Management of Pericardial Effusion in Patients With Solid Tumor: An Algorithmic, Multidisciplinary Approach Results in Reduced Mortality After Paradoxical Hemodynamic Instability

OBJECTIVE

This study compared outcomes in patients with solid tumor treated for pericardial effusion with surgical drainage versus interventional radiology (IR) percutaneous drainage and compared incidence of paradoxical hemodynamic instability (PHI) between cohorts.

BACKGROUND

Patients with advanced-stage solid malignancies may develop large pericardial effusions requiring intervention. PHI is a fatal and underreported complication that occurs following pericardial effusion drainage.

METHODS

Clinical characteristics and outcomes were compared between patients with solid tumors who underwent s urgical drainage or IR percutaneous drainage for pericardial effusion from 2010 to 2020.

RESULTS

Among 447 patients, 243 were treated with surgical drainage, of which 27 (11%) developed PHI, compared with 7 of 204 patients (3%) who were treated with IR percutaneous drainage ( P =0.002); overall incidence of PHI decreased during the study period. Rates of reintervention (30-day: 1% vs 4%; 90-day: 4% vs 6%, P =0.7) and mortality (30-day: 21% vs 17%, P =0.3; 90-day: 39% vs 37%, P =0.7) were not different between patients treated with surgical drainage and IR percutaneous drainage. For both interventions, OS was shorter among patients with PHI than among patients without PHI (surgical drainage, median [95% confidence interval] OS, 0.89 mo [0.33-2.1] vs 6.5 mo [5.0-8.9], P <0.001; IR percutaneous drainage, 3.7 mo [0.23-6.8] vs 5.0 mo [4.0-8.1], P =0.044).

CONCLUSIONS

With a coordinated multidisciplinary approach focusing on prompt clinical and echocardiographic evaluation, triage with bias toward IR percutaneous drainage than surgical drainage and postintervention intensive care resulted in lower incidence of PHI and improved outcomes.

Point-of-care Ultrasound (POCUS) Program for Critical Care Nurse Practitioners and Physician Assistants in an Oncological Intensive Care Unit and Rapid Response Team

ABSTRACT

Implementation of a comprehensive point-of-care ultrasound (POCUS) program for nurse practitioners (NPs) and physician assistants (PAs) in an intensive care unit (ICU) setting improves their diagnostic and therapeutic skills and enhances patient care. Overcoming staffing, IT infrastructure, and administrative challenges has allowed our critical care medicine service to develop a successful program that empowers NPs and PAs and boosts their professional growth. Our POCUS program underscores the necessity of institutional support, dedicated mentorship, collaboration with qualified faculty, and creation and maintenance of a curriculum that adheres to accepted national guidelines. Insights gained from our experiences can serve as a valuable resource for institutions aiming to develop their own POCUS programs.

A Rapid Response Team (RRT) System at a Cancer Center: Innovative Approaches to System Organization and Clinical RRT Pathways

The Rapid Response Team (RRT) system at Memorial Sloan Kettering Cancer Center led by critical care medicine (CCM) advanced practice providers (APPs) expanded exponentially between 2009 and 2021. CCM-APPs are trained for care of critically ill patients as well as to oversee rapid response calls. The RRT is composed of a CCM-based RRT-APP, respiratory therapist, RRT-RN, and nursing supervisor. Since program inception, 11 RRT pathways and interventions have been developed and adjusted to improve multidisciplinary patient management. Pathways vary in complexity and require multidisciplinary collaboration. In some circumstances, the RRT patient may require transfer to outside facilities for services not provided at our oncology-based facility. RRT data are tracked across the hospital continuum with on-line reporting through RRT website dashboards. 2021 RRT data on electronic sepsis alerts, behavioral RRT and stroke alerts are presented. The RRT program is monitored through robust quality assurance. The APP-led RRT system's scope of care has been continuously expanded through the creation of RRT pathways to meet the increasingly complex medical needs of our patients.

QLTI-11. IMPROVING ACUTE STROKE RESPONSE AT A COMPREHENSIVE CANCER CENTER: A MULTIDISCIPLINARY HOSPITAL-BASED QUALITY IMPROVEMENT PROJECT

BACKGROUND

Stroke is common in patients with malignancy, but cancer patients in treatment have contraindications to intravenous (IV) tissue plasminogen activator (tPA). Advancements in endovascular therapy (EVT) has expanded options for acute stroke management . Memorial Sloan Kettering (MSK) is a cancer center without a public emergency room. Acute stroke management occurs inpatient or in urgent care center (UCC). We determined a need for rapid identification and management for acute strokes in our patient population.

METHODS

We developed a multidisciplinary Acute Stroke Pathway relying on activation of our hospital’s rapid response team (RRT), neurology, radiology, nursing support, patient escort services, and pharmacy. We initiated hospital-wide education around stroke symptoms and the pathway. All stroke activations are reviewed by Neurology bi-weekly for real-time feedback. Metrics include the times of symptom identification (“door time” = UCC check in or symptom discovery for inpatients), evaluation, head computed tomography (CT), labs, and administration of IV tPA. Times are compared to our 2016 institutional baseline data and National Institute of Neurological Disorders and Stroke (NINDS) benchmarks.

