The impact of standardized structured reporting of pathology reports for breast cancer care.

PURPOSE: With the increasing complexity of modern oncological patient management and the growing amount of information needed from the pathologist, traditional narrative pathology reports (NR) do not suffice. Standardized synoptic reporting (SR) increases both completeness and readability. In the Netherlands SR for breast cancer was introduced in 2009. We explore the impact of synoptic reporting on breast cancer care. METHODS: Using data from the Netherlands Cancer Registry and Dutch Nationwide Pathology Databank, a retrospective population-based cohort study was performed. Data of breast cancer resections from 2007 to 2014 were collected to compare NR and SR for all outcome measures. Kaplan-Meier analyses and log-rank testing were used to estimate overall survival. RESULTS: Over time there was an increase from 12% to 78.9% in the use of SR. SR resulted in higher completeness of pathology reports, particularly for hormone and HER2/neu receptor status. Although there was no difference in the administration of antihormonal therapy, anti-HER2 treatment was more frequently administered to eligible patients in the SR group. An effect on overall survival could not yet be confirmed on multivariate analysis. CONCLUSIONS: We demonstrate that SR has led to more complete pathology reports, which meets the needs for precision of information in breast cancer care. This is expected to improve communication and discussions between specialists regarding parameters important for adjuvant breast cancer treatment decisions. SR thereby improves breast cancer care and leads to improved allocation of treatment based on pathologic parameters and more personalized treatment regimens.

DLL3 expression in large cell neuroendocrine carcinoma (LCNEC) and association with molecular subtypes and neuroendocrine profile.

OBJECTIVES: For stage IV pulmonary large cell neuroendocrine carcinoma (LCNEC), the only therapeutic option is palliative chemotherapy. DLL3 is a new therapeutic target, which seems to be often expressed in SCLC and LCNEC. It has recently been reported that DLL3 mRNA expression is particularly upregulated in the LCNEC subgroup with STK11/KEAP1 and TP53 co-mutations, in contrast to lower expression levels in RB1 and TP53 co-mutated LCNEC. Our aim was to investigate DLL3 protein expression in stage IV LCNEC and correlate data with mutational profiles (i.e.STK11/KEAP1/RB1), immunostaining results (pRb, NE markers) and clinical characteristics. MATERIALS AND METHODS: Immunohistochemical analysis for DLL3 (SC16.65) and ASCL1 (SC72.201) was performed on 94 and 51 FFPE tissue sections, respectively, of pathologically reviewed stage IV LCNEC. DLL3 and ASCL1 were scored positive if ≥1% of the tumor cells showed cytoplasmic/membranous or dotlike (DLL3) or nuclear (ASCL1) immunostaining. Data were correlated with available sequencing (TP53, RB1, STK11, KEAP1), immunostaining (pRb, NE markers) and clinical data. RESULTS: DLL3 was expressed in 70/94 (74%) LCNEC, 56 (80%) of which showed cytoplasmic/membranous staining. Median H-score was 55 (interquartile range 0-160). DLL3 staining was not different in pRb immunohistochemistry negative and positive patients (DLL3+ in 53/70 (76%) vs. 14/21 (67%), p = 0.409) or RB1 mutated and wildtype patients (DLL3+ in 27/34 (79%) vs. 23/33 (70%), p = 0.361). Nevertheless, 6/6 (100%) STK11 mutated, 10/11 (91%) KEAP1 mutated and 9/9 (100%) TP53 wildtype tumors were DLL3+ . Furthermore, DLL3 expression was associated with expression of ASCL1 and at least 2 out of 3 neuroendocrine markers. CONCLUSION: The high percentage (74%) of DLL3 expression in stage IV LCNEC denotes the potential of DLL3 targeted therapy in this patient group.

Large cell neuroendocrine carcinoma with a solitary brain metastasis and low Ki-67: a unique subtype.

