Challenges and opportunities of sharing animal health data for research and disease management: a case study of bovine tuberculosis

The sharing of animal disease data should be encouraged. The analysis of such data will broaden our knowledge of animal diseases and potentially provide insights into their management. However, the need to conform to data protection rules in the sharing of such data for analysis purposes often poses practical difficulties. This paper sets out the challenges and the methods used for the sharing of animal health data in England, Scotland and Wales - Great Britain - using bovine tuberculosis (bTB) data as a case study. The data sharing described is undertaken by the Animal and Plant Health Agency on behalf of the Department for Environment, Food and Rural Affairs and the Welsh and Scottish Governments. It should be noted that animal health data are held at the level of Great Britain (rather than the United Kingdom - which includes Northern Ireland), as Northern Ireland's Department of Agriculture, Environment and Rural Affairs has its own separate data systems. Bovine tuberculosis is the most significant and costly animal health problem facing cattle farmers in England and Wales. It can be devastating for farmers and farming communities and the control costs for taxpayers in Great Britain are over £150 million a year. The authors describe two methods of data sharing - first, where data are requested by, and delivered to, an academic institution for epidemiological or scientific analysis, and second, where data are proactively published in an accessible and meaningful way. They provide details of an example of the second method, namely, the free-to-access website ‘information bovine TB' (https://ibtb.co.uk), which publishes bTB data for the benefit of the farming community and veterinary health professionals.

Abstract P2-02-10: Circulating level of GP88/Progranulin is associated with clinical outcome and overall survival in stage 4 breast cancer patients

Monitoring of disease status in metastatic breast cancer (MBC) patients is a necessary step for an optimal management of patients during and post-therapy. Imaging technologies are the methods of choice in the standard of care to monitor therapy response and disease status in MBC patients. These methods are expensive, time-consuming and have limited sensitivity for real time monitoring. Measurements of circulating tumor markers CA15-3, CA125 and CEA have contributed, albeit with limitation, minimally invasive methods for MBC disease management. It is our hypothesis that measuring biomarkers involved in tumor biological processes may provide better evaluation of the disease state and thus aid real-time clinical management of MBC patients. Thus, addition of such new circulating disease biomarkers may improve the management of MBC patients. The 88kDa glycoprotein Progranulin (GP88/PGRN) fit these criteria. GP88/PGRN is expressed in tumor tissue and not in normal mammary tissue counterpart and secreted in the circulation of BC patients. Biological studies have established GP88/PGRN as a critical driver of BC cell proliferation, survival, invasiveness and drug resistance. Clinical studies have demonstrated that high tumor GP88/PGRN expression was prognostic for recurrence and that breast cancer patients had a statistically elevated GP88/PGRN serum level compared to healthy individuals. In the present study, we examined whether GP88/PGRN serum levels were elevated in MBC patients and whether GP88/PGRN circulating levels were correlated with patient clinical outcome and overall survival.

Under an IRB approved protocol at the University of Maryland Greenebaum Comprehensive Cancer Center, 101 stage 4 BC patients undergoing standard of care therapy and meeting the inclusion criteria were consented and enrolled. MBC patients' demographics, clinical and disease characteristics and therapies were collected as part of the study. Blood samples were collected from each patient at specific times at follow-up visits during and post-therapy. The prepared serum was stored at -80C until tested for GP88 using a GP88 enzyme linked immunoassay developed in our laboratory.

Statistical analysis using Kaplan-Meier functions established whether there was a correlation between GP88/PGRN serum level and overall survival in MBC patients. MBC patients with distinct survival characteristics (P=0.0002) could be stratified based on their circulating GP88/PGRN levels. Analysis of this association was carried out in MBC patients based on their age, race, tumor characteristics, receptor status and metastatic burden (number and sites of metastasis) and will be reported. We conclude that circulating levels of GP88/PGRN in MBC patients are correlated with overall survival and that monitoring circulating GP88/PGRN levels would provide additional information and valuable insight into real-time MBC disease status.

This work was supported by grant R43 CA 210817-01A1 to GS.

Citation Format: Serrero G, Hawkins D, Hicks D, Rosenblatt P, Tait N, Yue B, Tkaczuk K. Circulating level of GP88/Progranulin is associated with clinical outcome and overall survival in stage 4 breast cancer patients [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 P2-02-10.

Abstract P1-02-12: Determination of a serum progranulin (GP88/PGRN) level associated with overall survival in metastatic breast cancer patients

Imaging technologies are the methods of choice in the standard of care (SOC) to monitor therapy response in metastatic breast cancer (MBC) patients. However, such methods are expensive and have limited sensitivity to detect disease response in a timely manner. Measurement of the circulating tumor markers such as CA15-3, CA27.29 and CEA has provided additional minimally invasive methods in disease management of MBC patients. While useful, they have limitations in providing clinicians with a reliable insight into real-time disease monitoring. Understanding of real-time biological processes may provide better biomarkers of the disease state and thus aid real-time clinical management of MBC patients by identifying circulating disease associated biomarkers. Thus, addition of such new circulating biomarkers may improve the management of MBC patients. We have characterized a target biomarker that would fit these criteria, the 88kDa glycoprotein Progranulin (GP88). GP88 is expressed in tumor tissue and not in normal mammary tissue counterpart and is secreted in the circulation of BC patients. Biological studies have established GP88 as one of the critical drivers for breast cancer cell proliferation, survival, invasiveness and drug resistance. Clinical studies have demonstrated that elevated GP88 tumor levels were prognostic for recurrence and that breast cancer patients had a statistically elevated GP88 serum level than healthy individuals. Using tissue and serum tests to detect and quantify GP88 could provide an new strategies for identifying patients at high risk of recurrence and monitoring disease progression in BC patients undergoing therapy. In the present study, we examined whether GP88 serum levels were elevated in MBC patients and whether GP88 serum levels were correlated to patient overall survival.

Under an IRB approved protocol, 92 MBC patients that met the inclusion criteria and were undergoing therapy at the UMGCCC Breast Clinic were consented and enrolled. Clinical and disease characteristics along with serum CA15-3 values were collected as part of the study. Serum samples were collected from each patient during therapy and subsequently the patients were monitored. The serum was stored at -80C until tested for GP88 using a GP88 enzyme linked immunoassay developed in our laboratory.

Statistical analysis using Kaplan-Meier functions established whether there was a correlation between GP88 serum level and overall survival in MBC patients. By analyzing the KM plots at different GP88 cut points, we identified two populations with distinct survival characteristics. When examined more thoroughly the difference in overall survival of patients with <60ng/ml and >60ng/ml was statistically significant (P=0.0002). Correlation analysis of serum GP88 and CA15-3 were performed and will be presented.

We conclude that circulating levels of GP88 in MBC patients are correlated with overall survival. It would appear that patients that can be managed to have a GP88 below 60ng/ml will survive longer. Thus measuring circulating GP88 levels would provide additional information to that available in today's SOC for monitoring. This valuable insight into real-time disease status will assist clinicians in patient management.

Citation Format: Serrero G, Hawkins DM, Yue B, Hicks D, Tait N, Tkaczuk KR. Determination of a serum progranulin (GP88/PGRN) level associated with overall survival in metastatic breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-02-12.

