Abstract PD2-10: Treatment with abemaciclib modulates the immune response in gene expression analysis of the neoMONARCH neoadjuvant study of abemaciclib in postmenopausal women with HR+, HER2 negative breast cancer

Background: Abemaciclib is a selective inhibitor of CDK4 & 6 approved on a continuous dosing schedule for the treatment of HR+, HER2- metastatic breast cancer (MBC) patients (pts) in combination with endocrine therapy or as monotherapy. Recent studies have demonstrated the potential for CDK4 & 6 inhibitors, including abemaciclib, to promote anti-tumor immunity. Schaer et al., (Cell Reports 2018) showed that abemaciclib monotherapy results in upregulation of antigen presentation on tumor cells and increases T-cell activation. These activities synergized with anti-PD-L1 therapy to further enhance immune activation leading to complete tumor rejection in murine tumor models (Schaer et al., Cell Reports 2018). In this exploratory analysis, we evaluated the early and late immune-modulating effects of abemaciclib in the neoadjuvant study neoMONARCH (NCT02441946).

Methods: NeoMONARCH is a Phase II trial in women with stage I-IIIB HR+, HER2- BC evaluating neoadjuvant treatment with 2 weeks of abemaciclib, alone or in combination with anastrozole (abemaciclib+ANZ), or ANZ alone. All patients received 14 weeks of abemaciclib +ANZ after the first 2 weeks of treatment. Serial biopsies were collected at 3 time points: Baseline (BL) - prior to treatment, Early - after 2 weeks of therapy with abemaciclib, ANZ, or abemaciclib+ANZ, and Late – after 2 weeks of initial therapy followed by 14 weeks of abemaciclib+ANZ. RNA was extracted from formalin fixed paraffin embedded (FFPE) tumor biopsies at each time point and subjected to whole transcriptome RNA sequencing. The curated data were subjected to statistical analysis using ANOVA tests followed by pathway analysis using Ingenuity Pathway Analysis (IPA) and Gene Set Enrichment Analysis (GSEA).

Results: Consistent with the known activity of abemaciclib to inhibit the cell cycle, we observed at the early and late time points a significant treatment induced downregulation of genes related to mitotic spindle organization, replication stress response, G2M checkpoint, and E2F targets. Abemaciclib treatment for 2 weeks, alone or in combination with ANZ, followed by 14 weeks of combination therapy was associated with upregulation of gene expression signatures related to T-cell immune response and antigen presentation. Importantly, this phenomenon was notobserved with 2 weeks of ANZ treatment alone followed by 14 weeks of combination therapy.

Conclusion: These data lend support that continuous inhibition of CDK4 & 6 signaling by abemaciclib treatment leads to prolonged cell cycle arrest resulting in tumor cell apoptosis & senescence, which then leads to an enhanced immune activation.

Citation Format: Hurvitz S, Martin M, Press M, Wijayawardana S, Brahmachary M, Ebert PJ, Young S, Jansen V, Slamon D. Treatment with abemaciclib modulates the immune response in gene expression analysis of the neoMONARCH neoadjuvant study of abemaciclib in postmenopausal women with HR+, HER2 negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD2-10.

Abstract P2-03-03: A multicenter clinical study of Xpert® breast cancer STRAT4 demonstrates high concordance with central lab ER, PgR, HER2, and Ki67 IHC and HER2 FISH tests in FFPE breast tumor tissues

The Xpert® Breast Cancer STRAT4 (STRAT4) is a CE-IVD marked, semi-quantitative, cartridge-based RT-qPCR assay for the detection of ESR1, PGR, ERBB2 (HER2), and MKi67 mRNAs from formalin fixed, paraffin embedded (FFPE) breast tumors. The assay is fast (< 2 hrs), reproducible, robust, and easy to perform.

The aim of this multicenter clinical study was to assess the performance characteristics of the STRAT4 assay relative to central lab immunohistochemistry (IHC) for ER, PgR, HER2, and Ki67 and to fluorescence in situ hybridization (FISH) for HER2 gene amplification.

Methods: A total of 200 archived primary invasive breast cancer FFPE blocks were sourced from Indivumed for this study. From each block, twelve (12) adjacent tissue sections (4-µm thickness) on slides were prepared for pathological H&E confirmation to define tumor area, and for testing by STRAT4, IHC (ER, PgR, HER2,Ki67), and HER2 FISH. Standard STRAT4 lysate preparation using a single unstained slide per specimen and testing on N=84, N=68, and N=48 samples was performed at 3 independent sites, respectively (2 US and 1 EU). A single slide from each specimen was also processed using the recommended concentrated lysate procedure for STRAT4 testing at Cepheid. All IHC and FISH testing was performed by a central academic reference laboratory in the US. For a given sample, STRAT4 data generated using the standard lysate procedure was included for concordance analysis when all target gene test results were valid. In cases where the standard lysate preparation yielded indeterminate test results for any target, data from the concentrated lysate preparation was used for the data analysis. Receiver Operating Characteristic (ROC) analysis, overall percent agreement (OPA), positive percent agreement (PPA), and negative percent agreement (NPA) between STRAT4 and IHC (IHC/FISH for HER2) were determined for ESR1,PGR, ERBB2, and MKi67.

Results: Of the 200 samples tested by STRAT4, all samples generated valid results for ESR1 and ERBB2, 199 of 200 samples were valid for PGR, and 198 of 200 samples were valid for MKi67 using the standard or concentrated lysate preparation protocol. One sample failed to generate results for both ER and PgR IHC. Twelve samples failed to yield HER2 FISH results.

The STRAT4 success rate and results concordance with IHC were comparable across study sites. OPA between STRAT4 and IHC was 97% for ESR1, 88.9% for PGR, 93.3% for HER2 (92.4% for IHC and FISH), and 90.7% for MKi67 (excluding IHC 10-20% staining). Areas under the ROC curves were 0.9922 for ESR1, 0.9509 for PGR, 0.9958 for ERBB2, and 0.9395 for MKi67.

Conclusion: STRAT4 measurements for ESR1, PGR, ERBB2 and MKi67 mRNA expression are robust and highly concordant with IHC (IHC/FISH for HER2). The technical portion of the assay is easily performed in < 2 hrs including hands-on time using standard FFPE tissue sections. Xpert STRAT4 offers local pathology labs an alternative to centralized, subjective IHC/FISH tests that require a higher level of expertise. Further investigations correlating STRAT4 markers directly with clinical outcomes in independent cohorts are in progress.

Citation Format: Wu NC, Wong E, Acca B, Birkmeier J, Tran L, Zhao S, Wong W, Chu VC, Ho K, Malek M, Lu C, Ge G, David K, Quigley NB, Beqaj SS, Davenport S, Weidler J, Bates M, Press M. A multicenter clinical study of Xpert® breast cancer STRAT4 demonstrates high concordance with central lab ER, PgR, HER2, and Ki67 IHC and HER2 FISH tests in FFPE breast tumor tissues [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-03.

Abstract P1-08-14: HER2 extracellular domain (ECD): A predictive marker of lapatinib treatment benefit in advanced breast cancer

Pretreatment serum HER2 ECD may be associated with clinical outcome to lapatinib therapy and may also have treatment-independent prognostic value. We performed a meta-analysis to examine the prognostic and predictive role of baseline ECD (bECD) levels for lapatinib therapy. We also compared and contrasted its role with tumor HER2 status.

We analyzed bECD and tumor HER2 data in 1902 of 2264 patients (84%) with advanced breast cancer who were randomly assigned to receive lapatinib-containing therapy or control treatment in three clinical trials: EGF30001 (lapatinib and paclitaxel vs paclitaxel), EGF30008 (lapatinib and letrozole vs letrozole), and EGF100151 (lapatinib and capecitabine vs capecitabine). bECD was centrally measured by enzyme linked immunoassay and tumor HER2 was centrally determined by immunohistochemistry and fluorescence in situ hybridization. bECD and tumor HER2 status were examined for associations with objective tumor response (ORR), progression-free survival (PFS) and overall survival (OS) in the treatment groups.

