Impact of Prosigna test on adjuvant treatment decision in lymph node-negative early breast cancer-a prospective national multicentre study (EMIT-1).

BACKGROUND: EMIT-1 is a national, observational, single-arm trial designed to assess the value of the Prosigna, Prediction Analysis of Microarray using the 50 gene classifier (PAM50)/Risk of Recurrence (ROR), test as a routine diagnostic tool, examining its impact on adjuvant treatment decisions, clinical outcomes, side-effects and cost-effectiveness. Here we present the impact on treatment decisions. PATIENTS AND METHODS: Patients with hormone receptor-positive, human epidermal growth factor receptor 2-negative pT1-pT2 lymph node-negative early breast cancer (EBC) were included. The Prosigna test and standard histopathology assessments were carried out. Clinicians' treatment decisions were recorded before (pre-Prosigna) and after (post-Prosigna) the Prosigna test results were disclosed. RESULTS: Of 2217 patients included, 2178 had conclusive Prosigna results. The pre-Prosigna treatment decisions were: no systemic treatment (NT) in 27% of patients, endocrine treatment alone (ET) in 38% and chemotherapy (CT) followed by ET (CT + ET) in 35%. Post-Prosigna treatment decisions were 25% NT, 51% ET and 24% CT + ET, respectively. Adjuvant treatment changed in 28% of patients, including 21% change in CT use. Among patients assigned to CT + ET pre-Prosigna, 45% were de-escalated to ET post-Prosigna. Of patients assigned to ET, 12% were escalated to CT + ET and 8% were de-escalated to NT; of those assigned to NT, 18% were escalated to ET/CT + ET. CT was more frequently recommended for patients aged ≤50 years. In the subgroup with pT1c-pT2 G2 and intermediate Ki67 (0.5-1.5× local laboratory median Ki67 score), the pre-Prosigna CT treatment decision varied widely across hospitals (3%-51%). Post-Prosigna, the variability of CT use was markedly reduced (8%-24%). The correlation between Ki67 and ROR score within this subgroup was poor (r = 0.25-0.39). The median ROR score increased by increasing histological grade, but the ROR score ranges were wide (for G1 0-79, G2 0-90, G3 16-94). CONCLUSION: The Prosigna test result changed adjuvant treatment decisions in all EBC clinical risk groups, markedly decreased the CT use for patients categorized as higher clinical risk pre-Prosigna and reduced treatment decision discrepancies between hospitals.

Blood Chimerism in Dizygotic Monochorionic Twins During 5 Years Observation.

Dizygotic monochorionic twin pregnancies can result in blood chimerism due to in utero twin-to-twin exchange of stem cells. In this case, we examined the proportion of allogeneic red blood cells by flow cytometry and the proportion of allogeneic nucleated cells by digital polymerase chain reaction at 7 months and again at 5 years. We found an increase in the proportion of allogeneic cells from 63% to 89% in one twin, and a similar increase in autologous cells in the other twin from 57% to 84%. A paradigm for stem cell therapy could be modeled on this case: induction of tolerance and chimerism by antenatal transfusion of donor stem cells. The procedure would hold the promise of transplantation and tolerance induction without myeloablative conditioning for inheritable benign hematological diseases such as sickle cell disease and thalassemia.

Oral transmission as a route of infection for viral haemorrhagic septicaemia virus in rainbow trout, Oncorhynchus mykiss (Walbaum).

Surveys among wild marine fish have revealed occurrence of viral haemorrhagic septicaemia virus (VHSV) infections in a high number of diverse fish species. In marine aquaculture of rainbow trout, preying on invading wild fish might thus be a risk factor for introduction and adaptation of VHSV and subsequent disease outbreaks. Our objective was to determine whether an oral transmission route for VHSV in rainbow trout exists. Juvenile trout were infected through oral, waterborne and cohabitation transmission routes, using a recombinant virus strain harbouring Renilla luciferase as reporter gene. Viral replication in stomach and kidney tissue was detected through bioluminescence activity of luciferase and qRT-PCR. Replication was detected in both tissues, irrespective of transmission route. Replication patterns, however, differed among transmission routes. In trout infected through oral transmission, replication was detected in the stomach prior to kidney tissue. In trout infected through waterborne or cohabitation transmission, replication was detected in kidney prior to stomach or in both tissues simultaneously. We demonstrate the existence of an oral transmission route for VHSV in rainbow trout. This implies that preying on invading infected wild fish is a risk factor for introduction of VHSV into marine cultures of rainbow trout.

Revealing genetic relationships between compounds affecting boar taint and reproduction in pigs.

