Independent Predictor Of Disease-free Survival Research Articles

Prognostic implications of NPM1 mutations and FLT3 internal tandem duplications in Egyptian patients with cytogenetically normal acute myeloid leukemia

Nucleophosmin (NPM1) and fms-like tyrosine kinase 3-internal tandem duplication (FLT3-ITD) gene mutations represent the most frequent molecular aberrations in patients with cytogenetically normal-acute myeloid leukemia (CN-AML). We analyzed the prognostic impact of these mutations and their interactions in adults with CN-AML. NPM1 mutation (NPM1mut) and FLT3-ITD mutation (FLT3-ITD+) were analyzed by polymerase chain reaction and GeneScan assays of bone marrow samples obtained from newly diagnosed 104 CN-AML patients. FLT3-ITD+ and NPM1mut were detected in 36 (34.6%) and 30 (28.8%) out of 104 subjects, respectively, 16 cases (15.4%) had double NPM1mut/FLT3-ITD+. The incidence of FLT3-ITD+ was significantly higher in the NPM1mut group than in the NPM1 wild (NPM1wt) group (P = 0.018). Statistical analysis revealed that isolated NPM1mut group had a better clinical outcomes in terms of higher complete response (CR) rate (P = 0.01) and a trend towards favorable overall survival (OS) and disease-free survival (DFS) (P = 0.28, 0.40, respectively). In contrast, the isolated FLT3-ITD+ group had an unfavorable outcome in terms of lower CR rate (P = 0.12), shorter OS, and DFS (P < 0.0001 for both). The NPM1mut/FLT3-ITD-group had the best OS and DFS, while the NPM1wt/FLT3-ITD+ group had the worst OS and DFS than other groups (NPM1mut/FLT3-ITD+ or NPM1wt/FLT3-ITD−) (P < 0.0001 for both). Multivariate Cox regression analysis showed that age and FLT3/ITD+ were independent poor prognostic factors for OS (P = 0.006, <0.0001, respectively), while FLT3/ITD+ was independent predictor for DFS (P = 0.04). However, NPM1mut did not have a significant impact on OS and DFS. In conclusion, adult patients with CN-AML carrying isolated NPM1mut and isolated FLT3-ITD+ exhibit different clinical outcomes than those with NPM1mut/FLT3-ITD+ or NPM1wt/FLT3-ITD−. Patients with NPM1mut/FLT3-ITD− had the best prognosis in terms of higher CR, OS, and DFS, while those with NPM1mut/FLT3-ITD+ had the worst CR rate, and NPM1wt/FLT3-ITD+ had the lowest OS and DFS.

Triple Negative Breast Tumors in African-American and Hispanic/Latina Women Are High in CD44+, Low in CD24+, and Have Loss of PTEN

BackgroundAfrican-American women have higher mortality from breast cancer than other ethnic groups. The association between poor survival and differences with tumor phenotypes is not well understood. The purpose of this study is to assess the clinical significance of (1) Stem cell-like markers CD44 and CD24; (2) PI3K/Akt pathway associated targets PTEN, activation of Akt, and FOXO1; and (3) the Insulin-like growth factor-1 (IGF-I) and IGF binding protein-3 (IGFBP3) in different breast cancer subtypes, and compare the differences between African-American and Hispanic/Latina women who have similar social-economic-status.MethodsA total of N=318 African-American and Hispanic/Latina women, with clinically-annotated information within the inclusion criteria were included. Formalin fixed paraffin embedded tissues from these patients were tested for the different markers using immunohistochemistry techniques. Kaplan-Meier survival-curves and Cox-regression analyses were used to assess Relative Risk and Disease-Free-Survival (DFS).ResultsThe triple-negative-breast-cancer (TNBC) receptor-subtype was more prevalent among premenopausal women, and the Hormonal Receptor (HR) positive subtype was most common overall. TNBC tumors were more likely to have loss of PTEN, express high Ki67, and have increased CD44+/CD24- expression. TNBC was also associated with higher plasma-IGF-I levels. HR-/HER2+ tumors showed high pAkt, decreased FOXO1, and high CD24+ expression. The loss of PTEN impacted DFS significantly in African Americans, but not in Hispanics/Latinas after adjusted for treatment and other tumor pathological factors. The CD44+/CD24- and CD24+/CD44- phenotypes decreased DFS, but were not independent predictors for DFS. HER2-positive and TNBC type of cancers continued to exhibit significant decrease in DFS after adjusting for the selected biomarkers and treatment.ConclusionsTNBC incidence is high among African-American and Hispanic/Latino women residing in South Los Angeles. Our study also shows for the first time that TNBC was significantly associated with PTEN loss, high Ki67 and the CD44+/CD24- phenotype. The loss of PTEN impacts DFS significantly in African Americans.

