Prognostic and predictive value of circulating tumor cell analysis in colorectal cancer patients.

OBJECTIVE: The aim of this study was to assess the prognostic and predictive values of circulating tumor cell (CTC) analysis in colorectal cancer patients. PATIENTS AND METHODS: Presence of CTCs was evaluated in 60 colorectal cancer patients before systemic therapy--from which 33 patients were also evaluable for CTC analysis during the first 3 months of treatment--through immunomagnetic enrichment, using the antibodies BM7 and VU1D9 (targeting mucin 1 and EpCAM, respectively), followed by real-time RT-PCR analysis of the tumor-associated genes KRT19, MUC1, EPCAM, CEACAM5 and BIRC5. RESULTS: Patients were stratified into groups according to CTC detection (CTC negative, when all marker genes were negative; and CTC positive when at least one of the marker genes was positive). Patients with CTC positivity at baseline had a significant shorter median progression-free survival (median PFS 181.0 days; 95% CI 146.9-215.1) compared with patients with no CTCs (median PFS 329.0 days; 95% CI 299.6-358.4; Log-rank P < .0001). Moreover, a statistically significant correlation was also founded between CTC detection during treatment and radiographic findings at the 6 month staging. This correlation applied to CTC results before therapy (odds ratio (OR), 6.22), 1 to 4 weeks after beginning of treatment (OR, 5.50), 5 to 8 weeks after beginning of treatment (OR, 7.94) 9 to 12 weeks after beginning of treatment (OR, 14.00) and overall CTC fluctuation during the course of treatment (OR, 20.57). CONCLUSION: The present study provides evidence of a strong correlation between CTC detection and radiographic disease progression in patients receiving chemotherapy for colorectal cancer. Our results suggest that in addition to the current prognostic factors, CTC analysis represent a potential complementary tool for prediction of colorectal cancer patients' outcome. Moreover, the present test allows for molecular characterization of CTCs, which may be of relevance to the creation of personalized therapies.

Multimarker gene analysis of circulating tumor cells in pancreatic cancer patients: a feasibility study.

OBJECTIVE: The aim of this study was to develop an immunomagnetic/real-time reverse transcriptase polymerase chain reaction (RT-PCR) assay and assess its clinical value for the molecular detection of circulating tumor cells (CTCs) in peripheral blood of pancreatic cancer patients. METHODS: The presence of CTCs was evaluated in 34 pancreatic cancer patients before systemic therapy and in 40 healthy controls, through immunomagnetic enrichment, using the antibodies BM7 and VU1D9 [targeting mucin 1 and epithelial cell adhesion molecule (EpCAM), respectively], followed by real-time RT-PCR analysis of the genes KRT19, MUC1, EPCAM, CEACAM5 and BIRC5. RESULTS: The developed assay showed high specificity, as none of the healthy controls were found to be positive for the multimarker gene panel. CTCs were detected in 47.1% of the pancreatic cancer patients before the beginning of systemic treatment. Shorter median progression-free survival (PFS) was observed for patients who had at least one detectable tumor-associated transcript, compared with patients who were CTC negative. Median PFS time was 66.0 days [95% confidence interval (CI) 44.8-87.2] for patients with baseline CTC positivity and 138.0 days (95% CI 124.1-151.9) for CTC-negative patients (p = 0.01, log-rank test). CONCLUSION: Our results suggest that in addition to the current prognostic methods, CTC analysis represents a potential complementary tool for prediction of outcome in pancreatic cancer patients.

Development of a molecular multimarker assay for the analysis of circulating tumor cells in adenocarcinoma patients.