Boar taint is characterized by an unpleasant taste or odor in intact male pigs and is primarily attributed to increased concentrations of androstenone and skatole and to a lesser extent by increased indole. The boar taint compounds skatole and indole are produced by gut bacteria, metabolized in the liver, and stored in the fat tissue. Androstenone, on the other hand, is synthesized in the testis along with testosterone and estrogens, which are known to be important factors affecting fertility. The main goal of this study was to investigate the relationship between genetic factors involved in the primary boar taint compounds in an attempt to discover ways to reduce boar taint without decreasing fertility-related compounds. Heritabilities and genetic correlations between traits were estimated for compounds related to boar taint (androstenone, skatole, indole) and reproduction (testosterone, 17ß-estradiol, and estrone sulfate). Heritabilities in the range of 0.47 to 0.67 were detected for androstenone concentrations in both fat and plasma, whereas those for skatole and indole were slightly less (0.27 to 0.41). The genetic correlations between androstenone in plasma and fat were extremely high (0.91 to 0.98) in Duroc and Landrace. In addition, genetic correlations between androstenone (both plasma and fat) and the other sex steroids (estrone sulfate, 17ß-estradiol, and testosterone) were very high, in the range of 0.80 to 0.95. Furthermore, a genome-wide association study (GWA) and a combined linkage disequilibrium and linkage analysis (LDLA) were conducted on 1,533 purebred Landrace and 1,027 purebred Duroc to find genome regions involved in genetic control of the boar taint compounds androstenone, skatole, and indole, and sex hormones related to fertility traits. Up to 3,297 informative SNP markers were included for both breeds, including SNP from several boar taint candidate genes. From the GWA study, we found that altogether 27 regions were significant at a genome-wide level (P < 0.05) and an additional 7 regions were significant at a chromosomal level. From the LDLA study, 7 regions were significant on a genome-wide level and an additional 7 regions were significant at a chromosomal level. The most convincing associations were obtained in 6 regions affecting skatole and indole in fat on chromosomes 1, 2, 3, 7, 13, and 14, 1 region on chromosome 6 affecting androstenone in plasma only, and 5 regions on chromosomes 3, 4, 13, and 15 affecting androstenone, testosterone, and estrogens.

General and family-specific gene expression responses to viral hemorrhagic septicaemia virus infection in rainbow trout (Oncorhynchus mykiss).

The ability of rainbow trout (Oncorhynchus mykiss) to respond successfully to infection by viral hemorrhagic septicaemia virus (VHSV) is expected to involve a large number of biochemical processes. We hypothesized that this would be reflected at the gene expression level in infected fish, and we tested it by examining gene expression levels in the head kidney of trout at a genome-wide scale with a 16K cDNA microarray for salmonids. Expression levels were recorded during 16 days following bath challenge. The challenge experiment included a relatively low susceptibility (32% survival following challenge) and a relatively high susceptibility (18% survival following challenge) trout family that were both split into a group exposed to virus and a non-exposed control group. In total, 939 genes were differentially expressed between infected and non-infected fish (FDR p=0.05). Five groups of Gene Ontology categories were involved in immune-related processes and over-represented in infected fish: (i) stress and defense response, (ii) NFkappaB signal transduction, (iii) response to non-self, (iv) antigen processing and presentation, and (v) proteasome complexes. The first four categories were also over-represented among the 642 differentially expressed genes in the low-susceptibility trout family but not among the 556 differentially expressed genes in the high-susceptibility trout family. Expression profiles for most immune genes discussed showed increased transcription from day 3 post-challenge. The results suggest that the innate immune system may play an important role in the successful response to VHSV in rainbow trout. In addition, the results indicate that a superior regulation of the transcription of several key innate immune-related genes contribute to the increased survival in resistant fish.

Locally recurrent rectal cancer in Norway.

BACKGROUND: The purpose of this study was to describe management and outcome in patients with locally recurrent rectal cancer based on data from the Norwegian Colorectal Cancer Registry. METHODS: This was a prospective national cohort study of 577 patients with local recurrence after major resection (R0/R1) for rectal cancer between November 1993 and December 2001 (initial cohort of 4504 patients). RESULTS: Of the 577 patients, 185 (32.1 per cent) had curative resections (R0/R1), 203 (35.2 per cent) had palliative radiotherapy with or without palliative surgery and chemotherapy, and 189 (32.8 per cent) received no treatment at all or only palliative surgery or chemotherapy. The overall 5-year survival rate was 14.9 per cent. Ninety-seven patients had an R0 resection, and 88 had an R1 resection, with 5-year overall survival of 55 and 20 per cent respectively. This outcome reflected surgical treatment in 33 different hospitals. Some 274 patients (47.5 per cent) had metastases. The 5-year survival rate after R0 resection was 62 per cent in patients without metastases. CONCLUSION: Obtaining an R0 resection is the most important prognostic factor in treating recurrent rectal cancer.

