Klaus Orth

Methylated APC and GSTP1 genes in serum DNA correlate with the presence of circulating blood tumor cells and are associated with a more aggressive and advanced breast cancer disease.

BackgroundTumor-related methylated DNA and circulating tumor cells (CTC) in the peripheral blood might be of prognostic importance in breast cancer. Thus, the aim of our study was to examine free methylated DNA and CTC in the blood from breast cancer patients and to correlate it with clinicopathological features known to influence prognosis.Materials and methodsWe prospectively obtained serum samples from 85 patients with breast cancer and 22 healthy volunteers. Sera were analysed by methylation specific PCR (MethyLight PCR) for five genes: adenomatous polyposis coli (APC), ras association domain family protein 1A (RASSF1A), estrogen receptor 1 (ESR1), CDKN2A (p16) and glutathione s-transferase pi 1 (GSTP1). Beta actin (ACTB) served as control. In parallel matched peripheral blood of 63 patients was used to assay for circulating tumor cells in the peripheral blood by a modified immunomagnetic AdnaTest BreastCancerSelect with PCR detection for EPCAM, MUC1, MGB1 and SPDEF.ResultsWe found a hypermethylation in the APC gene in 29% (25/85), in RASSF1A in 26% (22/85), in GSTP1 in 18% (14/76) and in ESR1 in 38% (32/85) of all breast cancer patients. No hypermethylation of CDKN2A was found (0/25). Blood samples of patients were defined CTC positive by detecting the EPCAM 13% (8/63), MUC1 16% (10/63), MGB 9% (5/55), SPDEF 12% (7/58) and in 27% detecting one or more genes (15/55). A significant difference was seen in methylated APC DNA between cancer patients and healthy volunteers. Moreover, methylated APC, RASSF1 and CTC were significantly different in metastatic versus non-metastatic disease. In addition, the presence of methylated APC, RASSF1A and CTC correlated significantly with AJCC-staging (p = 0.001, p = 0.031 and 0.002, respectively). High incidences of methylations were found for the genes RASSF1 and ESR1 in healthy individuals (both 23% 5/22). Methylated GSTP1 was predominantly found in the serum of patients with large primaries (p = 0.023) and was highly significantly correlated with positive Her2/neu status (p = 0.003). Elevated serum CA15.3 was strongly correlated with methylated APC and CTC detection (both p = 0.000). Methylated ESR1 failed to exhibit significant correlations with any of the above mentioned parameters. The presence of CTC in peripheral blood was significantly associated with methylated APC (p = 0.012) and methylated GSTP1 (p = 0.001).ConclusionThe detection of methylated APC and GSTP1 DNA in serum correlated with the presence of CTC in the blood of breast cancer patients. Both methylated DNA and CTC correlated with a more aggressive tumor biology and advanced disease.

CHEST WALL AND INTRATHORACIC DESMOID TUMORS : SURGICAL EXPERIENCE AND REVIEW OF THE LITERATURE

Desmoid tumors are fibroblastic/myofibroblastic neoplasms, which originate from musculo-aponeurotic structures and are classified as deep fibromatoses. Despite their benign histologic appearance and lack of metastatic potential, desmoid tumors may cause aggressive local infiltrations and compression of surrounding structures. They are often associated with female gender, familial adenomatous polyposis (FAP) and sporadically may occur at sites of previous trauma, scars or irradiation. Molecular studies have demonstrated that these patients are associated with a bi-allelic APC mutation in the affected tissue. Radical tumor resection with free margins remains the first therapy of choice. In cases with anatomical or technical limitations for a wide excision, radiation therapy represents a proven and effective alternative or supplementary treatment.

Induction chemotherapy followed by concurrent radio-chemotherapy versus concurrent radio-chemotherapy alone as treatment of locally advanced squamous cell carcinoma of the head and neck (HNSCC): A meta-analysis of randomized trials

