Combined pathologic-genomic algorithm for early-stage breast cancer improves cost-effective use of the 21-gene recurrence score assay.

Background: The 21-gene recurrence score (RS) (Oncotype DX®; Genomic Health, Redwood City, CA) partitions hormone receptor positive, node negative breast cancers into three risk groups for recurrence. The Anne Arundel Medical Center (AAMC) model has previously been shown to accurately predict RS risk categories using standard pathology data. A pathologic-genomic (P-G) algorithm then is presented using the AAMC model and reserving the RS assay only for AAMC intermediate-risk patients. Patients and methods: A survival analysis was done using a prospectively collected institutional database of newly diagnosed invasive breast cancers that underwent RS assay testing from February 2005 to May 2015. Patients were assigned to risk categories based on the AAMC model. Using Kaplan-Meier methods, 5-year distant recurrence rates (DRR) were evaluated within each risk group and compared between AAMC and RS-defined risk groups. Five-year DRR were calculated for the P-G algorithm and compared with DRR for RS risk groups and the AAMC model's risk groups. Results: A total of 1268 cases were included. Five-year DRR were similar between the AAMC low-risk group (2.7%, n = 322) and the RS < 18 low-risk group (3.4%, n = 703), as well as between the AAMC high-risk group (22.8%, n = 230) and the RS > 30 high-risk group (23.0%, n = 141). Using the P-G algorithm, more patients were categorized as either low or high risk and the distant metastasis rate was 3.3% for the low-risk group (n = 739) and 24.2% for the high-risk group (n = 272). Using the P-G algorithm, 44% (552/1268) of patients would have avoided RS testing. Conclusions: AAMC model is capable of predicting 5-year recurrences in high- and low-risk groups similar to RS. Further, using the P-G algorithm, reserving RS for AAMC intermediate cases, results in larger low- and high-risk groups with similar prognostic accuracy. Thus, the P-G algorithm reliably identifies a significant portion of patients unlikely to benefit from RS assay and with improved ability to categorize risk.

Obesity and impaired prohormone processing associated with mutations in the human prohormone convertase 1 gene.

Human obesity has an inherited component, but in contrast to rodent obesity, precise genetic defects have yet to be defined. A mutation of carboxypeptidase E (CPE), an enzyme active in the processing and sorting of prohormones, causes obesity in the fat/fat mouse. We have previously described a women with extreme childhood obesity (Fig. 1), abnormal glucose homeostasis, hypogonadotrophic hypogonadism, hypocortisolism and elevated plasma proinsulin and pro-opiomelanocortin (POMC) concentrations but a very low insulin level, suggestive of a defective prohormone processing by the endopeptidase, prohormone convertase 1 (PC1; ref. 4). We now report this proband to be a compound heterozygote for mutations in PC1. Gly-->Arg483 prevents processing of proPC1 and leads to its retention in the endoplasmic reticulum (ER). A-->C+4 of the intro-5 donor splice site causes skipping of exon 5 leading to loss of 26 residues, a frameshift and creation of a premature stop codon within the catalytic domain. PC1 acts proximally to CPE in the pathway of post-translational processing of prohormones and neuropeptides. In view of the similarity between the proband and the fat/fat mouse phenotype, we infer that molecular defects in prohormone conversion may represent a generic mechanism for obesity, common to humans and rodents.

Pathology-based staging for HPV-positive squamous carcinoma of the oropharynx.

OBJECTIVE: The rapid worldwide rise in incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has generated studies confirming this disease as an entity distinct from traditional OPSCC. Based on pathology, surgical studies have revealed prognosticators specific to HPV-positive OPSCC. The current AJCC/UICC staging and pathologic nodal (pN)-classification do not differentiate for survival, demonstrating the need for new, HPV-specific OPSCC staging. The objective of this study was to define a pathologic staging system specific to HPV-positive OPSCC. METHODS: Data were assembled from a surgically-managed, p16-positive OPSCC cohort (any T, any N, M0) of 704 patients from five cancer centers. Analysis was performed for (a) the AJCC/UICC pathologic staging, (b) newly published clinical staging for non-surgically managed HPV-positive OPSCC, and (c) a novel, pathology-based, "HPVpath" staging system that combines features of the primary tumor and nodal metastases. RESULTS: A combination of AJCC/UICC pT-classification and pathology-confirmed metastatic node count (⩽4 versus ⩾5) yielded three groups: stages I (pT1-T2, ⩽4 nodes), II (pT1-T2, ⩾5 nodes; pT3-T4, ⩽4 nodes), and III (pT3-T4, ⩾5 nodes), with incrementally worse prognosis (Kaplan-Meier overall survival of 90%, 84% and 48% respectively). Existing AJCC/UICC pathologic staging lacked prognostic definition. Newly published HPV-specific clinical stagings from non-surgically managed patients, although prognostic, showed lower precision for this surgically managed cohort. CONCLUSIONS: Three loco-regional "HPVpath" stages are identifiable for HPV-positive OPSCC, based on a combination of AJCC/UICC primary tumor pT-classification and metastatic node count. A workable, pathologic staging system is feasible to establish prognosis and guide adjuvant therapy decisions in surgically-managed HPV-positive OPSCC.