RESULTS

Since implementation of the pathway (6/11/2018) through Q1 2022 (3/31/2022), there were 551 acute stroke activations, 13 IV tPA administrations, and 48 patients transferred to a comprehensive stroke center for consideration for EVT. Average 2021 door-to-evaluation time: 8 mins (baseline: 18 mins, NINDS: 10 mins), door-to-stroke team: 11 mins (baseline: unknown, NINDS: 15 mins), door-to-CT: 33 mins (Baseline: 95 mins, NINDS: 25min), door-to-CT interpretation: 34 mins (baseline: 251 mins, NINDS: 45 mins), door-to-labs: 50 mins (baseline: unknown, NINDS: 45 min), door-to-IV tPA: 62 mins (baseline: unknown, NINDS: 60min).

DISCUSSION

The patient population at MSK is distinct from most hospitals. Patients with cancer have a higher incidence of stroke but are unlikely candidates for intervention. Inter-professional collaboration resulted in early stroke care in oncology patients consistent with NINDS benchmarks.

Evaluation of the GeneQuence® DNA Hybridization Method in Conjunction with 24-Hour Enrichment Protocols for Detection of Salmonella spp. in Select Foods: Collaborative Study

A multilaboratory study was conducted to compare performance of the GeneQuence® DNA hybridization (DNAH) method incorporating new 24 h enrichment protocols and reference culture procedures for detection of Salmonella spp. in select foods. Six food types (raw ground turkey, raw ground beef, dried whole egg, milk chocolate, walnuts, and dry pet food) were tested by the DNAH method and by the culture methods of either the U.S. Department of Agriculture-Food Safety and Inspection Service (USDA-FSIS) or the U.S. Food and Drug Administration's Bacteriological Analytical Manual (FDA/BAM). Fifteen laboratories participated in the study. Four of the foods tested (raw ground turkey, dried whole egg, milk chocolate, and dry pet food), showed no statistically significant differences in performance between the DNAH method and the reference procedure as determined by Chi square analysis. Sensitivity rates for the DNAH method ranged from 92 to 100. The DNAH method, with the specific enrichment protocol evaluated, was found to be ineffective for detection of Salmonella spp. in walnuts. For raw ground beef, results from one trial showed a statistically significant difference in performance, with more positives obtained by the reference method. However, evidence suggests that the difference in the number of positives was likely due to lack of homogeneity of the test samples rather than to DNAH method performance.

Abstract ES7-3: Indications for radiation treatments after neoadjuvant chemotherapy while awaiting the results of clinical trials

Using systemic therapy prior to surgery has become an accepted standard for patients with lymph node-positive disease at presentation. Studies demonstrate that this approach can eradicate the disease in lymph nodes prior to local-regional interventions. This occurs particularly frequently for patients with HER2/neu-positive disease and to a relevant degree for those with triple negative disease. Patients with an excellent pathological response to treatment have improved outcomes compared to those with extensive residual disease. However, it is less clear whether local-regional therapies can be diminished or omitted in patients with an excellent pathological response. Accordingly, such questions are currently being investigated in phase III clinical trials.

Unfortunately, local-regional therapeutic trials require long-term outcome data, particularly for the endpoints of distant disease control and overall survival. Therefore, the ongoing studies addressing whether regional lymph node radiation can be omitted in selected patients after neoadjuvant chemotherapy will not provide clinically useful information in the near term. This is unfortunate because such questions arise with a high degree of frequency in oncology practices. This topic has also become increasingly important because completed clinical trials indicate that regional lymph node radiation combined with treatment of the chest wall/breast improves the outcome of patients with pathologically positive lymph node(s) and who are treated with surgery first followed by adjuvant systemic therapy.

While the sequencing of chemotherapy and surgery does not affect the risk of local-regional recurrence for populations of patients, it does affect an individual patient's risk. For example, patients with clinically stage II, lymph node-positive disease (who do not receive radiation) will have lower risk of local-regional recurrence if they achieve a pathological complete response to neoadjuvant chemotherapy compared to those with residual positive lymph nodes. This is also true for patients with clinical stage III disease, although patients with locally advance breast cancer have a high enough risk for local recurrence even with a complete pathological response to warrant adjuvant radiation.

Based on the data outlined above, the current standard outside the setting of clinical protocols is to recommend regional lymph node radiation with chest wall/breast radiation for all patients with residual positive lymph nodes after neoadjuvant chemotherapy and all patients who present with clinically stage III disease.

For patients with stage II disease who achieve a pathological complete response, the available evidence suggests that their predicted local regional recurrence risk without regional or postmastectomy radiation is 10% or less. Therefore the benefit from radiation is likely low and it is reasonable weigh out these small potential benefits in the context of associated treatment morbidities and costs. It is also important to further consider additional local-regional risk factors such as patient age, tumor biology, plans for prolonged systemic therapies, and other pathological factors at presentation in making radiation treatment decisions for such patients.

Citation Format: Buchholz T. Indications for radiation treatments after neoadjuvant chemotherapy while awaiting the results of clinical trials [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr ES7-3.

Survival of women with inflammatory breast cancer: a large population-based study

BACKGROUND

Our group has previously reported that women with inflammatory breast cancer (IBC) continue to have worse outcome compared with those with non-IBC. We undertook this population-based study to see if there have been improvements in survival among women with stage III IBC, over time.

