Collaboration to Accelerate Proteogenomics Cancer Care: The Department of Veterans Affairs, Department of Defense, and the National Cancer Institute's Applied Proteogenomics OrganizationaL Learning and Outcomes (APOLLO) Network.

A tri-federal initiative arising out of the Cancer Moonshot has resulted in the formation of a program to utilize advanced genomic and proteomic expression platforms on high-quality human biospecimens in near-real-time in order to identify potentially actionable therapeutic molecular targets, study the relationship of molecular findings to cancer treatment outcomes, and accelerate novel clinical trials with biomarkers of prognostic and predictive value.

Steroid induction of therapy-resistant cytokeratin-5-positive cells in estrogen receptor-positive breast cancer through a BCL6-dependent mechanism.

Therapy resistance remains a major problem in estrogen receptor-α (ERα)-positive breast cancer. A subgroup of ERα-positive breast cancer is characterized by mosaic presence of a minor population of ERα-negative cancer cells expressing the basal cytokeratin-5 (CK5). These CK5-positive cells are therapy resistant and have increased tumor-initiating potential. Although a series of reports document induction of the CK5-positive cells by progestins, it is unknown if other 3-ketosteroids share this ability. We now report that glucocorticoids and mineralocorticoids effectively expand the CK5-positive cell population. CK5-positive cells induced by 3-ketosteroids lacked ERα and progesterone receptors, expressed stem cell marker, CD44, and displayed increased clonogenicity in soft agar and broad drug-resistance in vitro and in vivo. Upregulation of CK5-positive cells by 3-ketosteroids required induction of the transcriptional repressor BCL6 based on suppression of BCL6 by two independent BCL6 small hairpin RNAs or by prolactin. Prolactin also suppressed 3-ketosteroid induction of CK5+ cells in T47D xenografts in vivo. Survival analysis with recursive partitioning in node-negative ERα-positive breast cancer using quantitative CK5 and BCL6 mRNA or protein expression data identified patients at high or low risk for tumor recurrence in two independent patient cohorts. The data provide a mechanism by which common pathophysiological or pharmacologic elevations in glucocorticoids or other 3-ketosteroids may adversely affect patients with mixed ERα+/CK5+ breast cancer. The observations further suggest a cooperative diagnostic utility of CK5 and BCL6 expression levels and justify exploring efficacy of inhibitors of BCL6 and 3-ketosteroid receptors for a subset of ERα-positive breast cancers.

Prolactin suppresses a progestin-induced CK5-positive cell population in luminal breast cancer through inhibition of progestin-driven BCL6 expression.

Prolactin controls the development and function of milk-producing breast epithelia but also supports growth and differentiation of breast cancer, especially luminal subtypes. A principal signaling mediator of prolactin, Stat5, promotes cellular differentiation of breast cancer cells in vitro, and loss of active Stat5 in tumors is associated with antiestrogen therapy failure in patients. In luminal breast cancer, progesterone induces a cytokeratin-5 (CK5)-positive basal cell-like population. This population possesses characteristics of tumor stem cells including quiescence, therapy resistance and tumor-initiating capacity. Here we report that prolactin counteracts induction of the CK5-positive population by the synthetic progestin (Pg) R5020 in luminal breast cancer cells both in vitro and in vivo. CK5-positive cells were chemoresistant as determined by fourfold reduced rate of apoptosis following docetaxel exposure. Pg-induction of CK5 was preceded by marked upregulation of BCL6, an oncogene and transcriptional repressor critical for the maintenance of leukemia-initiating cells. Knockdown of BCL6 prevented induction of CK5-positive cell population by Pg. Prolactin suppressed Pg-induced BCL6 through Jak2-Stat5 but not Erk- or Akt-dependent pathways. In premenopausal but not postmenopausal patients with hormone receptor-positive breast cancer, tumor protein levels of CK5 correlated positively with BCL6, and high BCL6 or CK5 protein levels were associated with unfavorable clinical outcome. Suppression of Pg-induction of CK5-positive cells represents a novel prodifferentiation effect of prolactin in breast cancer. The present progress may have direct implications for breast cancer progression and therapy as loss of prolactin receptor-Stat5 signaling occurs frequently and BCL6 inhibitors currently being evaluated for lymphomas may have value for breast cancer.