Abstract OT3-01-07: Phase II study of trastuzumab and pertuzumab alone and in combination with hormonal therapy or chemotherapy with eribulin in women aged ≥60 with HER2/neu overexpressed locally advanced and/or metastatic breast cancer

Her2 overexpression is both a predictive and prognostic marker with tumors overexpressing Her2 having an aggressive natural history, but also responding to targeted therapy. The standard of care for Her2 positive metastatic cancer is docetaxel paired with combined antibody therapy of pertuzumab (P) and trastuzumab (T). Older patients are known to have more difficulty tolerating traditional cytotoxic chemotherapy. Neoadjuvant studies have shown a proportion of patients have pathologic complete responses (pCR) with dual Her2 targeted therapy without chemotherapy. The NEOSPHERE trial demonstrated at 17% pCR after 3 cycles of T+P. The Translational Breast Cancer Research Consortium has shown 12-28% pCR with the combination of estrogen deprivation, trastuzumab, and lapatinib (TBCRC 006 and 023). We have designed a phase II study of T+P alone and then in combination with hormonal or chemotherapy after progression in women age ≥ 60 with Her2 overexpressed locally advanced or metastatic breast cancer (BC). As a primary endpoint, this study seeks to evaluate the overall response rate (ORR) of dual Her2 targeted therapy with T+P without chemotherapy in older patients with locally advanced or metastatic Her2 positive BC (cohort 1). At progression,depending on tumor characteristics and disease status, chemotherapy with eribulin or hormone therapy with anastrozole plus fulvestrant will be added (cohort 2 – A and B). ORR for cohorts 1, 2A and 2B will be determined. Secondary end points will evaluate clinical benefit, progression free survival, overall survival, tolerability, safety, and quality of life. Translational studies involving circulating tumor cells identified through OncoCEE – Biocept system and glycoprotein 88 expression will be performed. Eligibility includes patients' age ≥60 with locally advanced or metastatic Her2 positive BC treated with 0-3 lines of chemotherapy. Patients must have an ejection fraction >50% and meet set hematologic and metabolic lab criteria. Her2 status is per ASCO/ACP guidelines. Excluded patients include patients with active brain metastasis, second malignancies, anticancer treatment <3 weeks prior to the start of therapy. Patients must have not received pertuzumab, eribulin, anastrozole, or fulvestrant in the metastatic setting. A true ORR of 40% will be considered active. The study was designed assuming 25% of patients initially respond to T+P and 75% progress to cohort 2. With a type I error rate of 0.05 and power of 0.90, 40 patients will need to enroll in order to have 30 patients in cohort 2 (15 per arm). Data will be analyzed after eight patients are enrolled. If there are no responders in cohort 1 and 2, the accrual will be stopped and declared inefficient. After 15 patients are enrolled, if no more than 3 of the 15 respond, the therapy will be considered not promising and halted. Currently there are two patients enrolled at the University of Maryland. We are in negotiations to expand to additional sites. Questions can be directed to prosenblatt@umm.edu.

Citation Format: Rosenblatt PY, Kesmodel SD, Bellavance E, Nichols EM, Feigenberg SJ, Tait N, Lewis J, Sivisailam SS, Couzi R, Goloubeva O, Tkaczuk KHR. Phase II study of trastuzumab and pertuzumab alone and in combination with hormonal therapy or chemotherapy with eribulin in women aged ≥60 with HER2/neu overexpressed locally advanced and/or metastatic 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 OT3-01-07.

Spatially resolved and observer-free experimental quantification of spatial resolution in tomographic images

We present a novel framework and experimental method for the quantification of spatial resolution of a tomography system. The framework adopts the "black box" view of an imaging system, considering only its input and output. The tomography system is locally stimulated with a step input, viz., a sharp edge. The output, viz., the reconstructed images, is analysed by Fourier decomposition of their spatial frequency components, and the local limiting spatial resolution is determined using a cut-off threshold. At no point is an observer involved in the process. The framework also includes a means of translating the quantification region in the imaging space, thus creating a spatially resolved map of objectively quantified spatial resolution. As a case-study, the framework is experimentally applied using a gaseous propane phantom measured by a well-established chemical species tomography system. A spatial resolution map consisting of 28 regions is produced. In isolated regions, the indicated performance is 4-times better than that suggested in the literature and varies by 57% across the imaging space. A mechanism based on adjacent but non-interacting beams is hypothesised to explain the observed behaviour. The mechanism suggests that, as also independently concluded by other methods, a geometrically regular beam array maintains maximum objectivity in reconstructions. We believe that the proposed framework, methodology, and findings will be of value in the design and performance evaluation of tomographic imaging arrays and systems.

Abstract OT3-2-11: A phase II study of letrozole and lapatinib followed by an addition of everolimus in postmenopausal women with advanced endocrine resistant breast cancer (BC)

Background: Several preclinical studies demonstrated that crosstalk between growth factor receptor pathways, particularly HER2, and ER signaling confers resistance to endocrine therapy (ET). There are emerging data showing the involvement of immune system and miRNA with endocrine resistance. EGF30008 trial showed a benefit of lapatinib in combination with letrozole, mainly in HER2-positive (HER+) metastatic BC (MBC) while a subset analysis of this trial showed that HER2-negative (HER2-) patients (pts) with acquired endocrine resistance may also benefit from this combination. Our preclinical study suggests that everolimus is synergistic with letrozole and lapatinib.

Trial Design: This is a single arm phase II study for postmenopausal women with hormone receptor-positive MBC progressing after aromatase inhibitor, tamoxifen, or fulvestrant. The total target accrual is 76 pts (38 HER2+ pts and 38 HER- pts). In the first phase of the study, pts will be treated with letrozole and lapatinib (1,500 mg daily). Upon disease progression, pts will enter the second phase where everolimus (5 mg daily) will be added to letrozole and the dose of lapatinib will be reduced to 1,250 mg daily. For correlative studies, peripheral blood samples will be serially collected to evaluate for serum HER2 extracellular domain (ECD), circulating miRNAs, PC cell-derived growth factor (GP88), immune regulatory cells including myeloid-derived suppressor cells, NK cells, and Treg cells. These parameters will be correlated with tumor response. In pts with accessible tumors, optional serial biopsies will be performed at baseline and upon progression in each phase of the study. The tumor tissue will be tested for total HER1, HER2, and HER2 expressions as well as HER2:HER2 homodimers, HER2:HER3 heterodimers, HER1:HER2 heterodimers, p95, and HER3/PI3K (p85 subunit) using VeraTag assay.

Statistical Method: The primary objective is to evaluate the clinical benefit rate (CBR: CR, PR, SD > 24 weeks) of the combination of letrozole and lapatinib as well as the combination of everolimus, letrozole, and lapatinib. This is a three-stage design which is an extension of the Simon's two-stage design. The sample size is based on the assumption that a CBR below 10% (null hypothesis) would indicate ineffective therapy and the statistical power is set at a higher CBR of 30% which we consider is plausible. Therefore, if 0 of the first 10 pts in each cohort have clinical benefit, the study will be closed; otherwise additional 8 pts will be enrolled. If ≤ 1 of the total 18 pts has clinical benefit, the study will be closed; otherwise an additional 9 pts will be enrolled. If ≤ 5 pts have clinical benefit the therapy is considered not promising; and if ≥ 6 pts of the total of 27 have clinical benefit, the therapy is considered worth pursuing. This design has ∼90% probability to accept the therapy for further trials if the true CBR is indeed at least 30% and 10% probability to accept it if the true clinical benefit is indeed below 10%.

