Molecular subtypes of metastatic colorectal cancer are associated with patient response to irinotecan-based therapies

BACKGROUND

Currently, metastatic colorectal cancer is treated as a homogeneous disease and only RAS mutational status has been approved as a negative predictive factor in patients treated with cetuximab. The aim of this study was to evaluate if recently identified molecular subtypes of colon cancer are associated with response of metastatic patients to first-line therapy.

PATIENTS AND METHODS

We collected and analysed 143 samples of human colorectal tumours with complete clinical annotations, including the response to treatment. Gene expression profiling was used to classify patients in three to six classes using four different molecular classifications. Correlations between molecular subtypes, response to treatment, progression-free and overall survival were analysed.

RESULTS

We first demonstrated that the four previously described molecular classifications of colorectal cancer defined in non-metastatic patients also correctly classify stage IV patients. One of the classifications is strongly associated with response to FOLFIRI (P=0.003), but not to FOLFOX (P=0.911) and FOLFIRI + Bevacizumab (P=0.190). In particular, we identify a molecular subtype representing 28% of the patients that shows an exceptionally high response rate to FOLFIRI (87.5%). These patients have a two-fold longer overall survival (40.1 months) when treated with FOLFIRI, as first-line regimen, instead of FOLFOX (18.6 months).

CONCLUSIONS

Our results demonstrate the interest of molecular classifications to develop tailored therapies for patients with metastatic colorectal cancer and a strong impact of the first-line regimen on the overall survival of some patients. This however remains to be confirmed in a large prospective clinical trial.

P2-12-16: HER2 Expression Is the Major Risk Factor for Recurrence in pT1a-b,N0 Breast Cancer: A French Regional Population-Based Study of 671 Patients

Background: To evaluate the prognostic impact of HER2 overexpression in patients with pT1a-b, node negative, breast cancers.

Patients and Methods: A population of1127 patients whose diseases were staged as pT 1a-b, pN0 and who were treated in the Languedoc-Roussillon (ONCO LR Southern French regional network) from 1999 to 2004, was identified. 95% of patients had conservative management, no patient received adjuvant trastuzumab, 5% received chemotherapy and 80% anti-estrogen endocrine therapy. HER 2 status was retrospectively assessed by immunohistochemistry in 671 patients (122 pT1a/549 pT1b). Kaplan-Meier method was used to estimate disease-free survival (DFS). Cox proportional hazard models were used to determine associations between HER2 status and disease-free survival adjusting on variables significantly linked to it.

Results: 9-year Overall survival was 95%. HER2 overexpression (3+) was observed in 5.2% of the patients (n=35).

HER2 3+ category was most frequently identified in the following sub groups: pT1a lesion (12.3% vs 3.6%; p: 0.0001), mastectomies (14% vs 4.4%; p:0.023), Grade 2–3 (91% vs 50%; p<0.0001), estrogen receptor (ER) negative (−) tumors (57% vs 30%; p<0.0001), progesterone receptor (PR) - tumors (74% vs 42%; p: 0.0002). HER2 3+ was less frequent with adjuvant hormonal treatment (43% vs 80%; p<0.0001). 33 relapse (5%) were observed with a median follow-up of 6.4 years (range, 0.3 to 9.9 years). The 5-year DFS rates were 78% and 95% in patients with HER2−positive and HER2−negative tumors, respectively (p:0.017).

According to the immunohistochemical phenotype DFS5 were 95%, 94%, 85%, 73.6% for ER+/PR+/HER2− (n:502/75%), ER-/PR-/ HER2− (n:134/20%), ER+/PR+/HER2 3+ (n:15/2%) and ER-/PR-/ HER2 3+ tumors (n:20/3%), respectively (p:0.02).

In univariate analysis, HER2 positive tumors (p:0.017), phenotype classification (p:0.02) and adjuvant treatment (p:0.013) were significant prognostic factors. In multivariate analysis, only patients with HER2 3+ tumors had higher risks of recurrence (hazard ratio [HR], 2.41; 95% CI: [1.06−5.53]; p<0.05) than those with HER2 -tumors.