PATIENT AND METHODS

We searched the Surveillance, Epidemiology and End Results Registry to identify female patients diagnosed with stage III IBC between 1990 and 2010. Patients were divided into four groups according to year of diagnosis: 1990-1995, 1996-2000, 2001-2005, and 2006-2010. Breast cancer-specific survival (BCSS) was estimated using the Kaplan-Meier method and compared across groups using the log-rank test. Cox models were then fit to determine the association of year of diagnosis and BCSS after adjusting for patient and tumor characteristics.

RESULTS

A total of 7679 patients with IBC were identified of whom 1084 patients (14.1%) were diagnosed between 1990 and 1995, 1614 patients (21.0%) between 1996 and 2000, 2683 patients (34.9%) between 2001 and 2005, and 2298 patients (29.9%) between 2006 and 2010. The 2-year BCSS for the whole cohort was 71%. Two-year BCSS were 62%, 67%, 72%, and 76% for patients diagnosed between 1990-1995, 1996-2000, 2001-2005, and 2006-2010, respectively (P < 0.0001). In the multivariable analysis, increasing year of diagnosis (modeled as a continuous variable) was associated with decreasing risks of death from breast cancer (HR = 0.98, 95% confidence interval 0.97-0.99, P < 0.0001).

CONCLUSION

There has been a significant improvement in survival of patients diagnosed with IBC over a two-decade time span in this large population-based study. This suggests that therapeutic strategies researched and evolved in the context of non-IBC have also had a positive impact in women with IBC.

Clinical Data Do Not Support the Hypothesis That Irradiation Promotes Biologically Aggressive Local Recurrences through Stromal Activation

Objective: Recent data in select pre-clinical models suggest that radiation can activate normal stroma to promote tumor metastases and aggressiveness. We hypothesized that if these were occurring clinically, there would be a lower survival after locoregional recurrence (LRR) in patients after post-mastectomy radiation therapy (PMRT) compared to mastectomy (Mx) alone. This study used two independent datasets to compare survival after LRR in women treated with versus without PMRT.Methods: Data from 229 of 1,505 patients who experienced LRR after treatment on sequential non-randomized institutional prospective trials at the MD Anderson Cancer Center (MDA) and 66 of 318 patients enrolled in the British Columbia (BC) PMRT randomized trial who experienced LRR were analyzed. All patients underwent Mx and level I/II axillary dissection. In both data sets analysis was based on treatment received. Patients from MDA received doxorubicin based chemotherapy +/- PMRT, with 45 LRR after PMRT and 184 LRR after Mx alone). Patients treated on the BC trial received CMF chemotherapy +/- PMRT, with LRR in 14/160 after PMRT versus 52/158 after Mx alone. Survival was calculated from time of LRR to death using Kaplan-Meier and log rank statistics.Results:MDA Data: Median follow up of living patients was 192 months. Analyzing data from all patients with LRR regardless of distant metastasis (DM), patients with LRR after PMRT were younger (47 vs. 51 y, p = 0.033) and had shorter time to first LRR (40mo vs. 51 mo, p = 0.018). 5-yr/10-yr OS were 31%/16% without PMRT and 20%/7% after PMRT (p = 0.008). However, PMRT-treated patients had increased risk factors for DM (advanced T and N stage) and more PMRT-treated patients developed DM prior to LRR (58% vs. 36% p = 0.009). Analyzing only patients without DM there was no difference in OS between groups (p = 0.67), and a separate analysis of all patients who developed metastatic disease (N = 385 no PMRT, 233 after PMRT) revealed no difference in 5 or 10-yr OS after DR (15%/4% without PMRT vs. 13%/6% after PMRT, p = 0.5).BC Data: Median follow up of living patients was 235 months. The distributions of age, T stage, N stage, grade, LVI, ER status, excised nodes and nodal ratio were similar between patients with LRR after Mx alone vs. Mx plus PMRT. (all p &gt; 0.05). The mean time to first LRR was 39 mo in patients treated with Mx alone and 57 mo in patients treated with PMRT, p= 0.27). The rate of DM was similar in patients with LRR after Mx with vs without PMRT (93% vs. 96%, p=0.60). Distant relapse free survival after LRR was similar in Mx alone vs. PMRT-treated patients (log rank p=0.75). Overall survival was also similar in the two groups (5-yr/10-yr OS 21%/8% without PMRT vs. 23%/12% with PMRT, log rank p=0.93).Conclusions: Decades of randomized data have demonstrated that PMRT reduces LRR and improves overall survival. In the non-randomized dataset, removing the competing risk of DM which is higher in patients selected for PMRT by studying patients with isolated LRR, we find no difference in survival after LRR in the PMRT setting. Analysis of the randomized PMRT trial dataset confirmed the finding of similar survival among women with LRR irrespective of PMRT use.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4101.