Impact of radiotherapy on local recurrence of rectal cancer in Norway.

BACKGROUND: The purpose of this study was to analyse the impact of radiotherapy on local recurrence of rectal cancer in Norway after the national implementation of total mesorectal excision (TME). METHODS: This was a prospective national cohort study of 4113 patients undergoing major resection of rectal carcinoma between November 1993 and December 2001. RESULTS: The proportion of patients who had radiotherapy before or after operation increased from 4.6 per cent in 1994 to 23.0 per cent in 2001. The cumulative 5-year local recurrence rate decreased from 16.2 to 10.7 per cent. Multivariable analysis showed that preoperative radiotherapy significantly reduced local recurrence (hazard ratio 0.59 (95 per cent confidence interval 0.39 to 0.87)). The use of preoperative radiotherapy in patients from a local hospital offering radiotherapy was 50 per cent higher than that for patients from a hospital without such services (P = 0.003); cumulative 5-year local recurrence rates for these patients were 10.6 and 15.8 per cent respectively (P < 0.001). CONCLUSION: Following national implementation of TME for rectal cancer, increased use of preoperative radiotherapy appeared to reduce recurrence rates further.

Identification of immunogenic antigens using a phage-displayed cDNA library from an invasive ductal breast carcinoma tumour.

The identification of immunogenic antigens for serological testing and vaccine development is a major challenge facing cancer immunology research. To study the humoral immune response in patients with breast cancer, a T7 phage display cDNA library from an invasive ductal breast carcinoma was panned on patient serum IgG antibodies. By monitoring the selection with an immunoscreening technique, positive phage-displayed cDNA products reacting with breast cancer patient IgG antibodies were selected. Sequence analysis identified immunogenic antigens such as the cytochrome oxidase I, sp100 and Ran GTPase activating protein. Additionally, immunogenic uncharacterized gene products were also identified. Both the known and unknown immunoselected gene products should offer an additional source for cancer gene discovery for diagnostic testing and vaccine development.

The tumor-infiltrating B cell response in medullary breast cancer is oligoclonal and directed against the autoantigen actin exposed on the surface of apoptotic cancer cells.

Medullary carcinoma of the breast (MCB) is a morphologically and biologically distinct subtype of human breast cancer that, despite cytologically anaplastic features, has a more favorable prognosis than other types of breast cancer at similar stages of differentiation. It has been proposed that the improved clinical outcome is due, at least in part, to the presence of a prominent lymphoplasmacytic cell infiltrate in the tumor stroma. We studied the B lymphoplasmacytic cell infiltrates in MCB to determine the role of the antibody response produced by the local infiltrating cells. Oligoclonal predominance among tumor-infiltrating B cells in a panel of MCB patients was observed, suggesting that certain B cell clones were expanded, possibly in response to specific tumor-associated stimuli. IgG antibody phage-display libraries were generated from MCB-infiltrating lymphoplasmacytic cells of two patients, and MCB-reactive monoclonal antibodies were retrieved by selection on fresh-frozen MCB tissue sections. Analysis by mass spectrometry revealed that the antigen targeted by the dominant clones in the oligoclonal B lymphoplasmacytic response in both patients was not a cancer-specific antigen but the cytoskeletal protein beta-actin. MCB exhibits an increased rate of apoptosis, and apoptotic MCB cells were shown to expose actin on the cell surface, permitting its recognition by the humoral immune system. Further, actin fragments, similar to those observed after cleavage with the apoptotic protease granzyme B, were observed in MCB tissue. Our results indicate that the major antibody response produced by tumor-infiltrating B lymphoplasmacytic cells are autoimmune in nature and a consequence of the perturbed state of increased MCB apoptosis caused by granzyme B-induced T cell cytotoxicity and/or intrinsic cellular factors of MCB cells.

Antigen-specific IgG antibodies in stage IV long-time survival breast cancer patients.

