P01.02.B Case Report: Disruption of Resting-State Networks and Cognitive Deficits After Whole Brain Irradiation for Singular Brain Metastasis

Background

Long-term survivors of whole brain radiation (WBRT) are at significant risk for developing cognitive deficits, but knowledge about the underlying pathophysiological mechanisms is limited. Therefore, we here report a rare case with a singular brain metastasis treated by resection and WBRT that survived for more than 10 years where we investigated the integrity of brain networks using resting-state functional MRI.

Material and Methods

A female patient with a left frontal non-small cell lung cancer (NSCLC) brain metastasis had resection and postoperative WBRT (30.0 in 3.0Gy fractions) and stayed free from brain metastasis recurrence for a follow-up period of 11 years. Structural magnetic resonance imaging (MRI) and amino acid [O-(2-[18F]fluoroethyl)-L-tyrosine] positron emission tomography (FET PET) were repeatedly acquired. At the last follow up, neurocognitive functions and resting-state functional connectivity (RSFC) using resting-state fMRI were assessed. Within-network and inter-network connectivity of seven resting-state networks were computed from a connectivity matrix. All measures were compared to a matched group of 10 female healthy subjects.

Results

At the 11-year follow-up, T2/FLAIR MR images of the patient showed extended regions of hyper-intensities covering mainly the white matter of the bilateral dorsal frontal and parietal lobes while sparing most of the temporal lobes. Compared to the healthy subjects, the patient performed significantly worse in all cognitive domains that included executive functions, attention and processing speed, while verbal working memory, verbal episodic memory, and visual working memory were left mostly unaffected. The connectivity matrix showed a heavily disturbed pattern with a widely distributed, scattered loss of RSFC. The within-network RSFC revealed a significant loss of connectivity within all seven networks where the dorsal attention and fronto-parietal

control networks were affected most severely. The inter-network RSFC was significantly reduced for the visual, somato-motor, and dorsal and ventral attention networks.

Conclusion

As demonstrated here in a patient with a metastatic NSCLC and long-term survival, WBRT may lead to extended white matter damage and cause severe disruption of the RSFC in multiple resting state networks. In consequence, executive functioning which is assumed to depend on the interaction of several networks may be severely impaired following WBRT apart from the well-recognized deficits in memory function.

Evaluate the safety and efficacy of dura sealant patch in reducing cerebrospinal fluid leakage following elective cranial surgery (ENCASE II): study protocol for a randomized, two-arm, multicenter trial

BACKGROUND

Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants.

METHODS

We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H₂O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control.

DISCUSSION

This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019.

P04.07 Correlation of 18F-fluorethyl-L-tyrosine (18F-FET) uptake in positron emission tomography (PET) and MRI growth rate in low-grade glioma

BACKGROUND

Low-grade gliomas (LGGs, WHO grade II) are a heterogeneous group of tumors of the central nervous system with diverse behavior in histopathology, genetics and growth patterns. Therefore, different therapeutic strategies are discussed ranging from watchful waiting to radical resection and adjuvant radio-/chemotherapy. For a better evaluation of tumor progression or malignant transformation, the O-(2-18F-fluoroethyl)-L-tyrosine (18F-FET) uptake in PET or the tumor growth rate assessed on MRI are used depending on the neurooncological center. Here, we correlated both methods.

MATERIAL AND METHODS

Inclusion criteria for this retrospective study were (1) newly diagnosed and neuropathologically confirmed low-grade glioma; (2) at least two MRIs at initial diagnosis and follow-up for calculation of the tumor growth rate (using IDS7 by Sectra AB, Sweden, 2018); (3) and an additional preoperative 18F-FET PET scan.

RESULTS

From 2008 to 2018, 34 patients were identified (mean age 39.7 years; 68% diffuse astrocytoma). The mean tumor growth rate on MRI was 0.091 cm3/d. The average mean 18F-FET uptake was 1.42; the average maximum 18F-FET uptake was 2.18. The Pearson correlation coefficient between the tumor growth rate and the mean and maximum 18F-FET uptake was r=0.19, and r=0.10. In the group of diffuse astrocytomas, the mean growth rate in tumors with a mean 18F-FET uptake of >1.5 was significantly higher than the mean growth rate of those with a mean 18F-FET uptake of ≤1.5 (p<0.1).

CONCLUSION

Data suggest that astrocytic LGGs with increased 18F-FET uptake may show a more aggressive behaviour, with a potentially higher risk for an earlier tumor progression or malignant transformation. For further elucidation of a correlation between the tumor growth rate and the 18F-FET uptake, larger prospective studies are needed. In the future, the combination of both methods in the management of low-grade gliomas could help to detect tumor progression as well as tumor malignization more precisely.

Abstract P3-04-01: Molecular determinants of post-mastectomy breast cancer recurrence

Introduction

The management of breast cancer (BC) patients who undergo mastectomy in the setting of 1-3 positive lymph nodes has been controversial. This retrospective Translational Breast Cancer Research Consortium study evaluated the molecular aberrations associated with locoregional recurrence (LRR) or distant metastasis (DM) compared to controls in an effort to identify molecular predictors associated with recurrence.