Abstract IA18: Targeting the androgen receptor in multiple breast cancer subtypes

Abstract The androgen receptor (AR) is even more widely expressed in breast cancer (BC) than estrogen receptor alpha (ER) or progesterone receptor (PR), and recently AR has emerged as a useful marker to refine classification of breast cancer (BC). However, we still understand relatively little about the specific effects of AR or its potential as a therapeutic target in the different subtypes of BC. Our data from clinical samples suggests that some ER+ tumors can switch from growth driven by estrogens to growth driven by adrenal androgens, particularly when the estradiol (E2)/ER pathway is inhibited by standard ER-directed endocrine treatments. Indeed, we have evidence showing that a high ratio of AR to ER (≥2.0) leads to a &amp;gt; 4 fold increased risk for relapse while on tamoxifen (HR=4.43, P&amp;lt;0.0001) and is a strong independent predictor of disease-free survival (HR=4.04, P=0.002). Since approximately 30% of metastatic ER+ tumors exhibit de novo resistance to standard endocrine therapy and all patients with metastatic disease ultimately progress with acquired resistance, targeting AR in ER+ BC may be clinically useful. Thus, clinical trials evaluating the role of androgen receptor inhibition in BC are underway. Importantly, we find that new generation anti-androgens that block AR DNA binding affect BC differently than older generation anti-androgens (which allow DNA binding), leading to new insights into the role of AR. When AR is excluded from the nucleus, both androgen- and estradiol (E2)-stimulated proliferation is inhibited in ER+ breast cancers, suggesting that AR plays a previously-unknown role in E2-mediated ER activity. Both enzalutamide (ENZ) and bicalutamide inhibited androgen-mediated proliferation of breast cancer lines in vitro. Interestingly, ENZ uniquely inhibited E2-mediated proliferation of ER.+/AR+ breast cancer cells in vitro, and also inhibited E2-driven tumor growth as effectively as tamoxifen in vivo. When opposing androgen-stimulated tumor growth in ER+ BC in vivo models, ENZ inhibited proliferation and increased apoptosis, while in ER- models it increased apoptosis but did not alter proliferation. When opposing E2-stimulated tumor growth in vivo ENZ decreased proliferation but did not increase apoptosis. In Her2+ but non-amplified, BC models the AR inhibitor ENZ, inhibited proliferation as well or better than trastuzumab (TRAS), whereas TRAS showed a greater inhibitory effect than ENZ in Her2 amplified lines. In all models tested, the combination of ENZ and TRAS inhibited proliferation more effectively than either agent alone. In TRAS resistant lines, addition of ENZ to TRAS significantly inhibited proliferation. Liganded AR upregulates Her3 in some Her2+ BC lines; however, in other Her2+ lines, Her3 is not increased by androgen stimulation, yet anti-androgens still inhibit proliferation. Our data suggest that the AR and Her2 pathways are linked in ways not previously understood and that there are novel Her3-independent mechanisms whereby AR impacts Her2+BC. A subset of TNBC express AR and knock down of AR using lentiviral shRNAs significantly reduced proliferation in multiple TNBC lines. Propidium iodide cell cycle analysis demonstrated that knockdown of AR in TNBC decreased the percentage of cells in G2/M. Lastly, inhibition of AR with ENZ, blocked ligand-mediated nuclear translocation of AR as assessed by nuclear and cytosolic fractionation and significantly decreased proliferation of TNBC in vitro. In summary, our studies demonstrate that AR plays varying roles in the different BC subtypes and will serve to guide appropriate combinations with AR inhibitor and existing therapeutic strategies. Further, we find that assessment of the amount of AR relative to ER may be informative. Citation Format: Nicholas C. D'Amato, Dawn R. Cochrane, Valerie N. Barton, Liu Bolin, Susan M. Edgerton, Sebastian Bernales, Haihua Gu, Ann D. Thor, Jennifer K. Richer. Targeting the androgen receptor in multiple breast cancer subtypes. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr IA18.

Down-regulation of miR-145 and miR-143 might be associated with DNA methyltransferase 3B overexpression and worse prognosis in endometrioid carcinomas