BACKGROUND Induction chemotherapy with docetaxel, cisplatin and 5 FU (TPF) before radiotherapy (RT) or radio-chemotherapy (RT-CHX) has been shown to improve overall survival (OS) compared to induction chemotherapy with cisplatin and 5 FU in locally advanced squamous cell carcinoma of the head and neck (HNSCC). Whether TPF induction before RT-CHX improves clinical outcome in comparison with RT-CHX alone is still a matter of debate. Recently, the results of 5 randomized trials addressing this question have become available. METHODS In the 5 trials of interest, in total 1022 patients with locally advanced HNSCC were randomly assigned to receive either TPF induction CHX followed by concurrent RT-CHX or concurrent RT-CHX alone. Platin or taxane based CHX was used during RT. 51.3% of the patients had oropharyngeal, 7.3% hypoharyngeal, 18.7% laryngeal, 19.4% oral cavity and 3.5% had other HNSCC. Published hazard ratios and hazard ratios extracted from available survival curves for OS and progression free survival (PFS) were basis of the meta-analysis. Meta-analysis of the effect sizes on OS and PFS was performed using a random effects model based on parameter estimates of log hazard ratios in Cox models and their standard errors. RESULTS Additional induction CHX with TPF before RT-CHX did neither result in a significant improvement of OS (Hazard Ratio: 1.010, 95% confidence limits (CL) 0.84-1.21, p=0.92), nor in a statistically significant benefit of PFS (Hazard Ratio: 0.91, 95% CL 0.75-1.1, p=0.32). CONCLUSION Additional induction CHX with TPF before RT-CHX does not improve OS and PFS in locally advanced HNSCC compared to definite RT-CHX.

Gene expression of circulating tumour cells in breast cancer patients

BackgroundThe diagnostic tools to predict the prognosis in patients suffering from breast cancer (BC) need further improvements. New technological achievements like the gene profiling of circulating tumour cells (CTC) could help identify new prognostic markers in the clinical setting. Furthermore, gene expression patterns of CTC might provide important informations on the mechanisms of tumour cell metastasation.Materials and methodsWe performed realtime-PCR and multiplex-PCR analyses following immunomagnetic separation of CTC. Peripheral blood (PB) samples of 63 patients with breast cancer of various stages were analyzed and compared to a control group of 14 healthy individuals. After reverse-transcription, we performed multiplex PCR using primers for the genes ga733.3, muc-1 and c-erbB2. Mammaglobin1, spdef and c-erbB2 were analyzed applying realtime-PCR.Resultsga733.2 overexpression was found in 12.7% of breast cancer cases, muc-1 in 15.9%, mgb1 in 9.1% and spdef in 12.1%. In this study, c-erbB2 did not show any significant correlation to BC, possibly due to a highly ambient expression. Besides single gene analyses, gene profiles were additionally evaluated. Highly significant correlations to BC were found in single gene analyses of ga733.2 and muc-1 and in gene profile analyses of ga733.3*muc-1 and GA7 ga733.3*muc-1*mgb1*spdef.ConclusionOur study reveals that the single genes ga733.3, muc-1 and the gene profiles ga733.3*muc-1 and ga733.3*3muc-1*mgb1*spdef can serve as markers for the detection of CTC in BC. The multigene analyses found highly positive levels in BC patients. Our study indicates that not single gene analyses but subtle patterns of multiple genes lead to rising accuracy and low loss of specificity in detection of breast cancer cases.

Cystatin C - a fast and reliable biomarker for glomerular filtration rate in head and neck cancer patients.