Methods/Materials

We identified 115 HER2 negative, therapy naïve, T 1-3 and N 0-1 BC patients treated with mastectomy and no post mastectomy radiation therapy from 1997 to present with available FFPE tissue blocks. The cohort included 32 patients with LRR, 34 with DM, and 49 controls (without recurrence) who were matched for stage, grade, hormone receptor status, age ≤ or &gt; 50, chemotherapy receipt, and margin status. Matched primary and recurrent LRR samples were available for 3 patients. Hybrid capture next generation sequencing (NGS) of 142 cancer related genes and RNAseq were performed to identify DNA/RNA alterations associated with LRR or DM. The frequency of common alterations on NGS was compared with Fisher's exact test. Expression of each gene from mRNA-Seq was treated as an explanatory variable. Immunohistochemistry (IHC) was performed for PTEN, Ki-67 and cleaved caspase 3 (CC3). PTEN loss and percentage of Ki-67 and CC3 positive cells were compared between groups with Fisher's exact test and nonparametric methods, respectively.

Results

RNAseq was performed on 115 patients; there was no difference in RNA expression levels between the groups. DNA analysis was performed on 57 patients (17 LRR, 15 DM and 25 controls), NF1 mutation rate was significantly elevated in both the LRR (24%) and DM (27%) samples compared to controls 0%; (p=0.0070). The mitogen activated protein kinase (MAPK) pathway was significantly mutated in both LRR (47%) and DM (40%) samples compared to the controls 0%; (p&lt;0.0001). There was no significant difference in the rate of alterations of the PI3K/Akt/mTOR pathway among the three groups. Of three patients with matched primary vs LRR samples, one had concordant mutations. The second patient had additional mutations in the LRR, including gain of a NF1 mutation. The third patient had complete discordance of mutations identified in primary and LRR and had gain of HER2 amplification, suggestive of a new primary. There was no significant association between the groups and the loss of PTEN expression or CC3 expression. There was a significant difference between Ki 67 positive cells in patients with LRR (mean 29%), DM (mean 26%) versus controls (mean 14%, p= 0.0011). HR+ patients were significantly more likely to have a positive PTEN, lower Ki-67 and lower CC3 expression, p=0.0004, p&lt;0.0001, and p&lt;0.0001 respectively.

Conclusions

In this matched cohort analysis, mutations in the MAPK pathway, specifically NF1, were associated with both LRR and DM, suggesting that alterations in this pathway are associated with a more aggressive tumor phenotype. However, there were no molecular features that discriminated between those likely to recur locally alone versus distantly. Further study is needed to validate these findings, and to determine whether targeting alterations in this pathway could decrease the risk of recurrence.

Citation Format: Keene KS, King T, Hwang ES, Peng B, McGuire K, Tapia C, Zhang H, Bae S, Nakhlis F, Klauber-Demore N, Meszoely I, Sabel MS, Willey SC, Eterovic KA, Hudis C, Wolff A, De Los Santos J, Thompson A, Mills GB, Meric-Bernstam F. Molecular determinants of post-mastectomy breast cancer recurrence [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 P3-04-01.

Elevated S100A8 protein expression in breast cancer cells and breast tumor stroma is prognostic of poor disease outcome

PURPOSE

Elevated S100A8 expression has been observed in cancers of the bladder, esophagus, colon, ovary, and breast. S100A8 is expressed by breast cancer cells as well as by infiltrating immune and myeloid cells. Here we investigate the association of elevated S100A8 protein expression in breast cancer cells and in breast tumor stroma with survival outcomes in a cohort of breast cancer patients.

PATIENTS AND METHODS

Tissue microarrays (TMA) were constructed from breast cancer specimens from 417 patients with stage I-III breast cancer treated at the University of Michigan Comprehensive Cancer Center between 2004 and 2006. Representative regions of non-necrotic tumor and distant normal tissue from each patient were used to construct the TMA. Automated quantitative immunofluorescence (AQUA) was used to measure S100A8 protein expression, and samples were scored for breast cancer cell and stromal S100A8 expression. S100A8 staining intensity was assessed as a continuous value and by exploratory dichotomous cutoffs. Associations between breast cancer cell and stromal S100A8 expression with disease-free survival and overall survival were determined using the Kaplan-Meier method and Cox proportional hazard models.

RESULTS

High breast cancer cell S100A8 protein expression (as indicated by AQUA scores), as a continuous measure, was a significant prognostic factor for OS [univariable hazard ratio (HR) 1.24, 95% confidence interval (CI) 1.00-1.55, p = 0.05] in this patient cohort. Exploratory analyses identified optimal S100A8 AQUA score cutoffs within the breast cancer cell and stromal compartments that significantly separated survival curves for the complete cohort. Elevated breast cancer cell and stromal S100A8 expression, indicated by higher S100A8 AQUA scores, significantly associates with poorer breast cancer outcomes, regardless of estrogen receptor status.