Of the patients with both bECD and tumor HER2 data, 31% had HER2 bECD≥15 ng/mL and 28% had HER2+ cancer. The effectiveness of lapatinib-containing therapy was significantly associated with bECD level (treatment-bECD interaction P<0.001 [ORR], P<0.001 [PFS]). In patients with bECD≥15 ng/mL, lapatinib-containing therapy, compared to control, significantly improved ORR (odds ratio [OR] for complete and partial response, 1.88; P = 0.001) and PFS (hazards ratio [HR] for progression or death, 0.69; P<0.001). Among patients with bECD<15 ng/mL, there was no significant difference between treatment groups for ORR (OR, 1.17; P = 0.19) or PFS (HR, 0.93; P = 0.30). The effectiveness of lapatinib-containing therapy was also significantly associated with HER2 tumor status for ORR (OR [HER2+] 2.39, P<0.001; OR [HER2-] 1.10, P = 0.43; treatment-HER2 interaction P = 0.001) and PFS (HR [HER2+] 0.63, P<0.001; HR [HER2-] 0.95, P = 0.46; treatment-HER2 interaction P<0.001). When bECD and HER2 tumor status were examined together, the effectiveness of lapatinib-containing therapy was significantly associated with both bECD and HER2 tumor status for PFS (treatment-biomarker interaction P = 0.02[HER2], P = 0.001[bECD]) but only for bECD for ORR (treatment-biomarker interaction P = 0.07 [HER2], P = 0.003 [bECD]). The effectiveness of lapatinib-containing therapy was not significantly associated with OS for both biomarkers (treatment-biomarker interaction P = 0.30 [bECD] and P = 0.80 [HER2]). In the control groups, bECD≥15 ng/mL (HR 1.35, P = 0.003) and HER2+ (HR 1.67, P<0.001) were associated with shorter PFS after adjusting for other baseline characteristics. bECD≥15 ng/mL (HR 1.89, P<0.001) but not HER2+ (HR 0.97, P = 0.81) was associated with shorter OS after adjusting for other baseline characteristics.

Lapatinib therapy was associated with higher ORR and longer PFS in patients with elevated ECD levels. Elevated ECD was also associated with shorter PFS and OS in patients treated with non-lapatinib therapy. ECD provided additional predictive and prognostic information, in addition to tumor HER2 status, that if validated, could aid in treatment decisions. The predictive role of ECD in other anti-HER2 therapies requires further research.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-08-14.

Abstract PD02-01: Her2 expression measured by AQUA analysis on BCIRG-005 and BCIRG-006 predicts the benefit of Herceptin therapy

Introduction: There have been disparate results reported in breast cancer testing for HER2 assessment as measured by protein expression or DNA amplification, yet both tests are routinely used to prescribe the drug Herceptin (trastuzumab, Genentech, So San Francisco, CA). Typically, immunohistochemistry (IHC) staining intensity of 3+ or FISH copy ratio of ≥2.0 are used to establish the cutoff between a negative and a positive result. However, it is unclear whether positivity is correlated with differential response to therapy. We used Automated Quantitative Analysis (AQUA) and a fluorescent immunohistochemical assay to measure HER2 expression in cases scored by central laboratory FISH and also receiving Herceptin therapy. The intentions of the study were two-fold: first, to provide further validation of the AQUA technology as applied to the clinical measurement of HER2 expression in breast cancer and second, to examine the potential of drug response stratification within those patients that are considered positive.

Methods: AQUA fluorescence IHC staining was performed on a multi-cohort tissue microarray (TMA) set. The assay was constructed in the Genoptix CLIA laboratory per ASCO/CAP guidelines and with a cutpoint that was validated against IHC (with FISH reflex). The trial specimens tested were from the BCIRG-005/006 studies. BCIRG-005 had n=1544 cases all assessed as FISH- while the 006 cohort had n=1477 cases all assessed as FISH+. Disease free survival (DFS) was used as the variable in subsequent modeling and analysis.

Results: The BCIRG 005 and 006 cohorts, examined in aggregate, allowed for an initial examination of agreement relationships between HER2 levels as assessed by AQUA scoring and HER2 levels as assessed by central lab FISH. Results indicated a 77% negative agreement, a 97% positive agreement and an 87% overall concordance agreement for a total of n=3021 cases. Additional Cox modeling of the patients that were enrolled as FISH+ and stratified for those who did or did not receive Herceptin treatment demonstrated a significant overall hazard ratio (HR = 0.75, CI=0.60,0.93) and when stratified for response to Herceptin, cases determined to be positive by AQUA showed significant benefit from treatment (HR = 0.66, CI = 0.52,0.85) in contrast to those who were scored as negative by AQUA that did demonstrate benefit from therapy (HR = 1.19, CI=0.71,1.97).

Conclusions: Analysis of the cases in this study originally determined to be HER2+ by FISH indicates that AQUA may improve predictions of which patients will benefit from Herceptin therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD02-01.

"Embryo glue" does not seem to improve chances of subsequent pregnancy in refractory in vitro fertilization cases

PURPOSE

To determine if the use of Embryo glue improves implantation and pregnancy rates following embryo transfer (ET) in women who failed to conceive in three previous attempts.

METHODS

A matched controlled study was performed in women undergoing IVF-ET, donor oocyte recipients and women using their own oocytes having fresh or frozen ETs. A woman having Embryo glue was matched with the very next woman not using glue within six months of age and having the same number of previous failed ETs.

RESULTS

Embryo glue did not seem to improve pregnancy or implantation rates. In fact, in evaluating fresh embryo transfers there was a significantly higher live delivered pregnancy rate in the women not using Embryo glue (39.3%) vs those using the glue (14.3%).

CONCLUSIONS

Embryo glue does not improve pregnancy outcome in women failing in previous IVF cycles.

Pregnancy outcome following in vitro fertilization-embryo transfer according to the percentage of metaphase II oocytes retrieved

PURPOSE

To determine if the presence of a lower percentage of metaphase II eggs during oocyte retrieval leads to a lower fertilization rate of these metaphase II eggs since they may be more likely to be not quite fully mature, and to determine if transfer of embryos made from these eggs leads to lower pregnancy and implantation rates.

METHODS

Fertilization and pregnancy rates determined according to deciles of percent of metaphase II eggs beginning with <30%.

RESULTS

Though there was no difference in fertilization rates when comparing those with <60% metaphase II eggs vs a 60%, there were significantly higher clinical and live delivered pregnancy rates and implantation rates when there were a 60% of the eggs retrieved that were metaphase II.

CONCLUSIONS

An inferior pregnancy outcome with a lower percentage of metaphase II eggs despite similar fertilization rates is consistent with the hypothesis that subtle full maturation defects may result in pregnancy failure despite embryo transfer.

Oocytes from women of advanced reproductive age do not appear to have an increased risk of zona pellucida hardening

PURPOSE

To test the hypothesis that very advanced reproductive age leads to an increased risk of zona pellucida hardening by comparing fertilization rates and rates of failed fertilization with conventional oocyte insemination vs intracytoplasmic sperm injection (ICSI).

METHODS

Women aged > or = 45 were given the option of ICSI vs conventional oocyte insemination in circumstances where there was no male factor present. They were advised of the theoretical benefit of ICSI overcoming zona hardening but also advised that ICSI might lower pregnancy rates and is more costly.

RESULTS

There were 364 cycles evaluated and 74% chose ICSI. The failed fertilization rates were similar--28.4% (66/232) for ICSI vs 26.5% (35/132) for conventional insemination. The fertilization rates were similar 56.0% with ICSI vs 50.9% with conventional oocyte insemination.

