Cornelia Radke

Extended resections for hilar cholangiocarcinoma.

OBJECTIVE To evaluate different strategies for extended resections of hilar cholangiocarcinomas on radicality and survival. SUMMARY BACKGROUND DATA Surgical resection of hilar cholangiocarcinoma is the only potentially curative treatment. Resection of central bile duct carcinomas, however, cannot always comply with the general principles of surgical oncology to achieve wide tumor-free margins with no-touch techniques. METHODS From 1988 to 1998, 95 patients underwent resection of hilar cholangiocarcinoma. Eighty patients had hilar and hepatic resections and 15 had liver transplantation and partial pancreatoduodenectomy (LTPP; i.e., eradication of the entire biliary tract using a no-touch technique). RESULTS The 60-day death rate was 8%. The overall 1- and 5-year survival rates were 67% and 22%, respectively. Five-year survival rates after R0, R1, and R2 resections were 37%, 9%, and 0%. In a multivariate analysis, surgical radicality was the strongest determinant of survival (p < 0.001). The rate of formally curative resection (R0 resection) was significantly lower in hilar resections (29%) than in liver resections (left hemihepatectomy 59%, right hemihepatectomy 55%, right trisegmentectomy 65%; p < 0.05). The highest rate of R0 resection was observed after LTPP (93%; p < 0.05). Right trisegmentectomies achieved the highest rate of 5-year survival after R0 resection (57%). In a multivariate analysis of patient survival after R0 resection, additional portal vein resection was the only significant factor. The 5-year survival rate after formally curative liver resection with portal vein resection was 65% versus 28% without. CONCLUSION Extended resections, especially right trisegmentectomies and LTPP, resulted in the highest rate of R0 resection. Right trisegmentectomy together with portal vein resection best represents the principles of surgical oncology and may be regarded as the surgical procedure of choice. Immunosuppression limits the applicability of LTPP.

Glutamate enrichment as new diagnostic opportunity in breast cancer.

Exogenous glutamine is an important source of energy and molecular building blocks for many tumors. There is a renewed interest in therapeutically targeting glutamine metabolism due to the recent discovery of two novel glutaminase inhibitors. To quantify the dysregulation of the glutamate‐glutamine equilibrium in breast cancer, metabolomics analysis of 270 clinical breast cancer samples and 97 normal breast samples was carried out using gas chromatography combined with time‐of‐flight mass spectrometry. Positive correlation between glutamate and glutamine in normal breast tissues switched to negative correlation between glutamate and glutamine in breast cancer tissues. Compared with the ratio of glutamate to glutamine in normal tissues, we found 56% of the ER+ tumor tissues and 88% of the ER− tumor tissues glutamate‐enriched. The glutamate‐to‐glutamine ratio (GGR) significantly correlated with ER status (p = 8.0E‐09) and with tumor grade (p = 3.3E‐05). Higher levels of GGR were associated with prolonged overall survival in univariate analysis (HR = 0.77, p = 0.027) and in multivariate analysis (HR = 0.73, p = 0.038). GGR levels were reflected in an unsupervised clustering of metabolomics profiles. In a supervised analysis of metabolomics data and of genome‐wide expression data, replacement of GGR by metabolite surrogate markers was feasible, while replacement of GGR by RNA markers had a limited accuracy. Functional analysis of the gene expression data showed negative correlation between glutamate enrichment and activation of peroxisome proliferator‐activated receptor (PPAR) pathway. Our findings may have important implications for patient stratification related to utilization of glutaminase inhibitors.

Successful infliximab treatment of steroid and OKT3 refractory acute cellular rejection in two patients after intestinal transplantation

Acute rejection resistant to established immunosuppressive rescue protocols remains the most prominent risk factor after intestinal transplantation. In two patients presenting with steroid-resistant severe acute cellular rejection 9 months and 2 years after intestinal transplantation, complete resolution was not achieved despite 5 and 10 days of OKT3 treatment, respectively, and high-dose triple baseline immunosuppression with tacrolimus, rapamycin, and steroids. There was a dissociated course of rejection with persistent moderate to severe rejection in the terminal portion of the graft despite complete recovery from rejection in the proximal parts. Both patients were treated with four subsequent infusions of infliximab (3 mg/kg body weight), a chimeric anti-tumor necrosis factor-&agr; antibody. There was an immediate response regarding macroscopic appearance, graft histology, and clinical symptoms. Both patients recovered. In conclusion, infliximab has proven to be an effective rescue therapy in a selected group of patients with steroid and OKT3 refractory severe acute rejection after intestinal transplantation.