The aim of this study was to determine the clinicopathologic significance of miR-145 and miR-143 down-regulation in endometrial cancers. The microRNA profiles were analyzed by microRNA microarray. The expression levels of miR-145 and miR-143 in 73 endometrial cancers were further determined by quantitative real-time polymerase chain reaction. Potential targets of miR-145/143 were defined. The status of DNA methyltransferase 3B (DNMT3B), mutL homologs 1, and phosphatase and tensin homolog was assessed using immunohistochemistry. miR-145 and miR-143 frequently co-down-regulated in endometrial cancers, but the expression levels varied greatly between endometrioid carcinomas (ECs) and non-ECs (NECs); they were significantly lower in ECs than in NECs (P < .05). DNMT3B was defined as a potential target of miR-145/143 by Internet algorithms. In ECs, DNMT3B overexpression occurred more often in the miR-145 and miR-143 down-regulation subgroups, and the correlation between DNMT3B and miR-145 status reached statistical significance (P = .021), whereas such phenomena were not present in NECs (P > .05). In univariate analysis, the combination of DNMT3B overexpression and miR-145 or miR-143 down-regulation was more powerful in predicting shorter survival (P < .05) than use of the biomarkers individually (P > .05). In multivariate analysis, such combination was not an independent predictor of disease-free survival (P > .05). Our findings suggest that the target and function of miR-145 and miR-143 may differ in ECs versus NECs. DNMT3B might be a potential target of miR-145 and miR-143 in ECs. Furthermore, the combined miR-145 or miR-143 and DNMT3B status may have a prognostic impact on ECs.

Prognosis of Differentiated Thyroid Cancer in Relation to Serum Thyrotropin and Thyroglobulin Antibody Status at Time of Diagnosis

Serum thyrotropin (TSH) concentration and thyroid autoimmunity may be of prognostic importance in differentiated thyroid cancer (DTC). Preoperative serum TSH level has been associated with higher DTC stage in cross-sectional studies; data are contradictory on the significance of thyroid autoimmunity at the time of diagnosis. We sought to assess whether preoperative serum TSH and perioperative antithyroglobulin antibodies (TgAb) were associated with thyroid cancer stage and outcome in DTC patients followed by the National Thyroid Cancer Treatment Cooperative Study, a large multicenter thyroid cancer registry. Patients registered after 1996 with available preoperative serum TSH (n=617; the TSH cohort) or perioperative TgAb status (n=1770; the TgAb cohort) were analyzed for tumor stage, persistent disease, recurrence, and overall survival (OS; median follow-up, 5.5 years). Parametric tests assessed log-transformed TSH, and categorical variables were tested with chi square. Disease-free survival (DFS) and OS was assessed with Cox models. Geometric mean serum TSH levels were higher in patients with higher-stage disease (Stage III/IV=1.48 vs. 1.02 mU/L for Stages I/II; p=0.006). The relationship persisted in those aged ≥45 years after adjusting for sex (p=0.01). Gross extrathyroidal extension (p=0.03) and presence of cervical lymph node metastases (p=0.003) were also significantly associated with higher serum TSH. Disease recurrence and all-cause mortality occurred in 37 and 38 TSH cohort patients respectively, which limited the power for survival analysis. Positive TgAb was associated with lower stage on univariate analysis (positive TgAb in 23.4% vs. 17.8% of Stage I/II vs. III/IV patients, respectively; p=0.01), although the relationship lost significance when adjusting for age and sex (p=0.34). Perioperative TgAb was not an independent predictor of DFS (hazard ratio=1.12 [95% confidence interval=0.74-1.69]) or OS (hazard ratio=0.98 [95% confidence interval=0.56-1.72]). Preoperative serum TSH level is associated with higher DTC stage, gross extrathyroidal extension, and neck node metastases. Perioperative TgAb is not an independent predictor of DTC prognosis. A larger cohort is required to assess whether preoperative serum TSH level predicts recurrence or mortality.

CXCR4 Expression in Bladder Transitional Cell Carcinoma and Its Relationship with Clinicopathological Features

Objective: To elucidate the role of CXCR4 in the metastasis of bladder transitional cell carcinoma (BTCC) by examining CXCR4 expression in BTCC tissue and its correlation with clinicopathological features. Methods: The expression of CXCR4 was assessed in bladder tissues from 70 BTCC patients and 18 normal controls, respectively, using immunohistochemistry. The correlation of CXCR4 expression with lymph node metastasis was also examined by determining the lymphatic vessel density (LVD). Results: Overexpression of CXCR4 was detected in 58/70 (82.9%) BTCC tissues, whereas only in 3/18 (16.7%) normal bladder tissues. The expression was significantly higher in BTCC than that in normal controls (p < 0.01). CXCR4 expression level was closely associated with tumor size, pathological grades, clinical stages, and pelvic lymph node metastasis (p < 0.05). Multivariate analysis indicated that CXCR4 expression and lymph node metastasis were independent predictors for disease-free survival (both p < 0.05). The disease-free survival rate among the patients with high CXCR4 expression level was remarkably lower than that among the patients with no or low level expression (p < 0.01). Conclusion: Highly expressed in BTCC tissues, CXCR4 may play a critical role in the metastasis of BTCC, and the expression level in biopsy specimens might be a good indicator of lymph node metastasis.