Purpose:Determination of renal function is a prerequisite for planning therapy in cancer patients. Limitations of creatinine as marker for the glomerular filtration rate (GFR) led to the proposal of cystatin C as a more accurate biomarker especially in mild renal insufficiency or in patients with low muscle mass. We compared the accuracy of cystatin C- and creatinine-based equations to estimate GFR in head and neck cancer (HNC) patients receiving platinum-based radiochemotherapy.Patients and Methods:The study population consisted of 52 HNC patients (GFR range, 37–105 mL/min/1.73 m2 complemented by 17 patients with known renal insufficiency (GFR range, 10–60 mL/min/1.73 m2). Intraclass correlation coefficients were calculated between the reference method (51)Cr-EDTA clearance and estimated GFR by creatinine clearance and equations based on creatinine (Cockroft-Gault, modification of diet in renal disease (MDRD), Wright) or cystatin C (Larsson, Dade-Behring, Hoek). In addition, sensitivity and specificity to discriminate GFR > 60 mL/min/1.73 m2 were evaluated by receiver operating characteristic curve (ROC).Results:The highest correlation coefficients were found for the cystatin C-based estimates in comparison with creatinine-based estimates or creatinine clearance, even though Bland-Altman plots revealed GFR overestimation for all equations tested. The cystatin C-based Hoek formula exhibited the highest overall precision and accuracy. GFR of < 60 mL/min/1.73 m2 was assumed as a cut-off for chemotherapy. ROC analyses revealed the highest AUC to predict a GFR > 60 mL/min/1.73 m2 for the creatinine-based Wright formula, closely followed by the MDRD formula and cystatin C-based equations of Larsson, Dade-Behring, and Hoek.Conclusion:Cystatin C-based GFR estimates showed the overall strongest correlation to the reference method. Thus, we recommend cystatin C for GFR estimation in HNC patients as an alternative method to the estimated creatinine clearance in clinical practice.ZusammenfassungZielsetzung:Bei Tumorpatienten ist die exakte Bestimmung der Nierenfunktion eine wichtige Voraussetzung für die individuelle Therapieplanung. Die Aussagefähigkeit des Serumkreatinins als Marker der glomerulären Filtrationsrate (GFR) ist jedoch limitiert aufgrund seiner Abhängigkeit von der Muskelmasse sowie fehlendem Anstieg der Serumkonzentration bei einer GFR > 60 ml/ min/1,73 m2. Cystatin C wird als sensitiverer Parameter für das Vorliegen einer Niereninsuffizienz in den Frühstadien sowie bei Muskelschwachen Patienten diskutiert. In der vorliegenden Studie wurde die Präzision von Cystatin-C-basierten sowie Kreatinin-basierten Formeln zur Berechung der GFR in Kopf-Hals-Tumorpatienten verglichen.Patienten und Methodik:Die Studienkohorte bestand aus 52 Kopf-Hals-Tumorpatienten (GFR 37–105 mL/min/1,73 m2) sowie 17 Patienten mit bekannter Niereninsuffizienz Stadium 3–5 (GFR 10–60 mL/min/1,73 m2). Es wurde der Intra-Class-Correlation factor berechnet zwischen der Referenzmethode (51)Cr-EDTA-Clearance und der Kreatinin-Clearance, den Kreatinin-basierten Formeln (Cockroft-Gault, Modified Diet in Renal Disease, Wright) und den Cystatin-C-basierten Formeln (Larsson, Dade-Behring, Hoek) zur GFR-Berechnung. Zusätzlich ermittelten wir Sensitivität und Spezifität der verschiedenen Clearance-Bestimmungen zur Erkennung einer GFR > 60 ml/min/1,73 m2 mittels Receiver Operating Characteristic Curve (ROC).Ergebnisse:Die beste Korrelation zur Referenzmethode wurde für die Cystatin-C-basierten Formeln zur GFR-Bestimmung im Vergleich zu Kreatinin-basierten Formeln oder der Kreatinin-Clearance ermittelt. Jedoch zeigte der Bland-Altman-Plot, dass im Vergleich zur Referenzmethode alle Formeln – sowohl Cystatin-C- als auch Kreatinin-basiert – die Nierenfunktion überschätzen. Die höchste Genauigkeit und Präzision wurde bei der Hoek-Formel beobachtet. Da eine GFR < 60 ml/min/1,73 m2 häufig als Grenze angesehen wird zur Durchführung einer Chemotherapie, ermittelten wir die Präzision, mit der die verschiedenen GFR-Bestimmungen dies für den Einzelnen voraussagen konnten. Bei der ROC-Analyse zeigte die Kreatinin-basierte Formel nach Wright die höchste Area Under the Curve, dicht gefolgt von der Modified-Diet-in-Renal-Disease-Formel und den Cystatin-C-basierten Formeln nach Larsson, Dade-Behring und Hoek.Schlussfolgerung:Die Cystatin-C-basierten Formeln zur GFR-Berechnung zeigten insgesamt die beste Präzision und Korrelation zur Referenzmethode in Kopf-Hals-Tumorpatienten. Daher empfehlen wir Cystatin-C-basierte Formeln zur GFR-Berechnung im klinischen Alltag bei diesen Patienten.

The role of neoadjuvant and adjuvant treatment for adenocarcinoma of the upper gastrointestinal tract

Both locally advanced adenocarcinoma of the stomach and gastro-esophageal junction are associated with poor prognosis due to the lack of effective treatment. Recently multimodal treatment consisting of neoadjuvant chemotherapy in combination with radiotherapy is reported to improve survival when compared to surgery alone. Neoadjuvant therapy in these locally advanced tumors allows for early tumor responses and the extent of tumor regression that can be achieved is considered a significant prognostic factor. This, in turn, increases the resectability of these tumors. Also due to the high frequency of lymph node metastasis, patients with locally advanced adenocarcinoma should undergo a D2 lymphadenectomy. Postoperative chemoradiation and perioperative chemotherapy have been studied in gastric adenocarcinomas and showed a survival benefit. However, the surgical techniques used in these trials are no longer considered to be standard by todays surgical practice. In addition, there are no standard recommendations for adjuvant chemotherapy or chemoradiation after R0 resection and adequate lymph node dissection.

