Molecular Profiling in Thyroid cancer- Using next generation sequencing to differentiate rare cases of papillary thyroid hyperplasia from papillary thyroid carcinoma

Introduction/Objective

Differentiating papillary thyroid hyperplasia from papillary thyroid carcinoma is made primarily on differences in key histologic and cytomorphologic features. These include architectural features such as invasion and nuclear changes such as chromatin pallor, nuclear grooves, and intranuclear pseudoinclusions. Distinguishing between these two diagnoses is not always straightforward in a minority of cases, as papillary thyroid hyperplasia nodules can be misinterpreted as papillary thyroid carcinoma and vice versa. This is because the nuclear changes can be subtle and be induced artificially by poor or inadequate formalin fixation. Immunostains such as cytokeratin 19 (CK19), galectin-3, and HBME1 may be used to distinguish between papillary thyroid hyperplastic nodules and papillary thyroid carcinoma; however, as immunostaining results are not always definitive, other more definitive ancillary tests are sometimes utilized such as molecular testing.

Methods/Case Report

Thyroid cases with indeterminate diagnoses (n=6) were obtained from the archives. Such cases included papillary thyroid hyperplasia and cases with descriptive diagnoses such as well-differentiated encapsulated and low-grade papillary carcinoma. Five cases of definitive papillary thyroid carcinoma and one case of follicular thyroid carcinoma (n=6) were used as a comparison group. Next generation sequencing (NGS) assays were performed using a custom SLIMamp targeted DNA solid tumor panel (Pillar Biosciences) and a targeted multi gene RNA fusion panel (Invitae).

Results (if a Case Study enter NA)

All of the definitive cases of papillary thyroid carcinoma showed characteristic mutations such as BRAF V600E as well as RNA fusions such as RET/PTC while all of the indeterminate cases did not show any detectable DNA mutations or RNA fusions, confirming their benign nature. A separate case that was signed out as non-invasive follicular thyroid neoplasm with papillary-like nuclear features showed an NRAS Q61R mutation and a novel ETV1-ERG fusion.

Conclusion

This study demonstrates the utility of molecular testing as an adjunct to histopathological evaluation in definitive diagnosis and differentiation of papillary thyroid hyperplasia from papillary carcinoma. Next generation sequencing with targeted DNA and RNA panels will be beneficial for both known and novel variant or fusion detection in suspect cases.

The efficacy of unilateral laparoscopic nephrectomy in the pediatric hypertensive patient

BACKGROUND

Secondary hypertension due to a poorly functioning or non-functional kidney may be refractory to medical management. In such cases, nephrectomy can improve or cure hypertension. With the routine use of laparoscopy, nephrectomy can be performed in a minimally invasive manner, but surgery still carries inherent risks and complications.

OBJECTIVE

The objective of this study is to evaluate the outcomes of laparoscopic nephrectomy performed for secondary hypertension and identify potential predictors of postoperative hypertension resolution.

METHODS

After obtaining approval from institutional review board, patients from January 2002 to March 2018 who underwent laparoscopic nephrectomy were identified using Current Procedural Technology codes. All charts were then manually reviewed to isolate those patients with secondary hypertension present preoperatively. Patient demographics, urologic history, and laboratory and imaging findings were recorded for all patients. Serial blood pressures were recorded at all renal visits along with any antihypertensive medication changes. Postoperative outcomes and complications were also noted for all patients.

RESULTS

A total of 20 patients (7 girls, 13 boys) underwent laparoscopic nephrectomy to treat hypertension at an average age of 10.6 years (range 1.7-17.0 years). Etiology of a solitary non-functional kidney was vesicoureteral reflux in 10 of 20 patients, multicystic dysplastic kidney in 5 of 20, ureteropelvic junction obstruction in 2 of 20, ureteral obstruction in 1 of 20, and renal artery stenosis in 2 of 20 patients. At time of surgery, 3 of 20 patients were on two antihypertensives, 10 of 20 were on one antihypertensive, and 7 of 20 proceeded to surgery with no medical management. In the 30-day postoperative period, no complications were noted. Hypertension improved in 10 of 20 (50%) patients, all of whom were not on any antihypertensive medications after surgery. Hypertension persisted in 4 of 20 (20%) patients, requiring the same antihypertensive regimen and worsened in 6 of 20 (30%) patients, requiring increased doses and/or additional antihypertensives. Average follow-up time was 2.7 years. No significant predictors of postoperative hypertension result were identified when comparing the groups of responders and non-responders.

DISCUSSION

While laparoscopic nephrectomy for a non-functioning kidney in the setting of hypertension is a safe procedure, the cure rate for hypertension in the cohort appears to be on the low side of what was previously reported. While the small sample size is a main limitation, it is among the largest sample sizes for pediatric hypertensive patients. Previously shown predictors were not predictive in the similar-sized cohort.

CONCLUSIONS

Patients should be carefully counseled on the risks and benefits of nephrectomy to treat hypertension, the importance of continued follow-up after nephrectomy, and the possible need for chronic medical management with antihypertensives.

Do pediatricians routinely perform genitourinary examinations during well-child visits? A review from a large tertiary pediatric hospital

BACKGROUND

The male genital examination is a common source of discomfort for the patient and medical provider. Performance of male genital examination is imperative; however, as many treatable diagnoses can be made. Undescended testicles (UDTs), hernias, testicular tumors, and urethral abnormalities are all potentially concerning findings which can be discovered on routine examination.