BACKGROUND: The analysis of circulating tumor cells (CTCs) is emerging as a promising diagnostic tool in oncology. However, even if a variety of methods for CTC isolation have been already developed, their specificity and/or sensitivity still remain problematic. The aim of this study was to develop an immunomagnetic/real-time reverse transcription polymerase chain reaction (RT-PCR) assay for the molecular detection of circulating tumor cells (CTCs) in peripheral blood (PB) of adenocarcinoma cancer patients. METHODS: The presence of CTCs was evaluated in 945 PB blood samples from 247 adenocarcinoma cancer patients and in 42 healthy controls by immunomagnetic enrichment using the antibodies BM7 and VU1D9 followed by real-time RT-PCR analysis of the marker genes KRT19, MUC1, EPCAM, CEACAM5, BIRCS, SCGB2A2, and ERBB2. RESULTS: The developed assay showed not only high specificity, as none of the healthy controls were found positive for the multimarker gene panel, but also great sensitivity as CTCs were detected in adenocarcinomas arising from 10 different organs. According to tumor primary origin, CTC positivity was detected in 33.3% of Ampulla of Vater adenocarcinomas, 69.6% of bile ducts adenocarcinomas, 61.3% of breast adenocarcinomas, 61.3% of cardia adenocarcinomas, 60.6% of colon adenocarcinomas, 66.7% of esophagus adenocarcinomas, 57.1% of pancreas adenocarcinomas, 66.7% of rectum adenocarcinomas, 33.3% of small intestine adenocarcinomas, and 62.2% of stomach adenocarcinomas. CONCLUSIONS: Our results suggest that the current developed technique can be used to detect CTCs in all major adenocarcinomas, with great sensitivity without compromising specificity.

The PACOVAR-trial: a phase I/II study of pazopanib (GW786034) and cyclophosphamide in patients with platinum-resistant recurrent, pre-treated ovarian cancer.

BACKGROUND: The prognosis of patients with recurrent, platinum-resistant epithelial ovarian cancer (EOC) is poor. There is no standard treatment available. Emerging evidence suggests a major role for antiangiogenic treatment modalities in EOC, in particular in combination with the metronomic application of low dose chemotherapy. The novel, investigational oral antiangiogenic agent pazopanib targeting vascular endothelial growth factor receptor (VEGFR), platelet-derived growth factor receptor (PDGFR) and c-kit is currently being studied in different tumour types and is already used as first line therapy in recurrent renal cell carcinoma. A combined therapy consisting of pazopanib and metronomic oral cyclophosphamide may offer a well-tolerable treatment option to patients with recurrent, pretreated EOC. METHODS/DESIGN: This study is designed as a multicenter phase I/II trial evaluating the optimal dose for pazopanib (phase I) as well as activity and tolerability of a combination regimen consisting of pazopanib and metronomic cyclophosphamide in the palliative treatment of patients with recurrent, platinum-resistant, pre-treated ovarian cancer (phase II). The patient population includes patients with histologically or cytologically confirmed diagnosis of EOC, cancer of the fallopian tube or peritoneal cancer which is platinumresistant or -refractory. Patients must have measurable disease according to RECIST criteria and must have failed available standard chemotherapy. Primary objectives are determination of the optimal doses for pazopanib (phase I) and the overall response rate according to RECIST criteria (phase II). Secondary objectives are time to progression, overall survival, safety and tolerability. The treatment duration is until disease progression or intolerability of study drug regimen (with a maximum of 13 cycles up to 52 weeks per subject). DISCUSSION: The current phase I/II trial shall clarify the potential of the multitargeting antiangiogenic tyrosinkinaseinhibitor GW 786034 (pazopanib) in combination with oral cyclophosphamide as salvage treatment in patients with recurrent, pretreated ovarian cancer.

3'-Deoxy-3'-[(18)F]fluorothymidine (FLT) uptake in breast cancer cells as a measure of proliferation after doxorubicin and docetaxel treatment.

INTRODUCTION: The nucleoside analogue [(18)F]fluorothymidine (FLT) has been designed as a marker of cell proliferation that can be imaged in vivo by positron emission tomography. Clinical pilot studies have demonstrated decreasing FLT uptake following antiproliferative chemotherapy of breast cancer. However, the significance of posttreatment FLT uptake has not been evaluated at the cell level. The aim of this study was to investigate whether FLT uptake detects proliferation inhibition induced by docetaxel or doxorubicin treatment in an in vitro breast cancer model. METHODS: Breast cancer cells (MCF-7) were treated with docetaxel or doxorubicin for 24 h at drug doses inducing 25-99% inhibition of clonogenic survival (IC(25) to IC(99)). Cellular FLT uptake was estimated at 4 h and at 1, 3 and 5 days interval from chemotherapy. [(3)H]Thymidine incorporation and S-phase fraction were measured for comparison. Analysis of variance and the Bland-Altman difference plot were employed for statistical analysis. RESULTS: After treatment, FLT uptake was declined in dependence of the proliferation inhibition mediated by both chemotherapeutic agents (all P<.0001). The decrease of FLT was greater after doxorubicin treatment than after the corresponding docetaxel dose. With doxorubicin (IC(99)), FLT accumulation was reduced by 70% as early as 4 h after treatment. FLT uptake was closely correlated to [(3)H]thymidine incorporation and S-phase fraction (r=.84 to .93). CONCLUSIONS: Right after docetaxel or doxorubicin treatment, FLT uptake corresponds to the reduction of tumor cell proliferation induced. [(18)F]FLT appears promising for monitoring chemosensitivity in breast cancer.