Evaluation of the tissue toxicity of antiseptics by the hen's egg test on the chorioallantoic membrane (HETCAM)

BackgroundAntiseptics are frequently used for the prophylaxis and treatment of local infections of chronic wounds. Whereas local antiseptics in general have a positive effect on wound healing an uncritical use may impair wound healing due to toxic side effects.ObjectiveWe sought to assess the vascular irritation potential of different antiseptic solutions and ointments commonly used for short and long term application as a measure of tissue toxicity.MethodThe vascular irritation was evaluated by the hens egg test (HET) on the chorioallantoic membrane (CAM). The effects on the vessels of a mucous membrane were directly assessed by stereomicroscopic observation in vivo.ResultsSevere CAM irritation was observed after short-term applications of 1% octenidin-2HCl (Octeni sept™), 72% isopropanol (Cutasept™), 0.35% chloroxylenol (Dettol™) and 10% PVP-I ointment (Betaisodona™). Medium irritations were observed for 10% PVP-I solution (Betaisodona™), 3% lysosomal PVP-I ointment (Repithel™), 1.8% cadexomer-iodine ointment (Iodosorb™) and 1% cadexomer-iodine pellets (Iodosorb™). Finally, slight irritations were observed for 1% PVP-I solution (Betaisodona™), 0.1% polyhexanid plus betain (Prontosan™) and 1% silver-sulfadiazine ointment (Flammazine™), whereas 0.04% polyhexanid solution (Lavanid™), washings from sterile maggots of Lucilia sericata and filtrated enzymes from Clostridium histolyticum (Iruxol-N™) showed no effects of irritation. In the long-term approaches, no vascular irritations were found for polyhexanid, washings from Lucilia sericata and enzyme filtrations from Clostridium histolyticum.ConclusionThe vascular injuries caused by the studied antiseptics are an indirect indicator of their tissue toxicity. Strikingly, even therapeutic substances, which have been regarded as safe in their application for the treatment of chronic wounds in clinical studies, showed severe irritations on the CAM. We suggest that agents with no or low irritation potential on the CAM should be preferred in the clinical practice in order to obtain optimal results.

Compartmental resection for subfascial extremity soft tissue sarcoma and quality of life in long-term survivors

ZusammenfassungHINTERGRUND: Die chirurgische Behandlung von Weichteilsarkomen hat sich in den letzten Jahren stark verändert. Heute werden Patienten interdisziplinär multimodal behandelt. Bei großen Extremitätensarkomen wird oftmals eine Kompartmentresektion durchgeführt, auch wenn der onkologische Benefit letztlich noch nicht eindeutig bestätigt werden konnte. Ein Argument dafür sind die immer wieder nachgewiesenen Satellitenmetastasen im Kompartment. Hinzu kommt, dass der Versuch der Extremitätenerhaltung (im Vergleich zur primären Amputation) heute Therapieziel der Wahl ist. Letztlich liegen hier aber nur wenige Untersuchungen über den onkologischen Langzeitverlauf vor. Untersuchungen über die Lebensqualität sind fast nicht vorhanden. PATIENTEN UND METHODIK: 464 Patienten mit einem Weichteilsarkom (STS) einer Extremität wurden prospektiv gesammelt und retrospektiv ausgewertet. Eine Kompartmentresektion bei einem subfaszialen Tumor wurde bei 82 Patienten durchgeführt. Die Histologie und das Tumorstadium wurden erfasst, ebenso die klinischen Daten (Rezidiv, Überleben) und eine mögliche adjuvante Therapie. Die postoperative Lebensqualität wurde mit Hilfe des EORTC QLQ-C30 Fragebogens (www.eortc.be/home/qol) ausgewertet. ERGEBNISSE: In unserer Erhebung waren 52 % der STS schlecht, 32 % mäßig und 16 % gut differenziert. Das Gesamtüberleben war signifikant abhängig von Tumorgrad und der Tumorbiologie, nicht aber auf die Tumorgröße. Die Gesamtüberlebensrate betrug 81,5 %, 71,9 % und 58,3 % nach 2, 3 und 5 Jahre. Leiomyosarkome (39 %) und maligne fibröse Histiozytome (42 %) hatten eine schlechtere 5-Jahres-Überlebensrate im Vergleich zu Liposarkome (82 %). Metastasen wurden in 33 % der T1 und in 43 % bei T2 Tumoren gefunden. Bei G3-Tumoren entwickelten im weiteren Verlauf 51 % der Patienten Metastasen, während die bei G2-Tumoren 52 % und bei G1-Tumoren 23 % der Fall war. SCHLUSSFOLGERUNG: Die Lebensqualität war bei allen unseren Sarkompatienten im Vergleich zur Normalbevölkerung reduziert, aber überwiegend noch in einem recht hohen Bereich. Auch wenn Vergleiche zu einer Patientengruppe mit primärer Amputation oder mit weiter Resektion hier nicht angestellt werden konnten, verringerte die Kompartment-Resektion das Risiko eines lokalen Rezidivs und war vergleichbar mit der historischen Rezidivrate nach einer weiten Resektion oder Amputation in der Literatur.SummaryThe surgical management of soft tissue sarcoma has changed over the past years, resulting in an interdisciplinary multimodal approach and limb-preserving treatment modalities. From 464 consecutive patients with a soft tissue sarcoma (STS) of an extremity, a compartmental resection was performed in 82 patients, usually for primary subfascial large tumors. Postoperative quality of life was evaluated using the EORTC Score C30. In our study population, 52% of STS was poorly differentiated, 32% moderately, and 16% well differentiated. Survival proved to be dependent on tumor grade and tumor biology, but not on tumor size. The overall survival rate was 81.5%, 71.9%, and 58.3% after 2, 3, and 5 years, respectively. Leiomyosarcoma (39%) and malignant fibrous histiocytoma (42%) are associated with poor 5-year survival rate compared to liposarcoma (82%). Metastases were observed in 33% of T1 and 43% of T2 tumors corresponding to 51% with G3 tumors, 52% with G2 and 23% with G1 tumors. We found a decreased quality of life score in our patients in all dimensions compared to a normal population. Despite the elevated risk of a functional deficit, compartmental resection reduces the risk of local recurrence comparable to the recurrence rates after the most radical surgery limb amputation.

