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Background Current research in breast cancer focuses on individualization of local and systemic therapies with adequate escalation or de-escalation strategies. As a result, about two-thirds of breast cancer patients can be cured, but up to one-third eventually develop metastatic disease, which is considered incurable with currently available treatment options. This underscores the importance to develop a metastatic recurrence score to escalate or de-escalate treatment strategies. Patients and methods Data from 10,499 patients were available from 17 clinical cancer registries (BRENDA-project. In total, 8566 were used to develop the BRENDA-Index. This index was calculated from the regression coefficients of a Cox regression model for metastasis-free survival (MFS). Based on this index, patients were categorized into very high, high, intermediate, low, and very low risk groups forming the BRENDA-Score. Bootstrapping was used for internal validation and an independent dataset of 1883 patients for external validation. The predictive accuracy was checked by Harrell's c-index. In addition, the BRENDA-Score was analyzed as a marker for overall survival (OS) and compared to the Nottingham prognostic score (NPS). Results: Intrinsic subtypes, tumour size, grading, and nodal status were identified as statistically significant prognostic factors in the multivariate analysis. The five prognostic groups of the BRENDA-Score showed highly significant (p < 0.001) differences regarding MFS:low risk: hazard ratio (HR) = 2.4, 95%CI (1.7–3.3); intermediate risk: HR = 5.0, 95%CI.(3.6–6.9); high risk: HR = 10.3, 95%CI (7.4–14.3) and very high risk: HR = 18.1, 95%CI (13.2–24.9). The external validation showed congruent results. A multivariate Cox regression model for OS with BRENDA-Score and NPS as covariates showed that of these two scores only the BRENDA-Score is significant (BRENDA-Score p < 0.001; NPS p = 0.447). Therefore, the BRENDA-Score is also a good prognostic marker for OS. Conclusion: The BRENDA-Score is an internally and externally validated robust predictive tool for metastatic recurrence in breast cancer patients. It is based on routine parameters easily accessible in daily clinical care. In addition, the BRENDA-Score is a good prognostic marker for overall survival. Highlights: The BRENDA-Score is a highly significant predictive tool for metastatic recurrence of breast cancer patients. The BRENDA-Score is stable for at least the first five years after primary diagnosis, i.e., the sensitivities and specificities of this predicting system is rather similar to the NPI with AUCs between 0.76 and 0.81 the BRENDA-Score is a good prognostic marker for overall survival.
Differential diagnosis of parkinsonism: a head-to-head comparison of FDG PET and MIBG scintigraphy
(2020)
[\(^{18}\)F]fluorodeoxyglucose (FDG) PET and [\(^{123}\)I]metaiodobenzylguanidine (MIBG) scintigraphy may contribute to the differential diagnosis of neurodegenerative parkinsonism. To identify the superior method, we retrospectively evaluated 54 patients with suspected neurodegenerative parkinsonism, who were referred for FDG PET and MIBG scintigraphy. Two investigators visually assessed FDG PET scans using an ordinal 6-step score for disease-specific patterns of Lewy body diseases (LBD) or atypical parkinsonism (APS) and assigned the latter to the subgroups multiple system atrophy (MSA), progressive supranuclear palsy (PSP), or corticobasal syndrome. Regions-of-interest analysis on anterior planar MIBG images served to calculate the heart-to-mediastinum ratio. Movement disorder specialists blinded to imaging results established clinical follow-up diagnosis by means of guideline-derived case vignettes. Clinical follow-up (1.7 +/- 2.3 years) revealed the following diagnoses: n = 19 LBD (n = 17 Parkinson's disease [PD], n = 1 PD dementia, and n = 1 dementia with Lewy bodies), n = 31 APS (n = 28 MSA, n = 3 PSP), n = 3 non-neurodegenerative parkinsonism; n = 1 patient could not be diagnosed and was excluded. Receiver operating characteristic analyses for discriminating LBD vs. non-LBD revealed a larger area under the curve for FDG PET than for MIBG scintigraphy at statistical trend level for consensus rating (0.82 vs. 0.69, p = 0.06; significant for investigator #1: 0.83 vs. 0.69, p = 0.04). The analysis of PD vs. MSA showed a similar difference (0.82 vs. 0.69, p = 0.11; rater #1: 0.83 vs. 0.69, p = 0.07). Albeit the notable differences in diagnostic performance did not attain statistical significance, the authors consider this finding clinically relevant and suggest that FDG PET, which also allows for subgrouping of APS, should be preferred.