CONCLUSION

Based on similar fertilization and failed fertilization rates in women aged > or = 45 undergoing IVF-ET, zona hardening does not appear to be a consequence of reproductive aging.

Abstract P3-10-24: Fibroblast Growth Factor Receptor 1 Amplification and Overexpression in Breast Cancer Tissue Microarrays Using Chromogenic In Situ Hybridization and Immunohistochemistry

Fibroblast growth factor receptors 1 (FGFR1) belongs to a subfamily of receptor tyrosine kinases (RTKs), which are involved in proliferation and apoptosis. FGFR1 amplification and mRNA overexpression occurs in ∼10% of breast cancers and has been associated with poor outcome. However, studies assessing FGFR1 amplification and protein overexpression in a large collection of breast tumors are lacking. In this prospective, we examined a series of primary breast cancers samples derived from the BCIRG trials assembled into 15 tissue microarrays. FGFR1 gene amplification was studied using chromogenic in situ hybridization (CISH) and evaluated with respect to association with level of protein expression and clinicopathological parameters. FGFR1 gene amplification was significantly associated with high protein levels as determined by immunohistochemistry (P&lt;0.0001, 3294 pts with available matched CISH and IHC records). Overall, the incidence of FGFR1 amplification found was 9.7% (160 out of 1646 pts. with available clinicopathological records) without a statistically significant difference between Her2- (78 out 720 pts., 11%) and Her2+ (82 out of 926 pts., 9%) cancers. In both cohorts, the hormone receptor-positive (ER+/PR+) cancers showed statistically significant higher levels of FGFR1 amplification compared to hormone receptor-negative tumors. In the analysis of the association of FGFR1 and the presence of PIK3CA mutations, the incidence of FGFR1 amplificationwas greatly reduced in mutant vs. wt PI3KCA tumors. In these cohorts, a clear relationship between FGFR1 amplification status and clinical outcome was not detected. Data from this large study confirms recently reported incidences of FGFR1 amplification in breast cancer and shows for the first time an association between FGFR1 gene amplification and protein overexpression. Moreover, the lower incidence of FGFR1 amplification in PIK3CA mutated cancers suggests that these are largely exclusive molecular events that could benefit from different targeted therapies.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P3-10-24.

Use of perfluorodecalin for pancreatic islet culture prior to transplantation: a liquid-liquid interface culture system--preliminary report

Although the issue remains controversial, short-term culture is probably beneficial for islet graft quality. However, significant islet loss is invariably observed. This is related to reduced survival of large islets, which is compromised by hypoxia under standard culture conditions. We aimed to develop a method of culture, which would avoid exposure to relative hypoxia and hence maintain the quality of islets. Isolated rat islets cultured for 48 h in a liquid-liquid interface culture system (LICS) with a perfluorocarbon were compared to islets cultured under standard (C1) and suboptimal conditions (C2). Islets were tested for viability and response to a glucose challenge, and a marginal mass was transplanted into syngeneic diabetic recipients. The viability of islets after 24-h culture in LICS was higher than in C1 and C2 groups (89.0% vs. 77.5% and 64.6%, respectively) and decreased with time to reach 79.0%, 62.9%, and 53.4% after 72-h culture. The stimulation index in LICS-cultured islets was also significantly higher than in C1 and C2 groups (12.3 ± 0.4 vs. 5.8 ± 0.5 and 4.1 ± 0.2, respectively). Following transplantation of LICS-cultured islets 50% of recipients were rendered normoglycemic compared with 14.3% and 31.3% for C2 and fresh islets, respectively. Our liquid-liquid interface culture system using perfluorodecalin provides optimized culture conditions, which preserve both islet viability and their ability to engraft successfully after intraportal transplantation and could be used for islet transportation.

Cryopreservation of blastocysts using a modification of a simplified freezing protocol with a one step removal of cryoprotectant successfully used previously to freeze 2 pronuclear or multi-cell embryos

PURPOSE

To describe a modification of a simplified freezing protocol for the cryopreservation of blastocysts.

METHODS

1.5 M glycerol was substituted as a cryoprotectant instead of propanediol.

RESULTS

There was a survival rate of 59.1% (13/22) with three live deliveries in seven transfers (42.9% per transfer). The implantation rate was 28.6% (4/14).

CONCLUSIONS

This is the first description of a new technique for freezing blastocysts. A larger series is needed to determine if the good pregnancy rates will continue.

PI3 Kinase Pathway Analysis in Tissue Microarrays Using Laser Capture Microdissection and Immunohistochemistry

Background. During the performance of the BCIRG trials primary patient tumor samples were obtained from paraffin blocks and assembled into 15 tissue microarrays, including 3000 samples from trial 005 (adjuvant taxol in Her2- node positive patients), 2200 in 006 (adjuvant herceptin in Her2+ high risk patients) and 300 in 007 (addition of platinum in Her2+ first line therapy). This array set was prepared prospectively, in anticipation of molecular epidemiologic studies of a variety of targets in relation to outcome. In order to address the potentially important role of the PIK3CA pathway in modulating outcome in different clinical situations we assessed components of the PIK3CA pathway by various methods.Methods. We analysed the expression of PTEN, Cyclin D1, p53 and Stathmin by immunohistochemistry using standard methods. All markers were scored by histoscore. Phospho S6 240 and phospho Akt 473 were assessed simultaneously by quantum dot immunofluorescence using automated image capture and segmentation. PIK3CA mutations were evaluated using SnaPshot analysis of laser captured TMA spots in a subset of approximately 2000 samples.Results. In the samples analyzed PIK3CA mutation had an incidence of 23%, with 9% being mutations in exon 9 and 13% in exon 20, with 0.5% being mutant in both exons. Initial analysis of the results prior to outcome analysis indicated that Stathmin expression, while being a robust marker with good dynamic range, did not appear to correlate with PTEN loss by IHC or with PIK3CA mutation.Conclusions. PIK3CA mutational analysis is feasible from TMA cores and gives mutation incidences similar to the published literature for archival material. Relationships of markers with outcome will be presented.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4043.

First-line lapatinib combined with letrozole versus letrozole alone for hormone receptor positive (HR+) metastatic breast cancer (MBC): Subgroup analyses of borderline FISH+, IHC 2+, HER2 unknown (UNK), and treatment-naive (TN) populations from EGF30008

1062

Background: This double-blind, placebo-controlled, phase III trial assessed the benefit of adding lapatinib, an oral EGFR/HER2 tyrosine-kinase inhibitor, to letrozole alone in patients (pts) with HR+ MBC. The previously reported primary endpoint, investigator (INV) assessed PFS in HER2+ tumors, showed a significant benefit from dual therapy. Median PFS in the HR+ HER2+ population increased from 3 months (mo) in the letrozole/placebo group to 8.2 mo in the letrozole/lapatinib group [Hazard Ratio (95% CI)=0.71 (0.53,0.96), stratified log rank p = 0.019]. The HER-2-ve population did not derive benefit from the combination. Benefit from combined treatment was evaluated in a number of pre-planned exploratory subsets, including a noted trend in the HER2-ve population who progressed within 6 mo of receiving prior tamoxifen. Methods: 1286 pts were randomized to letrozole/lapatinib or letrozole/placebo. HER2 positivity was defined by a positive FISH ratio or by immunohistochemistry (IHC) 3+ in a central laboratory. INV assessed PFS in the sub-populations were analyzed using Kaplan-Meier with stratified log rank to compare treatment arms. These included tumor samples that were FISH borderline1.8–2.2 (n = 52), IHC 2+ (n = 215), HER2 status UNK (n = 115), and neo/adjuvant TN (n = 656). Results: INV assessed PFS demonstrated no significant prolongation for dual therapy for any of the exploratory populations [Hazard Ratio: (95%CI), p-value]; FISH 1.8–2.2 [1.03 (0.55, 1.95), p = 0.918]; IHC 2+ [1.13 (0.82, 1.57), p = 0.441]; HER2 UNK [0.71 (0.45,1.11), p = 0.126]; TN [0.88 (0.73, 1.07), [p = 0.199]. Conclusions: The combination of letrozole and lapatinib did not significantly improve PFS in any of the pts with lower levels of HER2 expression (borderline FISH, IHC 2+, or HER2 UNK) or in TN pts. These data confirm the HER2-ve result previously reported and substantiate that only tumors with the target benefit from the addition of a targeted therapy.