INTRODUCTION: Stage IV large cell neuroendocrine carcinoma (LCNEC) of the lung generally presents as disseminated and aggressive disease with a Ki-67 proliferation index (PI) 40-80%. LCNEC can be subdivided in two main subtypes: the first harboring TP53/RB1 mutations (small-cell lung carcinoma (SCLC)-like), the second with mutations in TP53 and STK11/KEAP1 (non-small-cell lung carcinoma (NSCLC)-like). Here we evaluated 11 LCNEC patients with only a solitary brain metastasis and evaluate phenotype, genotype and follow-up. METHODS: Eleven LCNEC patients with solitary brain metastases were analyzed. Clinical characteristics and survival data were retrieved from medical records. Pathological analysis included histomorphological analysis, immunohistochemistry (pRB and Ki-67 PI) and next-generation sequencing (TP53, RB1, STK11, KEAP1 and MEN1). RESULTS: All patients had N0 or N1 disease. Median overall survival (OS) was 12 months (95% confidence interval (CI) 5.5-18.5 months). Mean Ki-67 PI was 59% (range 15-100%). In 6/11 LCNEC Ki-67 PI was ≤40%. OS was longer for Ki-67 ≤40% compared to >40% (17 months (95% CI 11-23 months) vs 5 months (95% CI 0.7-9 months), P = 0.007). Two patients were still alive at follow-up after 86 and 103 months, both had Ki-67 ≤40%. 8/11 patients could be subclassified, and both SCLC-like (n = 6) and NSCLC-like (n = 2) subtypes were present. No MEN1 mutation was found. CONCLUSION: Stage IV LCNEC with a solitary brain metastasis and N0/N1 disease show in the majority of cases Ki-67 PI ≤40% and prolonged survival, distinguishing them from general LCNEC. This unique subgroup can be both of the SCLC-like and NSCLC-like subtype.

Prevalence and prognostic value of PD-L1 expression in molecular subtypes of metastatic large cell neuroendocrine carcinoma (LCNEC).

BACKGROUND: Pulmonary large cell neuroendocrine carcinoma (LCNEC) is a rare tumor with high mutational burden. Two subtypes of LCNEC are recognized, the co-mutated TP53 and RB1 group and the TP53 and STK11/KEAP1 group. We investigated PD-L1 and CD8 expression in a well characterized stage IV LCNEC cohort and compared expression in the two subtypes. METHODS: Immunohistochemical (IHC) analysis for PD-L1 and CD8 was performed on pathological reviewed pretreatment tumor samples for 148 stage IV LCNEC. Data about targeted next generation sequencing (TNGS) (TP53, RB1, STK11, KEAP1) and IHC for RB1 were available for most tumors. IHC staining for PD-L1 (DAKO 28-8) was performed and scored positive if tumors showed ≥1% membranous staining. CD8 was scored for intra-tumor T-cells and stromal cells. RESULTS: PD-L1 IHC expression data could be generated in 98/148 confirmed LCNEC samples along with RB1 IHC (n = 97) of which 77 passed quality control for TNGS. PD-L1 expression was positive in 16/98 cases (16%); 5 (5%) with ≥50%. PD-L1 expression was equal in RB1 mutated and RB1 wildtype tumors. None of STK11 mutated tumors (n = 7) expressed PD-L1. PD-L1 expression was correlated with superior overall survival (OS), hazard ratio 0.55 ((95% Confidence Interval 0.31-0.96), p = 0.038). Intra-tumor CD8 was associated with PD-L1 expression (p = 0.021) and stromal and intra-tumor CD8 were correlated with improved OS (p = 0.037 and p = 0.026 respectively). CONCLUSIONS: PD-L1 expression was positive in 16% of stage IV LCNEC tumors. This was independent of molecular subtype but associated with CD8 expression. In LCNEC patients with PD-L1 and/or CD8 expression superior OS was observed.

Salivary gland pleomorphic adenoma in the Netherlands: A nationwide observational study of primary tumor incidence, malignant transformation, recurrence, and risk factors for recurrence.