To date, there are a total of 6 pts enrolled. Accrual is currently ongoing. Please contact ntait@umm.edu for further information.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-2-11.

P4-12-13: A Multi-Center Randomized Controlled Double Blind Trial Assessing the Effect of Acupuncture in Reducing Musculoskeletal Symptoms in Breast Cancer Patients Taking Aromatase Inhibitors: First Interim Analysis

Background: Aromatase inhibitors (AIs) are recommended as first-line adjuvant hormonal therapy in postmenopausal women with hormone-receptor-positive breast cancer, as monotherapy or sequential therapy after tamoxifen. AI-associated musculoskeletal symptoms (AIMSS) occur in approximately 50% of women receiving AIs and in some may result in discontinuation of treatment. Symptom management is essential to ensure that breast cancer patients receive the full recommended duration of AI therapy. We conducted a randomized, placebo-controlled trial to evaluate the effect of acupuncture on AIMSS and report the first interim analysis.

Method: Postmenopausal women with early stage breast cancer, experiencing AIMSS, who had not had acupuncture in the year prior to the study, were eligible. Patients were randomized to 8 weekly acupuncture or sham acupuncture. Health assessment questionnaire disability index (HAQ-DI ranging 0–3.0) and pain visual analog scale (VAS ranging 0–100) were used to assess clinical musculoskeletal disorder severity at weeks 0, 4, 8, and 12 or 24. Change in HAQ-DI (ΔHAQ-DI) and VAS scores (ΔVAS) from baseline were compared between patients receiving acupuncture versus sham acupuncture using exact Wilcoxon rank sum test. Serum samples were collected for measurements of estrogens and beta endorphin concentrations and cytokine profile before and after the intervention to evaluate the etiology of AIMSS and the mechanism of acupuncture in treating AIMSS.

Results: Between May 2008 and June 2011, 48 patients were enrolled, 2 patients were not evaluable due to noncompliance to treatment and lost to follow up, 10 were still receiving treatment and therefore not evaluable. Thirty-six were evaluable, and were equally distributed between the real and sham acupuncture groups. Baseline characteristics were balanced between the two groups with regard to age, race, and body mass index (BMI) with the exception that baseline mean HAQ-DI was higher in the acupuncture group (0.9 vs 0.55, p=0.04). White/Black/Asian: 26/7/3, Median (range): age: 61 (45-82); BMI (kg/m2): 31.1 (22.9−59.6). At week 8, both groups showed a wide range of ΔHAQ-DI (ΔHAQ-DI =HAQ-DIweek8-HAQ-DIbaseline): from −1.38 to 0.5 in the acupuncture group versus from −1 to 0.12 in sham acupuncture group. There was no statistically significant difference in mean ΔHAQ-DI between the real and sham acupuncture groups (−0.33 vs −0.33, p=0.87). Eleven patients in each group (61%) reported decreased HAQ-DI scores, which correlated with improved function. There was no difference in mean ΔVAS between the real and sham acupuncture groups (−9.27 vs −13.82, p=0.67). No significant side effects were reported. Changes in other time points and in serum biomarkers will be presented at the meeting.

Conclusions: The majority of breast cancer patients experiencing AIMSS who participated in our study reported a reduced HAQ-DI score both from acupuncture and sham acupuncture. We did not observe significant differences between responses to real versus sham acupuncture after 8 weekly treatments. The study remains open to accrual to reach 50 evaluable patients.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-12-13.

GP88 Serum Level Is Increased in Breast Cancer Patients with Disease Progression

GP88 (progranulin) is an 88-kDa glycoprotein autocrine growth factor that plays a critical role in breast tumorigenesis. GP88 is expressed in human BC tumors in a positive correlation with their tumorigenicity. In estrogen receptor positive (ER+) cells, GP88 expression is low and is stimulated by estradiol whereas in ER negative (ER-) cells, it is constitutively overexpressed. In ER+ cells, increased GP88 expression was found to be associated with resistance to anti-estrogen therapy. In Her-2 overexpressing breast tumors, increased GP88 expression was associated with Herceptin resistance. Inhibition of GP88 expression in human breast adenocarcinoma cells resulted in a drastic reduction of tumor incidence and tumor growth in nude mice. Immunohistochemical studies carried out with 206 paraffin-embedded human breast biopsies have shown that GP88 is expressed in invasive ductal carcinomas in correlation with expression of markers of poor prognosis whereas normal tissues and benign breast lesions were negative. Importantly, high GP88 expression in tissue biopsies was accompanied by decreased disease-free and overall survival. Since GP88 contains a signal peptide for secretion, we have shown that GP88 can be found in serum. An IRB approve blood sampling study of 189 patients (Race: Caucasian- 91, African American-92, Asian-6; median age- 51 with a range from 26 to 81) established at the University of Maryland demonstrated that GP88 was measurable in serum and that GP88 serum level was statistically elevated in breast cancer patients when compared to healthy individuals. Median level of GP88 was 40.7 ng/ml (range 6.4-80) in early stage (stage 1 –3) BC pts (p- value = 0.007) and 45.3 ng/ml (range 9.8 to 158.4) in stage 4 metastatic BC patients (p-value= 0.0007). Statistically significant increase in circulating GP88 level was found in early stages as well as in metastatic disease when compared to healthy individuals.Since we have shown that GP88 tissue expression was associated with increased disease recurrence, the present study was focused on examining whether GP88 serum level was also increased in disease progression and could be used to monitor disease recurrence. Our data show that patients with disease recurrence or progression presented a 5 to 10 fold increase in their GP88 serum levels.This study identifies GP88 as a measurable biomarker for recurrence or disease progression not only at the tissue but also at the serum level.This study is supported by grants from MIPS, the Avon Foundation and from the National Cancer Institute.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6040.