The utility of a rapid parathyroid assay for uniglandular, multiglandular, and recurrent parathyroid disease.

The rapid parathyroid hormone assay (rPTH) is an effective tool in minimally invasive resections of parathyroid adenomas. However, there are relatively few reports examining its utility in the full spectrum of parathyroid disease. The purpose of this study was to examine the utility of the rapid parathyroid hormone assay in uniglandular, multiglandular, and recurrent hyperparathyroidism. A retrospective analysis of all patients undergoing parathyroid resection from June 2001 to March 2003 was undertaken. All patients underwent preoperative localization studies. Rapid parathyroid hormone (PTH) levels were drawn immediately prior to and 10 minutes following parathyroid resection. A decline of > or = 50 per cent rPTH qualified as a successful/complete resection. Additional intraoperative samples were drawn as needed for patients with multiglandular disease. Of 46 treated patients who were examined (average age, 54 years), 30 had single, 12 patients had multigland disease, and 4 had recurrent/persistent hyperparathyroidism. Thirty-seven patients had primary hyperparathyroidism (32 with single and 3 with double adenomas; 2 with hyperplasia), 4 patients had secondary hyperparathyroidism, and 5 tertiary hyperparathyroidism. All procedures were considered successful, as every patient exhibited a postresection decrement in rPTH exceeding 50 per cent (average decrement, 91%). Although 2 patients exhibited a postoperative PTH increase exceeding 50 per cent of the preoperative value, all remained asymptomatic and eucalcemic (median follow-up, 21.5 months). The rPTH assay is an effective tool in determining success of parathyroidectomy in patients with primary uni- and multiglandular as well as recurrent hyperparathyroidism. It can be used to achieve minimally invasive neck dissections or guide surgical decision-making in more complex cases.

Functional relationship and gene ontology classification of breast cancer biomarkers.

Breast cancer is a complex disease that still imposes a significant healthcare burden on women worldwide. The etiology of breast cancer is not known but significant advances have been made in the area of early detection and treatment. The advent of advanced molecular biology techniques, mapping of the human genome and availability of high throughput genomic and proteomic strategies opens up new opportunities and will potentially lead to the discovery of novel biomarkers for early detection and prognostication of breast cancer. Currently, many biomarkers, particularly the hormonal and epidermal growth factor receptors, are being utilized for breast cancer prognosis. Unfortunately, none of the biomarkers in use have sufficient diagnostic, prognostic and/or predictive power across all categories and stages of breast cancer. It is recognized that more useful information can be generated if tumors are interrogated with multiple markers. But choosing the right combination of biomarkers is challenging, because 1) multiple pathways are involved, 2) up to 62 genes and their protein products are potentially involved in breast cancer-related mechanisms and 3) the more markers evaluated, the more the time and cost involved. This review summarizes the current literature on selected biomarkers for breast cancer, discusses the functional relationships, and groups the selected genes based on a Gene Ontology classification.

Delayed nephrectomy in grade V renal injury with two interesting anatomic variations.

The decision to perform early nephrectomy in hemodynamically stable grade V injury rather than to provide supportive nonoperative care is not universally accepted. The management of isolated grade V renal injury, as well as the management of coexisting abdominal trauma that requires operative intervention, is an area of controversy. We present the case of a grade V renal injury that was initially managed expectantly at a level I trauma center. After transfer to our facility, nephrectomy was performed. The case illustrates the merit of prompt definitive surgical treatment.

Expression of the sodium iodide symporter and thyroglobulin genes are reduced in papillary thyroid cancer.