OBJECTIVE

The objectives of this study are to determine the rate at which general pediatricians perform routine genitourinary (GU) examinations in the pediatric population and to determine the rate at which UDT are diagnosed or documented in the patient's history. The authors hypothesize the rate of pediatric GU examination during routine well-child visits to be in line with the previously reported rates in the adult literature.

STUDY DESIGN

Nine hundred ninety-six consecutive male well-child visits conducted by general pediatricians at the study institution were reviewed. These visits were evaluated for documentation of a detailed GU examination as well as the presence of UDT from these examinations. In addition, past medical and surgical histories were reviewed to determine if a diagnosis of UDT was noted.

RESULTS

Pediatricians at the study institution documented GU examinations 99.1% of the time during male well-child visits. Only 1.1% of the cohort had a documentation of UDT at any time point. Of the 11 patients with UDT, 6 boys (54.5%) had spontaneous descent with no referral to urology, whereas 5 (45.5%) required orchidopexy.

DISCUSSION

Prior reports suggest 70-75% of routine office visits include a genital examination. None of these reports reviewed the pediatric population, thus making this review novel in this respect. In addition, the results are vastly different from these prior studies as the authors demonstrated over 99% of male well-child examinations included documentation of a thorough genital examination. A limitation of the study is its retrospective nature, which creates a lack of standardization across the data set. In addition, without being physically present in the examination room, one cannot discern whether an examination is simply being documented without actual performance because of the template format of the electronic medical record (EMR). Furthermore, the study was not designed to best evaluate the true rate of UDTs; therefore, the reported rate of 1.1% cannot be accurately associated with a particular age at diagnosis.

CONCLUSIONS

Pediatricians do, in fact, document GU examinations on a routine basis. This finding cannot be taken with complete certainty as verification of actual examination performance is impractical. While the data demonstrated a lower than expected rate of UDT, depending upon age at diagnosis, this could indicate that although examinations are being documented, their accuracy may be diminished because of various factors at play in the healthcare system as a whole, including improper exam performance and EMR templates. Follow-up studies are required to verify these potentially changing rates of UDT and to determine if there is discordance between documentation and performance of GU examinations.

Layered acoustofluidic resonators for the simultaneous optical and acoustic characterisation of cavitation dynamics, microstreaming, and biological effects

The study of the effects of ultrasound-induced acoustic cavitation on biological structures is an active field in biomedical research. Of particular interest for therapeutic applications is the ability of oscillating microbubbles to promote both cellular and tissue membrane permeabilisation and to improve the distribution of therapeutic agents in tissue through extravasation and convective transport. The mechanisms that underpin the interaction between cavitating agents and tissues are, however, still poorly understood. One challenge is the practical difficulty involved in performing optical microscopy and acoustic emissions monitoring simultaneously in a biologically compatible environment. Here we present and characterise a microfluidic layered acoustic resonator (μLAR) developed for simultaneous ultrasound exposure, acoustic emissions monitoring, and microscopy of biological samples. The μLAR facilitates in vitro ultrasound experiments in which measurements of microbubble dynamics, microstreaming velocity fields, acoustic emissions, and cell-microbubble interactions can be performed simultaneously. The device and analyses presented provide a means of performing mechanistic in vitro studies that may benefit the design of predictable and effective cavitation-based ultrasound treatments.

Abstract P2-09-17: Evaluation of the oncomine comprehensive assay for the identification of actionable mutations for therapeutic stratification from the TEAM pathology cohort

Large-scale sequencing initiatives have revealed a wealth of common and novel variants as well as copy-number aberrations, across different malignancies. This growing list of variants/aberrations can sometimes be matched to specific therapeutics. Such “actionable mutations/changes” hold promise for personalized treatment in the future, with treatments tailored to molecular abnormalities. Presently, women with hormone positive early breast cancer continue to experience improved survival on adjuvant anti-hormone therapy, but a significant number of women continue to progress. Therefore, there is a need to identify those women for whom current therapies are insufficient and to identify alternative therapeutic interventions. We explored the used of genetic profiling using a comprehensive solid tumor next generation sequencing (NGS) assay (the Oncomine Comprehensive Assay, OCA) to characterize early invasive breast cancer. The OCA is based on the Ion Torrent™ NGS platform and Ion AmpliSeq™ library preparation technology, coupled to the Oncomine™ Knowledgebase, for target selection, variant calling, and data annotations. The OCA includes 87 genes for hotspot mutation detection, 48 genes for full length sequencing and 43 genes for focal copy number assessment. The OCA provides a standardized informatics workflow and quality control (QC) parameters to process samples in a translational clinical research setting. To explore the application of the OCA to early invasive breast cancers, we performed a retrospective pilot study in a subset of cases from the TEAM trial. From the TEAM pathology samples, 420 were chosen in a case-control fashion, 413 samples were analyzed, 388 samples passed standard QC metrics, and 254 samples (65%) were found to contain 368 variants with Oncomine Knowledgebase annotations. Briefly, variants of PIK3CA were most frequent at 42.7% (157/368), followed by TP53 at 27.2% (100/368), PTEN at 5.7% (21/368), BRCA2 at 3.8% (14/368), SF3B1 (12/368), AKT1 (11/368) and PTCH1 (11/368) at 3.3%, 3.0%, 3.0%; respectively. Other variants were detected in ATM, ERBB2, RB1, FGFR2, NF1, CDKN2A, PIK3R1 and others. Amongst the 43 genes assessed for copy-number, 23 showed copy-number changes across 132 samples totalling 167 CNVs. 256 samples showed no copy-number alterations in any of the genes on the panel. ERBB2 was most frequently altered at 28.1% (47/167), followed by FGFR1 at 23.4% (39/167), CCND1 at 15.0% (25/167) and MDM2 at 10.2% (17/167). Copy-number losses were identified in TP53, RB1, PTEN, BRCA2 at 0.6% each; as well as CDKN2A at 1.8% (3/167). Analytical validation of a subset of gene variants and copy-number changes will be presented in addition to the evidence of potential future application of the Oncomine Comprehensive Assay to precision oncology goals.