Brain Metastases in Women with Inflammatory Breast Cancer (IBC): Incidence, Treatment and Outcome

Background: Brain metastases are an uncommon metastatic recurrence site in breast cancer with a median incidence of approximately 6% in unselected populations. Inflammatory breast cancer (IBC) is an aggressive disease associated with dismal outcome. The purpose of this study was to determine the incidence of and survival following brain metastases among women with IBC.Material and Methods: Two hundred and six women with newly diagnosed stage III or IV IBC diagnosed between the period of between 2003 and 2008 were identified in a prospectively maintained IBC database at the MD Anderson Cancer Center. Cumulative incidence of brain metastases was computed. Cox proportional hazards models were fitted to explore factors that predict for the development of brain metastases. Survival was computed using the Kaplan-Meier product limit method.Results: Median follow-up was 20 months. Eighty three (40.3%) women had de-novo stage IV disease and 123 (59.7%) had stage III disease at diagnosis. Thirty-three (16%) patients developed brain metastases with a cumulative incidence at 1 and 3 years of 2.7% and 22% respectively. Eleven (5.3%) patients developed brain metastases as the first site of recurrence with cumulative incidence at 1 and 3 years of 1.6% and 6.7% respectively. In the multivariable model, no specific factor was observed to be significantly associated with time to brain metastases, including HER-2 status. Median overall survival for the whole cohort was not reached. 3-year overall survival for the whole cohort was 78% (95% CI 69%-86%). Median survival following a diagnosis of brain metastases for all women who developed brain metastases or those who developed brain metastases as the first site of recurrence was 6 months.Conclusion: In this single-institutional study, women with IBC demonstrated a high early incidence of brain metastases associated with poor survival. As such IBC may be an ideal cohort to target screening procedures for brain metastases and/or enrollment of these women in clinical trials evaluating additional adjuvant preventive strategies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2102.

Value of adjuvant radiation therapy in breast cancer patients with one to three positive lymph nodes undergoing a modified radical mastectomy and systemic therapy

507

Background: Whether adjuvant radiation therapy should be utilized for patients (pts) with early stage breast cancer with up to 3 positive axillary lymph nodes treated with mastectomy and systemic therapy is controversial. This retrospective study was performed to determine if adjuvant radiation therapy had an impact on survival for this cohort of pts. Methods: 4240 pts with T1–2N0–1 breast cancers, diagnosed between 1980–2007, who underwent either mastectomy without adjuvant radiation therapy or segmental mastectomy with adjuvant radiation therapy were identified. All pts received systemic treatment. Women with >3 positive axillary lymph nodes were excluded. Overall (OS) and distant disease free survival (DDFS) were estimated using the Kaplan-Meir product method. Cox proportional hazards were used to determine associations between OS/DDFS and type of surgery after controlling for pt and disease characteristics. Results: 1336 (18.8%) had T1N0 disease, 1114 (26.27%) had T2N0 disease, 989 (23.33%) had T1N1 disease and 801 (18.89%) had T2N1 disease. Median follow-up was 54 months.5- year DDFS among women who underwent mastectomy and segmental mastectomy was 81% (95% 78%-83%) and 86% (95% CI 84%-87%), respectively (p < 0.0001). In the Cox analysis, pts who had mastectomy without radiation had a significantly increased risk of distant recurrence (HR= 1.39, 95% CI 1.14–1.70, p= 0.0013) than pts treated with segmental mastectomy and radiation. When looking at subgroups, no significant difference in DDFS was observed between the two groups in pts with lymph node negative disease. However, for pts with 1–3 positive lymph nodes, pts treated with mastectomy without radiation had significantly increased risk of distant recurrence compared to pts treated with segmental mastectomy with radiation (HR=1.614, 95% CI 1.198–2.177, p= 0.002). This difference was most pronounce in the subset of patients with T2N1 disease (HR= 1.794, 95% CI 1.220–2.637, p=0.003). Similar trends were observed for OS. Conclusions: This study provides provocative evidence for benefit of radiation therapy among pts with 1–3 positive axillary lymph nodes who are treated with surgery and systemic therapy.

No significant financial relationships to disclose.

Local-regional recurrence with and without radiation after neoadjuvant chemotherapy and mastectomy for T3N0 breast cancer patients

Abstract #74

Purpose: The goal of this study was to compare the local-regional recurrence (LRR) risk in patients with clinical T3N0 breast cancer who were treated with neoadjuvant chemotherapy (NeoChemo) and mastectomy (Mastx) according to the use of adjuvant radiation (RT).&#x2028; Methods: Clinicopathologic data from 164 patients with clinical T3N0 breast cancer who received NeoChemo and Mastx from 1985 to 2004 were retrospectively reviewed. In this cohort, 121 (74%) patients received adjuvant radiation (RT) while 43 (26%) patients did not. The median number of axillary lymph nodes (LN) dissected was 15. After NeoChemo, 54% of patients (n=89) had no pathologically involved lymph nodes at the time of surgery (ypLN-) while 46% (n=75) had at least 1 lymph node pathologically positive (ypLN+). Actuarial rates were calculated using Kaplan-Meier analysis and compared using log-rank test. Cox proportional hazards models were fit to determine the association of RT with the risk of LRR after adjustment for other patient and disease characteristics.&#x2028; Results: At a median follow-up of 77 months, 17 of the 164 patients had a LRR. For all patients, the 5-year local-regional control rates (5-yr LRC) were 90%. The 5-yr LRC for those who received RT (n=121) was 95% and for those who did not received RT (n=43) was 76% (p = 0.002), with a higher proportion of the patients who received RT having pathologically involved LN (+RT 53% vs –RT 23%, p=0.002).&#x2028; Among the entire cohort, the 5-yr LRC was 85% for patients with ypLN+ disease and 94% for patients with ypLN- disease (p=0.093). In patients with ypLN+, the 5-yr LRC with no RT (n=11) was 47% and with RT (n=64) was 92% (p&lt;0.001). In patients with ypLN-, the 5-yr LRC with no RT (n=32) was 86% and with RT (n=57) was 98% (p=0.063). Patients who had tumors with high nuclear grade had worse 5-yr LRC (Grade low 100%, intermediate 97%, high 81%, p=0.023). The presence of lymphovascular invasion, close/positive margin, or estrogen receptor status did not statistically correlate with LRC. In a Cox regression model, patients with tumor exhibiting high nuclear grade (Hazard Ratio (HR) 5.0, 95% Confidence Interval (CI) 1.6-15.4), ypLN+ (HR 6.6, 95% CI 2.0-22.1) and no adjuvant RT (HR 7.6, 95% CI 2.4-24.0) had increased risk of LRR.&#x2028; Conclusions: Post mastectomy adjuvant RT appears to improve LRC in clinical T3N0 breast cancer patients treated with neoadjuvant chemotherapy and mastectomy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 74.