BACKGROUND: Profiling the immune responses in patients with cancer is expected to facilitate the design of diagnostic tests and therapeutic vaccines. Such studies usually require the parental antigens. We attempted to profile the immune responses in patients with breast cancer using a peptide phage display selection strategy, which identifies antibody specificities whether or not the antigens are known. MATERIALS AND METHODS: A panel of random peptide phage libraries was panned on serum IgG antibodies from breast cancer patients with stage IV, seeking for disease specific IgG epitopes. ELISA, immunoscreening, and Western blotting techniques were the main approaches used. RESULTS: Phage-displayed peptides were specifically enriched for binding to IgG antibodies from patients with breast cancer. Several peptides have been identified, in particular the SQRIPARIHHFPTSI peptide, which was recognized by IgG antibodies from breast cancer patients, but not from normals (p < 0.0004). In patients who responded to the selected peptides, in particular the SQRIPARIHHFPTSI peptide, antibodies against a 66 kDa cellular protein were found. Interestingly, three out of six patients with the strongest immunoreactivity are still alive, with a mean survival time from first recurrence until now of 2553 days. In contrast, all the nonresponders (n = 10) are deceased. The mean survival time of these patients was 784 days, whereas the mean survival time of the three deceased responders was 1050 days (p < 0.02). CONCLUSIONS: The data provide the first example in which panning of peptide phage display libraries on patient IgG antibodies results in the isolation of breast cancer specific IgG epitopes, some of which correlate with patient survival time. Thus, the identified B-cell epitopes should be of great interest in vaccine development.

Profiling the immune response in patients with breast cancer by phage-displayed cDNA libraries.

Display on the surface of filamentous phages has been shown to be well suited for the enrichment of serum antibody-binding ligands. Here, we have taken the advantage of this technology to analyze the humoral immune response in patients with cancer. The cDNA repertoires from breast cancer cell lines T47D and MCF-7 were fused to the 3'-end of the filamentous phage M13 gene VI in all three reading frames. When the libraries were biopanned on rabbit polyclonal IgG against the human Bcl-x(L) protein, positive clones were selected, thus confirming the utility of the libraries. Using serum antibodies from patients with breast cancer, we specifically selected IgG-binding phage-encoded cDNA products. Sequence analysis of the selected clones identified important antigens including p53, centromere-F, int-2, pentraxin I, integrin beta5, cathepsin L2 and S3 ribosomal protein. The selected phage-displayed cDNA products were recognized by a significant number of breast cancer sera as compared to sera from normal individuals. Although the human pentraxin I mRNA was reported to be exclusively localized in the nervous system, we found it also expressed by breast cancer cell lines. Four out of 30 patients with breast cancer (13 %) showed reactivity with the recombinant pentraxin expressed in Escherichia coli, while no reactivity was found in normal sera. The obtained results demonstrate that phage display could be a valuable method for the identification of antigens recognized by the humoral immune system in patients with cancer.

Probing antinuclear antibody specificities by peptide phage display libraries.

OBJECTIVE: To uncover the specificities of autoantibodies to nuclear proteins (ANA) in patients with juvenile rheumatoid arthritis (JRA). METHODS: Peptide ligands for ANA were selected by panning random peptide phage display libraries on antibodies binding to HEp-2 cells. Positive phage clones were identified by the immunoscreening technique. RESULTS: Groups of peptides were identified, some of which share the core motifs of KTTTnPY, RVADnL/I or RnNSPL. Perinuclear and nuclear staining of HEp-2 cells were obtained with patient serum antibodies binding to the phage displaying the core peptide motifs. In contrast, no significant reactivity was seen with the antibodies binding to the wild type phage. Antibodies to the phage displaying peptides containing some of the core motifs were detected more frequently in ANA-positive as compared to ANA-negative JRA patients. Homology search with the selected core motifs revealed a significant homology with a number of human nuclear proteins and proteins from potential infectious agents that could serve as trigger in the breakdown of tolerance. CONCLUSION: Panning of phage display libraries on antibodies reacting with cellular structures can lead to the identification of their specificities. Thus, the peptide epitopes reported here constitute additional information that may lead to the development of diagnostic tests and the identification of the parental antigens that initiated the B cell responses in patients with JRA.

Progressive renal shrinkage after simple pyelonephritis.

Nonobstructive, nonrefluxing pyelonephritis (or "simple" pyelonephritis) is not commonly associated with progressive renal scarring and global shrinkage. Although children are believed to be particularly susceptible to renal parenchymal scarring after simple pyelonephritis, progressive and global renal shrinkage remains an elusive clinical entity. We present such a case with close radiologic documentation.

Surgical challenge of massive bilateral staghorn renal calculi in a spinal cord injury patient.

We report a rare case of massive bilateral staghorn calculi in a spinal cord injury patient with significant renal compromise. The patient was successfully treated with percutaneous nephrolithotomy to achieve a stone-free status. The various options of treatment are discussed with special attention to the technical aspects necessary to achieve complete eradication of the stone burden during percutaneous nephrolithotomy. Furthermore, the importance of treating bladder dysfunction and urinary metabolic abnormalities is emphasized.