Citation Format: Bayani J, Crozier C, Quintayo MA, Amemiya Y, Zhang X, Larivière M, Sadis S, Smith JM, Hasenburg A, Kieback D, Markopoulos C, Dirix L, Yaffe M, Seth A, Feilotter H, Rea D, Bartlett JMS. Evaluation of the oncomine comprehensive assay for the identification of actionable mutations for therapeutic stratification from the TEAM pathology cohort [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 P2-09-17.

Infant crossed renal ectopia with UPJ obstruction repaired via robot-assisted laparoscopic pyeloplasty

INTRODUCTION

We present a robot-assisted approach to surgical treatment of UPJ obstruction associated with crossed renal ectopia in a male infant.

METHODS

A 31 year-old woman presented at 37 weeks gestation for prenatal hydronephrosis and delivered at 39 weeks. Renal ultrasound identified the bladder and right kidney in a crossed ectopic position in the left pelvis, and MRI showed the cystic lesion to be hydronephrosis associated with a ureteropelvic junction obstruction of the crossed ectopic right kidney. At three months of age, a robot-assisted laparoscopic dismembered pyeloplasty was performed. Post-operative renal ultrasounds at one, two, and 7 months showed persistent but decreasing hydronephrosis. He remains asymptomatic.

DISCUSSION

Crossed renal ectopia with associated ureteropelvic junction obstruction has been reported in the literature and managed using both open and minimally invasive approaches. To our knowledge, this is the first reported robot-assisted pyeloplasty performed for this condition in an infant.

CONCLUSIONS

With careful patient selection, the robot-assisted laparoscopic approach can be applied to infants that require pyeloplasty for kidneys with anomalous development that have evidence of ureteropelvic junction obstruction.

The heart of the matter: cardiac assessment in professional footballers

AIM

Sudden cardiac death is the leading medical cause of death during exercise.1 Our objective was to retrospectively analyse the routine cardiac assessment of professional footballers to aid physician management and improve player safety.

METHODS

Footballers from five professional clubs between March 2012 and October 2014 were included (n=265). All were performed in line with the recommendations of the Football Association Cardiology Committee, incorporating clinical examination, 12-lead ECG, echocardiography and health questionnaire.2 Data was retrospectively collected, inspected and analysed using Excel spreadsheets. Findings were classified as 'normal' or 'not normal', and not normal assessments were further broken down into 'clear-cut pathology' (pathology with widely accepted guidance on management) or 'grey screen'.

RESULTS

Footballers were aged 13 to 37 years, with 69% aged over 18 and 31% under. The majority of the review population was White European (66%). Of the review population 11% had 'not normal' assessments, of these assessments 83% were considered grey screens (by Consultant Cardiologist) requiring further investigation or surveillance. Overall clear-cut pathology was identified in 2%.

CONCLUSIONS

A high proportion of the players (9%) had grey screens. The majority of these were due to ECG or structural abnormalities, which are clinically challenging to differentiate from physiological adaptation of the athletic heart and potentially fatal conditions. The extent to which these findings put the athlete at risk of a life threatening cardiac event is un-?quantified. Team physician's need to be aware of managing the on-going risk with these patients and ensure suitable ?follow up and assessment on a regular basis to mitigate this.

Primitive neuroectodermal tumors of kidney: Our experience in a tertiary care center

OBJECTIVES

Primitive neuroectodermal tumors (PNET) are rare highly aggressive neoplasms. The diagnosis is made by histopathology with the support of immunohistochemistry (IHC) and cytogenetics. The aggressive multimodality treatment is recommended for the management of these tumors. The purpose of our study is to review our experiences in the diagnoses and treatment of PNET of the kidneys.

MATERIALS AND METHODS

We retrospectively reviewed the data of all the patients, who were treated for the PNET of the kidneys at our institute between April and March 2011 and compared with the available literature.

RESULTS

A total of eight patients were treated for PNET of the kidney. Out of the eight patients, four were males and four females. Nearly 50% of our patients had inferior vena caval thrombus at the time of presentation. The diagnosis was made on histopathology supported by IHC. Out of the eight patients, one patient had intraoperative death due to massive pulmonary thromboembolism and another died on the 7th post-operative day due to disseminated intravascular coagulation and multiorgan failure. Rest six patients were treated with post-operative chemotherapy or a combination of chemotherapy and radiotherapy. For these six patients, overall median survival was 45 months with a 3 year disease-free survival of 66% and 5 year survival of 44%.

CONCLUSIONS

PNET of the kidneys are rare peripheral neuroectodermal tumors with an aggressive clinical course. These tumors carry a very poor prognosis. An aggressive treatment approach using a combination of surgery, chemotherapy and radiotherapy is recommended for a reasonable survival in these tumors.