Discussion: Node-negative, pT1a-b, breast cancer patients overexpressing HER2 have a significant risk of recurrence at 6 years median follow-up. In our series of small breast tumors, HER2 status seems to be a better prognostic factor than ER status. In patients with hormone receptor-positive diseases, HER2 positivity is associated with a worse DFS despite an anti-estrogen treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-16.

Characterization of Streptococcus salivarius growth and maintenance in artificial saliva

AIMS

To help gain a better understanding of factors influencing the establishment within the oral cavity of Streptococcus salivarius K12, a commensal oral bacterium, we characterized its behaviour in artificial saliva.

METHODS AND RESULTS

Streptococcus salivarius K12 was grown in artificial saliva complemented with a representative meal, under oral pH and temperature conditions. Exponential growth phase was characterized by a high specific growth rate (2.8 h(-1)). During maintenance phase, an uncoupling between growth and lactic acid production occurred, which allowed maintaining viability (95%), intracellular pH (6.6) and membrane polarisation (95%), and thus proton motive force. However, in late stationary phase, viability (64%) and vitality were degraded as a result of lower synthesis of energetic and glycogen-related proteins as compared to a richer medium.

CONCLUSIONS

Streptococcus salivarius was able to rapidly grow in complemented artificial saliva. Nevertheless, a degradation of its physiological state was observed in late-stationary phase.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work demonstrates, for the first time, that artificial saliva was a convenient medium that permitted Strep. salivarius to grow in oral conditions (physico-chemical environment, addition of meals) but not to maintain cellular viability and vitality in starvation conditions.

HER2 status determined on pre operative biopsies and in operative specimens: concordance among immunohistochemistry (IHC) fluorescence in situ hybridization (FISH) and chromogenic in situ hybridization (CISH) techniques in the CRITHER study

Abstract #1089

Background: In breast cancer, HER2 status is generally assessed by IHC or FISH on operative tissue sample and in situ hybridization techniques are standard tools for determining equivocal IHC 2+ overexpression and deciding the correct treatment for HER2-positive breast cancer patients. For the management of their patients, oncologists or surgeons sometimes ask for assessment of HER2 status on per cutaneous core biopsy (CB).The primary objective of the CRITHER study was to investigate concordance between the results of CISH, FISH, and IHC techniques on pre-operative CB samples for HER2 status compared with HER2 status determined by FISH on surgical specimen from a population of previously untreated non-metastatic breast cancer patients in France. Methods: Analysis was performed on samples from 260 patients recruited at 24 pathology centers for the period 2003 to 2006 inclusive. Recruitment was made on the basis of IHC obtained from operative tissue samples in order to obtain around 50% HER2-positive (3+), 30% HER2-negative (0/1+), and 20% HER2-equivocal (2+) cases. CISH and IHC were performed in parallel on the pre-operative biopsy and matched surgical specimen in the participating laboratories, and FISH on both specimens in each of four reference pathology centers. IHC staining was analyzed according to different scoring systems. Results: The rate of discordance between pre-operative CISH and operative FISH was 1.8% with 1.5% false-positives and 2.2% false-negatives (k=0.963; p<0.001); the corresponding rate for pre-operative IHC (excluding equivocal IHC 2+ cases) and operative FISH was 1.5% with 1.6% false-positives and 1.4% false-negatives (k=0.953; p<0.001). Comparison of pre-operative and operative samples showed expected low rates of discordance for CISH (0.85%; k=0.982; p<0.001) and FISH (0.45%; k=0.991; p<0.001), with no false positives in either case. Results for the IHC scoring system analyses on concordance will be presented at the meeting. Discussion: As expected, concordance for both CISH and FISH between pre-operative and operative results was excellent. There was a high rate of concordance for pre-operative CISH and IHC HER2 status determination on CB (excluding equivocal IHC 2+ cases) compared with operative FISH results in patients with previously untreated non-metastatic breast cancer.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1089.