Cell growth stimulation by CRASH, an asparaginase-like protein overexpressed in human tumors and metastatic breast cancers.

The gene encoding CRASH, a human asparaginase-like protein, has been cloned and its transcriptional activation has been detected in gynecologic cancers. To define the expression of CRASH in human tumors and its possible functional role, monoclonal antibodies against the CRASH protein have been generated. In non-transformed tissues CRASH was only detected in testis, brain, esophagus, prostate and proliferating endometrium. On the other hand, 36/50 ovarian carcinomas, 16/78 mammary carcinomas, 6/6 uroepithelial bladder carcinomas and 5/33 colon carcinomas scored positive for CRASH, with the absence of reactivity in the corresponding normal tissues. Strikingly, 11 out of the 16 breast cancers that expressed CRASH were metastatic, nominating CRASH to be functionally relevant in tumor progression. Twenty-eight out of 42 endometrium tumors expressed CRASH at high levels as did 5/41 prostate carcinomas, as well as ovary and breast cancers, indicating a regulation of CRASH expression by sex hormones. A bona fide estrogen responsive element was detected at bases -201/-183. This proved to be highly preserved across species, supporting an actual functional role. Asparaginase-like proteins play a role in growth regulation and signaling by p70 S6 kinase. The somatic knock-out of CRASH resulted in significant inhibition of growth of KM12L4A colon carcinoma cells, which abundantly express CRASH, whereas the proliferation of the syngeneic, weakly-expressing, slowly-growing KL12SM was not affected. These results are consistent with a selective growth advantage for aggressive cancers expressing CRASH, and nominate CRASH as a novel diagnostic and therapeutic tumor target.

Prognostic impact of hemoglobin levels before and during carboplatin/taxane-based chemotherapy in patients with primary invasive epithelial ovarian cancer.

BACKGROUND: Carboplatin/taxane-based chemotherapy is the standard treatment for advanced primary ovarian cancer. Anemia is a frequent side effect of platinum-containing chemotherapy regimens. Furthermore, ovarian cancer is often associated with tumor anemia. The aim of this study was to evaluate the prognostic relevance of the mean hemoglobin level before and during carboplatin/taxane-based chemotherapy. MATERIAL/METHODS: We studied retrospectively 92 patients with primary invasive epithelial ovarian cancer (EOC) receiving carboplatin/taxane-based chemotherapy. Hemoglobin levels were determined before each cycle of therapy. Study objectives were progression-free survival time (PFS) and overall survival time (OS). Univariate analyses and Cox-regression studies were undertaken to evaluate the prognostic impact of hemoglobin levels before and throughout chemotherapy. In addition, sensitivity/specificity analyses and Kaplan-Meier-studies were performed to determine the cut-off level of prognostically relevant hemoglobin levels. RESULTS: In univariate analysis hemoglobin levels throughout chemotherapy showed prognostic relevance in terms of PFS (p<0.05). Sensitivity/specificity and Kaplan-Meier analyses found a hemoglobin level of 11.2 g/dL to be a prognostically relevant cut-off level in terms of PFS (p<0.05). There was a borderline significance for pretherapeutic hemoglobin levels to influence PFS (p=0.07), with a prognostically relevant cut-off level of 11.6 g/dL (p=0.06). CONCLUSIONS: Hemoglobin levels before and particularly throughout therapy seem to have prognostic relevance for patients with primary EOC undergoing carboplatin/taxane-based chemotherapy. Further trials are required to confirm these data in a prospective attempt and to evaluate the role of correcting anemia as standard supportive therapy in the treatment of patients with primary EOC.

Extensive Osler-Rendu disease in a breast cancer patient: increasing hepatic arteriovenous malformations under endocrine therapy mimicking liver metastases.