[Preoperative dacryocystography in patients with epiphora]. / Praeoperativ dakryocystografi hos patienter med tåreflåd.

In this retrospective study 56 dacryocystographies (DCG) were performed preoperatively in 50 patients with epiphora, due to obstruction in the lacrimal drainage system. We found DCG to be an easy and sufficient examination of patients with uncomplicated epiphora without suspicion of tumour. Tumours in the lacrimal drainage system are rare, and CT-scan or MR-imaging as a routine examination is not indicated. DCG provides a fair prediction regarding success rate of the dacryocystorhinostomy operation (DCR). We found the DCR to be successful in 91.7% when the obstruction was located distally, but only in 45.5% when the obstruction was in the canaliculi. Further investigations are necessary to clarify whether higher success rates after surgery can be obtained in patients with canalicular obstruction by using the DCG-findings more specifically when planning operation type.

Pregnancy outcome after laser surgery for cervical intraepithelial neoplasia.

BACKGROUND: Little is published about obstetrical problems after treatment of cervical intraepithelial neoplasia with the C02-laser. The aim of this study was to determine the risk of low birth weight in the subsequent pregnancy after laser conization or vaporization in a follow-up study of women treated for cervical intraepithelial neoplasia (CIN). Methods. Of 319 women treated for CIN with the C02-laser in the Department of Obstetrics and Gynecology, University Hospital of Tromsø, Norway and followed for pregnancy outcome, 87 women had given birth (after 24th week) four to nine years after treatment. Sixty-five women had undergone conization and 22 women had been treated with vaporization. For each delivery, two controls matched for parity, age (+/- 3 years) and place of delivery were identified. The material was analyzed as a matched cohort study. RESULTS: A strong relationship was found between conization and low birth weight. Mean birth weight after conization was 3185 g vs 3473 g,in the control women (p=0.03). Thirteen (20%) infants from women subject to conization had birth weight less than 2500 g. Relative risk of birth weight<2500 g was 2.2 (1.04-4.5) after conization, for<2000 g and< 1500 g the risk was 3.5 (1.02-12.0) and 10.0 (1.2-85.6), respectively. Four women (6.2%) with normal deliveries prior to conization experienced one or several stillbirths after treatment. No difference in birth weight was observed for women after vaporization compared to their controls. CONCLUSION: Excisional surgery on the cervix increases the risk for low birth weight in subsequent pregnancies. Pregnant women with prior conization need careful antenatal care.

Intraocular pressure seven years after extracapsular cataract extraction and sulcus implantation of a posterior chamber intraocular lens.

Seven years after extracapsular cataract extraction (ECCE) and sulcus implantation of a posterior chamber intraocular lens, we measured the intraocular pressure (IOP) in 28 eyes of 28 patients. The results were compared with the preoperative IOP and with the postoperative IOP at four months and 2 1/2 years. The mean IOP value seven years after surgery was 1.3 mm Hg lower than the preoperative mean value. No significant difference was found among the values at four months, 2 1/2 years, and seven years. One patient experienced a marked rise in IOP between 2 1/2 years and seven years and was excluded from the calculations. However, we could not tell whether it was a consequence of the cataract surgery. In this study, we found that IOP stabilized at a postoperative level that was significantly lower than the preoperative value and has remained there for seven years.

Utility of a C-jun microsatellite marker in determining gene dosage for fatty (fa).

The Zucker fatty (fa) mutation provides a genetic model for obesity and non-insulin dependent diabetes mellitus. The molecular pathogenesis of the metabolic phenotype of these animals is not known. Detailed molecular maps of the region surrounding the fa locus on rat chromosome 5 can be used for positional cloning experiments as well as to permit genotyping of animals from appropriate crosses before the confounding metabolic effects of obesity have occurred. We describe the development of a polymerase chain reaction (PCR) assay for a polymorphic simple sequence repeat (SSR) in the promoter region of the protooncogene c-Jun. This assay was used to position c-Jun 4.5cM proximal to the fa locus in 111 F2 progeny of a 13MBN fa/+ F1 intercross. Concurrent use of the c-Jun SSR with a previously described assay for a microsatellite in the glucose transporter, Glut1, permits rapid and accurate assessment of genotypes at the fa locus in animals of any age using minimal amounts of DNA. A strategy is described which minimizes the error rate in assigning genotype at the fatty locus for backcross and intercross progeny.