Stereotactic vacuum biopsy of calcifications with a handheld portable biopsy system: a validation study

To prospectively evaluate a compact portable 10-gauge handheld battery-operated biopsy system for stereotactic biopsy of microcalcifications. The ethics committee of the hospital approved this prospective multicentric study, and informed consent was obtained. Biopsy under stereotactic guidance was performed in 215 patients for 219 lesions consisting of microcalcifications without mass. The feasibility and the tolerance of the procedure were evaluated. The mean weight of the specimen was calculated. In patients with surgical diagnoses, the underestimation rate in biopsy diagnoses of atypical ductal hyperplasia and ductal carcinoma in situ were evaluated. The sampled specimens were separated according to the presence of calcifications on magnified specimen radiographs and to the probe the rotation number in order to evaluate the contribution of each rotation and the contribution of the specimen with and without calcifications on the radiographs. The macrobiopsy was feasible in 98.5% of the patients and was well tolerated in 82% of patients. It identified 4.6% invasive carcinomas, 18.5% ductal carcinomas in situ, 14.8% atypical ductal hyperplasias, 22.2% benign proliferative mastopathies and 39.8% benign non-proliferative mastopathies. The underestimation rate was 26.6% when an atypical ductal hyperplasia was diagnosed at biopsy, and 7.7% when a ductal carcinoma in situ was diagnosed. In the 77 patients with surgical correlation, the accurate diagnosis was obtained in specimens sampled during the first, second, and third in 69%, 9%, and 4% of the biopsies, respectively, and the analysis of specimens without microcalcification had an added value in 8% of patients. The compact portable battery-operated biopsy system can be used successfully for stereotactic biopsy of microcalcifications and constitutes a valid alternative to current systems.

Doughnut mastopexy lumpectomy versus standard lumpectomy in breast cancer surgery: A prospective study

AIMS

Doughnut mastopexy lumpectomy (DML) is a unique breast resection in which a tissue segment is removed and the breast reshaped through a periareolar incision. The present prospective investigation compares DML and standard lumpectomy (SL) in relation to surgical variables, histological parameters, postoperative morbidity and cosmetic outcome.

METHODS

127 patients with breast cancer were offered the choice between two conservative surgical approaches: doughnut mastopexy lumpectomy (DML group, n=39) or standard lumpectomy (SL group, n=88). The groups were comparable for radiological tumour size, tumour location within the breast, histological size, and pT category. Comparison was performed in term of surgical variables, histological parameters, postoperative morbidity and cosmetic outcome.

RESULTS

The patients undergoing DML were younger than the patients who chose SL. In the DML group, the skin incision was 3-fold longer than in the SL group but was obtained with a final scar located around the nipple areola complex without further postoperative complications. The average volume of the breast specimen was higher in the DML group compared with SL group. The clinician assessment of cosmetic outcome reported a higher rate of acceptable result in the DML group than in the SL group. However, patient's assessment did not show difference of cosmetic satisfaction between groups.

CONCLUSION

Our comparative study indicates that DML may be a useful alternative to SL not only in terms of accurate breast tissue resection but also in term of cosmetic results.

Application of immersed MF (IMF) followed by reverse osmosis (RO) membrane for wastewater reclamation: A case study in Malaysia

A pilot scale membrane plant was constructed and monitored in Shah Alam, Malaysia for municipal wastewater reclamation for industrial application purposes. The aim of this study was to verify its suitability under the local conditions and environmental constraints for secondary wastewater reclamation. Immersed-type crossflow microfiltration (IMF) was selected as the pretreatment step before reverse osmosis filtration. Secondary wastewater after chlorine contact tank was selected as feed water. The results indicated that the membrane system is capable of producing a filtrate meeting the requirements of both WHO drinking water standards and Malaysian Effluent Standard A. With the application of an automatic backwash process, IMF performed well in hydraulic performance with low fouling rate being achieved. The investigations showed also that chemical cleaning is still needed because of some irreversible fouling by microorganisms always remains. RO treatment with IMF pretreatment process was significantly applicable for wastewater reuse purposes and promised good hydraulic performance.