BACKGROUND: Undefined, increasing hepatic lesions are a common issue in the follow-up care of breast cancer patients and frequently result in invasive diagnostic procedures. CASE REPORT: This case report describes the diagnostic approach in the case of a 58-year-old breast cancer patient with a previously unknown visceral involvement of Osler-Rendu disease. The patient was admitted to our institution because of newly diagnosed, increasing hepatic lesions occurring during endocrine treatment with aromatase inhibitors. On the basis of ultrasound findings, secondary liver metastases were suspected. After a thorough clinical and imaging examination, we reviewed the literature on typical radiological findings of visceral involvement of Osler-Rendu disease, and the impact of endocrine treatment on arteriovenous malformations. Multislice computed tomography scan identified the hepatic lesions as arteriovenous malformations. In the current literature, there are no reports available on the interaction between aromatase inhibitors and arteriovenous malformations. However, some data do show an effect of endocrine therapy with estrogen/progesterone, or tamoxifen on arteriovenous malformations, although some of the results are partially contradictory. CONCLUSION: This case report demonstrates that for undefined hepatic lesions in breast cancer patients, extensive Osler-Rendu disease should be considered as a potential differential diagnosis. Furthermore, we discuss the possible influence of aromatase inhibitors on arteriovenous malformations.

Treatment landscape of advanced breast cancer patients with hormone receptor positive HER2 negative tumors - Data from the German PRAEGNANT breast cancer registry.

PURPOSE: This study describes comprehensive data from a breast cancer registry concerning the use of endocrine treatment (ET) and chemotherapy in the first, second and higher therapy lines in hormone receptor (HR) positive, HER2 negative metastatic breast cancer (MBC). METHODS: The PRAEGNANT study is a real-time registry for patients with MBC. Therapies were categorized into the following categories: chemotherapy, aromatase inhibitor (AI), tamoxifen, fulvestrant, or everolimus plus ET and reported for first, second and third line or higher therapy use. Also treatment sequences for the first, second and third therapy line were analyzed. RESULTS: This analysis includes 958 patients with HR positive, HER2 negative MBC. 42.7% were treated with a chemotherapy in the first therapy line compared to 45.9% receiving an ET. A total of 25.9% were treated with everolimus plus anti-hormone therapy in any therapy line. 34.1% were treated with fulvestrant as single agent therapy. Analyzing therapy sequences, the administration of three different chemotherapies in a row was the most frequently used pattern. CONCLUSIONS: This analysis shows that across all three first therapy lines chemotherapy is a dominant therapy for HR positive, HER2 negative MBC patients. Education about the efficacy of ET might help to increase its use and decrease the possible burden of chemotherapy related toxicities.

Interest in Integrative Medicine Among Postmenopausal Hormone Receptor-Positive Breast Cancer Patients in the EvAluate-TM Study.

BACKGROUND: Breast cancer patients often use complementary and alternative medicine, but few prospectively collected data on the topic are available specifically for postmenopausal breast cancer patients. A large prospective study was therefore conducted within a noninterventional study in order to identify the characteristics of patients interested in integrative medicine. METHODS: The EvAluate-TM study is a prospective, multicenter noninterventional study in which treatment with the aromatase inhibitor letrozole was evaluated in postmenopausal women with hormone receptor-positive primary breast cancer. Between 2008 and 2009, 5045 postmenopausal patients were enrolled at 339 certified breast centers in Germany. As part of the data collection process, patients were asked at the baseline about their interest in and information needs relating to integrative medicine. RESULTS: Of the 5045 patients recruited, 3411 responded to the questionnaire on integrative medicine and took part in the analysis, 1583 patients expressed an interest in integrative medicine, and 1828 patients declared no interest. Relevant predictors of interest in integrative medicine were age, body mass index, tumor size, previous chemotherapy, and use of concomitant medications for other medical conditions. Interest in integrative medicine declined highly significantly ( P < .001) with age (<50 years, 74.1%; 50-60 years, 54.1%; >65 years, 38.0%). Patients in favor of integrative medicine were significantly less satisfied with the information received about individual treatments and antihormonal therapy. Patients with interest in integrative medicine were more often interested in rehabilitation and fitness, nutritional counseling, and additional support from self-help organizations. These women were mostly interested in receiving information about their disease and integrative medicine from a physician, rather than from other sources. CONCLUSIONS: This study shows that a considerable proportion of postmenopausal breast cancer patients are interested in integrative medicine. Information about integrative medicine should therefore be provided as part of patient care for this group. It was found that receiving concomitant medication for other medical conditions is one of the main predictors for women not being interested in integrative medicine. This group of patients may need special attention and individualized information about integrative medicine. Additionally, most patients were interested in obtaining the relevant information from their doctor.