Background: Adaptive Radiotherapy aims to identify anatomical deviations during a radiotherapy course and modify the treatment plan to maintain treatment objectives. This requires regions of interest (ROIs) to be defined using the most recent imaging data. This study investigates the clinical utility of using deformable image registration (DIR) to automatically propagate ROIs.
Methods: Target (GTV) and organ-at-risk (OAR) ROIs were non-rigidly propagated from a planning CT scan to a per-treatment CT scan for 22 patients. Propagated ROIs were quantitatively compared with expert physician-drawn ROIs on the per-treatment scan using Dice scores and mean slicewise Hausdorff distances, and center of mass distances for GTVs. The propagated ROIs were qualitatively examined by experts and scored based on their clinical utility.
Results: Good agreement between the DIR-propagated ROIs and expert-drawn ROIs was observed based on the metrics used. 94% of all ROIs generated using DIR were scored as being clinically useful, requiring minimal or no edits. However, 27% (12/44) of the GTVs required major edits.
Conclusion: DIR was successfully used on 22 patients to propagate target and OAR structures for ART with good anatomical agreement for OARs. It is recommended that propagated target structures be thoroughly reviewed by the treating physician.
Eczema often precedes the development of asthma in a disease course called the 'atopic march'. To unravel the genes underlying this characteristic pattern of allergic disease, we conduct a multi-stage genome-wide association study on infantile eczema followed by childhood asthma in 12 populations including 2,428 cases and 17,034 controls. Here we report two novel loci specific for the combined eczema plus asthma phenotype, which are associated with allergic disease for the first time; rs9357733 located in EFHC1 on chromosome 6p12.3 (OR 1.27; P = 2.1 x 10(-8)) and rs993226 between TMTC2 and SLC6A15 on chromosome 12q21.3 (OR 1.58; P = 5.3 x 10(-9)). Additional susceptibility loci identified at genome-wide significance are FLG (1q21.3), IL4/KIF3A (5q31.1), AP5B1/OVOL1 (11q13.1), C11orf30/LRRC32 (11q13.5) and IKZF3 (17q21). We show that predominantly eczema loci increase the risk for the atopic march. Our findings suggest that eczema may play an important role in the development of asthma after eczema.
The ERCC4 protein forms a structure-specific endonuclease involved in the DNA damage response. Different cancer syndromes such as a subtype of Xeroderma pigmentosum, XPF, and recently a subtype of Fanconi Anemia, FA-Q, have been attributed to biallelic ERCC4 gene mutations. To investigate whether monoallelic ERCC4 gene defects play some role in the inherited component of breast cancer susceptibility, we sequenced the whole ERCC4 coding region and flanking untranslated portions in a series of 101 Byelorussian and German breast cancer patients selected for familial disease (set 1, n = 63) or for the presence of the rs1800067 risk haplotype (set 2, n = 38). This study confirmed six known and one novel exonic variants, including four missense substitutions but no truncating mutation. Missense substitution p.R415Q (rs1800067), a previously postulated breast cancer susceptibility allele, was subsequently screened for in a total of 3,698 breast cancer cases and 2,868 controls from Germany, Belarus or Russia. The Gln415 allele appeared protective against breast cancer in the German series, with the strongest effect for ductal histology (OR 0.67; 95%CI 0.49; 0.92; p = 0.003), but this association was not confirmed in the other two series, with the combined analysis yielding an overall Mantel-Haenszel OR of 0.94 (95% CI 0.81; 1.08). There was no significant effect of p.R415Q on breast cancer survival in the German patient series. The other three detected ERCC4 missense mutations included two known rare variants as well as a novel substitution, p.E17V, that we identified on a p.R415Q haplotype background. The p.E17V mutation is predicted to be probably damaging but was present in just one heterozygous patient. We conclude that the contribution of ERCC4/FANCQ coding mutations to hereditary breast cancer in Central and Eastern Europe is likely to be small.