Policy and science of FMD control: the stakeholders' contribution to decision making. A call for integrated animal disease management

Effective control of foot-and-mouth disease (FMD)--prevention, surveillance and response--requires integrated animal disease management as a cooperative effort between stakeholders, scientists and decision makers, at all levels: local, national, regional and international. This paper suggests a process and outlines specific critical issues that need to be addressed in order to best use the science and technology that is available now and to develop new technologies that will lead to significant improvements. The overall objective is not to allow the disease or the disease control measures to damage, violate or destroy public health, the environment, or the economy, or to allow politics to drive disease control policies at the expense of the ethical relationship between man and animals. Critical issues of prevention, surveillance and response policies are examined, and specific recommendations are made to reduce the risk or effect of natural and deliberate introductions. For prevention: a) rapid portable diagnostics and provision of vaccines to control and eradicate the reservoirs of disease. b) alerts, leading to increased controls at borders, animal movement restrictions and biosecurity on farms. For surveillance: a) reporting of unusual symptoms, rapid diagnostics and identification of patterns. b) enhanced role of geographic information systems (GIS) linked to an IT system. c) collection, storage and sharing of disease information. For response policies: a) the role and implementation of stamping out and of vaccination. b) simulation exercises with stakeholder participation. For all aspects of FMD control, consideration should be given to: a) the composition, responsibilities and role of the balanced, permanently operational Expert Group in EU member states as specified in the EU FMD Directive. b) establishment of a balanced, permanently operational European Expert Group. c) establishment of both a European and an International FMD Task Force. Stakeholders need access to accurate, up-to-date, unbiased information about the science of disease control, how the technologies work and can be used, and an assurance that the technologies best fit for the required purpose will be used. Researchers need to work together to avoid duplications and gaps in their research and to recognise the benefit of new, and sometimes innovative, technologies. They also need feedback from stakeholders on the acceptability and best use of the technologies. A process to achieve these goals through an EU funded collaborative research project will be described.

Traitement conservateur des cancers du sein : zonectomie vs oncoplastie. Étude prospective à propos de 99 patientes

The integration of oncoplastic techniques with a concomitant contralateral symmetrization procedure is a novel surgical approach that allows wide excisions and prevents breast deformities.

AIM OF THE STUDY

This prospective study was undertaken to compare the accuracy of breast resection, between standard narrow lumpectomy and oncoplastic surgery.

PATIENTS AND METHODS

Ninety-nine consecutive women undergoing breast cancer resection were enrolled in a prospective study comparing oncoplastic surgery (42 women) and standard lumpectomy (57 women). The size of the glandular resection, the width of the nearest margins, the ratio of clear margins and the need for further surgery were recorded.

RESULTS

The oncoplastic approach resulted in significantly greater glandular resection and wider free histological margins than did standard lumpectomy. The need for re-exicsional surgery was significantly lower in the oncoplastic group than in the lumpectomy group. Furthermore, a trend towards fewer secondary mastectomies was seen for the oncoplastic approach versus standard lumpectomy.

CONCLUSIONS

The use of oncoplastic techniques and concomitant symmetrization of the contralateral breast allows extensive resections for conservative treatment of breast carcinoma achieves accurate tumour resection and reduces the need for further surgery.

Des cancers du sein sans signe en mammographie : quand et pourquoi ?

Breast carcinomas with false negative mammogram correspond to carcinomas diagnosed with means other than mammogram when the mammogram, at the time of diagnosis, showed no significant abnormality. The rate of false mammogram is difficult to ascertain because few studies have been published on this subject. The absence of mammographic abnormality is related to histopathological characteristics of the tumor and mammographic features of the patient's breast tissue. The small size of the tumor, the lack of microcalcifications often due to tumor necrosis and the absence of any significant associated desmoplastic reaction are the main histopathological factors encountered, particularly for dense breasts.

Pre-operative arterial embolisation of a uterine rhabdomyosarcoma in a 14-year-old girl

We report a young patient suffering from a uterine rhabdomyosarcoma. Particular features of the present case are: accuracy of the tumour spread evaluation performed by MRI of the pelvis; and the use of pre-operative arterial embolisation. The present multimodal management highlights the usefulness of cooperation between surgeons and radiologists in lowering operative bleeding and finally permitting uterine conservation.