Altered expression of the gene encoding the sodium iodine symporter (NIS) may be an important factor that leads to the reduced iodine accumulation characteristic of most benign and malignant thyroid nodules. Both up- and down-regulation of NIS gene expression have been reported in thyroid cancer using several different methods. The goal of the present study was to accurately identify alterations in NIS gene expression in benign and malignant thyroid nodules using an accurate real-time quantitative RT-PCR assay system. Total RNA was prepared from 18 benign thyroid nodules, 20 papillary thyroid cancers, and 23 normal thyroid samples from 38 subjects. Quantitative RT-PCR was used to measure NIS and thyroglobulin (TG) mRNA expression in normal thyroid tissue and in each nodular tissue sample. Papillary thyroid cancer samples had significantly lower NIS mRNA expression (72 +/- 41 picogram equivalents [pg Eq]), than did benign nodules (829 +/- 385 pg Eq), or normal tissues (1907 +/- 868 pg Eq, P = 0.04). Most important, in the paired samples, NIS gene expression was decreased in each papillary thyroid cancer compared with normal tissue (69% median decrease; range, 40-96%; P = .013). Eleven of the 12 benign nodules also demonstrated lower NIS gene expression than the normal tissue (49% decrease; range, 2-96%; P = .04). Analysis of the paired samples demonstrated that Tg mRNA expression was significantly lower in each of the thyroid cancer samples than in corresponding normal tissue (759 +/- 245 pg Eq vs. 1854 +/- 542 pg Eq, P = .03). We have demonstrated a significant decrement in NIS gene expression in all papillary thyroid cancers and in over 90% of benign nodules examined compared with adjacent normal thyroid tissue, using a highly accurate quantitative RT-PCR technique. Similarly, thyroid cancers demonstrated significantly lower TG mRNA expression than corresponding normal thyroid. Reduced NIS expression may be an important factor in the impairment of iodine-concentrating ability of neoplastic thyroid tissues.

Utility of computed tomographic enteroclysis for the general surgeon(1).

Enteroclysis uses contrast fluid distention of the small bowel through a jejunal catheter with flouroscopic imaging to identify abnormalities. Computed tomograpic enteroclysis (CT-E) adds cross-sectional imaging to identify small bowel pathology to include masses, gastrointestinal bleeding of unknown origin, and partial obstruction. Computed tomography-enteroclysis is being used more frequently in the assessment of patients with possible small bowel pathology. This study examines the applicability of CT-E and its superiority over conventional enteroclysis.A retrospective chart review was used to examine all CT-E and enteroclysis studies performed at our institution during a 24-month period (August 1997 to August 1999). All patients that had received CT-E or enteroclysis were divided into 3 categories; group I: small bowel mass, group II: gastrointestinal bleeding, and group III: partial small bowel obstruction (pSBO). All patients included had received other radiological procedures based on the indication for examination to include esophagogastroduodenoscopy, colonoscopy, CT, abdominal x-rays, barium enema, and upper gastrointestinal with small bowel follow-through.Forty-nine studies were performed, with enteroclysis or CT-E, used in 46 patients. Median age was 62 years (M:F, 1:1). In group 1 (n = 10), no masses were noted, but all patients identified as having a mass on previous studies (n = 6) were determined not to have a mass by CT-E (n = 1) and enteroclysis (n = 5). In group II (n = 19), 1 small bowel source (jejujunal arteriovenous malformation) was identified through CT-E, and all other studies in both categories were negative/normal. In group III (n = 20), 5 pSBO were identified through CT-E that had not been previously described.Enteroclysis and CT-E are both effective at disproving the presence of small bowel masses discovered through less-specific radiological methods. In terms of gastrointestinal bleeding, CT-E is as effective as enteroclysis at identifying source of bleeding and may have an added role through its ability to better identify anatomic relationships. Computed tomography-enteroclysis was able to determine the presence of pSBO in 5 patients that previously had been undiagnosed. In conclusion, enteroclysis remains an effective radiological study for examination of the small bowel. Computed tomography-enteroclysis matches that effectiveness with the added benefit on high-resolution anatomic images that serve it well as an additional diagnostic tool for the General Surgeon in patients with difficult to diagnose small bowel pathology.

5-year qualitative results of isolated cryosurgical ablation for hepatic malignancy at Walter Reed Army Medical Center(1).

