First evaluation of the diagnostic accuracy of an automated 3D ultrasound system in a breast screening setting.

BACKGROUND/AIM: Automated ultrasound examination of suspicious findings can reduce the physician's workload in screening mammography. The present study examines the diagnostic accuracy of this method in comparison to mammography as the reference standard for the first time. PATIENTS AND METHODS: A total of 304 patients underwent automated 3D ultrasound examination after screening mammography. Mammograms and ultrasound images were assessed by independent examiners, and sensitivity, specificity and the degree of agreement between both methods were calculated. RESULTS: The degree of agreement was moderate (Cohen's κ=0.130 for all and 0.153 for positive/negative ratings), mainly owing to a high percentage of false-positive ultrasound results. However, the results of sonographical re-examination of suspicious mammograms were favorable. The only two undetected proven malignant lesions were microcalcified, and in three more cases with disagreement, the ultrasound diagnosis was correct. CONCLUSION: Automated 3D ultrasound imaging appears to be on a par with hand-held ultrasound in terms of diagnostic quality.

High-frequency breast ultrasound for the detection of microcalcifications and associated masses in BI-RADS 4a patients.

AIM: To retrospectively evaluate the diagnostic value of high-frequency ultrasound for the detection of microcalcifications screening in BI-RADS 4a patients. PATIENTS AND METHODS: A total of 52 women (mean age 60.5±6.5 years) classified as BI-RADS 4a with microcalcifications, but without associated masses after X-ray mammography (XRM) underwent ultrasound (US) examination (B-mode, ApliPure™ , and MicroPure™ imaging). The results were assessed by two independent investigators and analyzed in relation to the B-classification. Written informed consent was obtained before enrolment. RESULTS: The rate of US microcalcification detection was 98.1% (B-mode), 100% (ApliPure™) and 25% (MicroPure™), respectively. The microcalcification extent was significantly underestimated with all US modalities in comparison with XRM, but the difference was lower for ApliPure™ as compared to B-mode. ApliPure™ was also superior in terms of puncture feasibility, facilitating US-guided biopsy in 67.3% as compared to 48.1% (B-mode) and 15.4% (MicroPure™). CONCLUSION: In BI-RADS 4a patients, both high-frequency B-mode US and ApliPure™ imaging are highly sensitive for the detection of microcalcifications, whereas MicroPure™ ultrasound imaging is unsuitable. ApliPure™ imaging allowed US guided biopsy for 67.3% of lesions, providing a convenient and economical alternative to stereotactically guided biopsy.

Prognostic significance of angiogenic factors in uterine cervical cancer.

BACKGROUND/AIM: Angiogenesis is pivotal in tumour development and progress, and targeted tumour therapies, such as bevacizumab, have shown promising results. However, in unselected patient populations, the treatment with angiogenesis-targeted combination regimens is marred by a variable response, non-negligible toxicity and questionable economy. The present study summarizes research to identify individual circulating angiogenic factors as markers for disease severity and possibly treatment response. PATIENTS AND METHODS: A total of 125 patients with cervical cancer from the ongoing cervical cancer monitoring database of the University Hospital Charité, Berlin, Germany, were included. Information obtained from the database included tumour stage, malignancy grade, presence of nodal metastases, lymph vessel invasion, patient age, HER2, HPV, smoking and menopausal status, and serum concentrations of vascular endothelial growth factor (VEGF), VEGF-D, VEGF-C, endoglin, endostatin, angiogenin, basic fibroblast growth factor (FGFb), vascular endothelial growth factor receptor (VEGF-R1), VEGF-R2, soluble inter-cellular adhesion molecule 1 (sICAM 1), soluble vascular adhesion molecule 1 (sVCAM 1), insulin-like growth factor 1 (IFG-1) and insulin like growth factor binding protein 3 (IGF-BP3). RESULTS: There was a clear association of angiogenic factor concentrations with stage of disease. Angiogenin showed an independent discrimination for cervical intraepithelial neoplasia (CIN) and invasive stages, and endoglin did so for invasive stages vs. recurrent disease. However, none of the potential markers under investigation was anywhere near selective enough to allow for a clinically meaningful prediction of prognosis or response. CONCLUSION: The association of circulating angiogenic factors with disease progression in cervical cancer is confirmed, but its utility for prognosis prediction and patient stratification for targeted therapies is doubtful.