INTRODUCTION: Whereas salivary gland pleomorphic adenoma (SGPA) is the most common type of salivary gland tumor, little is known about its epidemiology because national cancer registries do not register this disease. OBJECTIVES: To establish SGPA incidence trends, rates of secondary malignant transformation and recurrence and associated factors in the Netherlands. MATERIALS AND METHODS: Data on incidence, epidemiology, secondary malignant transformation and recurrence were retrieved from the Dutch pathology registry (PALGA) for the years 1992, 1997, 2002, 2007, and 2012. Multivariate analysis was performed to discover the risk factors for recurrence. RESULTS: 3506 cases of SGPA were recorded implying an overall European standardized rate of 4.2-4.9 per 100,000 person-years. Our figures showed a female preponderance (1:1.43) with an annual 1% rise in female incidence (95% confidence interval [CI]: 0.2-1.8) and a bimodal age distribution in women (p<0.0001). The overall 20-year recurrence rate was 6.7%, and median time to first recurrence was 7years. Positive and uncertain resection margins and younger age at diagnosis were risk factors for recurrence, with odds ratios (ORs) of 4.62 (95%CI 2.84-7.51), 4.08 (95%CI 2.24-7.43), and 0.42 (95%CI 0.29-0.63) respectively. Tumor locations in the minor salivary glands had lower odds of recurrence than tumors in the parotid (OR 0.24; 95% CI: 0.07-0.77; p<0.016). Malignant transformation occurred in 0.15% of SGPAs (3.2% of recurrences). CONCLUSION: This first nationwide study clearly showed sex differences in SGPA epidemiology, possibly suggesting some underlying hormonal mechanism. Long-term recurrence risks were low, and secondary malignant transformation risks were very low.

CFTR is a tumor suppressor gene in murine and human intestinal cancer.

This corrects the article DOI: 10.1038/onc.2015.483.

In Vivo Precipitation of Poorly Soluble Drugs from Lipid-Based Drug Delivery Systems.

Precipitation of poorly water-soluble drugs from lipid-based drug delivery systems (LbDDS) has been studied extensively during in vitro lipolysis but has never been shown in vivo. The aim of this study was therefore to investigate if drug precipitation can occur from LbDDS during transit of the gastrointestinal tract in vivo. Rats were administered 300 µL of either of two LbDDS (LbDDS I and LbDDS II) loaded with danazol or fenofibrate (or paracetamol to assess gastric emptying). The rats were euthanized at various time points after administration of both LbDDS containing either drug, and the contents of the stomach and proximal part of the small intestine were harvested. The contents were analyzed for crystalline drug by X-ray powder diffraction and polarized light microscopy. No drug precipitation was evident in the stomach or the intestine after administration of LbDDS I containing danazol at the tested time points. Fenofibrate precipitation was absent in the stomach initially after administration of LbDDS I, but was evident in the stomach 90 min after dosing. No crystalline fenofibrate was observed in the intestine. Danazol and fenofibrate precipitation was evident in the stomach following administration of LbDDS II containing either drug, but not in the intestine at the tested time point. Drug precipitation from LbDDS was observed in the stomach, but not in the intestine, which is contrary to what in vitro lipolysis data (obtained under human GI conditions) suggests. Thus, precipitation of drugs from LbDDS in vivo in rats is much lower than might be anticipated from in vitro lipolysis data.

CFTR is a tumor suppressor gene in murine and human intestinal cancer.