Quadruple tacrolimus-based induction therapy including azathioprine and ALG does not significantly improve outcome after liver transplantation when compared with standard induction with tacrolimus and steroids : Results of a prospective, randomized trial

BACKGROUND Tacrolimus in combination with prednisolone has been proven to be a safe and effective immunosuppressive induction therapy in solid organ transplantation. However, it remains unclear whether a tacrolimus-based quadruple induction regimen with azathioprine and an antilymphocytic preparation could further improve the results after orthotopic liver transplantation. Therefore, we designed a prospective, randomized study to compare the immunosuppressive efficacy of dual (tacrolimus and prednisolone) and quadruple (tacrolimus, azathioprine, ALG Merieux and prednisolone) induction after liver transplantation. METHODS After randomization, 120 consecutive patients of primary liver transplants were divided into the dual group (n=59) and the quadruple group (n=61) and followed for a minimum of 3 years. RESULTS Patient survival at 3 years was 88.2% in the dual versus 94.9% in the quadruple group. Overall 25 patients in each group (41 and 42%, respectively) developed acute rejection. There was no difference in the number and severity of rejections. In each group only four patients required OKT3-therapy, however, although three of four patients in the quadruple group responded to OKT3 and cleared rejection, none of the four patients in the dual group were treated successfully with OKT3 (P<0.02). Rejection in these patients resolved only after additional treatment with mycophenolate mofetil. Adverse events and infections were equally distributed in both groups. Asymptomatic Cytomegalovirus infections were more common in the quadruple group (P<0.02). As of today, only one patient developed posttransplant lymphoproliferative disease (dual group). CONCLUSIONS The data from our single-center study indicate that both tacrolimus-based dual and quadruple immunosuppressive induction regimens yield similar safety and effectiveness after liver transplantation.

Diagnostic value of peripheral blood T-cell activation and soluble IL-2 receptor for acute rejection in liver transplantation

BACKGROUND T-cells play an important role in the pathogenesis of rejection. Monitoring T-cells activation markers in peripheral blood may contribute to diagnosis of acute rejection after liver transplantation (LTX). METHODS Lymphocyte subset distribution, expression of T-cell activation markers (flow cytometry), concentration of soluble (s) interleukin-2 receptor (IL-2R) (solid phase chemiluminescence immunoassay), and liver enzymes as well as bilirubin were prospectively tested in peripheral blood samples of LTX patients with (n=69) and without acute rejection (n=50). Acute rejection was assessed by standard criteria including liver biopsies. RESULTS Intra-individual monitoring of immune parameters revealed an up-regulation of IL-2 receptor (CD25) expression on CD4 and CD8 T-cells together with increases in sIL-2R levels in patients with acute rejections. Measuring sIL-2R levels resulted in highest diagnostic efficiency (>85%). This level of diagnostic efficiency was not reached by any other marker tested. From all conventional markers of hepatocellular integrity and function, alkaline phosphatase reached the highest level of diagnostic efficiency with 70%. CONCLUSIONS Monitoring of up-regulation of the IL-2/IL-2R pathway represents a useful tool for assessment of acute rejection after LTX.