Cryosurgical ablation (CSA) is an established treatment for primary and metastatic liver malignancies. The study objective was to qualitatively define our patient CSA experience and compare it with the existing literature.A retrospective review was conducted of patients who underwent isolated CSA from September 1995 to April 2000. Data were collected on patient characteristics, tumor characteristics, sequential 12-hour laboratory data, transfusion requirements, and survival data. SPSS 9.0 (SPSS, Chicago, Illinois) was used for data analysis.Twenty-four patients (14 men, 10 women) were studied. Eighty-seven lesions (mean 3.8/patient) were treated. Six patients underwent treatment for primary liver tumors, whereas 16 were treated for metastatic disease. White blood cell count increased 1.7-fold, and platelet count decreased 2.0-fold. Aspartate aminotransferase and alanine aminotransferase increased significantly 42- and 29-fold, respectively. Seven out of 21 (33%) patients required blood transfusion. Our overall complication rate was 25%. Perioperative mortality was 0%. Kaplan-Meier survival analysis revealed an overall survival of 46% at a median follow-up of 33.7 +/- 6.8 months.CONCLUSIONS:Although isolated CSA of hepatic malignancies results in major and minor alterations in serologic parameters, they equate to little clinical significance. Blood product transfusions are necessary in 30% patients post-CSA. Significant perioperative complications occur in 25% of patients. Survival estimates suggest that nearly 50% of patients undergoing CSA can be expected to survive longer than 2 years post-CSA.

Desmoid tumors of the chest wall.

Desmoid tumors are rare soft tissue neoplasms derived from fascial or musculoaponeurotic structures. These tumors are histologically benign but may behave aggressively at the local level with multiple recurrences after complete resection being common. Chest wall desmoids account for approximately 20% of all patients with desmoid tumors. Patients with these lesions are often asymptomatic and thus commonly present with lesions greater than 10 cm in size. The treatment for these neoplasms remains margin negative surgical excision, and, given the often large size at presentation, may require extensive chest wall resection. When this is required, chest wall reconstruction with either prosthetic material and/or autologous tissue may be performed. There may be recurrence in as many as 75% of patients. Neither adjuvant radiotherapy or chemotherapy have been shown to reduce the rate of recurrence. Recurrence should also be treated with surgical resection because patients who undergo complete surgical resection of recurrence are as likely to remain disease free after resection as patients who present with primary disease.

Sentinel lymph node biopsy for breast cancer: the role of previous biopsy on patient eligibility.

Several reports have demonstrated the accurate prediction of axillary nodal status with radiolocalization and selective resection of sentinel lymph nodes (SLNs) in patients with breast cancer (BC). Because of concerns over lymphatic disruption, several authors have proposed that prior excisional breast biopsy is a contraindication for SLN biopsy. Clear unfiltered 99mtechnetium-sulfur colloid (1.0 mCi) was injected around the perimeter of the breast lesion (palpable and nonpalpable) or prior biopsy site. Resection of the radiolocalized SLN was then performed. Axillary lymph node dissection was performed immediately after SLN biopsy in the first 57 patients. Eighty-two BC patients underwent SLN biopsy. The SLN was localized in 98 per cent (80 of 82). The type of previously performed diagnostic biopsy or the location of the primary lesion did not influence the ability to localize the sentinel lymph node. In the 57 patients who had axillary lymph node dissection, metastatic disease was identified in 23 per cent (13 of 57). Axillary nodal status was accurately predicted in 98 per cent (56 of 57). Early experience with radiolocalization and selective resection of SLN in BC remains promising. By demonstrating the effective localization of the SLN regardless of the extent of prior biopsy, these data support expanding the number of patients potentially eligible for SLN biopsy.

Decision making on surgical palliation based on patient outcome data.

BACKGROUND: Strategies for the effective application of palliative procedures are infrequently standardized and incompletely understood. The effect on patient outcome as determined by elements such as resolution of chief complaints, quality of life, pain control, morbidity of therapy, and resource utilization should predominate decisions regarding surgical palliative care. METHODS: Articles published between 1990 and 1996 on the surgical palliation of cancer were identified by a MEDLINE search and reviewed for designated parameters considered important for good palliative care. RESULTS: A total of 348 citations were included. Entries considered these fundamental elements: cost (2%); pain control (12%); quality of life (17%); need to repeat the intervention (59%); morbidity and mortality (61 %); survival (64%); and physiologic response (69%). Established methods for quality of life and pain assessment were sporadically utilized. CONCLUSIONS: In the current surgical literature, there is uncommon reporting of the range of data required to recommend sound palliative surgical choices.