[New regulation mechanisms of cell cycle shown by analysis of thyroid cell proliferation stimulated by TSH and cyclic AMP]

In thyroid gland, different tumor types are associated with the oncogenic activation of distinct mitogenic cascades, which are normally activated either by TSH via cAMP or by growth factors. In primary cultures of thyroid cells, the cAMP-dependent mitogenic pathway, which is associated with an increased differentiation expression, does not involve most of the intermediates of the classical signalling pathways of growth factors. Especially, we have shown that TSH and cAMP trigger and support cell cycle progression, but they do not upregulate D-type cyclins and they paradoxically increase the accumulation of the CDK inhibitor p27kip1. Instead, cAMP phosphorylates and inactivates pRb by inducing the assembly and nuclear translocation of the cyclin D3-CDK4-p27 holoenzyme, and then by stimulating the activating phosphorylation of CDK4 within this complex.

[HER2 gene amplification assay: is CISH an alternative to FISH?]

The HER2 proto-oncogene encodes a transmembrane protein, which is considered to function as a growth factor receptor. Overexpression of this protein found by immunohistochemistry in about 20% of infiltrating breast carcinomas, has a predictive value of response to treatment by trastuzumab, an anti-HER2 humanized monoclonal antibody. Search for HER2 gene amplification is necessary to adapt the immunohistochemical technique quality and also in the cases of delicate analysis or weak overexpression. It is usually carried out by Fluorescence In Situ Hybridization (FISH). A more recent hybridization technique, named CISH because of its chromogenic revelation is an alternative method, which gives highly correlated results with FISH. We present details of this technique, which may be more familiar for the pathologists than FISH, because reading analysis is similar to that of immunohistochemical staining.

[Therapeutic strategies in somatotroph adenomas with extrasellar extension: role of the medical approach, a consensus study of the French Acromegaly Registry]

From the first 198 patient files included into the French Acromegaly Registry, we analyzed 68 patients harboring a somatotroph adenoma with extrasellar extension, after exclusion of those treated by stereotactic or conventional radiotherapy. In these patients (including 37 women), aged 21-77 yr. (45.7 +/- 13.3), GH concentrations ranged from 2-260 microg/L (38.6 +/- 44.3), and IGF I from 86-967% of age-matched upper limit of normal (303 +/- 164). Maximal diameter of the adenoma at MRI was 11-36.5 mm (20.4 +/- 6.5), with cavernous sinus involvement in 68% of cases. Three subgroups were defined: 20 patients treated by long-acting somatostatin analogs only (group M), for a mean duration of 3 yr. (extremes 1-7 yr.), 48 patients initially treated by transsphenoidal surgery (group C), of whom 21 were secondarily treated by long-acting somatostatin analogs (group CM) for a mean duration of 1.2 yr. (extremes 0.2-2 yr.). All 3 groups were not statistically different in terms of tumor mass and initial levels of GH and IGF-1. Patients from group M were significantly older than those of the other groups (p<0.05).

RESULTS

46% of patients from group C after surgery vs. 45% of patients from group M had a mean GH below 2.5 microg/L. Biochemical remission (GH<2.5 microg/L and normal IGF1 normal) was obtained in 31% of cases in group C, vs. 25% in group M. In this group, a decrease of the largest tumor diameter was observed in 10 patients (71.5%), ranging from 10-25% in 7 (50%) and exceeded 50% in 3 (21.5%). In group CM, the biochemical remission rate (42%) and final GH or IGF1 values were not significantly different from group M. In conclusion, these data suggest that surgery or long-acting somatostatin analogs have a comparable efficacy in terms of remission rates in somatotroph macroadenomas with extrasellar extensions.

[Pilot study and preliminary validation of the French version of a quality-of-life questionnaire specific for subjects with growth hormone deficiency]

This study forms part of a research project seeking to develop a standardized questionnaire by which clinicians can assess the impact of growth hormone (GH) deficiency and its treatment on the "perceived health" or health-related quality of life of adults. The specific aim of this study was to translate and adapt for French patients the AGHDA (Adult Growth Hormone Deficiency Assessment) a standardized health-related quality of life measure for use with GH-deficient adults, initially developed in the United Kingdom, and to collect data which could be used to assess the main psychometric characteristics of its French version the ISPA-HC (Indicateur de Santé Perceptuelle Adulte-Hormone de Croissance). The main properties analyzed are: 1/ The scale's acceptability, as determined by means of face-to-face interviews with a small number of subjects, then by an ad hoc questionnaire administered during a test-retest study; 2/ The scale's reliability, as determined by a test-retest study (with a 15-days interval between tests); 3/ The scale's concurrent validity, as expressed by comparison with scores obtained by means of a generic quality of life scale, the ISPN (the French version of the Nottingham Health Profile). The results of this first trial with the ISPA-HC are conforming to what one can expect from a good instrument. The ISPA-HC has been shown to have very good levels of reliability and internal consistency. Its scores show a close correlation with those of the ISPN (the French version of the Nottingham Health Profile). This instrument can be used to measure variations in the perceived health of subjects with growth hormone deficiency. Its responsiveness to change is to be examined in subsequent studies.