Microscopic Tumor Cell Dissemination in Gastric Cancer

PurposeThere is still much controversy surrounding the prognostic significance of microscopic tumor cell dissemination in gastric cancer and its correlation with histopathologic parameters. We herein investigate such dissemination, predominantly restricted to the subserosa, in patients with gastric cancer.MethodsIntraoperative bone marrow aspiration was done in 26 patients undergoing resection of gastric carcinoma. Peritoneal lavage could not be done in 8 of these 26 patients. The R0-resection rate was 84% (n = 22). A cytokeratin-directed antibody and an antibody directed against carcinoembryonic antigen served for the immunocytochemical detection of tumor cells, and the alkaline phosphatase antialkaline phosphatase method was used for visualization.ResultsThe bone marrow aspirate and peritoneal lavage fluid were immunocytochemically positive in 31% and 56% of the patients, respectively. There was a trend (P = 0.10) towards higher overall survival rates in patients with negative bone marrow samples than in those with tumor cells detected in bone marrow samples. Analyzing the results of peritoneal lavage did not reveal any significant differences. In the group of T1/2 cancers, survival was significantly worse if the bone marrow was positive for tumor cells, with 3-year survival rates of 25% vs 77%, respectively (P < 0.05).ConclusionThe rates of tumor cell dissemination into the bone marrow or into the peritoneal cavity were within the scope of previous reports. Dissemination into the bone marrow resulted in significantly impaired survival in patients with T1 and T2 gastric carcinoma, and it did not correlate with known prognostic parameters.

Functional Implications of LH/hCG Receptors in Pregnancy-Induced Cushing Syndrome

Context: Elevated human choriogonadotropin (hCG) may stimulate aberrantly expressed luteinizing hormone (LH)/hCG receptor (LHCGR) in adrenal glands, resulting in pregnancy-induced bilateral macronodular adrenal hyperplasia and transient Cushing syndrome (CS). Objective: To determine the role of LHCGR in transient, pregnancy-induced CS. Design, Setting, Patient, and Intervention: We investigated the functional implications of LHCGRs in a patient presenting, at a tertiary referral center, with repeated pregnancy-induced CS with bilateral adrenal hyperplasia, resolving after parturition. Main Outcome Measures and Results: Acute testing for aberrant hormone receptors was negative except for arginine vasopressin (AVP)–increased cortisol secretion. Long-term hCG stimulation induced hypercortisolism, which was unsuppressed by dexamethasone. Postadrenalectomy histopathology demonstrated steroidogenically active adrenocortical hyperplasia and ectopic cortical cell clusters in the medulla. Quantitative polymerase chain reaction showed upregulated expression of LHCGR, transcription factors GATA4, ZFPM2, and proopiomelanocortin (POMC), AVP receptors (AVPRs) AVPR1A and AVPR2, and downregulated melanocortin 2 receptor (MC2R) vs control adrenals. LHCGR was localized in subcapsular, zona glomerulosa, and hyperplastic cells. Single adrenocorticotropic hormone–positive medullary cells were demonstrated in the zona reticularis. The role of adrenal adrenocorticotropic hormone was considered negligible due to downregulated MC2R. Coexpression of CYP11B1/CYP11B2 and AVPR1A/AVPR2 was observed in ectopic cortical cells in the medulla. hCG stimulation of the patient’s adrenal cell cultures significantly increased cyclic adenosine monophosphate, corticosterone, 11-deoxycortisol, cortisol, and androstenedione production. CTNNB1, PRKAR1A, ARMC5, and PRKACA gene mutational analyses were negative. Conclusion: Nongenetic, transient, somatic mutation-independent, pregnancy-induced CS was due to hCG-stimulated transformation of LHCGR-positive undifferentiated subcapsular cells (presumably adrenocortical progenitors) into LHCGR-positive hyperplastic cortical cells. These cells respond to hCG stimulation with cortisol secretion. Without the ligand, they persist with aberrant LHCGR expression and the ability to respond to the same stimulus.

Clinical small bowel transplantation: Focus on mucosal barrier function

RECENTLY SMALL BOWEL transplantation has evolved to an established treatment for patients with short gut syndrome and intestinal failure. The introduction of new immunosuppressants offer the opportunity to minimize acute rejection episodes and associated problems. Nevertheless, good initial graft function with maintainance of the mucosal barrier function are of great importance. Preservation/reperfusion injury impairs mucosal barrier function and furthermore initiates the release of mediators. The release of specific and nonspecific inflammatory mediators may promote serious postoperative complications including the development of infection and acute rejection. Therefore, new strategies are required to decrease reperfusion injury and restore mucosal barrier function. Early postoperative enteral nutrition has been shown to restore mucosal barrier function and to decrease the incidence of infection including pneumonia, peritonitis, and sepsis. Enteral preparations containing glutamine, arginine, and omega-3 fatty acids, so called immunonutritions, are known to decrease the release of cytokines, reactive oxygen intermediates, and other mediators in critically ill patients. Lactobacilli, naturally found in the small intestine, have been shown to prevent bacterial overgrowth, to restore gut barrier function, and thereby, to reduce the occurrence of infection. To decrease infectious complications and possibly rejection, donors and recipients of small bowel grafts were treated with lactobacilli and immunonutrition.

