pelvic LAN, and 49.1 % for paraaortic LAN, respectively. More participants offered the LSA in 2013 compared to 2009 and 2006 (p values <0.014).

CONCLUSIONS

The paraaortic LAN, the LSA as well as the second operation on patients who had postoperatively been upstaged were not conducted in accordance with the guideline [CORRECTED]. Improvements concerning surgical treatment are possible and might lead to higher survival rates and a reduction of morbidity in patients with EC in Germany.

Über die Fluoreszenzfähigkeit von Triphenylcarboniumderivaten / Fluorescence Yields of Triphenylcarbonium Derivatives

The absolute fluorescence yields of triphenylcarbonium derivatives are correlated with the change of bond order between central-C-atom and phenyl group during the electronic transition. The fluo rescence yield is reduced by a rotation of the phenyl group only if the π-electron system of the phenyl group is sufficiently strong coupled to the other part of the molecule. The change of bond order can be assumed as a measure for the coupling.

Drug handling in a paediatric intensive care unit--can errors be prevented by a three-step intervention?

BACKGROUND

Drug handling in paediatric intensive care units (PICU) is prone to medication errors. We aimed to identify type and prevalence of those errors and to assess preventative interventions.

METHODS

Prospective intervention study investigating a 3-step intervention for preventing errors in drug handling in a 10-bed PICU of a university hospital. Nurses' drug handling was monitored in daily routine to identify the number of patients affected by errors and overall prevalence and types of errors in drug handling. We implemented a comprehensive intervention consisting of an information handout, a training course, and a 76-page reference book tailored to reduce the prevalence.

RESULTS

The prevalence of errors in drug handling decreased from 83 % (555 errors/668 processes)to 63 % (554/883; p < 0.001) after the intervention. The number of affected patients remained unchanged (95 % vs. 89 %, p = 0.370).Peroral (PO) drugs (1.33 errors/process) were more error-prone than intravenous (IV) drugs(0.64), despite being used less frequently (27 % vs.73 % of all processes, p < 0.001). The interventions decreased the prevalence to 0.77 errors/process(p < 0.001) in PO and to 0.52 in IV drugs (p = 0.025).

CONCLUSION

Errors in drug handling were alarmingly frequent. PO drugs were frequently subject to errors, even though being used less frequently. The implementation of a comprehensive intervention succeeded in reducing the prevalence of errors. Yet further refinements are necessary to decrease also the number of affected patients.