Abstract P1-05-27: Evaluation of the Oncomine focus and comprehensive assays for therapeutic stratification in early hormone receptor positive breast cancers

Large-scale sequencing initiatives have revealed a wealth of common and novel variants as well as copy-number aberrations, across different solid tumours and hematological malignancies. The growing list of variants/aberrations can sometimes be matched to specific therapeutics. Such “actionable mutations/changes” hold promise for personalized treatment, as treatments could be tailored to molecular abnormalities, rather than disease site. In breast cancer, women with hormone positive early breast cancer continue to experience improved survival on adjuvant anti-hormone therapy, but even today, a significant number of women continue to progress. Therefore there is not only a need to identify those women for whom current therapies are insufficient, but to identify alternative therapeutic interventions. The ThermoFisher Scientific Oncomine™ Focus and Oncomine™ Comprehensive Assays (OFA and OCA) are based on the Ion Torrent™ next-generation sequencing platform and Ion AmpliSeq™ library preparation technology, coupled to the Oncomine™ Knowledgebase, for target selection, variant calling, and data annotations. Both panels interrogate the most referenced oncology biomarker variants that are matched to curated published evidence from clinical trials supporting the matching of driver genetic variants with relevant potential clinical therapeutic options. The ability to identify SNVs, CNVs and fusion events in a single assay provides an unprecedented approach to maximizing the molecular information to be derived from a single tumour sample. To explore the value of the Oncomine™ assays in early invasive breast cancers, we have performed a pilot study to assess the reproducibility and accuracy of the OFA and OCA from nucleic acids extracted from formalin-fixed paraffin embedded tissues. In addition to the sequencing and copy-number data generated by these assays, we will compare these results to copy-number information generated using the Oncoscan® (Affymetrix)copy-number assay as well as information derived by Multiplex Ligation-dependent Probe Amplification-based panels (MRC-Holland) and Fluorescent in situ Hybridization (FISH). Our preliminary analyses of 35 invasive breast cancers by Oncoscan® identified the frequent whole chromosomal gains of 2, 3, 5, 7, 18, 19 and 20; gains of 1q, 7p, 8q, 11p, 16p, 17q; losses at 1p, 8p, 11q, 13, 16q, 17p and chromosome 18. High level amplifications were also identified for breast cancer related genes such as ERBB2, CCND1, MYC, FGFR1; in addition to the frequent losses of TP53, RB1, CDKN2A. Copy-number changes were confirmed by locus-specific FISH and MLPA. Data generated from the OFA and OCA from these same samples will be compared to the other platform findings and provide a snapshot of the mutational landscape of early breast cancers across these pan-cancer panels. Having established the robustness and accuracy of the assays, the applicability of the OCA in the context of improved stratification for breast cancers for prognostic and predictive tests will be discussed.

Citation Format: Bayani J, Crozier C, Zhang NX, Amemiya Y, Quintayo MA, Yan FJ, Dion D, Mccormack S, Yaffe M, Seth A, Feilotter H, Bartlett JMS. Evaluation of the Oncomine focus and comprehensive assays for therapeutic stratification in early hormone receptor positive breast cancers [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 P1-05-27.

Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma

INTRODUCTION

Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention.

MATERIALS AND METHODS

A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain.

RESULTS

One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P = 0.040) (Fig. A) and lacked ureteral opacification (P = 0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B).

CONCLUSIONS

Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.

Massive ossifying fibroma of the mandible in a child

An interesting case of large ossifying fibroma of the mandible in a child with a sickle-cell trait is reported.

How placement affects force and contact pressure between a volar plate of the distal radius and the flexor pollicus longus tendon: a biomechanical investigation

Open reduction and internal fixation of a distal radius fracture can leave a volar plate in close proximity or touching the tendons of the wrist. This cadaveric study examines the how volar plate position changes contact pressure and force against the flexor pollicis longus (FPL) tendon in multiple wrist extension positions. This study suggests that moving the plate from an ideal position (distal edge at the watershed line) to a malposition (5 mm distal to the watershed line) significantly increased the force by 72.7% and contact pressure by 33.5% on the FPL. Multiple clinical case reports have described rupture of the flexor tendons associated with distally positioned plates or protruding screw heads, creating prominent or sharp edges. This study illustrates that in order to minimize contact pressure on the flexor tendons, plating distal to the watershed line should be avoided when possible.

Thiazolidinediones (TZDs) affect osteoblast viability and biomarkers independently of the TZD effects on aromatase

Thiazolidinediones (TZDs) are insulin sensitizers used for treatment of diabetes. We have previously reported that TZDs reduce estrogen synthesis by inhibiting aromatase activity in human granulosa cells (HGC). Multiple clinical trials demonstrated that TZDs increase the risk of fractures in postmenopausal women with type 2 diabetes. We studied mouse osteoblasts alone or in a co-culture with HGC to determine whether TZD inhibition of aromatase plays a role in their effects on bone metabolism. Mouse osteoblasts were cultured with and without HGC, and incubated in a medium with or without testosterone, pioglitazone or rosiglitazone. Cell growth, oleic acid uptake, alkaline phosphatase activity, and osteocalcin production were measured. TZDs inhibited estradiol production by up to 84% in HGC/mouse osteoblast co-cultures. TZDs induced mouse osteoblast death and increased oleic acid uptake. TZDs also inhibited alkaline phosphatase activity (58-75%, p<0.046) and osteocalcin production (52-75%, p<0.031). For all the parameters, there were no significant differences between the osteoblast cultures alone and the HCG/osteoblast co-cultures. TZD effects on osteoblast viability, oleic acid uptake, alkaline phosphatase and osteocalcin production are independent of their effects on aromatase.