[Table: see text]

Magnetic Resonance Imaging quantification of breast density in BRCA carriers following gonadotropin releasing hormone agonist (GnRHA)-based hormonal chemoprevention

1506

Background: Breast tissue density limits the usefulness of mammography as a surveillance tool in young women. Breast Magnetic Resonance Imaging (MRI) provides high tissue contrast and three-dimensional structural information not impaired by high breast density. We developed a volumetric “MR density” measure of breast structural composition that may be complementary to mammographic breast density. We tested this MR density measure in unaffected women with known high risk of breast cancer due to a BRCA gene mutation (or empiric risk > 30% lifetime), who were recruited in a phase II trial to study the effects of a hormonal chemoprevention regimen. Methods: Nine premenopausal high-risk women age 21 to 48 were treated with intranasal GnRHA (deslorelin), low-dose estradiol, and testosterone daily for 10 months. All patients underwent one contrast-enhanced breast MRI exam before and after treatment. We measured MR density as the ratio of fibroglandular tissue volume to total volume of the breast, at both time points. Our technique involved the semi-automated delineation of the breast and the automated segmentation of fibroglandular from adipose tissue. An “MR index” was also defined to quantify partial voluming effects due to the presence of adipose/fibroglandular edges in the MR data. Results: Eight out of nine patients showed a reduction in MR density (p = 0.026) with treatment. Three patients had less than 5% MR density at baseline, making it difficult to quantitate a change with treatment. All of the remaining six patients had reduced MR density after treatment (mean reduction 35.5%; p = 0.035). Conclusions: We have demonstrated the use of breast MR density as a robust volumetric quantitative measure of breast tissue composition. Our findings suggest that MR could be used to measure hormonal chemoprevention effects in BRCA carriers.

[Table: see text]

Progression-free survival (PFS) of patients with HER2-negative, estrogen-receptor (ER)-low metastatic breast cancer (MBC) with the addition of lapatinib to letrozole: Biomarker results of EGF30008

1018

Background: Lapatinib (Lap), an oral, dual inhibitor of EGFR/HER-2, is approved with capecitabine for treatment of HER-2+ MBC for recurrence after taxane, anthracycline, and trastuzumab-based therapy. Letrozole (Let) has activity in hormone-receptor positive (HR+) BC. It has been hypothesized that peptide growth factor signaling and hormone signaling pathways interact and dual targeting of these pathways results in therapeutic synergy. We report a blinded analysis of HER-2, ER, and progesterone receptor (PR) expression for patients (pts) with HR+ MBC at first diagnosis or post-adjuvant relapse and response to Lap + Let versus Let. Methods: 1286 pts were randomized 1:1 to 2.5 mg Let daily plus either 1500 mg Lap daily or placebo. The primary endpoint was PFS in HR+, HER-2+ MBC pts; secondary endpoints included PFS in the intent-to-treat population. Blinded, centralized commerical laboratory analysis of archived tumor tissue for HER-2 (IHC and/or FISH) and academic laboratory semi-quantitative analysis of ER/PR (IHC, H-score) was performed and correlated with clinical outcome. Results: In 219/1286 (17%) HER-2+ (FISH+ or IHC3+) pts, a significant improvement in median PFS was observed for Lap + Let versus Let (8.2 v 3.0 mos, HR = 0.71, 95% CI 0.53, 0.96, p = 0.019). No significant difference in median PFS was seen in 952 (74%) HER-2-negative pts (13.4 v 13.7 mos, HR = 0.90, 95% CI 0.77, 1.05, p = 0.188). 821/952 (86%) HER-2-negative pts had tissue available for quantitative ER and PR analysis. Analysis of ER and PR by quartile identified a subgroup of HER-2-negative pts that benefitted from adding Lap to Let. Pts with the lowest quartile of ER expression (H-score <160, n = 207) had a significant improvement in median PFS (13.6 mos v 6.6 mos, HR = 0.65, 95% CI 0.47, 0.9, p < 0.005). Pts with higher levels of ER did not significantly benefit from adding Lap to Let. Analysis of PR expression did not identfiy a subgroup that benefited from Lap. Conclusions: Pts with HER-2-negative, ER+ MBC and low ER expression may benefit from the addition of lap to let. Additional analyses of EGFR, other biomarkers, and prior hormone therapy will be presented.

[Table: see text]

Relevance of serum HER2 extracellular domain (sECD) in EGF30008, a study of letrozole ± lapatinib in patients (pts) with hormone-receptor positive (HR+) metastatic breast cancer (MBC)

1019

Background: Elevated baseline sECD (BsECD) correlates weakly with HER2 overexpression (HER2+). HR+ MBC. Lapatinib benefit was reported in pts with HER2+ tumors irrespective of BsECD status; BsECD status did not predict benefit for HER2- negative (HER2-ve) tumors. sECD levels and their predictive and prognostic value for progression-free survival (PFS) were further examined in a randomized, phase III trial of letrozole ± lapatinib. Methods: Pts (n=1286) with HR+ MBC were randomized to letrozole with placebo (P) or lapatinib (L). HER2 status was evaluated by FISH or IHC in archived tissue. sECD was measured by ELISA at baseline (n=1102 available samples), and every 4 wk. Pts were considered sECD+ if serum sECD was >15 ng/ml. Results: BsECD was positive in 14% (125/894) and 42% (87/208) of pts with HER2-ve and HER2+ tumors, respectively. Correlation between BsECD and FISH was weak but significant in HER2+ pts (R=0.35, p<0.0001) but not in HER2-ve pts (R=0.03, p=0.362). Unlike for HER2+ tumors, BsECD+ did not predict benefit in PFS from L in pts with HER2-ve tumors. HR: Hazard Ratio In pts with HER2- ve tumors, median ECD levels were stable in the P arm but increased slightly (4 ng/mL) in the L arm. In the HER2+ group, median levels in the P arm declined (3.5 ng/mL) but increased at 4 wk in L arm (3.4 ng/mL) and were stable thereafter. Conversion from sECD-ve to sECD+ was observed in both arms but did not correlate with outcome or provide predictive value. Data related to ECD status conversion will be reported. Conclusions: BsECD+ status correlates with HER2+ tumor status and may predict L benefit but BsECD+ status did not predict benefit in pts with HER2-ve tumors. On therapy changes in median sECD were small. Conversion from BsECD-ve to sECD+ did not predict L benefit and we could not confirm that evaluation of on treatment ECD status may help treatment decision.