Association of serum levels of the growth factor GP88 with disease progression in breast cancer patients

e22021

Background: The autocrine growth factor GP88 is an important player in breast cancer. GP88 is expressed in human BC tumors in correlation with their tumorigenicity. Increased GP88 expression was associated with anti-estrogen therapy resistance in ER+ cells and Herceptin resistance in Her-2 overexpressing breast tumors. Inhibition of GP88 expression inhibited tumor incidence and growth in nude mice. Immunohistochemical studies have shown that GP88 is expressed in invasive ductal carcinomas (IDC) and that high GP88 expression correlated with increased recurrence and mortality. Since GP88 is found in serum, we hypothesized that GP88 was elevated in the sera of breast cancer patients compared to healthy individuals and that GP88 serum level increases with disease progression. Methods: An IRB approved prospective study was established at the University of Maryland Breast Clinic to determine the serum level of GP88 in breast cancer patients (BC pts). Approximately 5 ml of blood was drawn every three months. GP88 serum concentration was determined in triplicate by human GP88 enzyme immunoassay. 190 BC pts were accrued. Sera from healthy volunteers (HV) were obtained to establish GP88 baseline. BC patient characteristics: Caucasian- 91, African American-92, Asian-6; median age, 51 (range 29- 86), stage I - 48, II - 52, III - 26, IV - 63. Results: Median serum GP88 level was 28.7 ng/ml (range 16.6–38.2) in HV, 40.7 ng/ml (range 6.4–100) in early stage (stage 1 -3) BC pts (p- value = 0.007) and 45.3 ng/ml (range 9.8 to 158.4) in stage 4 BC patients (p- value= 0.0007). Statistically significant increase in serum GP88 level was found in early stages as well as in metastatic disease when compared to HV. In addition, patients that were initially diagnosed with early stage disease but recurred showed a 5 to 10 fold increase in their GP88 serum levels. Conclusions: GP88 serum level is significantly higher in the sera of BC than HV subjects. Moreover, GP88 serum level increased in association with disease recurrence and progression. This study identifies GP88 as a measurable biomarker for disease progression not only at the tissue but also at the serum level. These results are also interesting since GP88 is also a therapeutic target of malignant progression of breast carcinoma.

No significant financial relationships to disclose.

Variations in care for operable breast cancer and outcomes between rural and metropolitan centers in Australia

e11517

Background: The causes of variation in breast cancer survival remain uncertain. Care provided to women with breast cancer may vary in relation to both the care setting and characteristics of the clinicians. Methods: To compare the outcomes of management of breast cancer treated in rural and metropolitan centers, a prospective audit of breast cancer in a region of Australia was undertaken. Over a nine-year observation period 2102 women with invasive breast cancer underwent potentially curative surgery. Treatments received, including systemic adjuvant therapy, were compared to contemporary guideline-based indicators. Breast cancer specific mortality was analyzed using Cox proportional hazards models. Results: Overall agreement of received treatment with the indicators was high. Women treated within rural centers were, however, much less likely to receive post operative radiotherapy after breast conserving surgery (86.4% vs. 97.0%; p<0.001). The overall recurrence rate, including distant metastases, for all women was 11.6%. Local or regional recurrence was more frequent in rural centers compared with metropolitan centers (4.1% versus 2.1%; p=0.05). Breast cancer mortality was increased in women with large tumors, high grade disease, and positive axillary lymph nodes. Non-compliance with treatment guidelines was associated with a trend towards increased breast cancer mortality (HR=1.55; p=0.056). After adjustment for these factors and patient age, undergoing surgery in rural centers was associated with increased breast cancer mortality (HR=1.84; p<0.001). Although women treated in rural centers were older, their cancer stage and tumour characteristics were similar to those of women treated in metropolitan centers. Non-cancer related mortality was elevated in women treated in rural centers compared with women travelling to a city for surgery (HR=2.08; p=0.005). Conclusions: Increased non-cancer related mortality in rural treated women suggests increased medical co-morbidity in this group, which may have influenced treatment choices and outcomes. Low rates of adjuvant radiotherapy were noted for women treated in rural centers. In addition, clinically significant differences in outcome, including breast cancer mortality, were observed.

No significant financial relationships to disclose.

A predictive test for therapeutic treatment outcomes of advanced gastrointestinal cancer patients (AGC)

e15079

Background: There are currently limited options for selecting an optimal treatment regimen for AGC patients. The Drug Response Indicator Test (DRIT) is a platform technology that provides a detailed profile of a patient's tumor response to commonly used chemotherapeutic drugs, as a basis for individualized treatment. Establishment of DRIT will allow physicians to choose effective drug treatments to improve the efficacy of cancer therapies on an individual basis. Methods: DRIT analysis is based on fluorescent dye-labeled monoclonal antibody staining followed by computer-assisted microscopy to measure expression levels in tumor sections. The interpretation of the Drug Response Indicator (DRI) expression levels result in classification of tumors as sensitive or resistant to treatment with a mechanistically related drug. Clinical outcomes are then analyzed with respect to the DRI data. This study utilized the following drug/DRI combinations: capecitabine, 5-flurouracil/thymidylate synthase; docetaxel, paclitaxel, abraxane/β-tubulin isoform III; gemcitabine/ribonucleotide reductase; platinum salts/ERCC-1; Irinotecan/Topoisomerase I. Results: DRIT retrospective studies were performed on a cohort of 33 consented patients (pts) receiving 55 treatments for AGC at UMGCC. This cohort included pts treated for rectal/colon, gastric, esophageal & pancreatic cancers. DRIT sensitivity was 0.96, positive predictive value 0.84, negative predictive value 0.67 and overall predictive accuracy 83 %. DRI expression level cut-off points indicating sensitivity or resistance to a specific treatment were derived from previous retrospective breast cancer studies using similar drug complements (abstract 6075 San Antonio Breast Conference 2008). Conclusions: This study indicates that DRIT can provide accurate prediction of treatment outcomes for individual AGC patients. DRI expression level cut-off points indicating sensitivity or resistance to a specific treatment may be applied to both breast cancer & AGC. DRIT will allow for tailoring of chemotherapy based on the specific biomarker expression within each patient's tumor tissue.

[Table: see text]

Elevated serum levels of the growth factor GP88 are found in breast cancer patients when compared to healthy individuals

Abstract #2006

Background: GP88 is an autocrine growth factor that plays a critical role in breast tumorigenesis. GP88 is expressed in human BC tumors in a positive correlation with their tumorigenicity. Increased GP88 expression is associated with resistance to anti-estrogen therapy in ER + cells and with herceptin resistance in Her-2 overexpressing breast tumors. Inhibition of GP88 expression in human breast adenocarcinoma inhibited tumor incidence and growth in nude mice. Immunohistochemical studies have shown that GP88 was expressed in invasive ductal carcinomas in correlation with the expression of poor prognosis markers whereas normal tissues and benign lesions were negative. High GP88 expression in tumor biopsies was accompanied by decreased disease-free survival. Since GP88 can be secreted, we have hypothesized that GP88 could be secreted in the circulation and found in serum. We examined whether GP88 could be found in the circulation and whether GP88 could be elevated in the sera of breast cancer patients when compared to healthy individuals.&#x2028; Methods: An IRB approved blood sampling study was conducted at the University of Maryland Breast Clinic to determine the serum level of GP88 in healthy volunteers (HV) and breast cancer patients (BC pts). Serum GP88 concentration was determined in triplicate by quantitative enzyme immunoassay. 189 BC pts were accrued. In addition, sera from 18 HV were obtained to establish a GP88 baseline in healthy volunteers. BC patient characteristics: Race: Caucasian- 91, African American-92, Asian-6; median age, 51 (range 29-86), stage I – 48, II - 52, III – 26, IV - 63.&#x2028; Results: Circulating GP88 was measurable in the serum. Median level of GP88 was 28.7 ng/ml (range 16.6-38.2) in HV; 40.7 ng/ml (range 6.4-100) in early stage (stage 1 –3) BC pts (p- value = 0.007) and 45.3 ng/ml (range 9.8 to 158.4) in stage 4 metastatic BC patients (p-value= 0.0007). Statistically significant increase in circulating GP88 level was found in early stages as well as in metastatic disease. Correlation studies with BC prognostic factors such as stage, tumor size, lymph node involvement, tumor grade and presence of ER and HER-2 will be presented.&#x2028; Conclusion: GP88 can be detected in the sera of HV and BC pts. Comparison between the two groups of subjects indicates that GP88 level is significantly higher in the sera of BC pts. These studies are important as they identify as a measurable circulating biomarker GP88 that is also a therapeutic target of malignant transformation or malignant progression of breast carcinoma (BC). Future studies will examine whether there is any correlation between the serum level of GP88 and therapeutic response to systemic therapy in breast cancer patients.&#x2028; This study was supported by grant from MIPS, the Avon Foundation and 1R43 CA 124179-01A1 from the National Institutes of Health.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2006.