The benefit of adjuvant radiotherapy after breast conserving surgery in older patients with low risk breast cancer- a meta-analysis of randomized trials

Purpose/Objective(s)It is currently unclear whether patients with low risk breast cancer receiving adjuvant endocrine therapy need adjuvant radiation therapy after breast conserving surgery. The data of randomized trials are available.Materials/MethodsIn a database search 5 randomized trials including in total 3766 mostly elderly patients with early stage breast cancer treated either with adjuvant endocrine therapy or with endocrine therapy and additional whole breast radiation after breast conserving surgery were identified. Published hazard ratios for time to local recurrence were the basis of our meta-analysis. Meta-analysis of the effect sizes on local recurrence was performed using a random effects model based on parameter estimates of log hazard ratios in Cox models and their standard errors. Furthermore, overall survival was examined.ResultsAdjuvant hormone therapy alone in mostly older patients with low risk breast cancer resulted in significantly shorter time to local relapse compared to radiation therapy combined with hormone therapy (Hazard Ratio: 6.8, 95% CI: 4.23–10.93, p < 0.0001) . There was no significant difference for overall survival.ConclusionAdditional radiation therapy to hormone therapy did improve local relapse in breast cancer patients but did not show significant impact on overall survival.

Influence of dosimetric and clinical criteria on the requirement of artificial nutrition during radiotherapy of head and neck cancer patients

PURPOSE/OBJECTIVE(S) Intensification of radiotherapy and chemotherapy for head-and-neck cancer (HNC) may lead to increased rates of long term dysphagia as a severe side effect. Mucositis and consequent swallowing problems require artificial nutrition in many HNC patients undergoing radiotherapy or chemoradiation. It is unknown, which predict factors for prophylactic PEG tube insertion appear useful. MATERIALS/METHODS From an institutional database, 101 patients (72 male, 29 female, mean age 59.5years) were identified who underwent radiotherapy or chemoradiation for HNC. Primary end point of the investigation was the need for artificial nutrition for more than 4days during radiotherapy. Dose volume parameters of defined normal tissue structures potentially of relevance for swallowing ability as well as clinical factors were used to develop a predictive model using a binary multiple logistic regression model. RESULTS Whereas several dosimetric and clinical factors were significant predictors for the need of artificial nutrition on univariate analysis, on multivariate analysis only three factors remained independently significant: mean dose to the oropharynx+1cm circumferential margin, ECOG performance state (0-1 vs. 2-4), and the use of chemotherapy (yes vs. no). CONCLUSIONS Using a 3 parameter model we could distinguish HNC-patients with different risks for the need of artificial nutrition during radiotherapy. After independent validation, the model could be helpful to decision on prophylactic PEG tube insertion.