Trastuzumab treatment and the risk of central nervous system (CNS) metastases

1018

Background: In the era of trastuzumab, HER2-positive breast cancer confers an increased risk of central nervous system (CNS) metastases. While several studies have examined CNS metastases in trastuzumab-treated patients, data are sparse regarding CNS metastases in trastuzumab-naïve HER2-positive patients. We evaluated time to CNS metastasis, death, and death subsequent to brain metastasis in relation to trastuzumab treatment. Methods: The study population included 750 patients diagnosed with HER2-positive metastatic breast cancer (HER2+ MBC) between June 1977 and January 2006. The association between trastuzumab treatment and the outcomes of time to CNS metastasis and time to death following CNS metastasis were determined using Cox proportional hazards models that included trastuzumab treatment as a time-dependent covariate. Multivariable Cox proportional hazards models were fit to determine the association between trastuzumab treatment and outcomes after adjustment for known prognostic factors. Patients with HER2+ MBC treated at our institution before trastuzumab was available served as our control group. Results: Of the 750 patients included, 689 patients received trastuzumab during the follow-up period while 61 patients were not treated with trastuzumab. Median follow-up was 32 months. A total of 251 patients developed CNS metastases. After adjusting for other prognostic variables including age, ER status, PR status, pathological stage, and site of initial metastasis, patients who received trastuzumab had 2.84 times the risk of CNS metastases (95 % CI = 1.87, 4.30, p < 0.0001) compared to patients who did not receive trastuzumab. Time to death following brain metastasis did not differ significantly between trastuzumab- treated and -untreated patients. Conclusions: In our large series, patients with HER2+ MBC treated with trastuzumab were at significantly increased risk of developing CNS metastases compared to patients who did not receive trastuzumab. This finding warrants further investigation into biological mechanisms that may account for this difference.

No significant financial relationships to disclose.

Polymorphisms in the ACE and PAI-1 genes are associated with recurrent spontaneous miscarriages

BACKGROUND

Successful pregnancies require fine tuning of fibrinolytic activities in order to secure fibrin polymerization and stabilization of the placental basal plate as well as to prevent excess fibrin deposition in placental vessels and intervillous spaces. Fibrinolysis is tightly regulated by plasminogen activator inhibitor-1 (PAI-1). Endothelial PAI-1 synthesis is induced by angiotensin II, which is generated by angiotensin I-converting enzyme (ACE).

METHODS

We studied the ACE deletion (D)/insertion (I) polymorphism and the PAI-1 4G/5G polymorphism in women with recurrent spontaneous miscarriages (RM). Both polymorphisms have been shown to be associated with ACE and PAI-1 expression levels respectively. A study group of 184 patients with a history of two or more consecutive unexplained spontaneous miscarriages was compared with a control group of 127 patients with uneventful term deliveries and no history of miscarriages.

RESULTS

Our findings show: (i) homozygosity for the D allele of the ACE gene, which results in elevated PAI-1 concentrations and hypofibrinolysis, is associated with an elevated risk of RM; (ii) the combination of the D/D genotype with two 4G alleles of the PAI-1 promoter, which further increases PAI-1 plasma levels, is significantly more frequent in RM patients compared with controls.

CONCLUSIONS

Based on these results, we recommend the incorporation of these two polymorphisms into the spectrum of thrombophilic mutations which should be analysed in individuals with recurrent spontaneous miscarriages. Patients homozygous for both the ACE D and PAI-1 4G alleles may benefit from the application of low molecular weight heparin as early as possible in the pregnancy in order to prevent uteroplacental microthromboses.

Noncontact, laser-mediated extraction of polar bodies for prefertilization genetic diagnosis

PURPOSE

We tested an entirely noncontact polar body-extraction method using an ultraviolet laser beam for laser zona drilling and a near infrared laser beam for polar body (PB) trapping and extraction.

METHODS

A hole was drilled into the zona pellucida of an oocyte. Then, the PB was trapped with optical tweezers and dragged through the drilled hole.

RESULTS

Bovine first PBs could be extracted in 49 out of 63 oocytes (78%) using this method. In human oocytes, PB extraction was successfully demonstrated, which however was more time consuming. A number of extracted PBs were dried on a special membrane, circumcised with the laser microbeam, and successfully catapulted into the lid of a microfuge tube (laser pressure catapulting).

CONCLUSIONS

This solely laser-mediated extraction method allows convenient procurement of PBs without the danger of contamination and is a promising approach that might replace standard micromanipulation methods in the future.