[Table: see text]

[Table: see text]

A 6 gene molecular predictor of lapatinib related benefit: from cell line models to clinical trials

Abstract #58

Background: Identification of molecular predictors of response is an important aspect of individualized cancer treatment. Responses to lapatinib (L), an oral inhibitor of HER2 and EGFR, approved in combination with capecitabine for HER2+ metastatic breast cancer (MBC), were evaluated in a panel of BC cell lines. Computational approaches were used to identify transcripts that quantitatively associate with response to L in the cell line panel that were then tested in 2 clinical trials.&#x2028; Methods: The clinical utility of a 6-gene predictor was tested retrospectively using a branched-chain DNA assay in paraffin-embedded archival tumor tissue from patients (pts) with HER2 negative or untested MBC tumors enrolled in a phase III trial of paclitaxel (P) vs. P+L, and from pts with HER2 positive MBC enrolled in a L monotherapy trial. Expression of HER2 transcript using the branched-chain assay was compared with HER2 fluorescence in situ hybridization (FISH) and immunohistochemistry (IHC) status; discordant cases were analyzed. Response patterns for pts with HER2+ tumors and a computational model that predicts L sensitivity or resistance is described.&#x2028; Results: Ingenuity analysis of the mRNA predictors of response to L identified in the BC cell line panel revealed saturated gene networks with HER2 as a major node. The 6-gene predictor of response was comprised of 2 genes associated with sensitivity to L: HER2 and GRB7; 4 genes associated with resistance to L: CRK, ACOT9, FLJ31079, and DDX5. Expression results for the 6 genes and progression-free survival (PFS) data were available for 159 pts on L+P. Median PFS in the branched-chain HER2+ group was 32.9 wks vs. 22.4 wks in the HER2-negative group. The 6-gene predictor was used to predict response to L in the HER2+ pts. Comparison of PFS in the 24 “L sensitive” tumors vs. 25 “L resistant” tumors indicated that the predictor, derived from cell-line analyses, had the potential to predict clinical response to L in pts treated with L+P (HR=0.58; 95% CI=0.30-1.11; p=0.07). The 6-gene predictor was further tested in an independent L monotherapy study in pts with HER2 FISH+ MBC. Comparison of PFS in the 24 “L sensitive” tumors vs. 28 “ L resistant” tumors reconfirmed the potential of the 6-gene predictor to enrich for HER2+ pts most likely to experience clinical benefit from L (HR=0.40; 95% CI=0.19-0.84; p=0.015). Further testing is ongoing.&#x2028; Conclusions: This study suggests that molecular predictors of clinical response can be developed through an analysis of response from a collection of 50 BC cell lines. The identification of a L specific 6-gene assay is promising as a clinical predictor of benefit from L in pts with HER2+ BC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 58.

Can we predict future improvement in glycaemic control?

AIMS

To determine the factors responsible for poor glycaemic control in diabetes and whether any such factors are associated with likely improvement in glycaemic control.

METHODS

A prospective cohort study of 130 diabetic patients with poor glycaemic control (HbA(1c )> or = 10.0%) with 1-year follow-up in a teaching hospital Diabetes Clinic. Changes in HbA(1c) were measured after 1 year.

RESULTS

Poor glycaemic control was attributed to one of 15 possible causes. Those cases due to recent diagnosis of diabetes, inadequate treatment with diet, oral glucose-lowering agents or insulin, exacerbation of co-existent medical problems, recent stressful life-events and missed clinic appointments were all associated with significant improvement in HbA(1c) at 12 months. Patients with low mood or alcohol excess, inadequate blood glucose monitoring, poor exercise/sedentary lifestyle, refusal to take tablets or underdosing and refusal to take insulin at all or to increase the dose were all associated with continuing poor glycaemic control at 12 months. The patients were divided almost equally between the two groups.

CONCLUSIONS

In patients with poor glycaemic control, it is possible by simple features identified at clinic to predict which individuals are likely to show improvement in control and which will not. These findings have not been reported previously and suggest that about half of individuals with poor control will improve within our current diabetes clinic practice. Additional strategies will be required to address those individuals who are not likely to respond.

Elevated serum levels of visfatin in gestational diabetes: a comparative study across various degrees of glucose tolerance

AIMS/HYPOTHESIS

Concentrations of visfatin are increased in insulin-resistant conditions, but the relationship between visfatin and insulin and/or insulin resistance indices in pregnancy remains unclear. Insulin resistance in pregnancy is further accentuated in women with gestational diabetes mellitus (GDM). Thus we assessed serum levels of visfatin in pregnant women with varying degrees of glucose tolerance.

MATERIALS AND METHODS

Fasting visfatin levels were measured at 28 weeks of gestation in 51 women divided according to their response to a 50-g glucose challenge test (GCT) and a 75-g OGTT: control subjects (n = 20) had normal responses to both a GCT and an OGTT; the intermediate group (IG; n = 15) had a false-positive GCT, but a normal OGTT; the GDM group (n = 16) had abnormal GCTs and OGTTs.

RESULTS

There were no age or BMI differences between analysed groups. Across the subgroups there was a progressive increase in glucose and insulin at 120 min of the OGTT (p < 0.01). This was accompanied by an increase in visfatin, from 76.8 +/- 14.1 ng/ml in the control subjects, to 84.0 +/- 14.7 ng/ml in the IG group and 93.1 +/- 12.3 ng/ml in the GDM group (p < 0.01 for GDM vs control subjects). There was a positive correlation between visfatin and fasting insulin (r = 0.38, p = 0.007) and insulin at 120 min of the OGTT (r = 0.39, p = 0.006).

CONCLUSIONS/INTERPRETATION

An increase in fasting visfatin, the levels of which correlate with both fasting and post-glucose-load insulin concentrations, accompanies worsening glucose tolerance in the third trimester of pregnancy. However, the significance of these findings, and in particular the role of visfatin in the regulation of insulin sensitivity during pregnancy, remains to be elucidated.

Management strategies for brittle diabetes

Type 1 diabetes is an intrinsically unstable condition. However, the term "brittle diabetes" is reserved for those cases in which the instability, whatever its cause, results in disruption of life and often recurrent and/or prolonged hospitalization. It affects 3/1000 insulin-dependent diabetic patients, mainly young women. Its prognosis is poor with lower quality of life scores, more microvascular and pregnancy complications and shortened life expectancy. Three forms have been described: recurrent diabetic ketoacidosis, predominant hypoglycemic forms and mixed instability. Main causes of brittleness include malabsorption, certain drugs (alcohol, antipsychotics), defective insulin absorption or degradation, defect of hyperglycemic hormones especially glucocorticoid and glucagon, and above all delayed gastric emptying as a result of autonomic neuropathy. Psychosocial factors are very important and factitious brittleness may lead to a self-perpetuating condition. The assessment of brittle diabetes requires quantification of the variability of blood glucose levels. To quantify instability, measures which have been developed, include Mean Amplitude of the largest Glycemic Excursions (MAGE), Mean Of Daily Differences (MODD), Lability Index (LI), Low Blood Glucose Index (LBGI), Clarke's score, Hyposcore, and continuous blood glucose monitoring. Once psychogenic problems have been excluded, therapeutic strategies require firstly, the treatment of underlying organic causes of the brittleness whenever possible and secondly optimising standard insulin therapy using analogues, multiple injections and consideration of Continuous Subcutaneous Insulin Infusion. Alternative approaches may still be needed for the most severely affected patients. Isolated islet transplantation (IIT), which restores glucose sensing, should be considered in cases of hypoglycaemic unawareness and/or lability especially if the body mass index is < 25, but with current immunosuppressive protocols patients must have normal renal function and preferably no plans for pregnancy. Implantable pumps have advantages for patients who either weigh more than 80 kgs or have abnormalities of kidney or liver function or are highly sensitised.