CFTR, the cystic fibrosis (CF) gene, encodes for the CFTR protein that plays an essential role in anion regulation and tissue homeostasis of various epithelia. In the gastrointestinal (GI) tract CFTR promotes chloride and bicarbonate secretion, playing an essential role in ion and acid-base homeostasis. Cftr has been identified as a candidate driver gene for colorectal cancer (CRC) in several Sleeping Beauty DNA transposon-based forward genetic screens in mice. Further, recent epidemiological and clinical studies indicate that CF patients are at high risk for developing tumors in the colon. To investigate the effects of CFTR dysregulation on GI cancer, we generated Apc(Min) mice that carried an intestinal-specific knockout of Cftr. Our results indicate that Cftr is a tumor suppressor gene in the intestinal tract as Cftr mutant mice developed significantly more tumors in the colon and the entire small intestine. In Apc(+/+) mice aged to ~1 year, Cftr deficiency alone caused the development of intestinal tumors in >60% of mice. Colon organoid formation was significantly increased in organoids created from Cftr mutant mice compared with wild-type controls, suggesting a potential role of Cftr in regulating the intestinal stem cell compartment. Microarray data from the Cftr-deficient colon and the small intestine identified dysregulated genes that belong to groups of immune response, ion channel, intestinal stem cell and other growth signaling regulators. These associated clusters of genes were confirmed by pathway analysis using Ingenuity Pathway Analysis and gene set enrichment analysis (GSEA). We also conducted RNA Seq analysis of tumors from Apc(+/+) Cftr knockout mice and identified sets of genes dysregulated in tumors including altered Wnt ß-catenin target genes. Finally we analyzed expression of CFTR in early stage human CRC patients stratified by risk of recurrence and found that loss of expression of CFTR was significantly associated with poor disease-free survival.

Increased risk of chronic lymphocytic leukaemia among cancer survivors in the Netherlands: increased detection, causal factors or both?

We assessed the risk of chronic lymphocytic leukaemia (CLL) following earlier primary malignancies (EPM) to explore the extent and determinants of this risk. We used the Netherlands Cancer Registry data of 1,313,232 cancer survivors who were at risk to be subsequently diagnosed with CLL between 1989 and 2008. Cancer survivors were categorized based on gender, age, time since diagnosis of EPM and type of EPM. CLL was regarded synchronous when diagnosed within 3 months after diagnosis of EPM; metachronous CLLs were those diagnosed later. Overall, we found that cancer survivors had a 90 % higher risk to be diagnosed with CLL than the general population. In the first year after diagnosis, we found a more than four-fold increased risk of CLL (standardized incidence ratio (SIR), 4.4; 95 % confidence interval (CI), 4.1-4.8); however, no increased risk was observed after excluding synchronous cases. After 1 year, the excess risk of subsequent CLL ranged from 1.2 to 1.8. An increased risk for metachronous CLL was found in prostate (SIR 1.3; 95 % CI 1.1-1.5) and squamous cell skin cancer survivors (SIR 2.3; 95 % CI 1.9-2.7). Intensive clinical checkups after/around diagnosis of the EPM seemed to be the main cause for the increased risk of CLL among cancer survivors. However, possible shared risk factors between prostate cancer and CLL and skin cancer and CLL cannot be excluded. Further clinical research aimed at CLL as subsequent primary malignancy (SPM) is warranted to elucidate possible shared biological and predisposing risk factors.

Chronic lymphocytic leukaemia in the Netherlands: trends in incidence, treatment and survival, 1989-2008.

We present trends in incidence, early treatment and survival of Chronic Lymphocytic Leukaemia (CLL) between 1989 and 2008, based on population-based data from the Netherlands Cancer Registry. Incidence rates were stable at 5.1 per 100,000 person-years for males, but increased from 2.3 to 2.5 for females, especially for females aged 50-64 years (from 3.6 to 4.3). Patients were less likely to receive chemotherapy within six months, i.e. from 29% to 24% among males and from 25% to 21% among females. Five-year relative survival increased from 61% in 1989-1993 to 70% 2004-2008 for males, and from 71% to 76% for females. The relative excess risk of dying decreased in time to 0.7 (males) and 0.9 (females) in 2004-2008, reference 1989-1993, and increased with age to 2.9 (males) and 1.8 (females) in patients aged 75-94 years, reference 30-64 years. The increasing incidence among females aged 50-64 coincided with the introduction of mass screening for breast cancer, which resulted in a large group of women under increased surveillance and possibly led to increased detection of CLL. The increase in survival might be underestimated due to possible decreased or delayed registration of indolent cases and the retroactive effect of the introduction of new therapies.