CONCLUSIONS

Elevated breast cancer cell and stromal S1008 protein expression are significant indicators of poorer outcomes in early stage breast cancer patients. Evaluation of S100A8 protein expression may provide additional prognostic information beyond traditional breast cancer prognostic biomarkers.

Abstract P4-12-13: High intratumoral and stromal S100A8 expression is prognostic of poor outcome in breast cancer

Background: S100A8 and S100A9 are members of a family of calcium binding proteins that regulate inflammatory response, and are biomarkers of inflammatory diseases, S100A8/A9 preferentially form heterodimers that interact with their receptor, RAGE, to activate signaling pathways (ERK1/2 MAPK, JNK, and NF-κB) and stimulate tumor cells. Elevated expression of S100A8/A9 has been observed in cancers of the bladder, esophagus, colon, ovary, and breast. S100A8/A9 are expressed intratumorally by cancer cells and in the stroma by infiltrating immune and myeloid cells as well. We investigated the associations of elevated expression of intratumoral and stromal S100A8 with survival outcomes in breast cancer.

Methods: Tissue microarrays (TMA) were constructed from breast cancer specimens from patients with stage I-III breast cancer treated at the University of Michigan Comprehensive Cancer Center between 2004-2006, ensuring a minimum of 10-year follow-up. Each patient was represented on the TMA by representative regions of non-necrotic tumor and distant normal tissue. Automative Quantitative Immunofluorescence (AQUA) was performed for S100A8 protein, and samples were scored for intratumoral and stromal S100A8 expression. S100A8 staining was assessed as a continuous value and by exploratory dichotomous cutoffs. Associations with disease-free survival (DFS) or overall survival (OS) and S100A8 expression, either as continuous value or based on the exploratory cutoffs, were determined using the Kaplan-Meier method and Cox proportional hazards models.

Results: In the entire patient cohort, high intratumoral S100A8 expression, as a continuous measure, was a significant prognostic factor for OS (univariable hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.02-1.56, p=0.036), and for DFS (multivariable HR [95%CI] = 1.24 [1.01-1.53], p = 0.043). Exploratory analyses demonstrated optimal cutoffs of intratumoral and intrastromal staining that greatly separated survival curves. We evaluated whether the prognostic significance of S100A8 expression is different in breast cancer patients based on hormone receptor status and determined that neither intratumoral nor stromal S100A8 expression were significantly associated with outcomes.

Conclusions: Elevated intratumoral and stromal expression of S100A8 are significant indicators of poor outcome in breast cancer patients. These data further support a biological role for S100A8 signaling in mammary carcinogenesis and aggressive tumor behavior. Evaluation of S100A8 protein expression might provide additional prognostic information beyond traditional breast cancer prognostic biomarkers. Further validation is necessary to investigate these findings.

Citation Format: Miller P, Kidwell K, Thomas D, Sabel M, Rae J, Hayes DF, Lippman ME, El-Ashry D. High intratumoral and stromal S100A8 expression is prognostic of poor outcome in breast cancer [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 P4-12-13.

Frozen sections in patients undergoing breast conserving surgery at a single ambulatory surgical center: 5 year experience

OBJECTIVES

To evaluate outcomes of our breast frozen section (FS) practice in its first 5 years, including our specialized FS of margins (FSM) procedure for breast conserving therapy (BCT) patients.

METHODS

One thousand two hundred and forty eight patients undergoing 1303 breast FSM and/or sentinel lymph node (SLN) FS were included. Clinicopathologic features were assessed by chart review.

RESULTS

Use of SLN FS declined, from 43.5% of FS cases before to 19.2% of FS cases after 2012. FSM patients had a decline in overall reexcision to 12.3% in 2013-2014 (p = 0.063). There was also decline in reexcision for focally close margins (p < 0.0001) but no change in reexcision for extensively close margins. Reexcision was significantly associated with lobular subtype, multifocality and larger (≥T2) size. False negative FSM cases were most often influenced by extensively close or positive final (reexcised) margins sent for permanent section only (96/148; 64.9%).

CONCLUSIONS

Despite changing surgical practices, FSM remains a valuable service that reduces reexcision in BCT patients.

The impact of improved treatment strategies on overall survival in glioblastoma patients

BACKGROUND

The introduction of ALA-Fluorescence-guided surgery (FGS) followed by concomitant radiochemotherapy according to the Stupp-protocol is representative of the major changes in glioblastoma therapy in the past years. We were interested in the impact of this new first-line treatment on the overall survival of patients suffering from newly diagnosed primary glioblastoma in a retrospective single-centre study.

METHOD

For this retrospective analysis, data was derived from a prospective single-centre database. Patients were divided into three treatment groups: A (FGS-/radiochemotherapy-), B (FGS-/radiochemotherapy+) and C (FGS+/radiochemotherapy+). Further stratification was applied regarding MGMT-methylation status and degree of resection. Statistical analysis was performed to determine factors (treatment regime, age, gender, performance status, MGMT promoter methylation status) significantly influencing overall survival (OAS).