In vitro vascular tube formation testing as a tool for treatment individualisation in patients with cervical cancer.

BACKGROUND/AIM: Targeted tumour therapies are promising, but their results in unselected patient populations are modest and tumour growth and metastasis may be promoted rather than suppressed in some cases. The present study investigates the suitability of vascular in vitro tube formation as a tool for the identification of cervical neoplasms that will respond to bevacizumab therapy. PATIENTS AND METHODS: Fifteen patients with recurrent cervical cancer selected from the ongoing cervical cancer monitoring database of the Charité University Hospital Berlin, Germany, were included. Information obtained from the database included tumour stage, malignancy grade, presence of nodal metastases, lymph vessel invasion, patient age and menopausal status and serum concentrations of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), endostatin and vascular endothelial growth factor receptor 1 (VEGF-R1). Vascular tube formation was assessed with cultured human umbilical vein epithelial cells. RESULTS: Five patients showed a positive, 5 an inverse and 5 no in vitro response to bevacizumab. Tube length showed a marked and significant dependency on bevacizumab response. Besides tube length, VEGF-R1 concentration was the only variable with some correlation to bevacizumab response, with high levels especially for inverse responders. CONCLUSION: The identification of patients with a likely benefit from targeted therapies is crucial. Tube formation shows substantial potential, but its utility needs to be confirmed in studies on the clinical rather than in vitro response to bevacizumab.

Influence of a dose-dense adjuvant chemotherapy on sVCAM-1/sICAM-1 serum levels in breast cancer patients with 1-3 positive lymph nodes.

BACKGROUND/AIM: The aim of the present study was to investigate the effects of conventional and dose-dense chemotherapy on serum levels of soluble adhesion molecules sICAM-1 and sVCAM-1 in node-positive patients with breast cancer. PATIENTS AND METHODS: sICAM-1 and sVCAM-1 were measured in the blood serum of 147 patients with breast cancer and with 1 to 3 affected lymph nodes prior to and after conventional or dose-dense chemotherapy within a randomized phase III study (NOGGO trial). RESULTS: The increase in sICAM-1 (p<0.0001) and sVCAM-1 (p<0.001) levels after chemotherapy was statistically significant within the entire sample and the dose-dense study arm. sVCAM-1 levels were not altered by conventional chemotherapy, but were markedly and significantly increased after the dose-dense regimen. Higher sICAM-1 concentrations were found in postmenopausal patients, and the difference was significant before, but not after treatment. There was no significant correlation with other prognostic criteria. CONCLUSION: Both sVCAM-1 and sICAM-1 levels changed significantly after adjuvant chemotherapy, the effect being more marked under the dose-dense regimen. The possible prognostic relevance of adhesion molecule concentration and the effect of different modes of chemotherapy remains to be determined.

The utility of an in vitro angiogenesis score for prognosis assessment in patients with cervical cancer.

BACKGROUND/AIM: Angiogenesis plays a key role in tumour growth and metastasis. Expression of angiogenic factors has been suggested as a marker for tumour malignity, and may help to assess a patient's individual prognosis. The present study examines the relationship between angiogenic factor expression, an angiogenesis-based histoscore and clinical tumour criteria. PATIENTS AND METHODS: A total of 81 patients with cervical cancer who underwent follow-up examinations between October 2002, and June 2005, were enrolled, and serum samples were examined for vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), endostatin and VEGF-Receptor1 by means of an ELISA. Based on an endothelial-cell proliferation assay, an angiogenesis score was calculated. RESULTS: Higher endostatin and VEGF expressions indicated advanced disease, and VEGF allowed for a reliable distinction between patients with non-invasive and these with recurrent disease. There were some plausible correlations between the angiogenesis score and clinical criteria and individual angiogenic factors, but the score's discriminating power appears to be limited. CONCLUSION: The utility of angiogenesis factor testing notwithstanding, the value of an angiogenesis score for the identification of patients with a worse prognosis, and thus a resulting benefit from more aggressive treatment, is arguable.