Acute rupture of myxomatous mitral valve presenting as refractory cardiopulmonary arrest.

A 59 year old white woman had an out of hospital sudden cardiac arrest. Resuscitation at the scene restored spontaneous pulse, blood pressure and respiration but cardiovascular collapse recurred within 30 minutes of hospital arrival. Medically refractory cardiogenic shock of unclear origin prompted the placement of an intraaortic balloon pump, and hemodynamic stabilization was achieved over several hours. Acute rupture of the chordae tendineae of myxomatous mitral valve was diagnosed as the cause of the cardiac arrest. Mitral valve replacement was performed and the patient made an uneventful recovery. This report describes the first known case of rupture of a myxomatous mitral valve presenting as sudden cardiac death. The differential diagnosis of sudden death in this disorder is reviewed, the role of mechanical circulatory assistance in refractory cardiac arrest is discussed and several interesting hemodynamic aspects of the case are considered.

Tickborne oculoglandular tularemia: case report and review of seasonal and vectorial associations in 106 cases.

A patient acquired tickborne oculoglandular tularemia in early summer in rural Virginia. Tick exposure may be a clue to the diagnosis of tularemia in the eastern as well as the western United States, especially in summer months. A review of the experience with tularemia in Virginia for the last 13 years shows a bimodal seasonal incidence of tularemia with an associated vector exposure in 77.4% of 106 cases. The majority of cases occurring during winter months have been associated with rabbit exposure, while those in summer months are often associated with tick exposure.

The role of melanocortin signalling in the control of body weight: evidence from human and murine genetic models.

The peptide products of the pro-opiomelanocortin (POMC) gene have established roles in the control of physiological processes as diverse as adrenal steroidogenesis, skin pigmentation, analgesia and inflammation. In the last 5 years, evidence accumulated from murine and human genetic models of disrupted melanocortin signalling has firmly established a central role for a population of hypothalamic neurons expressing POMC in the control of appetite and body weight. Of the five known melanocortin receptors, the MC4R has been most closely linked to body weight regulation. While a-MSH is active at this receptor and suppresses appetite after central injection, important roles for other POMC-derived products have not been excluded. The development of pharmacological agonists acting on, or mimicking, the hypothalamic melanocortinergic pathway may provide exciting opportunities for the therapy of human obesity.

Capgras syndrome in adolescence.

Capgras syndrome, the delusion of substitution, has rarely been reported in adolescents. The etiology is unknown, and intense controversy surrounds the debate over the relative importance of biological versus psychological factors. Presented here are two cases of Capgras syndrome in adolescents and a review of the relevant biological, neuropsychological, and psychodynamic literature. The authors suggest that the psychological processes underlying the Capgras delusion are mediated by neuroanatomical connections between various brain areas and hypothesize that the fundamental lesion in Capgras syndrome may be the patient's inability or failure to acknowledge the authenticity of a person they clearly recognize.

Are patients with low serum thyroid stimulating hormone and normal total thyroxine hyperthyroid? Usefulness of 99mTc pertechnetate uptake.

The records of 107 patients who had had thyroid 99m Tc pertechnetate uptake measured, were reviewed. In patients with normal serum thyroxine (T4) and thyroid stimulating hormone (TSH), 35 of 36 with normal uptake and three with high uptake were clinically euthyroid. In patients with high serum T4 and low TSH, seven had normal and 29 had high uptake and all were clinically hyperthyroid. In patients with normal serum T4 and low TSH, 10 of 11 with high uptake were clinically hyperthyroid whereas only two of 18 with normal uptake were. The sensitivity, specificity and positive predictive value of pertechnetate uptake measurements were 83%, 94%, and 91%, respectively. The measurement of pertechnetate uptake is a rapid investigation and may help in the interpretation of patients with undetectable serum TSH found in the presence of normal serum T4.