Factors Influencing Decision-Making for or against Adjuvant and Neoadjuvant Chemotherapy in Postmenopausal Hormone Receptor-Positive Breast Cancer Patients in the EvAluate-TM Study.

BACKGROUND: Decision-making for or against neoadjuvant or adjuvant chemotherapy in postmenopausal patients with hormone receptor-positive breast cancer does not follow any clear guidelines, and some patients may unnecessarily undergo chemotherapy and be exposed to the associated toxicity. The aim of this study was to identify the patient population for whom this issue may bear relevance. METHODS: Patients being treated with letrozole in the prospective multicenter noninterventional EvAluate-TM study were recruited. The percentage of patients receiving chemotherapy and factors associated with chemotherapy administration were identified. RESULTS: In all, 3,924 (37.4%) patients received chemotherapy before treatment with letrozole. Of these, 293 (20%) underwent neoadjuvant therapy. Younger age was predictive for both adjuvant and neoadjuvant therapy. Overall, decisions in favor of administering chemotherapy are more likely to be made in patients with a higher body mass index (BMI), and neoadjuvant chemotherapy is administered at a higher rate in women with a lower BMI. Concomitant medication influenced the overall decision-making regarding chemotherapy, irrespective of whether it was given on a neoadjuvant or adjuvant basis. CONCLUSION: There is an ongoing debate as to whether all of the many patients who receive chemotherapy actually benefit from it. Neoadjuvant chemotherapy is frequently administered in this patient population, and this should encourage further research to resolve current clinical and research issues.

Diagnostic potential of targeted electrical impedance scanning in classifying suspicious breast lesions.

RATIONALE AND OBJECTIVE: To evaluate the potential of targeted electrical impedance scanning (EIS) for classifying suspicious breast lesions. METHODS: EIS was performed in full knowledge of mammographic findings and findings of clinical breast examination. One hundred seventeen patients with a total of 129 breast lesions were examined with EIS before breast biopsy (surgical excision or vacuum core biopsy). Diagnostic indexes of targeted EIS were calculated depending on major lesion characteristics. Capacitance and conductivity of all positive spots (S) and the surrounding normal breast tissue (NBT) were quantified using ROI measurements. The ratio S/NBT was calculated to compare true positive (n = 44) and false positive (n = 18) spots. RESULTS: With respect to histology, of the 129 lesions 71 were malignant and 58 lesions were benign. Overall sensitivity of targeted EIS was 62%, specificity 69%, PPV 71%, and NPV 60%. Sensitivity of EIS varied depending on the tumor size, which was between 48% (> 20 mm) and 71% (11-20 mm). Highest specificity (86%) was observed for large lesions (> 20 mm); however, the NPV was only 35% for lesions of that size. NPV was higher for nonpalpable lesions (74%) and clusters of microcalcifications (85.7%) compared with palpable lesions (39%) and solid lesions (44%). There was no statistical difference of S/NBT ratio neither for conductivity nor capacitance of true and false positive spots. Compared with true positive spots a trend of a higher conductivity ratio at 100 Hz and 200 Hz was seen for false positive spots. CONCLUSION: EIS showed mediocre overall diagnostic accuracy for classifying suspicious breast lesions. Quantitative analysis of positive EIS findings did not help to differentiate between false and true positive spots.

Multimarker Analysis of Circulating Tumor Cells in Peripheral Blood of Metastatic Breast Cancer Patients: A Step Forward in Personalized Medicine.