Prognostic significance of the angiogenic factors angiogenin, endoglin and endostatin in cervical cancer.

BACKGROUND/AIM: Angiogenesis plays a key role in tumour growth and metastasis. Expression of angiogenic factors has been suggested as a marker for tumour malignity, and it may help to identify those patients with a poorer prognosis, aiding patient stratification for more aggressive and/or angiogenesis-targeted therapy. The present study examines the relationship between concentration of circulating angiogenic factors and clinical tumour criteria as well as patient survival. PATIENTS AND METHODS: A total of 125 patients with cervical cancer who underwent follow-up examinations between October 2002 and June 2005 were enrolled, and serum samples were examined for angiogenin, endoglin and endostatin by means of an ELISA. Concentrations were statistically correlated with clinical and outcome parameters. RESULTS: Concentrations of all examined angiogenic factors were on average within the manufacturer-provided normal range. Both angiogenin and endostatin increased from non-invasive tumours through invasive lesions to recurrent disease, and endoglin showed an equally steady inverse trend; differences between non-invasive, invasive and recurrent stages of the disease were statistically significant. However it was not possible to determine a sufficiently selective cut-off point for either factor by receiver operating characteristic analysis, and there was no significant correlation with survival. CONCLUSION: Angiogenic factors angiogenin, endoglin and endostatin show a definite relationship with disease stage in uterine cervical cancer, but are presently not suitable for use in risk stratification.

Prostaglandin metabolising enzymes and PGE2 are inversely correlated with vitamin D receptor and 25(OH)2D3 in breast cancer.

BACKGROUND: Breast cancer is associated with inflammatory processes based on an up-regulation of cyclooxygenase-2 (COX-2) expression. The antiproliferative effects of calcitriol (1,25(OH)(2)D(3)) mediated via the vitamin D receptor (VDR) render vitamin D a promising target in breast cancer therapy. First data suggest a correlation between vitamin D and prostaglandin metabolism. MATERIALS AND METHODS: We determined the expression of VDR, COX-2, 15-PGDH and the prostaglandin receptors EP(2)/EP(4) in normal and malignant breast tissue by real-time PCR and Western blot analysis, as well as 25(OH)(2)D(3) and PGE(2) plasma levels from healthy and breast cancer patients. RESULTS: Significantly higher COX-2, lower VDR and lower EP(2) and EP(4) receptor protein levels in the malignant tissue and a significantly lower 15-PGDH protein level in normal breast tissue were detected. Breast cancer patients older than 45 years, diagnosed and sampled in the winter time had significantly lower 25(OH)(2)D(3) and higher PGE(2) serum levels. CONCLUSION: The inverse correlation between VDR and both COX-2 and 15-PGDH, as well as between PGE(2) and 25(OH)(2)D(3) levels, suggests a possible link between VDR-associated target genes and prostaglandin metabolism.

Tumor-specific correlation of tumor M2 pyruvate kinase in pre-invasive, invasive and recurrent cervical cancer.

UNLABELLED: The aim of this study was to investigate the diagnostic value of tumor M2 pyrurate kinase (Tu-M2-PK) as a tumor marker in patients with pre-invasive (CIN), invasive (PCC) and recurrent (RCC) cervical cancer. MATERIALS AND METHODS: Plasma samples were investigated from 125 patients, comprising 50 cases of CIN (I-III), 51 of PCC (FIGO I-IV) and 24 of RCC, before treatment. Tu-M2-PK levels were determined by using a quantitative sandwich enzyme immunoassay. RESULTS: With the increase in disease severity from CIN to PCC to RCC, levels of Tu-M2-PK significantly increased (p<0.001). Levels of Tu-M2-PK significantly increased with respect to the FIGO stage (p<0.001) and had significantly higher values in node+ patients (p=0.028). There was no significant difference in Tu-M2-PK levels in CIN I-III patients (p=0.626). Patients with distant metastasis had significantly elevated levels of Tu-M2-PK (p<0.001). CONCLUSION: Tu-M2-PK can be used as a marker to differentiate between malignant and premalignant cervical lesions. In addition, the concentration of Tu-M2-PK correlates with the clinical stage of the disease.