Guidelines for the safe use of radioactive materials during localization and resection of the sentinel lymph node.

BACKGROUND: Several reports have demonstrated accurate prediction of nodal metastasis with radiolocalization and selective resection of the radiolocalized sentinel lymph node (SLN) in patients with breast cancer and melanoma. As reliance on this technique grows, its use by those without experience in radiation safety will increase. METHODS: Tissue obtained during radioguided SLN biopsies was examined for residual radioactivity. Specimens with a specific activity greater than the radiologic control level (RCL) of 0.002 microCi/g were considered radioactive. Radiation exposure to the surgical team was measured. RESULTS: A total of 24 primary tissue specimens and 318 lymph nodes were obtained during 57 operations (37 for breast cancer, 20 for melanoma). All 24 (100%) of the specimens injected with radiopharmaceutical and 89 of 98 (91%) of the localized nodes were radioactive after surgery. Activity fell below the RCL 71+/-3.6 hours in primary tissue specimens, 46+/-1.7 hours in nodes from melanoma patients, and 33+/-3.5 hours in nodes from breast cancer patients (P = .037). The hands of the surgical team (n = 22 cases) were exposed to 9.4+/-3.6 mrem/case. CONCLUSION: Although low levels of radiation exposure are associated with radiolocalization and resection of the SLN, the presented guidelines ensure conformity to existing regulations and allow timely pathologic analysis.

Cyclical mastalgia: premenstrual syndrome or recurrent pain disorder?

Approximately 8-10% of premenopausal women experience moderate to severe perimenstrual breast pain or cyclical mastalgia, monthly. This mastalgia can occur regularly for years until menopause, can interfere with usual activities, and is associated with elevated utilization of mammography among young women. Although mastalgia is a well documented symptom in premenstrual syndrome (PMS), it is unknown whether PMS is necessarily present in women with cyclical mastalgia. The present study prospectively examined mastalgia and its relationship to PMS. Thirty-two premenopausal women reporting recent mastalgia completed breast pain and menstrual symptom scales daily for 3-6 months. Eleven women (34.4%) met criteria for clinically significant cyclical mastalgia, reporting an average of 10.2 days of moderate-severe mastalgia monthly. Five women (15.6%) met criteria for PMS. Mastalgia was not significantly associated with PMS: 82% of women with clinical cyclical mastalgia did not have PMS. Cyclical mastalgia, although by definition associated with the menstrual cycle, is not simply premenstrual syndrome, and merits further investigation as a recurrent pain disorder whose presentation, etiology, and effective treatment are likely to differ from those of PMS.

Diagnosis and management of the autonomously functioning thyroid nodule: the Walter Reed Army Medical Center experience, 1975-1996.

In order to characterize the clinical and laboratory features of autonomously functioning thyroid nodules (AFTNs), and to assess optimal diagnosis and management of patients with this disorder, we performed a retrospective analysis of 49 such patients over a 22-year period encompassing January 1975 to November 1996. The following data were analyzed: thyroid hormone levels, thyroid scintiscan, radioiodine uptake, fine-needle aspiration biopsy, triiodothyronine (T3) suppression testing, thyrotropin-releasing hormone (TRH) stimulation test, and thyroid ultrasound. Clinical outcomes assessed included persistent hyperthyroidism, hypothyroidism, and nodule shrinkage after treatment, or in patients followed without definitive therapy, nodule growth, spontaneous degeneration, and progression to hyperthyroidism. Biochemical hyperthyroidism, often subclinical, was found in 73.5% of patients at presentation and in an additional 24.4% of patients during subsequent follow-up. The introduction of sensitive thyrotropin (TSH) testing during the period of study resulted in a decrease in the use of the T3-suppression test and TRH stimulation test from 100% and 20%, respectively, in the period from 1976-1980, to 4% each in the period from 1991-1996. T3-thyrotoxicosis occurred in 12.2% of patients. Thyrotoxicosis at any time during the course of follow-up was positively correlated with nodule size at diagnosis. Definitive therapy, used in 42.8% of patients, consisted of radioiodine ablation (38.1%) or thyroidectomy (61.9%). No patient had recurrence of thyrotoxicosis after definitive therapy, but 25% became hypothyroid. During follow-up for a mean of 30.9 months, nodules enlarged in 25% of patients overall, or 33% of patients not receiving definitive therapy. Cystic degeneration was documented in 26.5% of patients, although this change rarely reversed subclinical hyperthyroidism. The diagnosis of an AFTN requires a demonstration of TSH-independent nodular hyperfunction. The introduction of sensitive TSH assays has simplified the evaluation of AFTN patients and revealed a high prevalence of subclinical thyroid hyperfunction in this disorder. In view of current increased awareness of adverse consequences associated with subclinical hyperthyroidism and the rarity of spontaneous resolution of hyperthyroidism in AFTN patients (despite a propensity for spontaneous hemorrhage), definitive therapy is recommended. Both radioiodine and hemithyroidectomy have high cure rates and a low posttreatment incidence of hypothyroidism.