AIM: To develop an immunomagnetic assay for the isolation of circulating tumor cells (CTCs) followed by the analysis of a multimarker panel, which will enable the characterization of these malignant cells with high accuracy. PATIENTS AND METHODS: Peripheral blood (PB) was collected from 32 metastatic breast cancer patients and 42 negative controls. The antibodies BM7 and VU1D9 were used for immunomagnetic tumor cell enrichment. A real-time reverse transcription-polymerase chain reaction (RT-PCR) approach for the markers KRT19, SCGB2A2, MUC1, EPCAM, BIRC5 and ERBB2 was used for CTC detection and characterization. RESULTS: THE POSITIVITY RATES FOR EACH MARKER WERE AS FOLLOWS: 46.9% for KRT19, 25.0% for SCGB2A2, 28.1% for MUC1, 28.1% for EPCAM, 21.9% for BIRC5, and 15.6% for ERBB2. After the creation of individualized cutoffs, the sensitivity and specificity of the combined marker gene panel increased to 56.3% and 100%, respectively. Interestingly, 27.0% of the HER2-negative tumor patients showed ERBB2 mRNA-positive CTCs. CONCLUSIONS: The described technique can be used to measure CTCs with great accuracy. The use of a multimarker panel for the characterization of CTCs may provide real-time information and be of great value in therapy monitoring.

MR imaging-detected breast lesions: histopathologic correlation of lesion characteristics and signal intensity data.

OBJECTIVE: The aim of our study was to differentiate benign from malignant breast lesions that had been detected exclusively on MR imaging by analyzing qualitative and quantitative lesion characteristics. MATERIALS AND METHODS: We performed 51 MR imaging-guided breast interventions (41 preoperative lesion localizations and 10 large-core needle biopsies) in 45 patients with exclusively MR imaging-detected lesions. All patients had previously undergone diagnostic dynamic contrast-enhanced MR imaging of the breast with a double breast coil at 1.0 T (n = 36) or 1.5 T (n = 15). The diagnostic MR images were evaluated on a workstation. Lesion morphology (size, shape, margin type, enhancement pattern), signal intensity parameters (time to peak enhancement, maximum slope of enhancement curve, washout, relative water content), and scores analogous to the Breast Imaging Reporting and Data System (BI-RADS) categories were correlated with histology. RESULTS: Histology revealed malignancy in 37.3% (19/51) of the lesions. The positive predictive value for malignancy of exclusively MR imaging-detectable lesions increased as the analogous BI-RADS category increased. Late inhomogeneous contrast enhancement was the only morphologic criterion that was statistically significantly correlated with malignancy. Malignant and benign lesions did not differ significantly in any of the quantitatively evaluated signal intensity parameters. Carcinomas showed a tendency toward faster and stronger enhancement and stronger washout. CONCLUSION: The classification of exclusively MR imaging-detectable breast lesions according to a combination of morphologic and perfusion parameters including the late enhancement pattern helps identify the lesions for which interventional MR imaging is required. Quantitative signal intensity data alone do not suffice.

PET with [18F]fluorothymidine for imaging of primary breast cancer: a pilot study.

The aim of this study was to evaluate the use of [(18)F]fluorothymidine (FLT) as a positron emission tomography (PET) tracer for the diagnosis of breast cancer. To this end, 12 patients with 14 primary breast cancer lesions (T2-T4) were studied by FLT-PET. For comparison, [(18)F]fluorodeoxyglucose (FDG) PET scans were performed in six patients. Thirteen of the 14 primary tumours demonstrated focally increased FLT uptake (SUV(mean)=3.4+/-1.1). Seven out of eight patients with histologically proven axillary lymph node metastases showed focally increased FLT uptake in the corresponding areas (SUV(mean)=2.4+/-1.2). The lowest SUV (mean =0.7) was observed in one of two inflammatory cancers. The contrast between primary tumours or metastases and surrounding tissue was high in most cases. In direct comparison to FDG-PET, the SUVs of primary tumours (5/6) and axillary lymph node metastases (3/4) were lower in FLT-PET (SUV(FLT): 3.2 vs SUV(FDG): 4.7 in primary tumours and SUV(FLT): 2.9 vs SUV(FDG): 4.6 in lymph node metastases). Since FLT uptake in surrounding breast tissue was also lower, tumour contrast was comparable to that with FDG. It is of note that normal FLT uptake was very low in the mediastinum, resulting in a higher tumour-to-mediastinum ratio as compared to FDG ( P=0.03). FLT-PET is suitable for the diagnosis of primary breast cancer and locoregional metastases. High image contrast may facilitate the detection of small foci, especially in the mediastinum.