Circulating levels of the breast cancer growth factor GP88 in the serum of breast cancer (BC) patients

20050

Background: The 88 kDa autocrine growth factor PC-Cell Derived Growth Factor (GP88) plays a critical role in breast tumorigenesis. GP88 expression was low in estrogen receptor positive cells, whereas in ER negative cells, it was constitutively overexpressed. Increased GP88 expression was associated with anti-estrogen therapy resistance in ER+ cells and Herceptin resistance in Her-2 overexpressing breast tumors. Antisense inhibition of GP88 expression in human breast adenocarcinoma lead to inhibition of tumor growth in vivo. Immunohistochemical studies have shown that GP88 was expressed in 80% of invasive ductal carcinomas in correlation with expression of poor prognosis markers whereas normal tissues and benign breast lesions were negative. Since GP88 is secreted by breast cancer cells, we examined whether GP88 was found in the circulation at an elevated level in the sera of breast cancer patients when compared to healthy individuals. Methods: A blood sampling study was conducted to determine the serum level of GP88 in healthy volunteers (HV) and breast cancer patients (BC pts). Ten ml of blood was drawn every three months to obtain serum. GP88 serum concentration was determined in triplicate by quantitative enzyme immunoassay using human GP88 as standard. 126 BC pts were accrued. . In addition, sera from 53 healthy volunteers were obtained to establish a GP88 baseline in HV. BC pts characteristics: race: Caucasian- 61, African American-60, Asian-5; median age: 52.5 (range 26–84), stage I-32, II-34, III-18, IV-42. Results: Circulating GP88 was measurable in the serum. Median level of GP88 was 32.8 ng/ml (range 15.3–42.8) in HV and 43.8 ng/ml (range 15.4–158.4) in BC pts, (p-value = 0.0007). Conclusions: GP88 is measurable in the sera of HV and BC pts. Comparison between the two groups indicates that GP88 level is significantly higher in the sera of BC pts. These studies are important since it identifies GP88 as a measurable biomarker that is also a therapeutic target of malignant transformation or malignant progression of breast carcinoma (BC). Future studies will examine the correlation of GP88 level with BC prognostic factors. Correlation between the serum level of GP88 and therapeutic response to systemic therapy in breast cancer patients will also be assessed.

[Table: see text]

Bayesian hierarchical modelling to enhance the epidemiological value of abattoir surveys for bovine fasciolosis

Four classes of Bayesian hierarchical models were evaluated using an historical dataset from an abattoir survey for fasciolosis conducted in Victoria, Australia. The purpose of this analysis was to identify areas of high prevalence and to explain these in terms of environmental covariates. The simplest of the Bayesian models, with a single random effect, validated the use of smoothed maps for cartographic display when the sample sizes vary. The model was then extended to partition the random effect into spatially structured and unstructured components, thus allowing for spatial autocorrelation. Rainfall, irrigation, temperature-adjusted rainfall and a remotely sensed surrogate for rainfall, the normalised difference vegetation index (NDVI), were then introduced into the models as explanatory variables. The variable that best explained the observed distribution was irrigation. Associations between prevalence and both rainfall and NDVI that were significant in fixed effects models were shown to be due to spatial confounding. Nevertheless, provided they are used cautiously, confounded variables may be valid predictors for the prevalence of disease.

Clinician opinion on the management of patients with hepatic colorectal metastases

BACKGROUND AND AIMS

Clinical practice is determined by many different factors, but with the advent of evidence-based medicine, there may be a tendency to concentrate upon the scientific facts when decision-making rather than focusing on the patient. Furthermore, individual clinician opinion or bias may potentially influence patient management. This study outlines clinician opinion with regard to management of patients with hepatic colorectal metastases, and compares it to present practice in the Sydney metropolitan area.

METHODS

Clinician opinion was assessed by using a questionnaire and compared to results from a prospective multicenter study looking at patterns of care of patients with hepatic colorectal metastases.

RESULTS

Clinicians participating in the present study had a good knowledge of the current evidence concerning hepatic colorectal metastases and its treatment. However, there was a discrepancy between clinician knowledge that matched scientific evidence and actual clinical practice.

CONCLUSIONS

This study suggests that clinician bias/opinion does influence patterns of care for patients with hepatic colorectal metastases.

Implementing clinical practice guidelines: a community-based audit of breast cancer treatment. Australian Capital Territory and South Eastern New South Wales Breast Cancer Treatment Group

OBJECTIVE

To improve breast cancer management by facilitating implementation of treatment guidelines.

DESIGN

A prospective, longitudinal study (developed by clinicians and consumers) of all patients with newly diagnosed breast cancer. Four locally agreed breast cancer management guidelines were established (based on 1995 National Health and Medical Research Council guidelines) as practice indicators.

SETTING

Breast cancer treatment facilities and medical practices in the Australian Capital Territory and South Eastern New South Wales, May 1997 to July 1998.

MAIN OUTCOME MEASURES

Actual treatment received by patients for primary breast cancer during the study period.

RESULTS

During the 14 months of the study, 19 clinicians registered 221 new patients with a proven diagnosis of breast cancer. Of 191 women with localised invasive breast cancer, 112 (59%) had tumours 2 cm or less in diameter. Axillary surgery in 173 (91%) of these women showed 107 (56%) had no axillary lymph node involvement. Of 87 women treated with breast-conserving surgery for locally invasive cancer, 85 (98%) also received postoperative radiotherapy. Some form of systemic adjuvant therapy was indicated in 99 women (axillary nodes positive or tumours > 2 cm diameter) and this treatment was received by 95 (96%). All 27 women aged under 50 years with node-positive disease received adjuvant chemotherapy.

CONCLUSIONS

Enhancing uptake of breast cancer management guidelines is feasible at a regional level with an audit program and broad support among clinicians and consumers.

Use of the Hasson cannula producing major vascular injury at laparoscopy

Despite the recent demonstration that vascular lesions occur significantly more frequently in patients having closed rather than "open" laparoscopy, there never has been a published case report of injury to the great vessels associated with the open technique of initial access to the peritoneal cavity at laparoscopy. We present the first two such cases reported, along with a brief review of the literature related to such major vascular injuries (MVI) sustained at laparoscopy. Lacking appreciation of aortic anatomy and intraoperative technical factors contribute to the occurrence of these injuries. Delayed diagnosis and management contribute to poor outcomes. Secondary injury frequently is associated with MVI at laparoscopy.