Circulating vascular endothelial growth factors and their soluble receptors in pre-invasive, invasive and recurrent cervical cancer.

AIM: To study the impact of circulating vascular endothelial growth factors (VEGF) -A, -C and -D and their soluble receptors VEGFR-1/-2 on disease invasion and progression in patients with pre-invasive (CIN), invasive (PCC) and recurrent (RCC) cervical cancer. PATIENTS AND METHODS: Blood samples were obtained from 125 women, including 50 cases of CIN, 51 of PCC and 24 of RCC, before treatment. Soluble (s) biomarker levels were determined by ELISA and tested for correlation with histopathological factors. RESULTS: With disease progression, sVEGF-A (p = 0.007) and sVEGFR-2 (p = 0.014) significantly increased, while sVEGF-D (p = 0.046) decreased. sVEGFR-2 levels were increased in node+ patients (p = 0.024) and in metastatic disease (p = 0.003). sVEGF-A values were higher in HPV+ cases (p = 0.019). In detecting disease invasiveness, sensitivity and specificity were 76% and 48% for sVEGF-A, 52% and 32% for sVEGF-D, 25% and 94% for sVEGF-C, 93% and 6% for sVEGFR-1 and 73% and 34% for sVEGFR-2, respectively. CONCLUSION: In cervical neoplasia, a switch from a lymphangiogenic phenotype towards a hemangiogenic phenotype occurs with disease invasion and progression. The sensitivity and specificity values, however, seem not convincing enough to establish these factors as clinical markers for disease invasiveness in cervical cancer.

Analysis of HER2 and HER4 in human myocardium to clarify the cardiotoxicity of trastuzumab (Herceptin).

PURPOSE: When combined with anthracyclines, the humanized anti-HER2 monoclonal antibody trastuzumab (Herceptin) provides significant clinical benefit for women with HER2-overexpressing metastatic breast cancer. However, its use is limited by severe cardiotoxicity. To clarify whether myocardial HER2 and HER4 expression in response to anthracycline exposure and cardiac damage contributes to cardiotoxicity, we assessed expression of HER2 and HER4 in pathologically altered myocardium. EXPERIMENTAL DESIGN: Cardiac biopsies from 60 patients with severe heart disease and cardiac tissue from 35 patients with breast cancer were obtained. Twenty-five of the patients with breast cancer had previously received anthracyclines. Three of 10 anthracycline-naïve patients with breast cancer had received trastuzumab. Expression of HER2 and HER4 was analyzed immunohistochemically (HER2: HercepTest/A0485 (Dako), Cy3 detection (Dianova); HER4: Ab-4 (NeoMarkers)). FISH analysis (Ventana) was used to assess HER2 gene amplification. RESULTS: Immunohistochemistry revealed weak HER2 membrane staining in six cardiac biopsies, appearing as dotted staining of the whole cell membrane and intensified HER2 signal using fluorescent Cy3 labeling. No HER2 membrane staining was detected in the remaining 54 cardiac biopsies or in the myocardium of the 35 patients with breast cancer. HER2 gene amplification was not observed. All specimens showed the mild cytoplasmatic HER4 staining of normal myocardium. No strong HER4 expression was detected. CONCLUSIONS: Cardiac alterations are not associated with an strong increase in HER2 and HER4 levels. IHC detects potential low-level HER2 expression in some samples. However, a more sensitive technique may be needed for studies of the role of HER2 in cardiac tissue. These data do not exclude a role for inhibition of cardiac HER2 expression by trastuzumab in the onset of heart failure in trastuzumab-treated patients.