RESULTS

Two hundred and fifty-three patients suffering from primary glioblastoma treated by cytoreductive surgery between 2002 and 2009 were included in this survey. Median OAS differed significantly between the treatment groups (A = 8.8, B = 16.6, C = 20.1, p < 0.01). Resection data was available in all 253 patients. The usage of FGS highly significantly correlated with a complete resection (p < 0.01). Complete resection was positively correlated with an increase in OAS (complete 20.3 months vs. incomplete 9.3 months, p < 0.01).

CONCLUSIONS

FGS and radiochemotherapy according to the Stupp protocol have induced an impressive improvement in overall survival in glioblastoma patients. This effect is not limited to clinical trials, but is reproducible in daily routine.

The impact of sequential vs. combined radiochemotherapy with temozolomide, resection and MGMT promoter hypermethylation on survival of patients with primary glioblastoma--a single centre retrospective study

BACKGROUND

The benefit of the introduction of alkylating chemotherapy in the treatment of glioblastoma multiforme (GBM) patients has been demonstrated by comparing radiotherapy with concomitant plus intermittent temozolomide (iTMZ) to radiation therapy. The isolated impact of the concomitant part of this protocol on survival was not investigated. We were therefore interested in the impact of the effect of the concomitant therapy part on survival. Hence, we compared patients treated with open surgery followed by radiotherapy and iTMZ with patients treated with concomitant plus iTMZ chemotherapy regarding overall (OS) and progression-free survival (PFS).

METHODS

We performed a retrospective database search for the period between 2002 and 2007 and aimed at the identification of patients with primary GBM treated by open resection, radiotherapy (only radiotherapy = Group A and plus concomitant TMZ = Group B) and at least two cycles of TMZ. Patients were stratified for established prognostic markers like extent of resection, MGMT promoter methylation, Karnofsky Performance Scale (KPS), and age.

RESULTS

Eighty-five patients were analysed, among which 42 patients (49%) were affiliated with Cohort A and 43 patients (51%) with Cohort B. Between both cohorts there was no significant difference regarding MGMT methylation status (p = 0.929), extend of resection (p = 0.102), KPS (p = 0.197) and age (p = 0.327). For the entire patient population, median OS was 18.6 months and PFS was 5.6 months. The extent of resection was significantly correlated with survival (OS: 21.5 vs. 16.1 months (p = 0.001) and PFS: 11.0 vs. 3.9 months (p = 0.044)). MGMT methylation status revealed a significant impact on OS (p = 0.008). Affiliation to Cohort A or B was neither correlated with PFS (p = 0.168) nor with OS (p = 0.343).

CONCLUSION

Our study demonstrates that PFS and OS are strongly determined by the MGMT status and the extent of resection. Interestingly, concomitant radiochemotherapy was not superior to radiotherapy followed by iTMZ chemotherapy regarding OS and PFS.

Alveolar soft part sarcoma metastatic to small bowel mucosa causing polyposis and intussuseption

A report of alveolar soft part sarcoma metastatic to the small bowel is presented. Hematogenous metastases to the small bowel from primary tumors outside the abdominal cavity are uncommon, and most remain asymptomatic and are not discovered until autopsy. However, small bowel metastases can lead to intestinal obstruction, intussuseption or even perforation. While metastases to the small bowel have been described for other tumor types, including melanoma and lung cancer, this is extremely uncommon for sarcoma, especially alveolar soft part sarcoma. We describe a 42-year-old male with a long history of alveolar soft part sarcoma, metastatic to the lung and brain, who developed an intussuseption from metastases to the small bowel.

[Evaluation of ADC mapping as an early predictor for tumor response to chemotherapy in recurrent glioma treated with bevacizumab/irinotecan: proof of principle]

PURPOSE

The assessment of the radiological response of recurrent glioma is based on the Macdonald or RECIST criteria 8 to 10 weeks from the start of treatment. Magnetic resonance imaging using an apparent diffusion coefficient map may provide an earlier measure for predicting the response to therapy of recurrent glioma.

MATERIALS AND METHODS

Twelve patients with recurrent high-grade glioma were enrolled in a feasibility study of pretreatment MRI on day 1, intra-treatment MRI in week 3, and post-treatment MRI in week 12. Prognostically relevant ADC values (ADCprog) of each recurrent glioma at 3 weeks were calculated as a function of their pre- and intra-therapy ADC values (ADCpre - ADCintra = ADCprog). Because we hypothesized that smaller ADC values correlate with less Brownian motion of water molecules in the extracellular space and that a higher cell density may restrain this water diffusion, we set smaller ADC values at a second time point as "progressive disease" (PD) and higher ADC values as "partial response" (PR). A change in ADCprog of less than 10 × 10⁻⁶mm² /sec was set as "stable disease" (SD). The ADCprog values were always calculated before the final scan after 3 months was performed. The readers were blinded to the future development of the tumor.

RESULTS

In 10 of the 12 patients we could correctly predict the tumor response to chemotherapy. One patient died before the three-month control, and one recurrent glioma did not develop as predicted. ADC mapping is found to predict patient response at 3 weeks from the start of treatment, revealing that early changes in tumor diffusion values could be used as a prognostic indicator also for chemotherapeutically treated recurrences of high-grade glioma.