Fine needle aspiration cytology and core biopsy histology in infiltrating syringomatous adenoma of the breast. A case report

BACKGROUND

Infiltrating syringomatous adenoma is a rare tumor of the breast that can radiologically mimic invasive duct carcinoma. Detailed fine needle aspiration cytology and needle core biopsy findings on this lesion have not been previously described.

CASE

The clinical, radiologic and pathologic findings of an infiltrating syringomatous adenoma of the breast in a 71-year-old female who presented with a subareolar lump are described. The cytology of the tumor was characterized by a combination of a background of plump, fibroblastoid cells and cohesive sheets of bland epithelial cells. Histologically the tumor showed infiltrating, duct-like structures with squamous metaplasia and a desmoplastic stroma.

CONCLUSION

Fine needle aspiration cytology and needle core biopsy can distinguish infiltrating syringomatous adenoma from malignant disease of the breast.

Fabrication of nanocolumns for liquid chromatography

This paper shows that in situ micromachining can be used to simultaneously position and define (i) support particles, (ii) convective transport channels, (iii) an inlet distribution network of channels, and (iv) outlet channels in multiple chromatography columns on a single quartz wafer to the level of a few tenths of a micrometer. Stationary phases were bonded to 5 x 5 x 10 microns collocated monolith support structures separated by rectangular channels 1.5 microns wide and 10 microns deep with a low degree of deviation of channel width between the top and bottom of channels. High aspect ratio microfabrication can only be achieved with deep reactive ion etching. The volume of a 150 microns x 4.5 cm column was 18 nL. Column efficiency was evaluated in the capillary electrochromatography (CEC) mode using rhodamine 123 and a hydrocarbon stationary phase. Plate heights in these columns were typically 0.6 micron in the nonretained and 1.3 microns in the retained modes of operation. Columns were designed to have identical mobile-phase velocity in all channels in an effort to minimize outgassing during operation. When the total lateral cross-sectional area of channels at all points along the separation axis is identical, linear velocity of the mobile phase in a CEC column should be the same. Columns were operated at atmospheric pressure.

Phase I study of the orally administered butyrate prodrug, tributyrin, in patients with solid tumors

Butyrates have been studied as cancer differentiation agents in vitro and as a treatment for hemoglobinopathies. Tributyrin, a triglyceride with butyrate molecules esterified at the 1, 2, and 3 positions, induces differentiation and/or growth inhibition of a number of cell lines in vitro. When given p.o. to rodents, tributyrin produces substantial plasma butyrate concentrations. We treated 13 patients with escalating doses of tributyrin from 50 to 400 mg/kg/day. Doses were administered p.o. after an overnight fast, once daily for 3 weeks, followed by a 1-week rest. Intrapatient dose escalation occurred after two courses without toxicity greater than grade 2. The time course of butyrate in plasma was assessed on days 1 and 15 and after any dose escalation. Grade 3 toxicities consisted of nausea, vomiting, and myalgia. Grades 1 and 2 toxicities included diarrhea, headache, abdominal cramping, nausea, anemia, constipation, azotemia, lightheadedness, fatigue, rash, alopecia, odor, dysphoria, and clumsiness. There was no consistent increase in hemoglobin F with tributyrin treatment. Peak plasma butyrate concentrations occurred between 0.25 and 3 h after dose, increased with dose, and ranged from 0 to 0.45 mM. Peak concentrations did not increase in three patients who had dose escalation. Butyrate pharmacokinetics were not different on days 1 and 15. Because peak plasma concentrations near those effective in vitro (0.5-1 mM) were achieved, but butyrate disappeared from plasma by 5 h after dose, we are now pursuing dose escalation with dosing three times daily, beginning at a dose of 450 mg/kg/day.

Use of spiral and non-spiral computed tomography arterial portography in the detection of potentially malignant liver masses

The present study assesses the usefulness of computed tomography (CT) arterial portography (CTAP) in detecting and defining the number and anatomy of potentially malignant liver lesions. One hundred and one adults studied in 1993 and 1994 were retrospectively reviewed, including patients with primary or secondary tumours for possible resection and patients with non-hepatic malignancies in whom the detection of liver metastases would preclude surgery. Twenty-three patients underwent non-spiral CT studies and 78 had studies on a spiral unit, with 22 of these having single phase and 56 having dual phase studies to overcome artefact problems. The relationship between lesion size and detection sensitivity is critical. On non-spiral studies, the overall lesion detection sensitivity and positive predictive value was 69 and 90%, respectively. Detection sensitivity was 100 and 20% for lesions > 1 cm and < 1 cm, respectively. On single phase spiral CTAP the overall detection sensitivity and positive predictive value was 80 and 66%, respectively. Detection sensitivity for lesions > 1 cm and < 1 cm was 100 and 0%, respectively. On dual phase spiral CTAP the overall detection sensitivity and positive predictive value was 76 and 71%, respectively. For lesions > 1 cm and < 1 cm the sensitivity was 81 and 55%, respectively. Eighteen patients with non-hepatic malignancies with unsuspected metastatic spread did not proceed to major surgery because of liver metastases detected on CTAP. Perfusion artefacts occurred in 30 and 64% of non-spiral and of initial portal venous spiral CTAP studies, respectively. By using the double-phase technique, these artefacts were substantially diminished. In conclusion, CTAP is a valuable tool for assessing the presence, site and size of possible liver tumours and confers a benefit even when previous ultrasound and conventional CT have already been used. In addition, CTAP has a lower limit of useful resolution of approximately 1 cm. Perfusion artefacts can be reduced by a dual phase protocol.

Intercostal pedicle flap for thoracic oesophageal perforations

Oesophageal perforations are associated with a high mortality and morbidity. Intrathoracic perforations especially are associated with mediastinitis and sepsis. The repair of these perforations may be difficult, particularly when there has been a delay to diagnosis. We report our use of a method to repair or buttress the suture line after repair with a vascularized intercostal muscle flap, having used it successfully in two patients with intrathoracic oesophageal perforations.

A phase-I study of cpt-11, weekly bolus 5-fu and leucovorin in patients with metastatic cancer

CPT-11 is a topoisomerase I inhibitor with activity against colorectal cancer. This study was designed to explore the potential for combining CPT-11 with fluorouracil and leucovorin. 5-FU (500 mg/m(2)) and leucovorin (500 mg/m(2)) were administered for 4 consecutive weeks and CPT-11 was given on weeks 1 and 4 of each 6 week cycle. The starting dose of CPT-11 was 25 mg/m(2) and the dosage was escalated by increments of 25 mg/m(2) in cohorts of 3 patients. Nine patients were treated on study. Grade 4 diarrhea was the dose limiting toxicity at 50 mg/m(2). Alternative strategies to combine CPT-11 with 5-FU and leucovorin are being explored.

Cold agglutinins: preoperative diagnosis leads to an uneventful perfusion

This report presents the successful use of normothermic cardiopulmonary bypass (CPB) and warm continuous retrograde cardioplegia to facilitate coronary artery bypass grafting (CABG) in a patient with cold agglutinins. As a result of their agglutinating action and resultant haemolysis, cold-reactive autoantibodies have the potential for causing morbidity and mortality when a patient is placed on hypothermic CPB and the heart is arrested with profoundly cold cardioplegia. The crux of the situation is to keep the temperature above the critical temperature of the cold agglutinin; this technique guarantees accomplishing that goal.