A prospective randomised controlled trial of ultrasound guided versus nerve stimulation guided distal sciatic nerve block at the popliteal fossa.

The direct visualisation of nerves and adjacent anatomical structures may make ultrasonography the preferred method for nerve localisation. In this prospective randomised study, we investigated whether, for distal sciatic nerve block in the popliteal fossa, an ultrasound guided technique would result in the use of less local anaesthetic without changing block characteristics and quality. Using electrical nerve stimulation or ultrasound guidance, the nerve was identified in two groups of 20 patients scheduled for lower limb surgery. Hereafter lignocaine 1.5% with adrenaline 5 microg/ml was injected. The attending anaesthesiologist assessed the injected volume. Significantly less local anaesthetic was injected in the ultrasound group compared to the nerve stimulation group (17 vs. 37 ml, P < 0.001), while the overall success rate was increased (100% vs. 75%; P = 0.017). We conclude that the use of ultrasound localisation for distal sciatic nerve block in the popliteal fossa reduces the required dose of local anaesthetic significantly, and is associated with a higher success rate compared to nerve stimulation without changing block characteristics.

Visual impairments in people with severe and profound multiple disabilities: an inventory of visual functioning.

BACKGROUND: The prevalence of visual impairments in people with severe and profound multiple disabilities (SPMD) is the subject of considerable debate and is difficult to assess. METHODS: In a typical Dutch care organization, all clients with SPMD (n = 76) participated in the study and specific instruments adapted to these clients (requiring a minimum of cooperation) were used to measure visual acuity, the visual field, binocular vision, contrast sensitivity, refractive errors and visual functioning behaviour. RESULTS: We found an unexpected 92% of clients with SPMD to have visual impairments. Previously, only 30% were known to have visual problems. None of the persons observed had normal visual acuity. Subnormal visual acuity was the best result. The severity of the visual impairment was related to the severity of the intellectual disability. In addition to the problem of acuity, impairments in the visual field, impaired contrast sensibility and impaired binocular functioning were found, as well as impaired visual attention, fixation and following. In 22% of the clients observed, refractive errors were found and glasses were advised. CONCLUSIONS: Consequences for caregiving and for modifications of the environment were discussed.

The workload of riding-school horses during jumping.

REASONS FOR PERFORMING THE STUDY: As there are no reports on the real workload of horses that jump fences, this study was undertaken in riding-school horses. OBJECTIVE: To compare the workload of horses jumping a course of fences with that of horses cantering over the same course at the same average speed without jumping fences. The workload variables included heart rate (HR), packed cell volume (PCV), acid-base balance (venous pH, pCO2, HCO3-) and blood lactate (LA), glucose, total protein and electrolyte concentrations. METHODS: Eight healthy riding-school horses performed test A (a course of approximately 700 m with 12 jumps from 0.8-1.0 m high at an average speed of approximately 350 m/min) and test B (same course at the same speed, but without the rails) in a crossover study with at least 4 h between the 2 tests. Before each test the horses were fitted with a heart rate meter (Polar Electro). Blood samples were taken from the jugular vein at rest prior to the test, after warm-up before starting the course, immediately after the course and after recovery. All samples were analysed immediately. RESULTS: The mean +/- s.d maximal HR (beats/min) during the course (184 +/- 17 and 156 +/- 21, respectively) and the mean HR after recovery (75 +/- 6 and 63 +/- 7, respectively) were significantly higher in test A compared to test B (P = 0.001 and P = 0.007 respectively). The mean LA concentrations after the course and after recovery (mmol/l) were significantly higher in test A (3.6 +/- 2.7 and 1.0 +/- 0.9, respectively) compared to test B (0.9 +/- 0.5 and 0.3 +/- 0.1, respectively), (P = 0.016 and P = 0.048 respectively). The mean PCV (I/l) after the course and after recovery was also significantly different between tests A (0.48 +/- 0.04 and 0.39 +/- 0.03, respectively) and B (0.42 +/- 0.04 and 0.36 +/- 0.03, respectively) (P<0.01). The mean pH and the mean HCO3- (mmol/l) after the course were significantly lower in test A (7.40 +/- 0.04 and 28.9 +/- 1.4, respectively) compared to test B (7.45 +/- 0.03 and 30.4 +/- 2.3, respectively) (P<0.05). CONCLUSIONS: This study indicates that in riding-school horses jumping fences, even at a low level competition, provokes a significant workload compared to cantering the same distance and speed without fences. POTENTIAL RELEVANCE: This study makes it clear that the extra workload of jumping fences should be taken into account in the training programmes of jumping horses. Further research with more experienced horses jumping higher fences will reveal the workload for top-level jumping horses.