ER+ PR- breast cancer defines a unique subtype of breast cancer that is driven by growth factor signaling and may be more likely to respond to EGFR targeted therapies

514

Background: Hormonal based therapy has long been the mainstay for treatment of ER+ breast cancer. ER+ PR- disease is now known to exhibit different clinical behavior compared to ER+PR+ disease. Recent data indicate that ER+PR- disease is characterized by a lower response rate to estrogen deprivation, has a worse prognosis compared to ER+ PR+ disease, and may be dependent on other signaling pathways. To evaluate the role of the EGFR tyrosine kinase inhibitor gefitnib in the treatment of breast cancer, we conducted a pre-surgical study in women with operable disease. Methods: Frozen core biopsies were obtained at baseline. Patients then received a short-term exposure to gefitinib (at least 2 weeks) prior to definitive surgery when a frozen tumor specimen was obtained. Tissue integrity and composition was verified by H and E and RNA was isolated for microarray analysis. 59 women were enrolled in the study of which 43 were evaluable for molecular analysis. Baseline microarrays were performed on the initial biopsies to classify the ‘subtype‘ of breast cancer (e.g. basal, luminal, HER2 amplified). To analyze the genetic changes that occur in breast cancer tissue with exposure to gefitinib, a direct comparison of the baseline sample and post-treatment tumor was performed. In addition, ER and PR status were determined by immunohistochemistry and compared to the microarray findings. Changes in Ki67 and a set of cell cycle genes were used to define ‘molecular response” to gefitinib. Of the 43 samples evaluated by microarray, 11 patients were categorized as exhibiting molecular growth inhibition, 10 patients as molecular growth proliferation, and 22 did not have a significant change in Ki67 and the cell cycle gene set to assign a response. When grouped by subtype, ER+PR- and HER2 amplified tumors define a subgroup more likely to show molecular growth inhibition with gefitinib. Conversely, ER+PR+ tumors were more likely to show molecular growth proliferation. Conclusions: These results support the hypothesis that ER+PR- breast cancer is growth factor dependent and constitutes a unique subgroup of ER+ patients which may be more likely to benefit from EGFR inhibition.

[Table: see text]

An Improved Method of Fluorescent Dual Insulin and Endothelial Staining Allows Visualisation of the Revascularisation of Intraportally Transplanted Islets

BACKGROUND

Intraportally transplanted islets are avascular at the time of transplantation and take up to 14 days to fully revascularize, during which time up to 60% of islet mass may be lost. To investigate and improve islet revascularization, a robust method for the visualization and quantification of this process is required.

METHODS

Islets isolated from Lewis rats were transplanted intraportally into the liver of diabetic syngeneic Lewis recipients. The animals were humanely killed either on the day of transplant or at 3, 5, 7, or 14 days posttransplant. The harvested livers were sectioned and stained with Bandeiraea simplicifolia lectin (for endothelial cells) and anti-insulin antibody and counterstained with DAPI. The slides were visualized with a fluorescent microscope.

RESULTS

Islets were visualized over the whole time course. Insulin and endothelial staining was clearly visualized on the day of transplantation, but by day 3 endothelial staining was scarce within the islet. By day 5, early vessel formation could be seen within the islet, but insulin staining was patchy and associated with apoptotic nuclei. By day 7, vessels could be seen throughout the islet and insulin staining had returned. Day 14 sections showed a fully revascularized islet.

CONCLUSIONS

The staining provided good delineation of islet endothelium and beta-cell location, with clear observation of the revascularization process. This technique also suggests that days 3 through 5 may be a critical period for islet survival and provides a good model for studying the effects of manipulating the revascularization process.

Effect of donor treatment with heparinoids on graft function after intraportal transplantation of a marginal islet mass: An experimental study

Heparinoids interact with factors that are involved in ischemia-reperfusion injury and thus may prevent organ injury. We therefore studied the effects on subsequent intraportal islet transplantation of systemic administration of unfractionated and N-desulphated heparin to donors prior to pancreatectomy. Donor rats were given an intravenous injection of either heparin (1.3 mg/kg or 13.3 mg/kg; 200 U/kg or 2000 U/kg, respectively) or N-desulphated heparin (50 mg/kg; approximately 5 U/kg) at 5 to 10 minutes prior to pancreas procurement. Five hundred freshly isolated islets were injected intraportally into syngeneic male Lewis recipients that had developed streptozotocin-induced diabetes. Blood glucose and body weight were monitored for 5 weeks thereafter. Rats transplanted with islets from donors given high dose heparin showed a fall in blood glucose from 25.1 +/- 1.4 to 11.0 +/- 2.7 mmol/L (P <.01) with 60% of animals euglycemic within the first week. In contrast, the controls, did not show a fall in glucose levels at 1 week and none had become euglycaemic. Normalization of glycemia was slower in recipients of islets from animals treated with the lower dose of heparin. Results were intermediate with islets from donors given N-desulphated heparin. Nevertheless, all heparinoids used in this study caused more than a doubling of the number of animals achieving normoglycemia by 3 to 4 weeks. We hypothesize that pretreatment of the donor with heparin protects islet integrity during procurement and isolation and hence accelerates islet engraftment and remodelling. Since the effect was seen with N-desulphated heparin, which has negligible anticoagulant properties, we believe the mechanism to be independent of the anticoagulant activity.

The effects of transdermal estradiol alone or with cyclical dydrogesterone on markers of cardiovascular disease risk in postmenopausal women with type 2 diabetes: a pilot study

The objective of this open, longitudinal, controlled study was to assess the effect of transdermal estradiol alone or combined with cyclical dydrogesterone on the markers of cardiovascular disease (CVD) risk in postmenopausal women with type 2 diabetes. The control group consisted of postmenopausal diabetic women who declined menopausal hormone replacement therapy (HRT). Twenty-eight postmenopausal women (19 on HRT and 9 controls) with type 2 diabetes were followed up for 12 months. From the active treatment group 14 women with a uterus in situ had 80 microg/24 hr transdermal estradiol (Fematrix 80; Solvay Healthcare Ltd, Southampton, UK) and oral dydrogesterone 10 mg daily for the first 12 days of the calendar month, whereas 5 women with previous hysterectomy had 80 microg/24 hr transdermal estradiol (Fematrix 80) alone. CVD risk markers were measured before and at regular intervals after starting HRT. The main outcome measures were weight, systolic and diastolic blood pressure, fasting plasma glucose, glycated hemoglobin (HbA1c), glucose/insulin ratio, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, lipoprotein (a), high-sensitivity C-reactive protein (hs-CRP), fibrinogen, and endothelin-1. Transdermal estradiol with or without dydrogesterone in women with type 2 diabetes did not adversely affect any of the measured markers of cardiovascular risk. There was a significant decrease in HbA1c, total cholesterol, and LDL cholesterol at 6 months in women receiving HRT. Some of the cardiovascular disease risk markers may improve in postmenopausal women with type 2 diabetes with transdermal estradiol. This effect may have important clinical implications and it deserves further investigation in appropriately designed trials.

Treating dyslipidaemia in non-insulin-dependent diabetes mellitus -- a special reference to statins

Patients with non-insulin-dependent diabetes (NIDDM) have an increased incidence of ischaemic heart disease (IHD) when compared with nondiabetic subjects. In addition, they have a worse prognosis after their first myocardial infarction (MI). According to the recent USA recommendations, the threshold for initiation of dietary intervention in diabetic subjects is an LDL greater than 2.6 mmol/l, with the goal to achieve levels less than 2.6 mmol/l (100 mg/dl). This is also the threshold for initiation and treatment goal for pharmacological intervention in diabetic subjects, unless they are completely free of IHD, peripheral vascular disease or cerebrovascular disease and have no other IHD risk factors. In the latter circumstances, the threshold for treatment is an LDL greater than 3.38 mmol/l (130 mg/dl), with the goal to achieve levels less than 3.38 mmol/l. The HMG-CoA reductase inhibitors (statins) can improve the lipid profile effectively and safely in NIDDM. Results from post hoc analyses of diabetic subgroups in the large intervention trials suggest that some statins significantly reduce the risk for IHD-related mortality/morbidity. However, because these results are derived from secondary prevention trials, we cannot be sure if these benefits apply to all diabetic subjects or only to those who already have IHD. Nevertheless, it seems logical to assume that this benefit also applies to NIDDM patients who do not have IHD because they share a similar vascular risk as nondiabetic subjects who have IHD. Intervention trials using statins and fibrates, alone or in combination, in NIDDM are under way. In a few years these trials will provide definitive end-point-based evidence in this high-risk group of patients.