The treatment of gall stones

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Is an intercalated BSc degree associated with higher marks in examinations during the clinical years?

Do medical students taking an intercalated BSc degree obtain higher marks during their subsequent clinical examination? Fourteen students who did a BSc during the academic year 1988-89 were matched, by sex and preclinical grades, with students in the year they left, and with students in the year they subsequently joined. Marks or grades in 10 subsequent examinations were compared. Seven of 10 comparisons with the year the BSc students left were to the advantage of the intercalated students, and two comparisons were statistically significant. Seven of 10 comparisons with the year the BSc students subsequently joined were to the advantage of the non-intercalating students, though none reached statistical significance. No consistent short-term academic advantages arising from having done a BSc could be found. We suggest the study be replicated in other medical schools with different course examination structures.

Frantz's tumour: papillary and cystic carcinoma of the pancreas

Frantz's tumour (papillary and cystic tumour) of the pancreas is a rare neoplasm usually seen in young women. It is of low grade malignancy and deserves special note among pancreatic malignancies as it is frequently amenable to local resection and has a good long-term survival rate after excision. Three such cases have been treated at Westmead Hospital, one young male and two females. In two the disease was confined to the pancreas. In one, local invasion outside the pancreas and trans-coelomic spread to the ovaries was present at the time of diagnosis. Complete surgical removal of macroscopic disease was achieved in all three and all remain disease free between 2 and 4 years post-surgery. All have good exocrine and endocrine pancreatic function. These cases are discussed in detail. The need to be aware of this uncommon variant of pancreatic cancer is stressed. Investigation and treatment options are reviewed. The role of cytology studies in diagnosis and the potential for long-term surgical control of this tumour are highlighted on the basis of our limited experience and that presented in recent surgical literature.

Oesophageal cancer: outcome of modern surgical management

Many clinicians still associate oesophagectomy for oesophageal carcinoma with low cure rates, poor palliation and prohibitive peri-operative mortality. Surgical advances have rendered such perceptions inaccurate. A prospective study of all patients undergoing surgery for oesophageal cancer in an Australian teaching hospital between 1979 and 1993 has been undertaken. Selection, staging, pre-operative preparation, surgical technique and postoperative care were all carefully controlled. One hundred and thirty-seven patients were explored. Twenty-one were inoperable. One hundred and sixteen underwent resection with intent to cure. Hospital mortality for oesophagectomy was 1.7%. There were no cases of clinical anastomotic leakage. Eighty-nine per cent achieved excellent to good swallowing. The median survival for all cases was 14 months and the 5 year survival was 18%. Median survival for resected cases was 18 months and the 5 year survival was 26%. The long-term survival was related to postoperative stage of the disease but not to tumour type. Oesophagectomy for oesophageal cancer will restore good swallowing in 90% of cases. Operative mortality should be less than 5% and the overall 5 year survival 20-30%. Early tumours can often be cured (ca in situ 100%, stages I and II 50-60%), indicating the benefits of early detection. Poor survival in advanced disease (stage III 15%, stage IV 0%) on a background of low surgical mortality indicate the need for better staging and more effective adjuvant therapies.

Hepatocellular carcinoma in western Sydney. Aetiology, changes in incidence, and opportunities for better outcomes

OBJECTIVES

To examine the incidence of hepatocellular carcinoma (HCC) in western Sydney over the last 14 years, to assess risk factors for the disease among ethnic groups of Australian residents, and to consider the opportunities for improving its usually poor outcome.

DESIGN AND SUBJECTS

Retrospective case-record review of clinical features in all (122) patients discharged from a 900-bed tertiary-referral teaching hospital with a diagnosis of HCC from January 1979 to March 1993.

MAIN OUTCOME MEASURES

Annual number of new cases; risk factors according to birthplace; surgical resectability of tumours.

RESULTS

New cases admitted each year at least doubled between 1979-1985 and 1986-1992. This apparent increase involved individuals born in Australia (50% of all patients) as well as immigrants. Cirrhosis was found in 93% at liver biopsy or autopsy. Excessive alcohol intake was an associated risk factor for 46% of Australian-born patients and for 13% of those born overseas. Among the latter, HCC was associated with markers of hepatitis B virus infection in 64%. Since hepatitis C virus (HCV) tests became available in 1990, five of nine patients tested were anti-HCV positive. Surveillance screening of patients known to have cirrhosis detected eight cases of early HCC. Seven of these had surgical resection and all are alive.

CONCLUSIONS

New diagnoses of HCC have increased recently, irrespective of country of birth. In Australian-born patients alcoholic liver disease remains a major aetiological factor but the role of HCV requires further evaluation. Among immigrants, cirrhosis from chronic viral hepatitis accounts for most cases. We propose that prevention of cirrhosis caused by chronic viral hepatitis should have the greatest long-term impact on prevention of HCC in Australia. The role of surveillance of people with cirrhosis to detect small and potentially resectable tumours should be explored.

Non-iatrogenic trauma to the extrahepatic biliary tract

Between 1980 and 1991, 15 cases of non-iatrogenic extrahepatic biliary tract trauma have been managed at Westmead and the Royal Canberra Hospitals. There were seven cases of gall-bladder injury and eight bile duct injuries. Four cases resulted from penetrating trauma whereas 11 resulted from blunt trauma. Associated injuries were common. Cholecystectomy was the preferred method of management for gall-bladder injuries whereas the bile duct injuries were managed by a variety of techniques. There were three deaths in the series, mostly related to associated injuries. Bile duct injuries were associated with longer hospitalization than gallbladder injuries.

A case of cholangitis glandularis proliferans and cholangiocarcinoma of the common bile duct

A case of Cholangitis Glandularis Proliferans (CAGP) in association with a cholangiocarcinoma of the common bile duct as described. This is the eighth case of CAGP described and the second association with cholangiocarcinoma.

Dieulafoy's ulcer: a palpable entity?

Two cases of Dieulafoy's ulcer are reported. Diagnosis was delayed but successful surgical treatment was achieved once the lesion was located by palpation.

IATROGENIC INJURIES TO THE EXTRAHEPATIC BILIARY TRACT

Iatrogenic injuries to the extrahepatic biliary tract continue to occur and result in significant morbidity. Over the last 10 years, 26 patients have been referred to Westmead Hospital for management of iatrogenic biliary tract injuries. Of these injuries, 22 occurred during cholecystectomy, three during hepatectomy and one during a pancreaticoduodenectomy. The principles of avoidance and repair are discussed. It is concluded that these injuries, although uncommon, continue to occur and that the best treatment results are achieved in specialized hepatobiliary units.