Comparison of paired short Synacthen and insulin tolerance tests soon after pituitary surgery.

The cortisol responses to hypoglycaemia (insulin tolerance test, ITT) and tetracosactrin (short Synacthen test, SST) were compared after hypophysectomy to evaluate the SST for the assessment of hypothalamo-pituitary-adrenocortical (HPA) axis function in the immediate post-operative period. In 12 patients who were tested a mean of 21 months postoperatively (range 1-96) peak plasma cortisol in the SST correlated with that in the ITT (r = 0.90). Correlation was also seen in 12 patients tested a mean of 9 days (range 4-18) after hypophysectomy (r = 0.73). Basal-peak cortisol increments did not correlate. The peak plasma cortisol response in each test was classified by comparison with a reference value of 550 nmol/L. On this basis there was a notable discrepancy between the ITT and SST results in only one patient who was tested 4 days after hypophysectomy. The close correlation between ITT and SST responses after pituitary surgery extends into the immediate post operative period and indicates that the latter test can be used to screen HPA axis function at this time.

Vertebral artery anomaly with atraumatic dissection causing thromboembolic ischemia: a case report.

STUDY DESIGN: A case report is presented. OBJECTIVES: To illustrate a rare cause of atraumatic vertebral artery dissection resulting from anomalous entry of the vessel at the C3 transverse foramen induced by normal physiologic head and neck motion, and to review vertebral artery anatomy and mechanisms whereby it is vulnerable to pathologic compression. SUMMARY OF BACKGROUND DATA: The vertebral artery usually enters the transverse foramen at C6. Rarely, the artery enters at C5 or C4. Only one prior case with entry at C3 has been reported. That patient experienced recurrent quadriplegia and locked-in syndrome caused by vertebral artery obstruction. A 27-year-old woman with a history of classic migraine experienced neurologic symptoms on three occasions related to physiologic neck and arm movements. Magnetic resonance angiogram was not diagnostic, but standard arteriography demonstrated anomalous vertebral artery entry into the C3 transverse foramen and focal dissection. METHODS: Pertinent literature and the patient's history, physical examination, and radiologic studies were reviewed. RESULTS: Standard cervico-cerebral arteriogram demonstrated focal dissection at C4 and thromboembolic complications in distal vertebral and basilar arteries. Initially, diagnosis by magnetic resonance angiogram was elusive. However, arteriography allowed prompt diagnosis followed by anticoagulation with resolution of neurologic symptoms. CONCLUSIONS: Vertebral artery dissection without trauma is rare, but should be considered when neurologic symptoms accompany physiologic cervical movements. For cases in which vertebrobasilar thromboembolic ischemia is suspected, magnetic resonance angiogram may prove inadequate for demonstrating the causative vascular pathology. Therefore, standard cervico-cerebral arteriography should be performed.

Intermediate filament, laminin and integrin expression in lacrimal gland acinar cells: comparison of an immortalized cell line to primary cells, and their response to retinoic acid.