Ki67 is an independent predictor of oncological outcomes in patients with localized clear‐cell renal cell carcinoma

To validate the impact of Ki67 expression on oncological outcomes of patients treated for clinically localized clear-cell renal cell carcinoma (ccRCC). Immunohistochemistry for Ki67 was performed on tissue microarray constructs of patients treated with radical or partial nephrectomy for clinically localized (M0) ccRCC and Ki67 expression >10% was considered abnormal. Clinical and pathological data elements were entered into an institutional review board-approved database. The Kaplan-Meier method and Cox regression models were used to analyse disease-free survival (DFS) and cancer-specific survival (CSS) probabilities. Of 401 patients, 59.6% were males. The median (range) age was 58 (17-85) years, follow-up was 22 (0-150) months and time to death was 27 (0-150) months. A total of 20.2% of patients had advanced stage (pT3-T4) and 31% had advanced grade (3-4) disease. Abnormal expression of Ki67 was seen in 6.5% of our cohort and was associated with adverse pathological features (P < 0.05). Patients with high expression of Ki67 were found to have 5-year DFS and CSS rates of 67 and 84%, respectively, vs 87 and 95%, respectively, in those with normal expression (P < 0.001 and P < 0.05, respectively). In multivariable analyses, adjusting for stage and grade, abnormal Ki67 expression was an independent predictor of DFS (hazard ratio [HR] 3.77, P = 0.011, 95% confidence interval [CI] 1.35-10.52), but not of CSS (HR 3.51 P = 0.137, 95% CI 0.671-18.35). Our findings support the role of Ki67 as a powerful independent predictor of inferior oncological outcomes in patients with ccRCC. Further prospective studies are needed to determine the clinical applicability of these findings.

Downregulation of EIF4A2 in Non–Small-Cell Lung Cancer Associates with Poor Prognosis

BackgroundEIF4A2, which belongs to the eukaryotic initiation factor 4A family, is a highly conserved gene for one of the protein-synthesis initiation factors involved in the binding of messenger RNA to the ribosome. The role of EIF4A2 in some cancers, eg, breast cancer and melanoma, has been studied. However, the clinical significance and biologic role of EIF4A2 in lung cancer remains unknown. Patients and MethodsA total of 170 patients with non–small-cell lung cancer who were undergoing surgical resection were studied. We applied the tissue microarray by using immunohistochemistry to study the expression of EIF4A2 in patients with non–small-cell lung cancer (NSCLC). ResultsWe found that the expression rate of EIF4A2 in NSCLC was 87.6%. The expression of EIF4A2 was significantly correlated with the histopathologic classification (P = .049) and tumor grade (P < .019). Moreover, NSCLC patients with low EIF4A2 expression survived shorter than those with high EIF4A2 expression, as indicated by overall survival (P = .023) and disease-free survival (P = .011) assessed by the Kaplan-Meier method. In addition, multivariate analysis suggested EIF4A2 as an independent predictor of disease-free survival (hazard ratio 0.543 [95% CI, 0.329-0.897]; P = .017). ConclusionCollectively, our study demonstrated that EIF4A2 was remarkably involvement in the development of NSCLC and could be served as a potential prognostic marker for patients with this deadly disease.

Does conversion affect short-term and oncologic outcomes after laparoscopy for colorectal cancer?

Conversion of laparoscopic colorectal resection (LCR) for cancer has been associated with adverse short-term and oncologic outcomes. However, most studies have had small sample sizes and short follow-up periods. This study aimed to evaluate the impact of conversion to open surgery on early postoperative outcomes and survival among patients undergoing LCR for nonmetastatic colorectal cancer. A prospective database of consecutive LCRs for nonmetastatic colorectal cancer was reviewed. Patients who required conversion (CONV group) were compared with those who had completed laparoscopic resection (LAP group). Only patients with a minimum 5-year follow-up period were included in the oncologic analysis. Kaplan-Meier curves were compared to analyze survival. A multivariate analysis was performed to identify predictors of poor survival. The conversion rate was 10.9%. The most common reason for conversion was a locally advanced tumor (48.4%). Conversion was associated with a significantly longer operative time and a greater blood loss. No differences were observed in terms of postoperative morbidity, mortality, or hospital stay between the CONV and LAP patients. During a median follow-up period of 120 months (range, 60-180 months), the CONV group had a significantly worse 5-year overall survival (OS) (79.4 vs 87.4%; p = 0.016) and disease-free survival (DFS) (65.4 vs 79.6%; p = 0.013). Univariate analysis showed that conversion to open surgery, postoperative complications, anastomotic leakage, pT4 cancer, stage 3 disease, and adjuvant chemotherapy were significant risk factors for OS and DFS. On multivariate analysis, pT4 cancer and a lymph node ratio (LNR) of 0.25 or greater were the only independent predictors of DFS and OS, whereas a LNR of 0.01 to 0.24 showed a trend that did not reach statistical significance. Conversion to open surgery per se is not associated with worse early postoperative outcomes and does not adversely affect long-term survival per se.