Calibration of immunohistochemistry for assessment of HER2 in breast cancer: results of the French multicentre GEFPICS study

AIMS

HER2 protein is over-expressed in 15-30% of breast carcinomas. Immunohistochemistry (IHC) is a common and inexpensive method able to specifically detect HER2 protein. However, lack of standardization of IHC has been considered responsible for discrepancies in HER2 status assessment performed by IHC and fluorescence in-situ hybridization (FISH). This prompted us to perform a multicentric IHC calibration test to achieve a maximum accuracy of HER2-IHC compared with HER2-FISH taken as the reference method.

METHODS AND RESULTS

Twelve French laboratories participated in this study, including 119 cases of invasive breast carcinomas for which both fixed and frozen tissues were available. HER2 expression was determined in fixed tissues by individual in-house IHC techniques, using either CB11 (Novocastra, Newcastle, UK) or A0485 (Dako, Glostrup, Denmark) anti-HER2 antibodies. Two cut-off values were used: 10% and 60% of immunostained cells. In 116 of the 119 cases, HER2 gene status could also be determined by FISH on frozen sections, performed in a single laboratory. Results were centralized and compared. When suboptimal concordance between IHC and FISH was observed, IHC was calibrated and a second run was performed. The specificity, sensitivity and accuracy of IHC compared with FISH were noted before and after calibration. Forty-four out of 116 (38%) tumours showed HER2 gene amplification. Accuracy of IHC was complete in the first run for 6/12 laboratories. Calibration, necessary for the six others, relied mainly on the combination of a heat-induced epitope retrieval step with an increase of dilution of the primary antibody. In the second run, HER2 over-expression was found in 46 (40%) and 44 (38%) of the 116 cases, using 10% or 60% of stained cells as cut-offs, respectively. The corresponding accuracy rates were 93% and 95%.

CONCLUSIONS

This study showed that a high accuracy of IHC could be obtained for the determination of HER2 status in all laboratories using their in-house IHC technique, provided that a calibration process was performed. Antigen retrieval procedure, high dilutions of anti-HER2 antibody and the use of specific controls were crucial for HER2-IHC calibration. A 95% accuracy rate of IHC, using FISH as gold standard, was obtained by considering immunolabelling HER2-IHC results as a continuous variable, and taking 60% invasive stained cells as the cut-off for HER2 over-expression.

Mannose-6-phosphate/insulin-like growth factor-II receptor expression levels during the progression from normal human mammary tissue to invasive breast carcinomas

The putative role of mannose-6-phosphate/insulin-like growth factor-II receptor (M6P/IGFII-R) as a tumour suppressor and its value as a prognostic marker of breast cancer was studied in 42 benign breast diseases (BBD), 61 in situ carcinomas (CIS) and 133 invasive carcinomas. The receptor was quantified by immunohistochemistry with a computerised image analyser, using specific polyclonal IGY antibodies. The M6P/IGFII-R level varied markedly according to the different patient samples, but median values and distributions were similar in lesions and normal adjacent glands. However, the receptor level was significantly increased in high-grade ductal carcinomas in situ (DCIS) and decreased in invasive carcinomas relative to adjacent normal tissue. The M6P/IGFII-R protein concentration in invasive breast carcinomas was mostly independent of prognostic parameters: tumour size, histological grade, lymph node (N) invasiveness and oestrogen receptor alpha (ERalpha) status. The only positive correlation was with cathepsin D, the progesterone receptor (PgR) and with patients aged >60 years. These results do not support the hypothesis of a frequent and early inactivation of the M6P/IGFII-R gene in breast cancer. Clinical follow-up of patients might reveal a prognostic value for one of the cathepsin receptors.