Surviving native beta-cells determine outcome of syngeneic intraportal islet transplantation

In moderately diabetic rats (plasma glucose 20-30 mmol/L), where there is some residual pancreatic islet function, normoglycemia can be restored by transplantation of pancreatic islets into the liver via the portal vein. To examine whether normoglycemia can also be achieved in more severely diabetic animals (which more closely resemble human type I diabetes), we have compared the effect of transplanting 1000 islets intraportally in Lewis rats made moderately diabetic (55 mg/kg streptozotocin injected IP while nonfasting) or severely diabetic (65 mg/kg streptozotocin injected IP while fasting). In the moderately diabetic rats in which residual pancreatic insulin was 128 +/- 40 mU insulin (2.0% of control), plasma glucose stabilized (32 +/- 2.8 mmol/L at 1 week, 34 +/- 2 mmol/L at 3 weeks) as did body weight (falling from 290 +/- 5 to 265 +/- 5 g at 1 week and 253 +/- 6 g at 3 weeks). In contrast, in severely diabetic rats in which residual pancreatic insulin was only 13.5 +/- 4.2 mU insulin (0.21% of control), there was a progressive rise in plasma glucose (30 +/- 1.3 mmol/L at 1 week, 49 +/- 4 mmol/L at 2 weeks, and 67 +/- 7 mmol/L at 3 weeks) and a progressive fall in body weight (from 304 +/- 10 to 260 +/- 5 g by week 1 and to 209 +/- 6 g by week 3). Following islet transplantation, nonfasting plasma glucose normalized in moderately diabetic rats (10.5 +/- 0.6 vs. 9.1 +/- 0.6 mmol/L in nondiabetic controls, NS) after 23 +/- 5 days. In contrast, in the severely diabetic rats plasma glucose stabilized at 32 +/- 5 mmol/L (p < 0.05 compared to moderately diabetic group) but did not normalize. This difference was not attributable to different plasma glucose levels at the time of transplantation (35.1 +/- 1.8 in moderately diabetic vs. 32.5 +/- 2.5 mmol/L in severely diabetic rats). These observations demonstrate that residual native beta-cells (equivalent to only 60-80 islets) contribute to the survival or function of intraportally transplanted islets.

Growth and survivorship of dipterocarp seedlings: differences in shade persistence create a special case of dispersal limitation

A series of growth experiments and observations on natural populations have been carried out on dipterocarp species of contrasting ecology growing in artificial gaps and the forest understorey. These studies have demonstrated that although differences exist between species in photosynthetic and growth responses to the high-light environment, competition for light in canopy gaps is highly asymmetrical and tends to reinforce any pre-existing dominance hierarchy. We propose that differences in seedling persistence in forest canopy shade are highly influenced by species-specific biotic and abiotic interactions. Our experiments suggest that as seedlings, dipterocarp species trade off traits which enhance persistence and growth in shade against those that enhance their ability to exploit gaps. Less competitive species survive for progressively longer periods of time after a gregarious fruiting event. This leads to significant shifts with time in the number of species present in the seedling bank and hence in the importance of interspecific competition in determining which species dominates regrowth in gaps. We propose that this special case of dispersal limitation is more likely to account for coexistence of dipterocarp species than differences in growth responses to gaps of different size, with stochastic and environmental variables interacting to determine species distribution and abundance.

Elevated serum creatine kinase activity in a patient with acute pancreatitis

A 62-year-old man presented with a five-day history of a 'flu-like' illness, epigastric pain and a state of increasing confusion. His serum values for amylase and glucose were grossly elevated, as was the creatine kinase (CK) activity, being 23 times above the upper limit of normal. CK-MB was less than 5% of his total CK activity. There was no past history of diabetes or recent history of intramuscular injections or injury. A diagnosis of acute pancreatitis complicated by hyperosmolar non-ketotic (HONK) diabetic pre-coma was made. The patient was treated with intravenous fluids, insulin and subcutaneous heparin. Normal values for serum amylase and CK activity were recorded with convalescence. This case indicates a possible association of a rise in total CK activity with acute pancreatitis complicated by HONK diabetic pre-coma. This observation was made in the absence of clinically evident muscle pathology.

Original p53 status predicts for pathological response in locally advanced breast cancer patients treated preoperatively with continuous infusion 5-fluorouracil and radiation therapy

PURPOSE/OBJECTIVE

1) To test feasibility of preoperative continuous infusion (c.i.) 5-Fluorouracil (5-FU) and radiation (RT) in locally advanced breast cancer. 2) To study clinical and pathological response rates of 5-FU and radiation. 3) To attempt preliminary correlations between biological probes and pathological response.

METHODS AND MATERIALS

Previously untreated, locally advanced breast cancer patients were eligible: only patients who presented with T3/T4 tumors that could not be resected with primary wound closure were eligible, while inflammatory breast cancer patients were excluded. The protocol consisted of preoperative c.i. infusion 5-FU, 200 mg/m2/day with radiotherapy, 50 Gy at 2 Gy fractions to the breast and regional nodes. At mastectomy, pathological findings were classified based on persistence of invasive cancer: pathological complete response (pCR) = no residual invasive cells in the breast and axillary contents; pathological partial response (pPR) = presence of microscopic foci of invasive cells in either the breast or nodal specimens; no pathological response (pNR) = pathological persistence of tumor. For each patient pretreatment breast cancer biopsies were analyzed by immunohistochemistry for nuclear grade, ER/PR hormonal receptors, her2/neu and p53 overexpression.

RESULTS

Thirty-five women have completed the protocol and are available for analysis. 5-FU was interrupted during radiation in 10 of 35 patients because of oral mucositis in 8 patients, cellulitis in 1, and patient choice in another. Objective clinical response rate before mastectomy was 71% (25 of 35 patients): 4 CR, 21 PR. However, in all 35 patients tumor response was sufficient to make them resectable with primary wound closure. Accordingly, all patients underwent modified radical mastectomy: primary wound closure was achieved in all patients. At mastectomy there were 7 pCR (20%), 5 pPR (14%) and the remaining 23 patients (66%) had pathological persistence of cancer (pNR). Variables analyzed as potential predictors for pathological response (pPR and pCR) were: initial TNM clinical stage, clinical response, nuclear grade, hormonal receptor status, p53 overexpression, and Her2/neu overexpression in the pretreatment tumor biopsy. Only initial p53 status (lack of overexpression at immunohistochemistry) significantly correlated with achievement of a pathological response to this regimen (p = 0.010).

CONCLUSION

The combination of c.i. 5-FU and radiation was well tolerated and generated objective clinical responses in 71% of the patients. With the limitation of the small sample size, the complete pathological response achieved (20%) compares favorably with that reported in other series of neoadjuvant therapy for similar stage breast cancer. These preliminary data suggest that initial p53 status predicts for pathological response (pPR and pCR) to the combination of c.i. 5-FU and radiotherapy in locally advanced breast cancer.

Telomerase activity in normal and neoplastic breast

Telomerase activity is detected in the majority of human tumors and provides a mechanism to escape from proliferative limitations due to telomere loss. Similar to other studies, telomerase activity was detected with a modified telomeric repeat amplification protocol in the majority (76%) of 49 human breast cancer specimens, including most (75%) ductal carcinoma in situ specimens. There were no correlations between telomerase activity and tumor stage or estrogen/progesterone receptor status. In four of seven invasive tumors, telomerase expression seemed to be heterogeneous because not all microdissected regions were telomerase positive. Low levels of telomerase activity were also detected in a minority (17%) of breast specimens from patients without evidence of cancer. These findings suggest that telomerase activation can occur early in breast cancer progression and may be periodically down-regulated during subsequent progression.