Thrombophilic gene mutations and recurrent spontaneous abortion: prothrombin mutation increases the risk in the first trimester

PROBLEM

Thrombophilic predisposition may be one of the underlying causes of recurrent spontaneous abortions (RSA). We studied the prevalence of five thrombophilic gene mutations in patients with RSA.

METHOD OF STUDY

102 patients with two or more consecutive abortions and 128 women without miscarriage were analyzed for factor V Leiden mutation (FVL), prothrombin G20210A mutation (PTM), C677T mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene, glycoprotein IIIa (GPIIIa) C1565T polymorphism, and beta-fibrinogen G-455A polymorphism by polymerase chain reaction (PCR) techniques.

RESULTS

No differences in the prevalence of FVL, MTHFR T/T, GPIIIa and 1-fibrinogen polymorphism were detected. Heterozygous PTM occurred more often in patients with RSA. This effect was significant in a subgroup with abortions exclusively in the first trimester (6.7%, vs. 0.8%, P = 0.027, OR 8.5).

CONCLUSIONS

In contrast to the other mutations and polymorphisms, heterozygous PTM is more common in patients with abortions in the first trimester. This might reflect an influence of PTM on pathogenesis of early pregnancy loss.

Laser microdissection as a new approach to prefertilization genetic diagnosis

The genetic status of oocytes can be determined by polar body (PB) analysis. Following PB extraction, a genetic evaluation is performed. As each PB contains the complementary genetic material of the oocyte, PB analysis reveals information about its genetic status. Genetically altered oocytes may then be excluded from in vitro fertilization. The aim of our study was to evaluate laser microdissection as a tool for PB extraction purposes. Compared to the PB extraction with a sharp-ending pipette only, we could show that laser microdissection of the zona pellucida (laser zona drilling) with a UV-A laser and subsequent extraction with a blunt-ending pipette decreases the degeneration rate of oocytes. It is shown that laser pressure catapulting of extracted PB enables their contact-free transfer into tubes, thus decreasing the risk of contamination for further analysis.

Comprehensive methylation analysis in typical and atypical PWS and AS patients with normal biparental chromosomes 15

Imprinting defects in 15q11-q13 are a rare but significant cause of Prader-Willi syndrome (PWS) and Angelman syndrome (AS). Patients with an imprinting defect have apparently normal chromosomes 15 of biparental origin, but are recognised by @parental DNA methylation at D15S63 (PW71) or SNURF-SNRPN exon 1. We have investigated the methylation status of five additional loci in 12 such patients with or without a deletion in the imprinting centre. In each patient, the imprinting defect affected all loci tested. During routine diagnostic testing we identified four patients who had a normal methylation pattern at SNURF-SNRPN exon 1, but an abnormal pattern at D15S63. In two of these patients, who were suspected of having PWS, this change was restricted to D15S63. In two patients suspected of having AS, several but not all loci were affected. Using a newly developed methylation-specific PCR test for D15S63 we found that these methylation changes are rare in patients suspected of having AS. Although we can not prove that the methylation changes in the four patients are causally related to their disease, our findings demonstrate that spatially restricted changes in methylation can occur. In some cases, these changes may reflect incomplete imprint spreading.

Clinical presentation of congenital sialidosis in a patient with a neuraminidase gene frameshift mutation

Congenital sialidosis is a rare lysosomal storage disease caused by a primary neuraminidase deficiency which results from defects in the neuraminidase gene on chromosome 6p. The inheritance is autosomal recessive. Patients exhibit excessive urinary excretion of bound sialic acid and decreased or undetectable amounts of neuraminidase activity in various tissues. The clinical expression is variable, but ascites and hepatosplenomegaly are hallmarks of the disease. Skeletal abnormalities, facial dysmorphism and inguinal herniae have been described in most of the few reported cases. We describe a baby girl with biochemically proven sialidosis, who in addition to the above clinical features, had severely dilated coronary arteries, excessive retinal vascular tortuosity and an erythematous, macular rash. Homozygosity for a frameshift mutation at residue 623 of the neuraminidase cDNA was found. We speculate that the additional features found in our patient might be associated with the here described genotype of congenital sialidosis.

CONCLUSION

Severely dilated coronary arteries, excessive retinal vascular tortuosity and an erythematous macular rash might be associated features of congenital sialidosis.

Presentation, management and outcome of axillary recurrence from breast cancer

BACKGROUND

The impact of axillary node dissection on breast cancer survival is unclear. Limited axillary surgery has been proposed but may increase regional recurrence rates. Optimal management for axillary recurrence is poorly understood.

METHODS

Axillary recurrences were initial treatment failure sites in 44 of 4,255 breast cancer patients (1%) seen at M.D. Anderson Cancer Center, 1982 to 1992.

RESULTS

Twenty-one patients (48%) had early stage disease (0, I, II) at diagnosis. With 70.8 months median follow-up, complete control of axillary recurrence was achieved in 31 patients (71%). Distant metastases developed in 50% and were more likely with uncontrolled axillary recurrences. Failure to receive multimodality therapy and failure to undergo surgery for the recurrence correlated with resistant axillary disease.

CONCLUSIONS

Axillary recurrence from breast cancer is uncommon but may follow any stage of disease. One half of affected patients develop distant metastases. Durable disease control is best achieved with multimodality therapy including a surgery component.