Background: A novel non-invasive asthma prediction tool from the Leicester Cohort, UK, forecasts asthma at age 8 years based on 10 predictors assessed in early childhood, including current respiratory symptoms, eczema, and parental history of asthma.
Objective: We aimed to externally validate the proposed asthma prediction method in a German birth cohort.
Methods: The MAS-90 study (Multicentre Allergy Study) recorded details on allergic diseases prospectively in about yearly follow-up assessments up to age 20 years in a cohort of 1,314 children born 1990. We replicated the scoring method from the Leicester cohort and assessed prediction, performance and discrimination. The primary outcome was defined as the combination of parent-reported wheeze and asthma drugs (both in last 12 months) at age 8. Sensitivity analyses assessed model performance for outcomes related to asthma up to age 20 years. Results: For 140 children parents reported current wheeze or cough at age 3 years. Score distribution and frequencies of later asthma resembled the Leicester cohort: 9% vs. 16% (MAS-90 vs. Leicester) of children at low risk at 3 years had asthma at 8 years, at medium risk 45% vs. 48%. Performance of the asthma prediction tool in the MAS-90 cohort was similar (Brier score 0.22 vs. 0.23) and discrimination slightly better than in the original cohort (area under the curve, AUC 0.83 vs. 0.78). Prediction and discrimination were robust against changes of inclusion criteria, scoring and outcome definitions. The secondary outcome 'physicians' diagnosed asthma at 20 years' showed the highest discrimination (AUC 0.89).
Conclusion: The novel asthma prediction tool from the Leicester cohort, UK, performed well in another population, a German birth cohort, supporting its use and further development as a simple aid to predict asthma risk in clinical settings.
Mechanistic possibilitles responsible for nonlinear shapes of the dose-response relationship in chemical carcinogenesis are discussed. (i) Induction and saturation of enzymatic activation and detoxification processes and of DNA repair affect the relationship between dose and steady-state DNA adduct Ievel; (ii) The fixation of DNA adducts in the form of mutations is accelerated by stimulation of the cell division, for Jnstance due to regenerative hyperplasia at cytotoxic dose Ievels; (iii) The rate of tumor formation results from a superposition of the rates of the individual steps. It can become exponential with dose if more than one step is accelerated by the DNA damage exerted by the genotoxic carcinogen. The strongly sigmoidal shapes often observed for dose-tumor incidence relationships in animal bioassays supports this analysis. A power of four for the dose in the su~linear part of the curve is the maximum observed (formaldehyde). In contrast to animal experiments, epidemiological data ln humans rarely show a slgnificant deviation from linearity. The discrepancy might be explained by the fact that a I arge nu mber of genes contribute to the overall sensitivity of an individual and to the respective heterogeneity within the human population. Mechanistic nonlinearities are flattened out in the presence of genetic and life-style factors which affect the sensitivity for the development of cancer. For a risk assessment, linear extrapolation from the high-dose lncidence to the spontaneaus rate can therefore be approprlate in a heterogeneous population even if the mechanism of action would result in a nonlinear shape of the dose-response curve in a homogeneaus population.
Diese Arbeit vergleicht verschiedene Methoden zur Berechung der Lebenserkrankungswahrscheinlichkeit bei familiärem Brustkrebs. Dabei handelt es sich um Tabellen von Chang-Claude und die Computerprogramme Cyrillic Version 2.1 sowie IBIS Breast Cancer Risk Evaluation Tool. Es stellte sich heraus, dass sich die Ergebnisse der Modelle nicht wesentlich voneinander unterscheiden.