Cardiological Society of India practice guidelines for angiography in patients with renal dysfunction

PREAMBLE: The potential risk of contrast-induced acute kidney injury (CI-AKI) has made utilization of coronary angiography in the work-up for the diagnosis of coronary artery disease in CKD quite low.(1) This is in contrast to increasing prevalence and severity of CAD as the serum creatinine rises.(2) In fact most CKD patients will succumb to CAD and not to ESRD.(3) Thus the judicious use of CAG/PCI in this setting is of prime importance but underused. The CSI began to develop guidelines for Indian context as most guidelines are those developed by ACC/AHA or ESC. The aim was to assist the physicians in selecting the best management strategy for an individual patient under his care based on an expert committee who would review the current data and write the guidelines with relevance to the Indian context. The guidelines were developed initially in June 2010 as an initiative of Delhi CSI. Three interventional cardiologist (SB, AS, KKS), one nephrologist (SCT) and two clinical cardiologists (ST, RG) along with Dr. Roxana Mehran (New York) and Dr. Peter McCullough (Missouri), U.S.A.; were involved in a three-way teleconference to discuss/debate the data. This was presented by SB, and over the next two hours each data subset was debated/agreed/deleted and this resulted in the "Guidelines for CAG in Renal Dysfunction Patients". These were then written and re- circulated to all for final comments. Further, these guidelines were updated and additional Task Force Members nominated by Central CSI were involved in the formation of the final CSI Guidelines. Both (Roxana Mehran and Peter McCullough) reviewed these updated Guidelines in October 2012 and after incorporating the views of all the Task Force members-the final format is as it is presented in this final document.

Identification of differentially expressed genes in breast cancer

A number of genes differentially expressed in breast cancer were isolated using a subtractive cloning technique. DNA sequence analysis and GenBank searches of T4F10, T2H7, and T2E5 cDNA clones found them to be identical with E2A, MSS1, and SEC13R genes. Their expression in a variety of primary breast tumor and cancer cell lines was compared with c-ERB-B2 and pS2 by Northern blot analysis. In breast cancer cell lines, the genes that we isolated are more frequently expressed than the previously described c-ERB-B2 and pS2.

Pleiotropic functions of ETS-1 (Review)

ETS-1 is a cellular homologue of the viral ets oncogene of the E26 virus and functions as a sequence specific transcription factor. It plays an important role in cell proliferation, differentiation, lymphoid cell development, transformation, angiogenesis and apoptosis. ETS-1 may control the expression of critical genes involved in these processes by binding to ets binding sites present in their transcriptional regulatory regions. Recent progress in understanding the multiple functions of ETS-1 is summarized in this review.

Influence of nucleotides flanking the ggaa core sequence on ets1 and ets2 DNA-binding activity and the mechanism of ets1 autoregulation

The Ets family of genes encode nuclear proteins that activate transcription by binding to a specific purine-rich (GGAA) ets binding sequence (EBS) present in promoters/enhancers of various genes. We have previously shown that over-expression of ets1 via transfection of ets1 expression vectors into NIH3T3 cells induced the expression of the endogenous Ets1 gene. Here we report that the autoregulation occurs as a result of the ets1 protein binding to the EBS-core located in its own promoter. In the present study, we have also identified Ets binding sites in the IL-4, G-CSF (granulocyte colony stimulating factor), and the 2'5' OAS (oligoadenylate synthetase) promoters by binding with Ets1 and Ets2 proteins using electrophoretic mobility shift assays. Interestingly, we have found that the EBS containing T nucleotides on either side of the GGAA core sequence, does not bind Ets1 or Ets2 proteins. Our findings demonstrate that the sequences surrounding the purine core - GGAA- have a profound influence on the binding of Ets proteins.

Holocord Syrinx, Tethered Cord and Diastematomyelia: Case Report and Review of Literature

Syringomyelia refers to the presence of cavities within the spinal cord or a dilatation of the central spinal cord canal. In 90% of cases, syringomyelia is associated with a Chiari I malformation. The association of syringomyelia with tethered cord is well known but syrinxes associated with these defects are usually below vertebral level T6. Holocord syrinx associated with tethered cord is rare and is almost always associated with Chiari 1 malformation. To the best of our knowledge, only a single case report of holocord syrinx with tethered cord has been reported, but this patient had multiple overt lumbosacral defects (tethered cord, meningocele and diastematomyelia). We are reporting a three year old child with holocord syrinx with tethered cord and diastematomyelia and no evidence of Chiari malformation, meningocele or any overt spinal malformation and minimal neurological abnormalities. J Nepal Paediatr Soc 2012;32(2):169-171 doi: http://dx.doi.org/10.3126/jnps.v32i2.6098

Correlation between the preoperative serum prostate specific antigen, Gleason score, and clinical staging with pathological outcome following robot-assisted radical prostatectomy: an Indian experience

OBJECTIVES

To correlate the preoperative serum prostate specific antigen (PSA), Gleason score, and clinical staging with pathological outcome following robot-assisted radical prostatectomy (RARP) in Indian men with clinically localized cancer prostate.