Monitoring of immunosuppression after clinical small bowel transplantation

ACUTE REJECTION (AR) remains the most prominent risk factor following small bowel transplantation. Despite improved patient and organ survival rates from approximately 50% to 97% and 71%, respectively, by switching immunosuppression from cyclosporine (CsA)based protocols to tacrolimus (Tac)-based regimens, the rejection rate remains as high as 95% with 60% of rejection episodes occurring in the initial 3 months. New potent immunosuppressants, such as rapamycin (Rapa) and monoclonal antibodies against IL-2 receptor (daclizumab [Dac]), are believed to have the potential to further decrease rejection rates and improve outcomes after small bowel transplantation (SBTx). Pinna et al compared different induction protocols, including cyclophosphamide, mycophenolate mofetil, OKT3, and Dac, with Dac resulting in slightly decreased rejection rates and fewer infectious complications. Abu-Elmagd et al presented preliminary data suggesting the efficacy of Dac as induction therapy together with a Tac-based immunosuppressive regimen to reduce acute rejection (AR) rates (by 43%). The incidence rate of viral infection for and posttransplant lymphoproliferative disease was 7% for each. The impact of additional to Tac-based protocols of Rapa, steroids, and Dac induction therapy is undergoing evaluation in terms of whether they decrease the AR rate while increasing the risk for development of immunosuppression-associated infections, including CMV and EBV. However, monitoring of immunosuppression may facilitate individualized rather than fixed dosing of induction therapy with Dac.

Abstract 5573: GC-TOF mass spectroscopy reveals strong dependence of breast cancer metabolome on estrogene receptor, but not on HER2 status

Breast cancer is a biologically inhomogeneous disease that has been extensively studied using molecular high-throughput platforms like microarrays. Molecular methods have been shown to be useful for therapy selection, prediction of disease outcome or complications such as metastases. Worldwide, immunhistological determination of estrogene receptor (ER) and HER2 status is part of the everyday routine diagnostics. A bunch of new biomarkers and biomarker signatures is currently under development and expected to further individualize and improve breast cancer treatment. Here, we present results of a GC-TOF mass spectrometry (GC-MS) metabolite study conducted by the METACancer consortium. In this project, 275 breast cancer tissues collected as fresh-frozen samples in the METACancer tumor bank were analyzed using GC-MS. Prior to metabolic profiling, tumors were divided in a training (187 tumors) and a validation cohort (88 tumors) with comparable clinicopathological characteristics. Both cohorts were profiled at the Fiehn lab (UC Davis, CA), the training cohort at the end of 2008, the validation cohort at the beginning of 2009. Analysis of the training cohort led to the identification of 468 metabolites that are abundant in breast cancer tissues. 161 out of these could be mapped to known chemical structures and metabolite names. Metabolite-by-metabolite analysis of the training cohort revealed 70 metabolites with significantly (p Next, we asked if the tumor cells exhibit metabolite patterns that are specific for ER status. To this end, a metabolic index (MI) was constructed as linear combination of 15 metabolites. The MI was constructed and optimized using only tumors of the training cohort. ROC analysis showed an excellent perfomance of the MI for prediction of the ER status in the training cohort (AUC = 0.91, leave-one-out cross-validation). Validation of the MI in the validation cohort affirmed the excellent performance (AUC = 0.97). A similar approach for prediction of the HER2 status failed (AUC not significantly better than 0.50). In this project, we have shown that metabolic profiling of fresh-frozen breast cancer samples with GC-MS is feasible. Interestingly, we detected a strong dependence of the metabolite patterns on ER status, but no dependence on HER2 status. Analysis of the changes in metabolic pathways between ER+ and ER- breast cancers may contribute to a better understanding of estrogen driven tumor growth. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 5573.