Contributions from surgeons to clinical trials and research on the management of soft tissue sarcoma.

BACKGROUND: Surgical resection is the primary treatment for soft tissue sarcoma. Surgeons are in a position to develop and define appropriate treatment strategies for this disease. In an effort to define the contributions of surgeons to the management of sarcoma, the surgical and clinical oncology literature from January 1983 through June 1996 was reviewed. METHODS: A computerized literature search of the Cancerlit database for January 1983 to June 1996 was performed. The search was limited to the topic of soft tissue sarcoma and was further confined to 15 journals that publish articles relevant to surgical management. These studies were then categorized by multiple parameters and analyzed. RESULTS: The Cancerlit file contained 4478 articles in which sarcoma was the primary topic. When the search was limited to 15 journals frequently read by surgeons, 479 references (11%) were retrieved. Within the surgical literature, 95 of the 479 articles (20%) described prospective studies, of which 33 were prospective and randomized. These studies represent all but three of the prospective randomized trials within the literature during the time period reviewed. The management of patients with sarcoma was evaluated in 26 of the prospective randomized trials; of these, 13 trials evaluated adjuvant chemotherapy, three evaluated adjuvant radiotherapy, and ten evaluated the chemotherapeutic treatment of metastatic disease. Surgical oncologists were the first or senior author on 10 of the 16 prospective randomized studies regarding adjuvant radiation or chemotherapy. Four of the 16 trials evaluating adjuvant therapy contained more than 100 patients, and three of those four were from cooperative group efforts. All but one of the studies of adjuvant therapy with less than 100 patients were from single institutional trials. CONCLUSIONS: Although the surgical and clinical oncology literature on soft tissue sarcoma is composed primarily of retrospective reviews, the prospective randomized trials reported represent almost all of the randomized trials in the literature and have significant contributions from surgeons. Surgeons can guide and design clinical trials, but overall patient accrual as represented by soft tissue sarcoma is low, and may be improved through cooperative group efforts.

Ultrasonographically guided injection improves localization of the radiolabeled sentinel lymph node in breast cancer.

BACKGROUND: Several reports have demonstrated the accurate prediction of axillary nodal status (ANS) with radiolocalization and selective resection of sentinel lymph nodes (SLN) in breast cancer. To date, no technique has proven to be superior in localizing the SLN. METHODS: 1.0 mCi of clear unfiltered 99mtechnetium sulfur colloid was injected under ultrasonographic (US) guidance around the perimeter of the breast lesion (palpable and nonpalpable) or previous biopsy site. Resection of the radiolocalized nodes was performed, followed by complete axillary lymph node dissection (AXLND). RESULTS: Forty-two breast cancer patients underwent SLN biopsy after US-guided radiopharmaceutical injection. The SLN was localized in 41 patients (98%). The type of previously performed diagnostic biopsy did not influence the ability to localize the sentinel lymph node. Pathology revealed nodal metastasis in 7 of the 41 evaluable patients (17%). ANS was accurately predicted in 40 of 41 patients (98%). CONCLUSIONS: Early experience with radiolocalization and selective resection of SLN in breast cancer remains promising. Use of US-guided injection facilitates localization of the SLN, perhaps as a result of more accurate placement of the radionuclide marker. Use of this technique allowed for effective management of patients regardless of tumor size or the extent of prior biopsy, thereby expanding the potential number of eligible patients for SLN biopsy.