MATERIALS AND METHODS

A prospective study analysis was done for 166 consecutive patients of prostate cancer who underwent RARP at our center from June 2006 to October 2009. Preoperative workup included serum PSA, biopsy Gleason score, and clinical staging. The preoperative parameters were correlated with final Gleason score, capsular penetration, seminal vesicle involvement, and lymph node status on final histopathology.

RESULTS

The mean age was 64 years (range: 50-76 years) with mean and median PSA of 17.98 ng/ml (range: 0.3-68.3 ng/ml) and 12.1 ng/ml, respectively. With increase in preoperative Gleason score, chance of organ confinement decreases (P=0.002) and capsular penetration increases (P=0.004) linearly. With increasing serum PSA, there is linear decrease in trend of organ-confined disease (P=0.03) and increased chances of seminal vesicle involvement (P=0.02). Patients with higher clinical stage have less probability of localized disease (P=0.007) and more chances of capsular penetration (P=0.04) and seminal vesicle involvement (P=0.004).

CONCLUSION

Our data suggest that patients with higher preoperative serum PSA, Gleason score, and clinical stage have more chances of advanced pathological stage following RARP.

Perioperative outcome of initial 190 cases of robot-assisted laparoscopic radical prostatectomy - A single-center experience

OBJECTIVE

To analyze the perioperative outcome of the first 190 cases of robot-assisted laparoscopic radical prostatectomy performed at our center from July 2006 to December 2010.

MATERIALS AND METHODS

Operative and recovery data for men with localized prostate cancer undergoing robot-assisted radical prostatectomy at our center were reviewed. All surgeries were performed using the 4-arm da Vinci-S surgical robot. Preoperative data included age, body mass index (BMI), prostate specific antigen (PSA) level, prostate weight, biopsy Gleason score and TNM staging, while operative and recovery data included total operative time, estimated blood loss, complications, hospital stay and catheter time. These parameters were evaluated for the safety and efficacy of this procedure in our center.

RESULTS

The mean age of our patients was 65 ± 1.2 years. The mean BMI was 25.20 ± 2.88 and the median PSA was 14.8 ng/ml. Majority of our patients belonged to clinical stage T2 (51.58%). The mean total operative time was 166.44 ± 11.5 min. Six patients required conversion to open procedure and there was one rectal injury. The median estimated blood loss was 302 ± 14.45 ml and the median duration of hospital stay was 4 days. The overall margin positivity rate was 12.63%.

CONCLUSION

Despite our limited robotic surgery experience, our perioperative outcome and complication rate is comparable to most contemporary series. Robot-assisted laparoscopic prostatectomy (RALP) is easy to learn and provides the patient with the benefits of minimally invasive surgery with minimal perioperative morbidity.

MicroRNAs in prostate cancer: from biomarkers to molecularly-based therapeutics

MicroRNAs (miRNAs) are effective regulators of gene expression that have a significant role in the pathogenesis of prostate and various other cancers. The high prevalence of aberrant miRNA expression in prostate cancer, and miRNAs' distinctive properties, give much hope that they can be used as biomarkers and next generation of molecular anticancer therapeutics. Herein, we review the literature on miRNA involvement in prostate cancer pathogenesis and the current understanding of their role as oncogenes, tumor suppressors and metastasis-regulators. We also review the latest research on miRNAs in prostate cancer preclinical studies and clinical trials, and highlight the advantages and challenges of possible miRNA-based therapies. The emerging information regarding the biology of miRNAs in prostate cancer is promising, and may lead to a role(s) for these molecules as diagnostic/prognostic markers and effective therapeutic tools for better molecularly targeted treatment of prostate cancer.

Continuous insulin infusion is associated with a reduced post-surgical length of stay, but not with the complication rate, in patients with diabetes mellitus undergoing coronary artery bypass graft

OBJECTIVE

To establish if glucose management with continuous intravenous insulin infusion (CII) in the early post-operative period after coronary artery bypass graft (CABG) surgery is associated with complication rate and length of hospital stay (LOS) in patients with diabetes mellitus (DM).

RESEARCH DESIGN AND METHODS

We reviewed the records of 587 patients with DM who underwent CABG from January 1999 until January 2008; 316 patients were placed on CII, while 271 patients were treated with subcutaneous insulin. We examined patient age, glycated hemoglobin (HgbA1c), 24- and 72-h post-operative average capillary blood glucose (CBG), length of stay (LOS), and the rate of complications.

RESULTS

There was no difference in HgbA1c between the groups. Mean CBG values at both 24 h and 72 h remained the same in the CII group (167 mg/dl), while in the non-CII group they were 194 mg/dl and 189 mg/dl, respectively (p<0.001 between the groups). Post-surgical median LOS was 6 days in the CII group and 6.5 days in the non-CII group (p=0.003). Complications occurred at similar rate (in 10% and 11% of patients) in the two groups.

CONCLUSIONS

CII is associated with a reduced post-surgical LOS in patients with DM who undergo CABG.

Open nephron-sparing surgery in renal tumors with normal contralateral kidney: A single centre experience of 8 years

Introduction:

We present our eight-year experience with open nephron-sparing surgery (NSS) in renal tumors with contralateral normal kidney to assess its oncological efficacy and safety.

Materials and Methods:

Thirty-six patients undergoing open NSS for small localized renal tumors with normal contralateral kidney from January 1998 to August 2006 were studied regarding demographic, clinical and pathological characteristics along with long-term follow-up.