Alpha-fetoprotein expression in hepatocellular carcinoma: a clinical study

Alpha-fetoprotein (AFP) levels were studied in 51 consecutive patients with hepatocellular carcinoma that presented to the Surgical Hepatobiliary Unit at Westmead Hospital over 12 years. Twenty-three were hepatitis surface antigen (HBsAg) positive and 13 of those patients were Asian. Thirteen patients drank more than 60 g of alcohol each day. A significantly raised level of AFP was defined as more than 20 ng/mL, and 31 of the 51 patients had AFP levels exceeding this at some stage during surveillance. Twenty-five demonstrated levels above 200 ng/mL. Univariate statistical methods suggested that men were more likely to express raised AFP than women, Asians more likely than other races, patients with chronic active hepatitis more likely than those without and those with chronic hepatitis B infection more likely than those who were HBsAg negative. Those who drank more than 60 g alcohol each day were less likely to demonstrate a raised serum AFP than those who drank less. Multivariate logistic regression demonstrated that HBsAg carriage was the only statistically significant independent determinant of a raised AFP. Age 65 years or more was associated with a chance of a raised AFP.

Hepatic cavernous haemangioma: a 10 year review

Between January 1981 and July 1991, 61 patients with hepatic haemangiomata were examined at Westmead Hospital. There were 14 males (22%) and 47 females (78%). The age range was 26-85 years with a median of 49 years. Forty-one had abdominal symptoms but these could be attributed to a haemangioma in only seven cases. There was at least one subcapsular lesion in 17 (28%). Six of the seven symptomatic lesions were subcapsular and five of these were giant haemangiomata (i.e. more than 4 cm in greatest diameter). One large symptomatic lesion was intrahepatic. No association was observed between hepatic haemangiomata and other hepatic or extrahepatic diseases. Haemangiomata were resected from six patients, four of whom were symptomatic. Symptoms improved in all four but did not resolve completely in any. Follow-up ranged from nil in five patients to 108 months in one. The median follow-up was 12 months after initial diagnosis. Ten patients showed evidence of change in their lesions or symptoms while under observation. Only three had worsening symptoms or suspected change in size of a haemangioma. This study highlights the benign, static nature of most hepatic haemangiomata. When this lesion is suspected, the diagnosis should be confirmed with ultrasound (US) and labelled red blood cell scanning (RBCS). Referral for evaluation by a specialist hepatobiliary surgery unit is necessary when symptoms are intolerable, increasing size is definitely demonstrated or the diagnosis is uncertain and cannot be established without specialized investigations. Bleeding into or from these lesions is rare.

Chronic pancreatitis beginning in childhood and adolescence

We identified 10 patients with symptoms beginning before the age of 20 years in a group of 69 patients with proven chronic pancreatitis. Six of the 10 patients were women. There was a family history of pancreatitis in three patients and alcohol exposure in seven patients. Three patients were dependent on narcotics at the time of presentation. Six of the 10 patients had pancreatic duct dilatation to 10 mm or more in diameter during observation. These six patients underwent pancreaticojejunostomy, with clinical improvement in five patients. The median time of follow-up was 19 years from presentation. No patient developed diabetes and one developed malabsorption. Only three patients were free of pain, but four other patients had only mild episodes that rarely required hospital admission. One patient died of metastatic abdominal carcinoma of unknown origin 51 years after developing familial pancreatitis. Chronic pancreatitis beginning at a young age is sufficiently common to merit special awareness. It is compatible with prolonged survival, and pancreaticojejunostomy may help if the pancreatic duct reaches sufficient size. The disease does not seem to burn out with time.

Hepatic focal nodular hyperplasia: a benign incidentaloma or a marker of serious hepatic disease?

Amongst 17 patients with hepatic focal nodular hyperplasia (FNH) encountered at Westmead Hospital between 1981 and 1990, FNH was found in association with hepatocellular carcinoma (HCC) in three (3/17), one male and two females, one of whom also had peliosis and an hepatic adenoma. FNH was also found in association with other conditions which may affect hepatic function, structure or circulation, including chronic obstructive airways disease (2), congestive cardiomyopathy (1), chronic active hepatitis (1), granulomatous hepatitis (1), coeliac artery stenosis (1) and metastatic malignant melanoma (1). This report, derived from our experience with FNH over 10 years draws attention to a possible link between FNH, hepatic malignancy and conditions which may disturb the hepatic circulation. We suggest that patients with FNH should be investigated thoroughly and an aggressive management policy should be adopted.

A phase I/II study of high-dose megestrol acetate in the treatment of metastatic breast cancer

A dose-response relationship has been suggested for medroxyprogesterone acetate in the treatment of advanced breast cancer. To determine the tolerability and efficacy of increasing doses of megestrol acetate in the treatment of metastatic breast cancer, we conducted a phase I/II study among 57 patients. Three patients each received 480, 800, and 1280 mg/d; 48 patients received 1600 mg/d. Of the 57 patients, 56 patients had had disease progression on prior hormone therapy, chemotherapy, or both. Twenty-seven patients had previously received standard-dose MA (160 mg/d). Among the 37 patients with measurable disease, high-dose megestrol acetate (HDMA) produced 6 (16%) complete responses (CRs) and 6 (16%) partial responses (PRs); 11 patients achieved stable disease (SD). HDMA resulted in improvement or stabilization in 12 of the 20 patients with evaluable, non-measurable disease. There were no responses among the 6 patients with liver metastases. Among the 27 patients who were previously treated with standard-dose MA, including 9 patients with primary treatment failure, HDMA resulted in 1 CR, 3 PRs, and 10 SD. Toxicities, which were mild and reversible, included fluid retention, hypertension, hyperglycemia, and mild congestive heart failure. Two patients had superficial phlebitis. The most profound side effect was weight gain which occurred in 43 patients (75%). This study suggests a dose-response relationship for MA in the treatment of advanced breast cancer. A randomized trial to determine the optimal dose is ongoing.

Phase I/II study of cyclophosphamide, doxorubicin, fluorouracil, and leucovorin for treatment of metastatic adenocarcinoma

Leucovorin enhances the cytotoxicity of fluorouracil (5-FU) in patients with colorectal cancer and may increase the efficacy of combination chemotherapy regimens containing 5-FU. To determine the maximum tolerated dose of 5-FU with leucovorin for use in combination with cyclophosphamide and doxorubicin, we conducted a phase I/II trial in 20 patients. The doses of leucovorin (200 mg/m2 on days 1-5), cyclophosphamide (500 mg/m2 on day 1), and doxorubicin (40 mg/m2 on day 1) were held constant, while the dose of 5-FU was escalated in cohorts of patients beginning at 150 mg/m2 on days 1-5. Cycles were repeated every 3 weeks. Significant mucositis, diarrhea, and myelosuppression were infrequently observed in patients receiving up to 250 mg/m2 5-FU on days 1-5. In contrast, at a dose of 300 mg/m2 on days 1-5, three of six patients had granulocyte count nadirs of less than 500/microL during the first cycle of therapy, and two of these three had platelet counts of less than 25,000/microL. In addition, two patients treated at this dose had significant mucosal toxic effects, and three had insufficient recovery to permit a second course by day 22. Among 14 patients with assessable breast cancer, there were one complete and nine partial responses (response rate 71%). Leucovorin modulation of 5-FU can be safely incorporated into combination chemotherapy with cyclophosphamide and doxorubicin and provides a highly active regimen for treatment of metastatic breast cancer. Further study will be required to determine whether the addition of leucovorin significantly enhances the activity of this regimen.