Relevance of human papillomavirus screening in management of cervical intraepithelial neoplasia

OBJECTIVE

To evaluate the utility of human papillomavirus detection in identifying women with abnormal Papanicolaou smears who can be safely followed up with cytologic study only, we conducted a study to determine the sensitivity, specificity, and negative and positive predictive values of a Food and Drug Administration-approved human papillomavirus test kit for detection of cervical intraepithelial neoplasia in colposcopically directed biopsy specimens.

STUDY DESIGN

We enrolled women with abnormal Papanicolaou smears referred to a colposcopy clinic serving indigent patients. All 1128 women had a referral Papanicolaou smear, a clinic Papanicolaou smear, and a sample for human papillomavirus deoxyribonucleic acid test; 1075 underwent colposcopically directed biopsies and endocervical curettage. We used the HPV Profile kit for human papillomavirus testing.

RESULTS

Of 486 women with low-grade squamous intraepithelial lesions on Papanicolaou smear, 35.4% had high-risk human papillomavirus deoxyribonucleic acid detected, and of 592 with high-grade lesions, 44.4% had high-risk human papillomavirus detected. Among 527 women with biopsy specimens showing cervical intraepithelial neoplasia and in 267 with cervical intraepithelial neoplasia grades 2 or 3, 38.7% and 56.2% had high-risk human papillomavirus deoxyribonucleic acid detected. However, the sensitivity of human papillomavirus deoxyribonucleic acid detection to identify biopsy-confirmed cervical intraepithelial neoplasia grades 2 or 3 was 55.7%, and the positive predictive value of the test was only 34.9%.

CONCLUSION

Human papillomavirus appears to be causally associated with cervical cancer but human papillomavirus screening does not appear to be of value to identify women with abnormal Papanicolaou smears who can be safely followed up with cytologic study alone.

Testosterone deficiency myopathy

Testosterone is recognized to have a positive effect on nitrogen balance and muscle development in hypogonadal men, but significantly myopathy secondary to testosterone deficiency has been reported only rarely. We describe a patient who presented with a myopathy associated with testosterone deficiency, and who demonstrated a significant functional and myometric response to treatment.

Myopathy in acquired partial lipodystrophy

We describe two women with acquired partial lipodystrophy, one with significant myopathic symptoms and signs. Muscle biopsy of deltoid and quadriceps was performed in each case. The light microscopy findings were of type 1 and type 2 fibre hypertrophy, with an increase in intracytoplasmic fat in both cases. Electron microscopy showed normal fibres, with accumulations of electron-lucent fat droplets between the myofibrils. The cause of the lipodystrophies is uncertain, but myopathy may be a feature, and muscle biopsy studies may help in further defining the syndrome.

Search for optimal parent for recombinant vaccinia virus vaccines. Study of three vaccinia virus vaccinal strains and several virus lines derived from them

Three vaccinia virus strains (Praha, DD--a DRYVAX Wyeth vaccine-derived virus-and LIVP) were examined for growth in various cell cultures and for virulence and immunogenicity in mice. The viruses did not differ by their growth rates in monkey kidney cells (CV-1), human diploid cells (LEP), rat TK cells (RAT 2) or primary dog kidney cells. The immunogenicity of Praha and DD viruses was similar, the virus LIVP was somewhat more immunogenic. In terms of virulence in 3-day-old mice, the DD virus was the most attenuated. Single-plaque progenies were derived from the original smallpox vaccines VARIE Sevac (strain Praha) and DRYVAX Wyeth and tested for the above markers and DNA restriction patterns. The results obtained demonstrated biological and molecular heterogeneity of the original virus populations. Close linkage was observed between immunogenic activity and virulence in 3-day but not in 3-week mice. The results indicate that smallpox vaccine preparations may serve as an abundant source of virus mutants.

Expression of the c-kit proto-oncogene and its ligand stem cell factor (SCF) in normal and malignant human testicular tissue

Recent findings suggest an important role of the proto-oncogene c-kit, a surface membrane receptor of the tyrosine kinase family, and its ligand stem cell factor (SCF) in normal spermatogenesis and possibly in the pathogenesis of certain testicular germ cell tumors. To further investigate this potential role, the expression of c-kit and SCF was studied in normal and malignant human testicular tissue specimens at the mRNA and protein level by Northern blot analysis and immunohistochemistry, respectively. The detection of the c-kit receptor in normal human germ cells and its natural ligand SCF in Sertoli cells suggests the presence of a local trophic regulatory system that may be active in human spermatogenesis. Additionally, c-kit expression was detected in the seminoma but not in the nonseminoma subtype of human testicular germ cell tumors (GCT). Stem cell factor was not expressed at the mRNA level in tissue from either subtype of GCT as determined by Northern blot analysis; however, the protein was detected immunohistochemically in the cytoplasm of rare tumor cells.

A carboxy-terminal portion of the preS1 domain of hepatitis B virus (HBV) occasioned retention in endoplasmic reticulum of HBV envelope proteins expressed by recombinant vaccinia viruses

The large envelope glycoprotein (L protein) of Hepatitis B virus (HBV) contains the preS1 domain, which is responsible for retention of the protein in the endoplasmic reticulum. To identify sequences of the preS1 domain involved in this phenomenon we constructed vaccinia virus-HBV recombinants containing the gene for L protein in which the preS1 coding sequence had been partially deleted. The retention of L protein in the endoplasmic reticulum was found to be mediated by a sequence contained within a region of 35 amino acids of the preS1 C-terminus, and not exclusively by amino acid sequences of the N-terminus of the preS1 domain as proposed by Kuroki et al. (Mol. Cell. Biol. 9, 4459-4466, 1989). Our finding could be explained by a specifically VV promoter sequence leading to exclusive synthesis of L or deleted (delta)L proteins, respectively. The ability of the coexpressed HBV S protein to facilitate export of the delta L proteins was demonstrated by coinfection experiments.

Male:female sex ratio in births resulting from IVF according to swim-up versus Percoll preparation of inseminated sperm

Two centers have independently reported a higher rate of male to female births following insemination of sperm prepared by a modified swim-up technique. The principle of the modified swim-up is that a small percentage of the x-bearing sperm are the fastest and travel to the top of the supernatant, followed by the y-bearing sperm; the bulk of the x-bearing sperm remain in the pellet. In this technique, the very top layer is discarded and the resulting supernatant is collected, leaving only the pellet. In contrast, with the conventional swim-up technique, the entire supernatant is collected. The study presented herein retrospectively evaluated the male to female sex ratio of births from in vitro fertilization using standard swim-up technique and compared these results to the ratio obtained from separating with Percoll. There were 53% male births with swim-up vs. 54% with Percoll in singleton pregnancies and 51% males with swim-up vs. 40% with Percoll with multiple births. Thus, conventional swim-up alone does not increase percentage of male births.

Effect of shortened exposure time to the critical period for ice crystal formation on subsequent post-thaw semen parameters from cryopreserved sperm

Cryopreservation of human sperm using present methods leads to a reduced fertility potential of the specimen. In many instances this prevents the successful fertilization of the female partner from the frozen-thawed specimens of males whose semen has been cryopreserved prior to surgery, chemo-therapy, or even vasectomy. Furthermore, even though some donor specimens can be successfully used for achieving pregnancies, one needs to place the sperm intrauterine to approach the same pregnancy rates as those of fresh intracervical insemination. The main mechanism considered for sperm damage by cryopreservation is ice crystal formation. The most critical time for forming ice crystals is from 0 to -10 degrees C. In the present study the effect of a modified rapid cryopreservation technique with reduction of exposure time to the 0 to -10 degrees C temperature range was compared to standard freezing procedures on subsequent semen parameters. Though no significant differences were found on post-thaw motile densities or hypoosmotic swelling test scores, a new, equally effective, but more rapid technique for cryopreservation is reported.