Results:

The mean age was 48.28 ± 9.5 years. The mean tumor size was 3.72 cm (range 1.5-6). The following surgeries were performed: Wedge resection-13, partial polar nephrectomy-15, segmental resection-eight. The following techniques were used for vascular control: clamping and cooling-eight, warm ischemia-12, a novel technique of serial encirclage-16. The mean warm ischemia time was 23.2 ± 3.2 min. The mean operating time was 190.07 ± 11.3 min. The mean estimated blood loss was 331 ± 17.4 ml. The majority of renal tumors were renal cell carcinoma (97.22%). There were no positive surgical margins. There were no major intraoperative and postoperative complications. The mean follow up was 52.1 months (range 4-80) with no case showing progression to renal insufficiency (defined as serum creatinine > 2 mg/dl). There was only one local recurrence. However, four distant metastases were reported. The five-year cancer-specific survival, recurrence-free survival and overall survival were 94.4%, 88.88% and 86.11% respectively.

Conclusions:

In patients with solitary, small localized, unilateral renal tumors with normal contralateral kidney, elective open NSS is feasible, safe and provides excellent long-term local control and oncological efficacy with functional benefits.

Abstract P5-05-01: IGFBP-7 Reduces Growth of Xenografted Breast Tumors in Mice and Inhibits Breast Cancer Cell Proliferation and Migration through the MEK-ERK Pathway

To identify genes correlated with breast tumorigenesis and eventual metastasis, gene expression profiles were generated using 28K whole genome microarrays. Gene expression profiles of primary breast tumors that grew and metastasized in the NOD/SCID mice were compared with other primary breast tumors that had different growth and metastatic potentials. Five hundred and eighty two genes were significantly differentially expressed by our statistical comparison criteria using the GeneSpring GX 7.3.1 software suite. In the metastatic set eight genes were selectively overexpressed (YB1, MMP7, MMP9, RAB5A, RABGDIB, EPHRB3, WNT2B, CSF1R) and 12 were selectively underexpressed (IGFBP7, GATA3, CST5, CDK6, SERBP1, MGP, TGF1L4, ESE3, ELF3, EDNRB, HECTD1, TINP1). In the present study we focused on the IGFBP-7 gene product which was found to be inversely correlated with disease progression in breast cancer. To further investigate the role of IGFBP-7 in breast tumor suppression, it was overexpressed in the triple negative MDA-MB-468 human breast cancer line. Ectopic overexpression of IGFBP-7 clearly reduced the growth of the MDA-MB-468/IGFBP-7 cells compared to the parental MDA-MB-468 cells. Ectopic overexpression or addition of rIGFBP-7 to breast cancer cell lines in vitro clearly reduced the growth of several breast cancer cell lines and resulted in phenotypic changes characterized by cell aggregation. Investigation of downstream signalling pathways affected by IGFBP-7 revealed that addition of IGFBP-7 to a triple negative breast cancer cell line not only inhibited phosphorylation of ERK-1/2 but also increased expression of the cyclin-dependent kinase inhibitor 1, p21. Similar IGFBP-7 treatment of an ER+ breast cancer line resulted not only in inhibition of ERK-1/2 phosphorylation, but also AKT phosphorylation, suggesting that IGFBP-7 may affect multiple pathways in hormone responsive breast cancer cell lines. IGFBP-7 protein is processed into a shorter form by matriptase. Breast cancer cell lines which were unable to process IGFBP-7 into the shorter form were unaffected by IGFBP-7 mediated growth inhibition, suggesting that cleaved IGFBP-7 may be required for growth inhibitory effects. When injected subcutaneously into NOD/SCID mice, the increased expression of IGFBP-7 in the MDA-MB-468/IGFBP-7 cells reduced the rate of tumor growth in comparison to the parental MDA-MB-468 cells. Furthermore, injection of rIGFBP-7 protein at the tumor site into breast cancer xenografted NOD/SCID mice also resulted in significant tumor growth reduction. These results suggest that the growth of breast cancer could be prevented by the forced expression of IGFBP-7 protein. Work in progress will further uncover the mechanism of IGFBP-7-mediated inhibition on signalling pathways, as well as differentiate the impact of both full length and cleaved IGFBP-7 protein on breast tumor inhibition.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-05-01.

Renal tumors presentation: changing trends over two decades

PURPOSE

We have analyzed the changing trends in surgical treatment of renal tumors over the last 2 decades with regard to age incidence, presentation, incidental detection, and histopathology.

MATERIALS AND METHODS

Records of renal tumors were analyzed from January 1, 1988 to December 31, 2007. Data were split into 4 parts based on a 5-year time period, 1 for each cohort of patients: cohort 1 (1988-1992)-103 patients, cohort 2 (1993-1997)-161 patients, cohort 3 (1998-2002)-243 patients, and cohort 4 (2003-2007)-304 patients. A comparative study was performed with regard to age incidence, presentation, incidentallomas, histopathology, and management with statistical analysis.