Characterization of the sialidase molecular defects in sialidosis patients suggests the structural organization of the lysosomal multienzyme complex

Sialidosis is an autosomal recessive disease caused by the genetic deficiency of lysosomal sialidase, which catalyzes the hydrolysis of sialoglycoconjugates. The disease is associated with progressive impaired vision, macular cherry-red spots and myoclonus (sialidosis type I) or with skeletal dysplasia, Hurler-like phenotype, dysostosis multiplex, mental retardation and hepatosplenomegaly (sialidosis type II). We have analyzed the genomic DNA from nine sialidosis patients of multiple ethnic origin in order to find mutations responsible for the enzyme deficiency. The activity of the identified variants was studied by transgenic expression. One patient had a frameshift mutation (G623delG deletion), which introduced a stop codon, truncating 113 amino acids. All others had missense mutations: G679G-->A (Gly227Arg), C893C-->T (Ala298Val), G203G-->T (Gly68Val), A544A-->G (Ser182Gly) C808C-->T (Leu270Phe) and G982G-->A (Gly328Ser). We have modeled the three-dimensional structure of sialidase based on the atomic coordinates of the homologous bacterial sialidases, located the positions of mutations and estimated their potential effect. This analysis showed that five mutations are clustered in one region on the surface of the sialidase molecule. These mutations dramatically reduce the enzyme activity and cause a rapid intralysosomal degradation of the expressed protein. We hypothesize that this region may be involved in the interface of sialidase binding with lysosomal cathepsin A and/or beta-galactosidase in their high-molecular-weight complex required for the expression of sialidase activity in the lysosome.

Evaluation of methylation analysis for diagnostic testing in 258 referrals suspected of Prader-Willi or Angelman syndromes

Prader-Willi syndrome (PWS) and Angelman syndrome (AS) are distinct neurodevelopmental disorders with interrelated genetic mechanisms because genomic imprinting within the chromosome 15q11-13 region affects both the PWS and the AS locus. Methylation analysis is one method of distinguishing between the maternally and paternally inherited chromosome 15. Here we present clinical and molecular data on a large series of 258 referred patients, evaluated with methylation analysis: 115 with suspected PWS and 143 with suspected AS. In these patients, the clinical phenotype was graded into three groups: classical (group 1); not classical but possible (group 2); not classical and unlikely (group 3). For PWS, a fourth group consisted of hypotonic babies. DNA methylation analysis confirmed the diagnosis of PWS in 30 patients (26%) and AS in 28 patients (20%). For 21 PWS patients the mechanism was established: 15 had deletions, 4 had uniparental disomy (UPD) and 2 a presumed imprinting defect. Clinically all those with an abnormal methylation pattern had the classical phenotype and none of those with a normal methylation pattern had classical PWS. For 23 AS patients in whom a mechanism was established, 17 had a deletion, 3 had UPD and 3 had a presumed imprinting defect. There was greater clinical overlap in AS, with 26 classical AS patients having a normal methylation pattern while an abnormal methylation pattern was seen in one patient from group 2. In addition, there were a further 40 patients with a normal methylation pattern in whom AS was still a possible diagnosis. Our conclusion is that methylation analysis provides an excellent screening test for both syndromes, providing approximately 99% diagnosis for PWS and for AS, a 75% diagnostic rate, supplemented for the remaining 25% with an essential basic starting point to further investigations.

Rett syndrome: significant clinical overlap with Angelman syndrome but not with methylation status

Rett syndrome and Angelman syndrome are neurodevelopmental disorders characterized by severe intellectual disability, microcephaly, speech disturbance, movement disorders with gait and/or truncal ataxia, and occasionally a similar facial appearance. Both conditions can be difficult to diagnose in girls early in their clinical course and can be difficult to distinguish from each other. Genomic imprinting is a known association in Angelman syndrome and previously has been suggested in Rett syndrome. Our aim was to evaluate the methylation status in a cohort of classical patients with Rett syndrome, using a methylation system for chromosome 15q11-13. Methylation analysis of chromosome 15 has not been previously reported in Rett syndrome. Furthermore, we document the clinical features of 31 girls with classical Rett syndrome and confirm the phenotypic similarities between Rett syndrome and Angelman syndrome. The methylation studies in these girls with Rett syndrome were normal. This excludes an imprinting error of the Angelman syndrome critical region on chromosome 15 (15q11-13) as an association with Rett syndrome, and indicates that methylation studies may be useful in distinguishing Rett syndrome from Angelman syndrome in young patients with an overlapping clinical phenotype. A normal methylation pattern, however, does not exclude the diagnosis of Angelman syndrome and clear distinction between the two syndromes will evolve over time.

Sporadic imprinting defects in Prader-Willi syndrome and Angelman syndrome: implications for imprint-switch models, genetic counseling, and prenatal diagnosis

The Prader-Willi syndrome (PWS) and the Angelman syndrome (AS) are caused by the loss of function of imprinted genes in proximal 15q. In approximately 2%-4% of patients, this loss of function is due to an imprinting defect. In some cases, the imprinting defect is the result of a parental imprint-switch failure caused by a microdeletion of the imprinting center (IC). Here we describe the molecular analysis of 13 PWS patients and 17 AS patients who have an imprinting defect but no IC deletion. Heteroduplex and partial sequence analysis did not reveal any point mutations of the known IC elements, either. Interestingly, all of these patients represent sporadic cases, and some share the paternal (PWS) or the maternal (AS) 15q11-q13 haplotype with an unaffected sib. In each of five PWS patients informative for the grandparental origin of the incorrectly imprinted chromosome region and four cases described elsewhere, the maternally imprinted paternal chromosome region was inherited from the paternal grandmother. This suggests that the grandmaternal imprint was not erased in the father's germ line. In seven informative AS patients reported here and in three previously reported patients, the paternally imprinted maternal chromosome region was inherited from either the maternal grandfather or the maternal grandmother. The latter finding is not compatible with an imprint-switch failure, but it suggests that a paternal imprint developed either in the maternal germ line or postzygotically. We conclude (1) that the incorrect imprint in non-IC-deletion cases is the result of a spontaneous prezygotic or postzygotic error, (2) that these cases have a low recurrence risk, and (3) that the paternal imprint may be the default imprint.