Antibacterial effect of garlic and omeprazole on Helicobacter pylori.

The antibacterial effect of a home-made raw garlic extract and commercial garlic tablets alone and in combination with antibiotics or omeprazole was determined against clinical isolates of Helicobacter pylori. MIC values of raw garlic extract and three types of commercial garlic tablets ranged from 10,000 to 17,500 mg/L. When MIC values of the commercial tablets were based on the allicin content, no differences between the three types were observed. The combination of garlic and omeprazole, studied with killing curves, showed a synergic effect which was concentration dependent. Further clinical evaluation of garlic in combination with the conventional agents for H. pylori treatment seems warranted.

[Problems in the use, cleaning and maintenance of nebulization equipment in the home situation]. / Problemen met gebruik, reiniging en onderhoud van vernevelapparatuur in de thuissituatie.

OBJECTIVE: To determine whether jet nebulizers used at home for the treatment of children with asthma are used optimally. DESIGN: Descriptive. SETTING: Outpatient clinic for child pulmonary diseases of the Academic Hospital/Sophia Children's Hospital Rotterdam and outpatient clinic for child diseases of the Baronie Hospital Breda, the Netherlands. METHOD: Thirty-nine children aged 0-13 years and their parents were interviewed at home, and medication cup, saline and aerosol were cultured for bacterial analysis. The pressures of the compressor and nebulizer were measured with a manometer, and the particle size of the aerosol of 10 jet nebulizers was measured by laser technique. RESULTS: The suppliers of the nebulizer did not provide clear instructions on user-related aspects and technical maintenance of the jet nebulizer. Many patients used damaged and poorly functioning, contaminated jet nebulizers. Contamination by potentially pathogenic micro-organisms was present in 50% of the saline, medication cups and aerosols (Klebsiella, Enterobacter, Pseudomonas, Serratia, Escherichia coli). The operating pressure of compressor and nebulizer was below the requirements in more than 50% of the jet nebulizers. In addition, we found that the aerodynamic mass median diameter increased considerably as the nebulizer became older. In 6/10 nebulizers the particle size was below 5 microns. CONCLUSION: A periodical checkup of user-related aspects and technical quality of jet nebulizers is necessary. The quality of the instruction to users about the procedure for cleaning and maintenance of the jet nebulizer should be improved.

Studies on the life cycle of Asymphylodora tincae (Modeer, 1790) (Trematoda: Monorchiidae) in a small lake near Amsterdam. Part 1. The morphology of various stages.

Aspects of the life cycle of Asymphylodora tincae have been studied in a small lake near Amsterdam. Bithynia tentaculata, being the only snail species that was very numerous in the lake, was the first as well as the main second intermediate host; adult trematodes were found exclusively in the tench, Tinca tinca. A small part of the cercariae that penetrate into B. tentaculata was able to develop into progenetic specimens. A morphological description is given of the following stages of A. tincae: adult, egg, redia, cercariaeum, metacercaria and progenetic stage. The cercariaeum is identified as Cercariaeum paludinae impurae De Filippi, 1854. It is concluded that A. tincae is a species, capable of large variation regarding both morphological structure (e.g. body spination, size) and life cycle.