Prognostic Value of Early Postoperative Tumor Marker Response in Gastric Cancer

The clinical usefulness of tumor markers as predictors of treatment outcome in patients with stomach cancer after radical gastrectomy has been poorly defined. The purpose of this study was to evaluate a comprehensive understanding of the impact of early postoperative tumor marker normalization on survival after gastrectomy. Between January 2001 and December 2007, we enrolled 206 patients who had received radical gastrectomy as an initial treatment and had elevated carcinoembryonic antigen (CEA) (>5 ng/mL) or carbohydrate antigen (CA) 19-9 (>37 U/mL) levels. Early tumor marker response was defined as a normalization of preoperative CEA or CA19-9 values 1-2 months after gastrectomy. The mean patient age was 61 years (range 29-84 years), and 139 patients (67.5%) were male. Early tumor marker response was identified in 150 of 206 (72.8%) patients. Of the patients, 49 (23.8%), 41 (19.9%), and 116 (56.4%) were stages I, II, and III, respectively, according to the seventh edition of the American Joint Commission on Cancer (AJCC) staging system. Both disease-free survival (DFS) and overall survival (OS) were significantly longer in patients with tumor marker response compared with nonresponse (61.5 vs. 37.6 months; P = 0.010 and 71.3 vs. 50.9 months; P = 0.008, respectively). Multivariate analyses showed that high CA19-9 level, early tumor marker response, and tumor, node, metastasis classification system stage were independent predictors of DFS and OS (P < 0.05). Early CEA or CA19-9 normalization after radical gastrectomy is a strong prognostic factor for gastric cancer, especially in patients with high preoperative levels of tumor markers.

Prognostic Role of Cell Cycle and Proliferative Biomarkers in Patients with Clear Cell Renal Cell Carcinoma

Cell cycle regulatory molecules are implicated in various stages of carcinogenesis. In this proof of principle study we systematically evaluate the association of aberrant expression of cell cycle regulators and proliferative markers and their effect on oncologic outcomes of patients with clear cell renal carcinoma. Immunohistochemistry for Cyclin D, Cyclin E, p16, p21, p27, p53, p57 and Ki67 was performed on tissue microarray constructs of 452 patients treated with extirpative therapy for clear cell renal cell carcinoma between 1997 and 2010. Clinical and pathological data elements were collected. A prognostic marker score was defined as unfavorable if more than 4 biomarkers were altered. The relationship between marker score and pathological features and oncologic outcomes was evaluated. Median age was 57 years (range 17 to 85) and median followup was 24 months (range 6 to 150). An unfavorable marker score was found in 55 (12.2%) patients and was associated with adverse pathological features. A significant correlation between unfavorable marker score and disease-free survival (HR 26.62, 95% CI 43.38-100.04, p=0.000) and with cancer specific survival (HR 8.15, 95% CI 74.42-101.56, p=0.004) was demonstrated on Kaplan-Meier survival analysis. On multivariate analysis an unfavorable marker score was an independent predictor of disease-free survival (HR 2.63, 95% CI 1.08-6.38, p=0.033). The cumulative number of aberrantly expressed cell cycle and proliferative biomarkers correlates with aggressive pathological features and inferior oncologic outcomes in patients with clear cell renal cell carcinoma. Our findings indicate that interrogation of cell cycle and proliferative markers is feasible, and further prospective pathway based exploration of biomarkers is needed.

Prognostic Impact of Nucleophosmin 1 (NPM1) Gene Mutations in Egyptian Acute Myeloid Leukemia Patients

Objective: Somatic mutations of the nucleophosmin gene (NPM1), which alter the subcellular localization of the product, are the most frequent mutations in patients with acute myeloid leukemia. The aim of the study was to assess the prevalence and prognostic impact of NPM1 gene mutations in adult AML patients.Materials and Methods: Polymerase chain reaction and single-strand conformation polymorphism (PCR-SSCP) were used to screen 55 AML patients for mutations of NPM1 gene.Results: NPM1 mutations were found in 12 (21.8%) of 55 patients, significantly associated with higher total leukocytie count, marrow blast percentage (p=0.03 and p=0.02, respectively), and M5 subtype (p<0.001). Patients with NPM1 mutations had significantly higher complete remission rates (p=0.003) and a trend to lower rates of mortality, relapse and refractory disease (p=0.28, p=0.45 and p=0.08, respectively). Survival analysis showed significantly longer disease-free survival (mean 18.635±1.229 versus 11.041±1.250 months, p=0.044) and overall survival (mean 19.810±1.624 versus 12.063±1.244 months, p=0.041) in patients with NPM1 mutations compared with those without. Multivariate analyses confirmed NPM1 mutation as a significant independent predictor for disease-free survival (HR=0.066, p=0.001) and overall survival (HR=0.125, p=0.002).Conclusion: NPM1 mutation is a prognostic factor for a favorable outcome in Egyptian population. This finding is of major clinical importance since it strongly suggests that NPM1 mutations may allow one to divide the heterogeneous patient group of AML into prognostically different subgroups.Conflict of interest:None declared.