Obesity and Angiolymphatic Invasion in Primary Breast Cancer

Background and Objectives: Obesity is associated both with higher rates of breast cancer and with unfavorable breast cancer outcomes. Small studies have suggested that obesity may be associated with unfavorable tumor biologic characteristics, such as angiolymphatic invasion. The purpose of this study was to characterize the independent association of obesity with the presence of angiolymphatic invasion, stage at presentation, estrogen receptor (ER) status, the triple-negative phenotype, and tumor grade after controlling for clinical factors.Methods: Detailed clinical and pathologic data were abstracted from the medical records of all 1361 patients with 1398 Stage I, II, or III primary breast cancers who had breast surgery at the University of Michigan Comprehensive Cancer Center between January 1, 2000 and December 31, 2006. A second abstractor, who did not have access to the clinical and pathologic tumor characteristics, collected patient height and weight. Bivariate and multivariate analyses were conducted to investigate the relationships between body mass index (BMI) and tumor biologic features controlling for menopausal status, comorbid diabetes and hypertension, use of hormone replacement therapy before the diagnosis of breast cancer, race, and ethnicity. Results: In bivariate analyses, obesity was not associated with hormone receptor status, HER2 status, triple-negative phenotype, or histologic grade. There was a borderline significant association between obesity category and the presence of angiolymphatic invasion (p = 0.06) in the sample of 1398 tumors, severely obese women being the most likely to have angiolymphatic invasion. Among pre- and perimenopausal women, the likelihood of angiolymphatic invasion in the tumors varied by obesity category (p = 0.02) with angiolymphatic invasion more likely in obese (20.0%) compared with the tumors of healthy weight (14.4%) women. In multivariate analyses, obesity status was independently associated with the presence of angiolymphatic invasion (joint test of significance, p = 0.04) after controlling for menopausal status, use of hormone replacement therapy at the time of diagnosis, diabetes and hypertension, and tumor features, including grade, stage, estrogen receptor status, and HER2 status. Obesity was associated with lower odds of triple-negative disease (odds ratio, OR, among severely obese women 0.37, 95% C.I. 0.15 – 0.92). There were significant associations between diabetes and tumor biology in multivariate analyses restricted to tumors in pre- and perimenopausal women. Diabetes was associated with ER-negative tumor status (OR 5.66, 95% C.I. 1.05 to 30.55) and with the triple-negative phenotype (OR 13.73, 95% C.I. 2.23 to 84.50).Discussion: In this large sample of invasive breast cancers, obesity was independently associated with the presence of angiolymphatic invasion. Furthermore, diabetes was found to be associated with ER-negative and triple-negative breast cancer among premenopausal women. Higher rates of angiolymphatic invasion among obese women may account in part for the poorer outcomes among obese women with breast cancer, and higher rates of triple-negative breast cancer may account for poorer outcomes among women with diabetes.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5151.

First analysis of an international pediatric melanoma and atypical melanocytic neoplasm database

9013

Background: Pediatric melanoma (PM) care has been extrapolated from adult melanoma data. PM and atypical melanocytic neoplasms (AMNs) appear to have different biology. An international database (DB) was developed to clarify their behavior. Methods: IRB approval was obtained at 12 institutions. An SQL-DB was developed for web entry of de-identified demographic and pathologic data for PM and AMN patients (pts) < 21yr through an honest broker system at the University of Pittsburgh. Institutions retained a key of pts entered with assigned numbers for quality assurance and updates. Statistical analysis used Kaplan-Meier survival curves, univariate linear trends and log rank tests. In situ melanoma was excluded from PM survival analysis. Results: 828 pts were registered as of 31 Oct 2008 (ages 11mo-23; median 15yr). 34 pts 21–23yr entered were left in the DB for statistical comparison. Diagnosis years ranged from 1936–2008. 455 pts had complete follow-up. Too few AMN pts had complete follow-up for analysis (18/208). After excluding 32 in situ and 40 with other incomplete data, 365 PM out of 415 total PM were evaluable for OS and 351 for DFS (Stage IV removed). Mean/median age for evaluable PM pts was 16.44/17-yrs (range 1–21yr). 591 pts were age 10–20 while 203 were < 10. Sentinel lymph node (SLN) biopsy showed spread in 30.1 % PM pts (compared to 50% [4/8] of AMN SLN pts). 10-yr PM OS was 80.6%, and pts 0–10 yr had 100% 10-yr OS compared to 69.6% for pts age 10–15 and 79.49% for age 15–20 (p= 0.1473). OS did not differ significantly by gender. Stage predicted OS (p<0.0001). 10-yr OS was 94.13% for Stage I (n=174), 79.62% for stage II (n=67) & 77.14% for stage III (n=75). Thickness affected 10-yr OS: 0–1mm=97% (n=147), 1.1–2mm 70% (n=84), 2.01–4mm 78% (n=71) & >4mm 81% (n=25), p= 0.0099. Survival was similar for pts with PM > 1mm of the several T stage groupings. Ulceration adversely affected OS (p=0.022). Mitosis, defined as present/absent did not alter survival. Nodal metastasis correlated with worse OS (p= 0.170). Conclusions: Stage, thickness, ulceration, and nodal status are significant predictors of OS for PM. Further study will focus on multivariable analysis of PM and AMNs after updating pts, increasing accrual, and cleaning data.