Manifestations in institutionalised adults with Angelman syndrome due to deletion

Undiagnosed institutionalised patients were reviewed in an attempt to identify those with Angelman syndrome (AS). The aim was to test these patients for deletion of chromosome 15(q11-13) and to describe the adult phenotype. The selection criteria included severe intellectual disability, ataxic or hypermotoric limb movements, lack of speech, a "happy" demeanour, epilepsy, and facial appearance consistent with the diagnosis. Patients were examined, medical records perused, and patients' doctors contacted as required. Genetic tests performed included routine cytogenetics, DNA methylation analysis (with probe PW71B), and fluorescence in situ hybridisation (with probes D15S10, GABRbeta3, or SNRPN). A deletion in the AS region was detected in 11 patients (9 males and 2 females) of 22 tested. The mean age at last review (March 1996) was 31.5 years (range 24 to 36 years). Clinical assessment documented findings of large mouth and jaw with deep set eyes, and microcephaly in nine patients (two having a large head size for height). No patient was hypopigmented; 1/11 patients was fair. Outbursts of laughter occurred in all patients but infrequently in 7/11 (64%) and a constant happy demeanour was present in 5/11 (46%). All had epilepsy, with improvement in 5/11 (46%), no change in 4 (36%), and deterioration in 2 (18%). The EEG was abnormal in 10/10 patients. Ocular abnormalities were reported in 3/8 patients (37.5%) and 4/11 (36%) had developed kyphosis. Two had never walked. All nine who walked were ataxic with an awkward, clumsy, heavy, and/or lilting gait. No patient had a single word of speech but one patient could use sign language for two needs (food and drink). Our data support the concept that AS resulting from deletion is a severe neurological syndrome in adulthood. The diagnosis in adults may not be straightforward as some manifestations change with age. Kyphosis and keratoconus are two problems of older patients.

Molecular analysis of an extra inv dup(15)(q13) chromosome in two patients with Angelman syndrome

Angelman syndrome (AS) is caused by the loss of function of yet unidentified gene(s) which map within 15q 11-13 and show monoallelic expression from the maternal allele. Lack of the maternal allele(s), due to either a deletion on the maternal chromosome 15 (about 70% of AS patients) or a paternal uniparental disomy (UPD)15 (<5%), are the most common molecular defects in AS. Prader-Willi syndrome (PWS) also maps to proximal 15q, but is caused by the loss of function of paternally expressed gen(s) [1]. Here we describe clinical, cytogenetic and molecular data for two non-related patients with AS who carry a nonmosaic extra cromosome inv dup(15).

DNA, FISH and complementation studies in ICF syndrome: DNA hypomethylation of repetitive and single copy loci and evidence for a trans acting factor

ICF syndrome (ICFS) is a rare immunodeficiency disorder characterized by instability of the pericentromeric heterochromatin predominantly of chromosomes 1 and 16. DNA methylation studies in two unrelated ICFS patients provide further evidence for a marked hypomethylation of satellite 2 DNA. The ICFS-specific disturbances of chromatin structure take place within the satellite 2 DNA regions, as demonstrated by fluorescence in situ hybridization analysis. Moreover, methylation studies of genomic imprinted loci D15S63, D15S9, and H19 have revealed hypomethylation to different degrees in both patients; this provides evidence for hypomethylation at autosomal single copy loci in ICFS. Cell fusion experiments have revealed a distinct reduction of chromosomal abnormalities in ICFS cells after fusion with normal cells, suggesting that the abnormalities are caused by the loss of function of an as yet unknown trans acting factor. Although it is now clear that wide-spread DNA hypomethylation is a characteristic feature of ICFS, neither the cause and mechanism of hypomethylation nor their relationship to the clinical symptoms is known. We speculate that a phenotypic effect might result from tissue-dependent abnormal gene expression and/or from a possible structural disturbance of DNA domains, which, with respect to the immunodeficiency, partially prevents the normal somatic recombinations in immunologically active cells.

Erythropoietin response to anemia as a function of age

The erythropoietin (EPO) response to anemia was assessed for 244 subjects aged 1-64 years (mean 45.2 years) and 121 subjects aged 65-94 years (mean 68.3 years). Subjects included non-anemic individuals as well as those with anemia of various etiologies, excluding renal disease and pregnancy. Significant inverse correlations between serum immunoreactive EPO and hematocrit were noted for both groups. Regression lines failed to show a significantly lower slope or y-intercept for older compared to younger subjects. EPO levels were not significantly lower for older compared to younger subjects when controlled for hematocrit level. These results suggest that the EPO response to anemia in older subjects is similar to that of younger subjects.