1758 THE PROGNOSTIC ROLE OF PT2 STRATIFICATION IN BLADDER UROTHELIAL CARCINOMA

INTRODUCTION AND OBJECTIVES: We evaluated the prognostic role of pT2 subtaging according to 2009 TNM staging system in muscle invasive bladder cancer. METHODS: Between January 1998 and October 2010 data of radical cystectomies performed at three different institutions were collected in a prospectively-maintained database. Out of 2224 patients, we selected 368 (16.4%) patients with non metastatic pT2 urothelial carcinoma of the bladder not receiving neoadjuvant therapies. All patients underwent pelvic lymph node dissection at least up to iliac bifurcation. Univariable analysis was performed to test the effect of age, gender, pathological T (pT) and N (pN) stages, lymph-node count (LN-c), lymph-node density (LN-d) and extent of pelvic lymph node dissection (PLND) on disease-free survival (DFS) and cancer specific survival (CSS). Significant variables (log-rank p 0.05) were entered in a multivariable Cox-regression model to identify independent prognostic factors. RESULTS: Out of 368 patients, 152 were pT2a (41.3%) and 216 were pT2b (58.7%). The rate of positive nodes was 46.2%. The median number of nodes removed was 20 (IQR 12-34) and 24 (IQR range 14-41) for the pT2a and pT2b group, respectively. Significant variables at univariable analysis were age, gender, pT, pN, LN-d and extent of PLND. At log-rank test 5yr DFS and CSS of the two groups (pT2a and pT2b) were significantly different (log rank p 0.015 and 0.007 for DFS and CSS, respectively). At Cox regression analysis age, pT and LN-d were independent predictor of DFS [Age: p 0.004, HR 0.98 (95% CI: 0.96-0.99)], [pT2a vs pT2b: p 0.021, HR 1.67 (95% CI: 1.08-2.60)], [LN-d: p 0.001, HR 21.89 (95% CI: 7.17-66.83] and CSS [Age: p 0.001, HR 0.97 (95% CI: 0.95-0.98)], [pT2a vs pT2b: p 0.005, HR 2.07 (95% CI: 1.25-3.42)], [LN-d: p 0.001, HR 25.21 (95% CI: 7.18-88.54)]. CONCLUSIONS: Invasion of deep muscular layer is an independent predictor of oncologic outcome regardless of nodal status and substaging pT2 urothelial carcinomas at radical cystectomy into pT2a and pT2b has a significant prognostic role.

The HER2 status of disseminated tumor cells in the bone marrow of early breast cancer patients is independent from primary tumor and predicts higher risk of relapse

Overexpression of the HER2-receptor in early breast cancer (EBC) patients is associated with aggressive tumor behavior. However, women suffering from HER2-positive EBC benefit from trastuzumab treatment. As the HER2 status of the primary tumor may differ from that of disseminated tumor cells (DTC) in bone marrow (BM), the aim of this study was (1) to compare the HER2 status of the primary tumor (prim-HER2-status) with that of DTC (DTC-HER2-status) and (2) to analyze the influence of the DTC-HER2-status on patient survival. For this purpose, BM aspirates from 569 EBC patients were analyzed for the presence of DTC. The DTC-HER2-status was identified by a double-staining procedure against cytokeratin and the HER2-receptor. DTC were detected in 151 (27%) patients. The concordance between the HER2 status of DTC and the primary tumor was 51%. In patients with detectable DTC, mean disease-free survival was 77.44 (95% CI 74.72-80.17) months for DTC-HER2-negative and 55.15 (95% CI 48.57-61.79) months for DTC-HER2-positive patients (p=0.044). The multivariate analysis showed that the DTC-HER2-status was an independent predictor of disease-free survival. In conclusion, the presence of HER2-positive DTC in EBC patients is associated with an increased risk of relapse. Due to the low concordance between the HER2 status of the primary tumor and DTC, only a minority (13%) of the DTC-HER2-positive patients was treated with trastuzumab. These patients might, however, benefit from HER2-directed therapy.