PURPOSE: The goal of this study was to characterize intermediate filament, integrin and laminin expression by rabbit lacrimal gland acinar cells in culture, to determine whether retinoic acid (RA) alters expression of these proteins and to compare primary cells to an immortalized rabbit lacrimal gland acinar cell line using flow cytometric analysis. METHODS: Primary cells, maintained in serum free medium, were exposed to 10(-6) M retinoic acid for 24 hours. Immortalized cells were grown in defined medium with Nu-Serum and exposed to retinoic acid. Cells were labeled with monoclonal antibodies to cytokeratins (AE1, AE2, AE3, AE5, CK10/13, CK18), integrins (alpha(3), alpha(6), alpha(V), beta(1), beta(2), beta(3) and beta(4)), laminin, or vimentin and with FITC-conjugated secondary antibodies. Cells were analyzed for antigen expression by flow cytometry and immunocytochemistry. RESULTS: Primary and immortalized cells expressed type I and type II epithelial cytokeratins (AE1 and AE3), cytokeratin 18, and cytokeratin 3 (AE5) Both cell types were negative to AE2 and CK10/13. Primary and immortalized cells expressed vimentin in culture, with immortalized cells expressing this protein at higher levels. Lacrimal acinar cells appear to synthesize laminin which was detected intracellularly in both cells types. Integrins alpha(6) (CD49f) and alpha(V) (CD51) were expressed by primary and immortalized cells. Expression of integrin alpha(6) was 10-fold higher in immortalized cells compared to primary cells. Retinoic acid increased integrin alpha( V) expression by primary and immortalized cells 1.3-fold and 3-fold, respectively, and caused a slight increase in integrin alpha(6) expression by primary cells. Both cell types also expressed integrins beta( 1), beta(2) and beta(3), but beta(4) was detected only in immortalized cells. Lacrimal acinar cells do not express integrin alpha(3). CONCLUSIONS: Expression of cytokeratins, laminin and integrins by primary and immortalized cells was similar, suggesting that the immortalized cell line is a good model for the study of lacrimal structure and function. Since retinoic acid up-regulated only integrin alpha(V), but not cytokeratins, these cells appear to be highly differentiated. Flow cytometry is a useful method for analysis of protein expression by lacrimal acinar cells.

The African American church and university partnerships: establishing lasting collaborations.

This article highlights the experiences of the Health Wise Church Project, a community outreach initiative between a diverse group of African American churches and a university health education program. The objective of the program was to develop early detection and illness prevention networks among older church members. Not all partnerships results in long-term collaborations, and this article makes a clear distinction between different types of "working together" arrangements. The project discussed in this article presents a four-stage model to illustrate how organizations achieve collaborative partnerships. Involving community partners in the early phase of project planning contributed to the success of the church-university collaboration. This type of shared planning helped to sustain community interest during the project's implementation.

Implementing continuous quality improvement in primary care: implications for preventive services.

The implementation of CQI must be done in a manner that capitalizes on the challenges of primary care, including the professional autonomy of the physician, the availability of data, issues of cost and efficiency of service, and the expanding role of patient expectations in quality care. Analysis of these factors is based on an ongoing study designed to help community-based primary care practices increase the utilization of prevention and early detection services offered to patients.

A reciprocal role of prostate cancer on stromal DNA damage.

DNA damage found in prostate cancer-associated fibroblasts (CAF) promotes tumor progression. In the absence of somatic mutations in CAF, epigenetic changes dictate how stromal coevolution is mediated in tumors. Seventy percent of prostate cancer patients lose expression of transforming growth factor-beta type II receptor (TGFBR2) in the stromal compartment (n=77, P-value=0.0001), similar to the rate of glutathione S-transferase P1 (GSTP1) silencing. Xenografting of human prostate cancer epithelia, LNCaP, resulted in the epigenetic Tgfbr2 silencing of host mouse prostatic fibroblasts. Stromal Tgfbr2 promoter hypermethylation, initiated by LNCaP cells, was found to be dependent on interleukin 6 expression, based on neutralizing antibody studies. We further found that pharmacologic and transgenic knockout of TGF-ß responsiveness in prostatic fibroblasts induced Gstp1 promoter methylation. It is known that TGF-ß promotes DNA stability, however, the mechanism is not well understood. Both prostatic human CAF and mouse transgenic knockout of Tgbr2 had elevated DNA methyltransferase I (DNMT1) activity and histone H3 lysine 9 trimethylation (H3K9me3) to suggest greater promoter methylation. Interestingly, the conditional knockout of Tgfbr2 in mouse prostatic fibroblasts, in modeling epigenetic silencing of Tgfbr2, had greater epigenetic gene silencing of multiple DNA damage repair and oxidative stress response genes, based on promoter methylation array analysis. Homologous gene silencing was validated by reverse transcriptase (RT)-PCR in mouse and human prostatic CAF. Not surprisingly, DNA damage repair gene silencing in the prostatic stromal cells corresponded with the presence of DNA damage. Restoring the expression of the epigenetically silenced genes in wild-type fibroblasts with radiation-induced DNA damage reduced tumor progression. Tumor progression was inhibited even when epigenetic silencing was reversed in the Tgfbr2-knockout prostatic fibroblasts. Taken together, fibroblastic epigenetic changes causative of DNA damage, initiated by association with cancer epithelia, is a dominant mediator of tumor progression over TGF-ß responsiveness.