No significant financial relationships to disclose.

Animal-type melanoma: a clinical and histopathological study of 22 cases from a single institution

Background Animal-type melanoma is a rare distinct melanoma subtype, characterized by proliferation of heavily pigmented epithelioid and spindled melanocytes that resembles the heavily pigmented melanomas seen in grey horses. While animal-type melanoma is generally considered to be more indolent than conventional melanoma, only a limited number of cases have been reported and, as such, the clinical characteristics of animal-type melanoma are incompletely understood. Objectives To characterize the clinical and histopathological features of animal-type melanoma, and determine any features that may predict outcome. Patients/Methods Data was extracted from a prospectively collected melanoma database (1994-2008), and a retrospective pathology database (1991-2008) for all patients with a diagnosis of both equivocal (8) and unequivocal (14) malignant animal-type melanoma. We reviewed the clinical and histopathological features, including the sentinel lymph node biopsy (SLNB) status. Results A total of 22 patients were identified, with a median age of 35 years. The median Breslow depth was 2.22 mm. A SLNB was performed in 17 patients, eight (47%) were positive. Younger age was associated with: (i) animal-type melanoma with features equivocal for malignancy (median age of 7 vs. 48 years, P = 0.01), and (ii) a negative SLNB (median age 12 vs. 53 years, P = 0.03). Four patients with unequivocal animal-type melanoma developed recurrent metastatic disease, with one patient death. No patient with an equivocal animal-type melanoma or negative SLNB developed recurrent disease; however, this did not reach statistical significance (P = 0.13 and P = 0.09, respectively). Conclusions Animal-type melanoma has a propensity for regional lymphatic metastasis and is rarely capable of disseminated metastatic disease and death. Animal-type melanoma appears to exhibit a spectrum of biological behaviour, with young patient age associated with more indolent disease.

Hypermethylation and transcriptional downregulation of the CITED4 gene at 1p34.2 in oligodendroglial tumours with allelic losses on 1p and 19q

Deletions of chromosomal arms 1p and 19q are frequent in oligodendroglial tumours and have been associated with sensitivity to radio- and chemotherapy as well as favourable prognosis. By using microarray-based expression profiling, we found that oligodendroglial tumours with 1p and 19q losses showed significantly lower expression of the CBP/p300-interacting transactivator with glutamic acid/aspartic acid-rich carboxyl-terminal domain 4 gene (CITED4) at 1p34.2 as compared to tumours without 1p and 19q losses. Mutational analysis showed no CITED4 mutations in gliomas. However, 1p and 19q losses as well as low expression of CITED4 transcripts were significantly associated with hypermethylation of the CITED4-associated CpG island. In line with the latter finding, treatment of CITED4 hypermethylated glioma cell lines with 5-aza-2'-deoxycytidine and trichostatine A resulted in a marked increase of the CITED4 transcript levels. Furthermore, CITED4 hypermethylation was significantly associated with longer recurrence-free and overall survival of patients with oligodendroglial tumours. Taken together, our results indicate that CITED4 is epigenetically silenced in the vast majority of oligodendroglial tumours with 1p and 19q deletions and suggest CITED4 hypermethylation as a novel prognostic marker in oligodendroglioma patients.

The role of the surgeon in the management of melanoma

While multimodality therapy has become the standard for most solid tumors, the mainstay of therapy for melanoma remains surgical. This includes not only early stage disease, but advanced melanoma as well. The surgical approach to melanoma has changed dramatically, with a trend towards less aggressive resection of the primary tumor, and towards a more aggressive approach to regional and metastatic disease. Melanoma surgery has been altered by our knowledge of the biology of the disease, and the results of well-designed, prospective randomized trials. Conversely, new surgical approaches have expanded our understanding of melanoma biology, and new randomized trials are needed to further define the optimal surgical approach. This article will review the evolution of melanoma surgery and the evidence behind today's recommendations.

Current state of treatment for primary cutaneous melanoma

The incidence of malignant melanoma has been rising steadily for the last 30 years. Through physician and patient education, surveillance of high-risk individuals, and biopsy of any suspicious lesions, more lesions are being diagnosed earlier, where there is a high cure rate. Unfortunately many patients will still present with thicker lesions or nodal involvement, which carries a significantly worse prognosis. Over the past decade, there have been several changes in the management of primary cutaneous melanoma. These have stemmed from novel surgical approaches, a new understanding of melanoma biology, and randomized clinical trials designed to improve outcome and decrease the morbidity of therapy. This article will review the clinical evidence behind the current treatment recommendations for primary cutaneous melanoma as well as some of the emerging data on innovative immunologic-approaches to melanoma treatment.

Decompressive Craniectomy in Severe Brain Injury

OBJECT

The goal of this study was to evaluate the therapeutic role of decompressive craniectomy in severe brain injury.