199 Vasohibin-1 is a novel independent predictor of disease-free survival in curatively operated renal cell carcinoma patients

199 Vasohibin-1 is a novel independent predictor of disease-free survival in curatively operated renal cell carcinoma patients

Impairment of CD4+ cytotoxic T cells predicts poor survival and high recurrence rates in patients with hepatocellular carcinoma

The role of CD4(+) cytotoxic T cells (CTLs) in hepatocellular carcinoma (HCC) remains obscure. This study characterized CD4(+) CTLs in HCC patients and further elucidated the associations between CD4(+) CTLs and HCC disease progression. In all, 547 HCC patients, 44 chronic hepatitis B (CHB) patients, 86 liver cirrhosis (LC) patients, and 88 healthy individuals were enrolled in the study. CD4(+) CTLs were defined by flow cytometry, immunohistochemistry, and lytic granule exocytosis assays. A multivariate analysis of prognostic factors for overall survival was performed using the Cox proportional hazards model. Circulating and liver-infiltrating CD4(+) CTLs were found to be significantly increased in HCC patients during early stage disease, but decreased in progressive stages of HCC. This loss of CD4(+) CTLs was significantly correlated with high mortality rates and reduced survival time of HCC patients. In addition, the proliferation, degranulation, and production of granzyme A, granzyme B, and perforin of CD4(+) CTLs were inhibited by the increased forkhead/winged helix transcription factor (FoxP3(+) ) regulatory T cells in these HCC patients. Further analysis showed that both circulating and tumor-infiltrating CD4(+) CTLs were independent predictors of disease-free survival and overall survival after the resection of the HCC. The progressive deficit in CD4(+) CTLs induced by increased FoxP3(+) regulatory T cells was correlated with poor survival and high recurrence rates in HCC patients. These data suggest that CD4(+) CTLs may represent both a potential prognostic marker and a therapeutic target for the treatment of HCC.

Ki-67 Labeling Index Is a Predictor of Postoperative Persistent Disease and Cancer Growth and a Prognostic Indicator in Papillary Thyroid Carcinoma

Background: We previously reported that the Ki-67 labeling index (LI) in primary tumors and the thyroglobulin (Tg)-doubling time (DT) were potent prognostic indicators in patients with papillary thyroid carcinoma (PTC). Objectives: To elucidate the relationship between these two factors. Methods: A total of 390 patients with PTC who underwent total thyroidectomy between 1998 and 2004 and in whom the Tg-DT was calculated were enrolled. We determined the Ki-67 LI in primary tumors and compared these values with the patients' clinicopathological factors, postoperative Tg status, Tg-DT, and prognosis. Tg status was categorized by postoperative serum Tg values: biochemically persistent disease (BPD), equivocal state, and biochemical remission. Results: The Ki-67 LI was ≤5% in 312 patients (80%), 5%-10% in 48 patients (12%), and >10% in 30 patients (8%). Ki-67 LI was significantly associated with BPD (p < 0.0001). The proportion of BPD patients increased with the higher Ki-67 LI category: 24, 67, and 87%, respectively. The Ki-67 LI had a significant inverse correlation with the Tg-DT (Spearman's ρ = −0.5267, p < 0.0001). Of the 378 patients without distant metastasis at surgery, 68 patients had recurrence, and 6 of the 390 patients died of PTC during the follow-up (mean 88 months). On multivariate analyses, the Ki-67 LI remained an independent predictor of disease-free survival and disease-specific survival when Tg-DT and Tg status were excluded from the analyses. Conclusions: Evaluation of the Ki-67 LI in primary tumors may allow the prediction of the postoperative Tg status, Tg-DT and prognosis of patients with PTC.

Analysis of recurrence after resection of pancreatic neuroendocrine tumors.

304 Background: Outcomes after recurrence of resected pancreatic neuroendocrine tumors (PNETs) are not well described. Our aim is to assess the rate and sites of recurrence and its effect on clinical outcomes. Methods: Retrospective chart review of patients (n= 80) who underwent surgical resection of PNETs at two institutions. Patients were treated from September 2002 to July 2010. Charts were reviewed for disease recurrence, date, site, and treatment of recurrence. Results: There were a total of 14 (17.5%) recurrences. The most common site of recurrence was the liver (10 patients, 71.4%). The most common treatment of recurrences was chemotherapy (5 patients, 35.7%). The 1, 3, and 5 year disease-free survival (DFS) was 90.9%, 82.7%, and 72.5% respectively. Median recurrence free survival (RFS) was 127 months. The median follow-up for all PNET patients was 25.8 months (range 1 to 140 months). Three-year survival was 97%. Local, distant, and combined recurrences occurred in 7.5%, 12.5%, and 5% of all patients, respectively. Multivariate analysis found AJCC stage (p=0.03) to be an independent predictor for DFS. Median follow-up of patients after they were found to have a recurrence was 13.8 months. Three-year survival for those with and without recurrence was 96.3% and 100%, respectively (p=0.36). Conclusions: AJCC stage is a significant predictor of recurrence after resection of PNETs with hepatic metastases being most common. Survival of patients with recurrence is not significantly different from patients without recurrence and is likely due to the indolent nature of the disease.