RESULTS

Out of 811 renal tumors, 17.63% cases were benign and 82.37% were malignant. In the first cohort, 34.95% cases were detected in the seventh decade as compared with cohort 4 in which these were detected in the sixth (34.86%) and fifth decades (21.38%). Incidentallomas increased from 11 (10.67%) in cohort 1 to 84 (27.63%) in cohort 4 (P = 0.001). The cases of surgically treated tumors increased in number from 103 to 304 in cohort 4. Among the presenting features, incidence of weight loss, flank pain, and lump decreased while other clinical syndromes were constant. Only open radical nephrectomy was performed in the first 2 consecutive timeperiods. Laparoscopic radical nephrectomy was increasingly used in cohort 4 as compared with cohort 3 (121 vs 32, respectively). Similarly, open nephron sparing surgery (NSS) was increasingly used in cohort 4 as compared with cohort 3. Among the histopathologies, clear cell carcinoma was most common (73.35 %), but Fuhrman grading showed a trend toward more cases detected with grade 1 and 2 in cohort 4; 23.73% and 61.86%, respectively, as compared with 15.85% and 45.12% in cohort 1 (P = 0.001); more T1 tumors were detected (63.42% in cohort 4 as compared with 41.46% in cohort 1).

CONCLUSIONS

A majority of renal tumors presented as symptomatic tumors. Recently, tumors are being detected at an early stage and grade; in the younger patients, with an increasing trend of laparoscopic and open NSS.

Prostate cancer genes associated with TMPRSS2-ERG gene fusion and prognostic of biochemical recurrence in multiple cohorts

Background:

Recent studies have indicated that prostate cancer patients with the TMPRSS2–ERG gene fusion have a higher risk of recurrence. To identify markers associated with TMPRSS2–ERG fusion and prognostic of biochemical recurrence, we analysed a cohort of 139 men with prostate cancer for 502 molecular markers.

Methods:

RNA from radical prostatectomy tumour specimens was analysed using cDNA-mediated, annealing, selection, extension and ligation (DASL) to determine mRNAs associated with TMPRSS2–ERG T1/E4 fusion and prognostic of biochemical recurrence. Differentially expressed mRNAs in T1/E4-positive tumours were determined using significance analysis of microarrays (false discovery rate (FDR) <5%). Univariate and multivariate Cox regression determined genes, gene signatures and clinical factors prognostic of recurrence (P-value <0.05, log–rank test). Analysis of two prostate microarray studies (GSE1065 and GSE8402) validated the findings.

Results:

In the 139 patients from this study and from a 455-patient Swedish cohort, 15 genes in common were differentially regulated in T1/E4 fusion-positive tumours (FDR <0.05). The most significant mRNAs in both cohorts coded ERG. Nine genes were found prognostic of recurrence in this study and in a 596-patient Minnesota cohort. A molecular recurrence score was significant in prognosticating recurrence (P-value 0.000167) and remained significant in multivariate analysis of a mixed clinical model considering Gleason score and TMPRSS2–ERG fusion status.

Conclusions:

TMPRSS2–ERG T1/E4 fusion-positive tumours had differentially regulated mRNAs observed in multiple studies, the most significant one coded for ERG. Several mRNAs were consistently associated with biochemical recurrence and have potential clinical utility but will require further validation for successful translation.

A Randomized Controlled Multicenter Trial of a Nutritional Formula in Women with Mastalgia Associated with Fibrocystic Breast Changes

Objective: Nodularity is a problem for clinical and radiological evaluation of the breast. A randomized, controlled, double-blinded trial was performed in women with cyclic breast pain (mastalgia) associated with fibrocystic breast changes to determine the effect of a liquid nutritional formula on breast pain and nodularity.Study Design: Following a one month baseline assessment, women were randomly assigned to receive 4 ounces per day of an experimental (EXP) or control liquid nutritional formula (CONT) for three months. The EXP contained 1 gram of gamma linolenic acid (GLA) (as borage oil), 750 mcg of iodine (as potassium iodide), and 70 mcg of selenium (as sodium selenate). The CONT was an isonitrogenous, isocaloric formula prepared with high-oleic safflower oil in place of borage oil, and without additional GLA, iodine, or selenium. Women were asked to record breast pain, supplemental medications, and menstrual signs daily using an interactive voice-response system (IVRS). Physical breast exams were performed by a healthcare professional at baseline and at the end of the study for a determination of nodularity.Results: A total of 503 women were screened for eligibility from 21 centers distributed across the United States. From this group, 188 women were randomized to receive the EXP or CONT intervention. The groups were similar at baseline. Peak breast pain scores were reduced from baseline similarly in the EXP (-32.2%) and CONT (-33.1%) groups (p=0.64). Among women who continued to take non-prescription pain medication for management of breast pain, the amount of medication was significantly less in the EXP group (p=0.0143). In addition, there was a greater reduction in breast nodularity in women taking the EXP compared to the CONT (p=0.03 vs. p=0.64). Both groups reported similar average weight at baseline, but women in the EXP lost an average of 2.6 lbs. of body weight, while those in the CONT gained an average of 3.6 lbs by the end of the study. Both formulas were well tolerated and willingness to consume the nutritional intervention was 82.7% in the CONT and 90.4% in the EXP as calculated by the number of voluntary withdrawals from the study and discontinuation of treatment for any reason. Women were considered compliant if the consumed at least 70% of the study product (daily reported by IVRS).Conclusion: These results indicate that the daily liquid nutritional formula containing GLA, iodine, and selenium may provide a safe nutritional alternative for reducing both nodularity and nonprescription medication use associated with cyclic breast pain in women with fibrocystic breast changes. Reduction in nodularity may improve physician and mammographic evaluation of the breast.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5034.