Risikostratifikation grosszelliger B-Zell Non-Hodgkin Lymphome anhand immunhistochemischer Parameter
(2007)
Die diffusen großzelligen B-Zell-Lymphome (DLBCL) stellen den häufigsten Typ aller Non-Hodgkin-Lymphome dar, sind aber morphologisch, immunologisch, genetisch und klinisch eine sehr heterogene Gruppe. Aufgrund dieser Heterogenität von DLBCL wurde in mehreren Studien untersucht, ob eine molekulare Heterogenität der Tumoren vorläge, bzw. versucht, eine molekulare Reklassifikation zu erreichen. Resultat dieser Bemühungen war eine Unterscheidung bzw. Definition einer Keimzentrums- ähnlichen (GCB-cell-like) Gruppe und einer aktivierten B-Zellen-ähnlichen (ABC-like) Gruppe, die sich in ihrem Ansprechen auf übliche Therapieschemata, mit einer deutlich besseren Prognose für die GCB-like-Gruppe, unterschieden. Die hierbei angewendete Microarray-Technologie hat den entscheidenden Nachteil, dass hierfür qualitativ hochwertige RNA zur Verfügung stehen muss. Neu ist der Ansatz, unterschiedliche Proteinexpressionsmuster am Paraffinmaterial zur Unterscheidung prognostisch relevanter Gruppen heranzuziehen. Die hierbei erzielten Daten sind allerdings in Ihren Aussagen hinsichtlich der prognostischen Wertigkeiten widersprüchlich. In der vorliegenden Arbeit wurden zunächst verschiedene biologische Parameter am Paraffinmaterial hinsichtlich ihrer prognostischen Wertigkeit in der Risikostratifikation von DLBCL untersucht. In einem ersten Schritt wurden klinische Daten von 99 de novo entstandenen großzelligen B-Zell-Lymphomen erhoben, bei denen es sich um 84 DLBCL und um elf DLBCL mit einer weiteren Komponente eines follikulären Lymphoms Grad 3B bzw. auch um vier Fälle mit ausschließlich follikulärem Wachstumsmuster handelte. Die Klassifikation der Fälle nach dem Internationalen Prognostischen Index (IPI) sowie der einzelnen klinischen Parameter des IPI zeigte eine deutliche prognostische Relevanz. In einem zweiten Schritt wurden immunhistochemische Färbungen mit verschiedenen Antikörpern durchgeführt und auf ihre prognostische Bedeutung überprüft. Als negative prognostische Parameter erwiesen sich die Negativität für CD10 sowie BCL-6, also Antigene, die mit einer Keimzentrumszell-Differenzierung assoziiert werden, sowie eine Überexpression von MUM-1, das mit einer postfollikulären Differenzierung assoziiert wird. Weiterhin konnte gezeigt werden, dass einer Expression von BCL-2 und einem Ki67-Index von unter 80 % eine negative prognostische Bedeutung zukommt. Die Stratifikation der Fälle in einen GCB- und einen ABC- Typ anhand des Hans-Klassifikators zeigte nur eine schwache Korrelation zur Überlebenswahrscheinlichkeit. In einem dritten Schritt wurde gezeigt, dass die kombinierte Analyse jeweils zweier Parameter eine relative Abhängigkeit ihrer Expression von der Expression weiterer Marker erkennen ließ. Aus diesem Grunde wurde ein Modell einer sequentiellen Addition negativer prognostischer Indikatoren entwickelt, in der bei Anwesenheit einer negativen Variable (CD10-Negativität, BCL-6 < 20%, BCL-2 positiv, MUM-1≥ 50% und Ki67 < 80%) ein negativer Faktor gewertet und die Summe dieser als Risiko-Score angegeben wurde. Die Stratifikation der Patienten anhand dieses „kombinierten immunhistochemischen Risiko-Scores“ zeigte drei prognostisch deutlich unterschiedliche Gruppen: In der Gruppe von Patienten ohne Risikofaktoren verstarb lediglich eine Patientin (die eine Behandlung abgelehnt hatte); in der Hochrisikogruppe (Score 5) verstarben alle Patienten innerhalb eines Jahres. Die multivariate Analyse des Scores ergab dabei eine Unabhängigkeit von den Parametern des IPI. In der intermediären Gruppe mit einem Risiko-Score von 1-4 zeigten sich der IPI sowie eine LDH-Erhöhung und das Vorhandensein einer B-Symptomatik als geeignete Parameter, um hier eine weitere Stratifizierung durchzuführen. Die vorliegende Arbeit stellt somit eine Erweiterung der publizierten Ansätze einer Erfassung prognostischer Indikatoren in kombinierten Algorithmen dar. Eine Verifizierung der gezeigten Ergebnisse in einer homogen behandelten Patientengruppe innerhalb einer klinischen Studie muss Ziel weiterer Untersuchungen sein.