The Role of Immunohistochemistry in Breast Cancer Patients Treated With Neoadjuvant Chemotherapy: An Old Tool With an Enduring Prognostic Value

BackgroundTo assess the molecular subtypes determined by hormonal receptors (HR) and human epidermal growth factor receptor 2 (HER2) status and the role of proliferation measured by the Ki-67 marker as predictive and prognostic factors in breast cancer patients treated with neoadjuvant chemotherapy. MethodsA total of 127 breast cancer patients were treated with neoadjuvant chemotherapy every 2 weeks as part of 2 studies. Study A consisted of the administration of Adriamycin (40 mg/m2) on day 1 plus paclitaxel (150 mg/m2) and gemcitabine 2000 mg/m2) on day 2 for 6 cycles (n = 54). Study B consisted of the administration of epirubicin (90 mg/m2), cyclophosphamide (600 mg/m2) on day 1 for 3 cycles, followed by the administration of paclitaxel (150 mg/m2) and gemcitabine 2500 (mg/m2) on day 1 with or without trastuzumab according to HER2 status (n = 73). In study A, patients did not receive trastuzumab regardless of HER2 status. The molecular subtypes of the patients with breast cancer were classified as 49% HR+/HER2−, 17.5% HR+/HER2+, 13.5% HR−/HER2+, and 20% HR−/HER2−. ResultsPathologic complete response (pCR), defined as the absence of invasive cells in the breast and the lymph nodes, was achieved in 35 (28%) patients. The pCR rate was significantly different between the molecular subtypes of breast cancer, with 9% in HR+/HER2−, 23% in HR+/HER2+, 50% in HR−/HER2+, and 56% in HR−/HER2− tumors (P < .001). The pCR rate was significantly higher in tumors that had high Ki-67 (≥20%) expression and were HR−. HER2+ was associated with a higher trend of pCR but did not reach statistical significance. The median follow-up was 81 months (r = 15-150 months). Patients who achieved a pCR had a significantly lower recurrence (P = .01) and higher overall survival (P = .02) compared with those who did not achieve pCR. A multivariate analysis revealed that pCR (hazard ratio 0.24 [95% CI, 0.07-0.7]; P = .019), the molecular subtype (hazard ratio 0.3 [95% CI, 0.1-0.8]; P = .02), and the Ki-67 index (hazard ratio 3.2 [95% CI, 1.4-7.1]; P = .004) were significant independent predictors of disease-free survival. Similar results were obtained for overall survival, in which the pCR rate (hazard ratio 0.119 [95% CI, 0.028-0.5]; P = .004), the molecular subtype (hazard ratio 0.17 [95% CI, 0.03-0.86]; P = .02), and the Ki-67 index (hazard ratio 3.6 [95% CI, 1.3-9.7]; P = .01) also displayed a significant influence on survival. ConclusionsMolecular subtypes and Ki-67 index were independent prognostic factors for disease-free survival and overall survival in breast cancer patients treated with neoadjuvant chemotherapy. A high rate of Ki-67 and HR− expression were predictors of pCR.

Validation of the IASLC/ATS/ERS Lung Adenocarcinoma Classification for Prognosis and Association with EGFR and KRAS Gene Mutations: Analysis of 440 Japanese Patients

This study aimed to validate the utility of the new histological classification proposed by the International Association for the Study of Lung Cancer (IASLC), American Thoracic Society (ATS), and European Respiratory Society (ERS) for identifying the prognostic subtypes of adenocarcinomas in Japanese patients; correlations between the classification and the presence of EGFR or KRAS mutation status were also investigated. We retrospectively reviewed 440 patients with lung adenocarcinoma, who underwent resection. The tumors were classified according to the IASLC/ATS/ERS classification. EGFR and KRAS mutations were detected using the established methods. Five-year disease-free survival rates were: 100% for adenocarcinoma in situ (n = 20) and minimally invasive adenocarcinoma (n = 33), 93.8% for lepidic-predominant adenocarcinoma (n = 36), 88.8% for invasive mucinous adenocarcinoma (n = 10), 66.7% for papillary-predominant adenocarcinoma (n = 179), 69.7% for acinar-predominant adenocarcinoma (n = 61), 43.3% for solid-predominant adencoarcinoma (n = 78), and 0% for micropapillary-predominant adenocarcinoma (n = 19). Multivariate analysis revealed that the new classification was an independent predictor of disease-free survival. EGFR and KRAS mutations were detected in 90 cases (53.9%) and 21 cases (13.3%), respectively; EGFR mutations were significantly associated with adenocarcinoma in situ, minimally invasive adenocarcinoma, lepidic- and papillary-predominant adenocarcinoma, and KRAS mutations adenocarcinomas with mucinous tumor subtypes. We found that the IASLC/ATS/ERS classification identified prognostic histologic subtypes of lung adenocarcinomas among Japanese patients. Histologic subtyping and molecular testing for EGFR and KRAS mutations can help predict patient prognosis and select those who require adjuvant chemotherapy.