METHODS AND RESULTS

Between 1996 and 1998 we treated 87 patients with severe brain injury (GCS 3-8) in our department. In 70 cases follow up data could be obtained. Mean age was 49 years (range 1-79). Initial CT scans of all patients demonstrated diffuse brain injury with generalised brain swelling and/or mass lesion. In 51 of these patients uni (n=40)- or bilateral (n=11) decompressive craniectomy was performed initially or secondarily after failure of standard treatment. In a retrospective analysis we performed statistical tests of the follow-up group. The mortality rate did not show a significant difference between the two treatment groups (p=0.802) with a slight advantage for the decompression. The log-rank-test demonstrated a non-significant improvement of the survival time for decompressed patients (p=0.632). Secondary decompression showed a significantly better survival rate and time compared to primary decompression. In all 7 pediatric cases (1-16 yrs) we performed craniectomy. 2 of them died immediately post emergency operation, 5 survived with good outcome (1 LOF).

CONCLUSIONS

A slight, but non-significant benefit could be demonstrated after decompressive craniectomy in the whole patient population. In young patients decompression seems to have a more positive influence on outcome and survival.

[Glomerulonephritis secondary to chronic infection of a ventriculoatrial shunt]

HISTORY AND ADMISSION FINDINGS

A 39-year-old man was referred for assessment of a nephrotic syndrome. He reported deteriorating health with bouts of fever and microhaematuria and proteinuria in the past year. At the age of 24 years a ventriculoatrial shunt had been inserted for an internal hydrocephalus. At another hospital he was given steroids for a nephrotic syndrome suspected of being associated with membranoproliferative glomerulitis, but the disease progressed. On admission he had severe generalised oedema with a temperature of 38,5;C. His general condition was poor. He had no neck stiffness.

INVESTIGATIONS

Parameters of inflammation were raised. Serum creatinine and creatinine clearance were normal. Levels of complements C3 and C4 were reduced. The proteinuria was 9g/24h. Renal biopsy revealed type 1 membranoproliferative glomerulonephritis. Micrococcus roseus/varians was demonstrated several times by aerobic blood cultures.

TREATMENT AND COURSE

The findings suggested chronically infected ventriculoatrial shunt as cause of the glomerulonephritis. The shunt was, therefore, removed. The same pathogens were grown from it on aerobic culture medium. Six months after removal and replacement of the shunt and treatment of the infection the proteinuria had fallen to 0.45 mg/h; serum creatinine was 1.0 mg/dl.

CONCLUSION

When membranoproliferative glomerulonephritis has been demonstrated, secondary forms should be considered in the differential diagnosis. In most cases specific treatment can prevent progression of the renal disease.

Neoadjuvant therapy with interleukin-12-loaded polylactic acid microspheres reduces local recurrence and distant metastases

BACKGROUND

We previously demonstrated that the intratumoral injection of biodegradable polylactic acid microspheres that were loaded with interleukin (IL)-12 can induce a systemic antitumor immunity. We sought to investigate the clinical potential as neoadjuvant therapy.

METHODS

Mice were inoculated with 5 x 10(7) Line-1 cells subcutaneously. Six days later, a single intratumoral injection of IL-12- or BSA-loaded microspheres were given; 14 days later, autopsy was performed to document metastases. Mice were inoculated with 5 x 10(7) Line-1 cells and 10 days later either treated with IL-12- or BSA-loaded microspheres or resected. Treated tumors were resected 6 days after treatment. Mice were observed 45 days for local recurrence before autopsy.

RESULTS

Intratumoral injection of IL-12 microspheres resulted in significant suppression of tumor growth compared with controls (599 +/- 255 mm(3) vs 1591 +/- 372 mm(3); P =.001) and pulmonary metastases (0.4 vs 3.8 nodules per mouse; P =.003). Given before the operation, IL-12-loaded microspheres both decreased the local recurrence rate (100% to 40%) and pulmonary metastases (5.2 vs 0.6 nodules per mouse; P =.06). Earlier resection did not improve local recurrence or distant metastases.

CONCLUSIONS

Intratumoral injection of IL-12-loaded polylactic acid microspheres promotes the development of systemic antitumor immunity that can eradicate micrometastases. As a neoadjuvant therapy, this can result in decreased local and distant recurrence.

Is MUGA scan necessary in patients with low-risk breast cancer before doxorubicin-based adjuvant therapy? Multiple gated acquisition

Doxorubicin-based chemotherapy in the adjuvant treatment of breast cancer has become standard. Use of doxorubicin is limited by cardiac dysfunction; however, the incidence is dramatically reduced by limiting the dose to less than 550 mg/m(2). Although the cumulative dose in breast cancer is typically 240 mg/m(2), multiple gated acquisition (MUGA) scans are still recommended for determining cardiac functional status in these patients. To examine the need for this practice, we reviewed 296 patients who underwent surgery for breast cancer at Roswell Park Cancer Institute between July 1997 and December 1998. Fifty-nine of 95 (62%) patients receiving doxorubicin-based regimens, and 3 of 39 (7%) receiving nondoxorubicin regimens had pretreatment MUGA scans. The MUGA scans showed normal results in 58 patients and low-normal in 4 (6.5%), with no wall motion abnormalities encountered. There were no cases where doxorubicin was not used because of an abnormal MUGA scan. There were no cardiac complications in the 59 women who received doxorubicin-based chemotherapy. MUGA will screen out few, if any, women under consideration for doxorubicin-based adjuvant therapy; the decision to avoid doxorubicin can be made based on age and preexisting comorbidity. Guidelines recommending routine use of MUGA before the administration of doxorubicin for adjuvant therapy for breast cancer should be reconsidered.

Accuracy of sentinel node biopsy in predicting nodal status in patients with breast carcinoma

BACKGROUND AND OBJECTIVES

While sentinel lymph node biopsy is considered by many to have replaced axillary node dissection in the management of breast cancer, concerns remain regarding false-negative results.

METHODS

To investigate the accuracy of sentinel node biopsy, we reexamined all sentinel and nonsentinel nodes with multilevel sectioning and immunohistochemical staining in 42 consecutive cases of breast cancer in which sentinel node biopsy was performed and followed by axillary dissection.

RESULTS

By routine hematoxylin and eosin (H&E) staining, 34% of patients were found to be node positive, with no cases of false-negative sentinel node biopsy. Reevaluation of 775 negative sentinel and nonsentinel nodes with an additional two levels and immunohistochemistry identified three "node-negative" patients who had micrometastases in the sentinel node, increasing detection in 8% of cases. More important, is the fact however, that there were no cases where additional sections and immunohistochemistry identified metastases in nonsentinel nodes that had bypassed the sentinel node. The accuracy of the sentinel node in predicting the nodal status was 100%.

CONCLUSIONS

Cytokeratin immunohistochemistry will identify more patients with nodal micrometastases; however, it was unable to identify any cases where micrometastases were present in nonsentinel nodes when the sentinel node was negative. The status of the sentinel node accurately identifies the status of the axillary basin.

Long-term survival of a patient with giant cell glioblastoma. Case report

The authors report on a patient who had undergone resection of a left-sided temporal giant cell glioblastoma at the age of 69 years and who survived for more than 17 years. This man had not undergone postoperative radiotherapy or adjuvant chemotherapy. He died at the age of 86 years without clinical evidence of tumor recurrence. Histologically, the lesion was characterized by highly pleomorphic tumor cells (including bizarre multinucleated giant cells) with high mitotic activity, large necroses, and prominent mononuclear infiltration. A point mutation in the TP53 tumor suppressor gene (c.524G>A; R175H) and no epidermal growth factor receptor gene amplification were revealed on molecular genetic analysis. No diagnostic chromosomal imbalances were identified on comparative genomic hybridization, although the average ratio profile for chromosome 10 indicated loss of 10p15 in a subpopulation of tumor cells. This patient is exceptional because tumor resection, probably in conjunction with a marked antitumor immune response, apparently resulted in eradication of the lesion.

Molecular genetic alterations in glioblastomas with oligodendroglial component

Glioblastoma multiforme is the most malignant astrocytic glioma and usually resistant to chemotherapy. A small fraction of glioblastomas may contain areas with histological features of oligodendroglial differentiation. To determine the molecular genetic alterations in such "glioblastomas with oligodendroglial component", we investigated 13 of these tumors for genetic alterations and/or expression of the TP53, CDKN2A, PTEN, and EGFR genes. In addition, we performed microsatellite analyses for loss of heterozygosity (LOH) on chromosome arms 1p, 19q and 10q. None of tumors showed evidence for LOH on 10q. LOH on 1p was detected in 3 tumors, 1 of which additionally showed LOH on 19q. The 3 tumors with LOH on 1p showed neither TP53 mutations nor nuclear p53 accumulation. In contrast, 9 of 10 tumors without demonstrated losses on 1p showed nuclear p53 accumulation. TP53 mutations were identified in 3 of these cases. Further aberrations detected were epidermal growth factor receptor (EGFR) overexpression (3 of 13 tumors), homozygous CDKN2A deletion (2 of 11 tumors), and PTEN mutation (1 of 13 tumors). Taken together, our results indicate that "glioblastomas with oligodendroglial component" carry heterogeneous genetic alterations. LOH on 10q, PTEN mutation, and homozygous CDKN2A deletion appear to be less common in these tumors as compared to ordinary glioblastomas. Furthermore, a subset of these tumors demonstrates LOH on 1p, i.e., an alteration that has recently been linked to chemosensitivity and good prognosis in anaplastic oligodendrogliomas.

Intracerebral neurocysticercosis mimicking glioblastoma multiforme: a rare differential diagnosis in Central Europe

A 47-year-old Greek man presented with a 4-week history of speech difficulties. CT and MRI revealed a low-density multilobulated cystic frontal mass with peripheral ring contrast enhancement adjacent to the sylvian fissure. Examination was normal. Blood tests revealed leucocytosis (16,000 cells/microl) and an elevated erythrocyte sedimentation rate (30/52). A malignant brain tumour was suspected and surgically removed. Histological examination disclosed intracerebral neurocysticercosis.