EndoPredict and Mammaprint Risk Classification

EndoPredict and Mammaprint Risk Classification Comparison of risk classification between EndoPredict and Mammaprint in ER-positive/HER2-negative primary invasive breast cancer. Alberto Pelez-Garcia, Laura Yebenes, Alberto Berjon, Antonia Angulo, Pilar Zamora, Jose Ignacio Snchez-Mendez, Enrique Espinosa, Andres Redondo, Victoria Heredia, Marta Mendiola, Jaime Feliu, David Hardisson Corresponding Author: David Hardisson, MD, PhD; Department of Pathology; Hospital Universitario La Paz, IdiPAZ; Paseo de la Castellana, 261; 28046 Madrid, Spain. ABSTRACT Purpose To compare the prognostic performance of the EndoPredict assay with the MammaPrint scores obtained for the same cancer samples on 40 estrogen-receptor positive/HER2-negative breast carcinomas. Methods Formalin-fixed, paraffin-embedded invasive breast carcinoma tissues that were previously analyzed with MammaPrint as part of routine care of the patients, andwere classified as high-risk (20 patients) and low-risk (20 patients), were selected to be analyzed by the EndoPredict assay, a second generation gene expression test that combines expression of 8 genes (EP score) with two clinicopathological factors (tumor size and nodal status, EPclin score). Results The EP score classified 15 patients as low-risk and 25 patients as high-risk. EPclin re-classified 5 of the 25 EP high-risk patients into low-risk, resulting in a total of 20 high-risk and 20 low-risk tumors. EP score and MammaPrint score were significantly correlated (p=0.008). Twelve of 20 samples classified as low-risk by MammaPrint were also low-risk by EP score (60%). 17 of 20 MammaPrint high-risk tumors were also high-risk by EP score. The overall concordance between EP score and MammaPrint was 72.5%.   EPclin score also correlated with MammaPrint results (p=0.004). Discrepancies between both tests occurred in 10 cases: 5 MammaPrint low-risk patients were classified as EPclin high-risk and 5 high-risk MammaPrint were classified as low-risk by EPClin (overall concordance 75%). Conclusions This study demonstrates a moderate concordance between MammaPrint and EndoPredict. Differences in results could be explained by the inclusion of different gene sets in each platform, and the inclusion of clinical parameters, such as tumor size and nodal status, in the EndoPredict test. Keywords:  Breast cancer prognosis; gene expression signatures; EndoPredict; MammaPrint INTRODUCTION Breast cancer is the most common cancer and the second most frequent cause of cancer death among women in developed countries. Approximately 231,840 new cases of invasive breast cancer and 40,290 deaths are expected among US women in 2015 [1]. Currently, the decision on adjuvant treatment for breast cancer patients is based on risk assessment using clinicopathological criteria, such as patient age, menopausal status, axillary lymph node status, tumor size, tumor grade, estrogen receptor (ER)/progesterone receptor (PgR) expression, HER2 status, and Ki67 score. However, decision making in adjuvant treatment of women with ER-positive/HER2-negative early breast cancer remains a difficult task. Routinely, all of these patients will receive adjuvant hormonal treatment. However, a substantial proportion of these patients are also treated with adjuvant chemotherapy, although a significant part of these will not achieve a further reduction of their risk of recurrence [2].Therefore, a major challenge for clinical oncologists is to identify those patients who will not benefit for adjuvant chemotherapy, and those who are more likely to develop recurrence, so that the most appropriate therapeutic regime can be administered [2, 3]. In recent years, molecular characterization of breast cancer has contributed to broaden our understanding of breast cancer as a heterogeneous disease, and led to the development of a variety of prognostic and predictive gene signatures [4]. Morever, these assays may also be useful in recurrence prediction and treatment decision making [5]. One of the most widely used tests is the MammaPrint (MP) assay (Agendia Laboratories, Amsterdam, The Netherlands), which is a prognostic score performed by a central laboratory that was cleared by the FDA in 2007. MP was initially limited by its requirement for fresh tissue, but it is now validated for formalin-fixed, paraffin-embedded (FFPE) tissue [6]. MP measures the expression of 70 genes using a microarray platform, and reports a binary risk classification (low-risk or high-risk) for recurrence without adjuvant chemotherapy. This information is intended to spare patients at low-risk of recurrence from receiving adjuvant chemotherapy, with its attendant morbidity. It is not intended to predict the response, per se, to chemotherapy; rather, it helps to select patients who are likely to benefit from chemotherapy from a prognostic point of view [7]. More recently developed, the EndoPredict assay (EP) (Sividon Diagnostics GmbH, Cologne, Germany), is a diagnostic test based on gene expression data in combination with clinicopathological risk parameters to assess the risk of distant metastasis in patients with ER-positive/HER2-negative primary breast cancer if treated with adjuvant endocrine therapy alone [8]. This test measures the expression of eight cancer-related genes of interest (BIRC5, UBE2C, DHCR7, RBBP8, IL6ST, AZGP1, MGP and STC2) and three reference genes (CALM2, OAZ1 and RPL37A) to calculate a molecular risk score (EP score). The molecular risk score is then combined with the nodal status and tumor size resulting in a molecular-clinicopathological hybrid score (EPclin score) with improved prognostic power. Using a p redefined cutoff value, patients are stratified into low- or high-risk of distant recurrence. The test can be carried out on routinely processed and archived FFPE tissue, and is designed to be performed decentrally [9, 10]. EP was validated in three randomized endocrine phase III trials with patients with ER-positive/HER2-negative node negative and node positive breast carcinomas [5, 8]. The EP provided additional prognostic information to conventional risk factors such as grading, quantitative ER, or Ki67 and outperformed risk classification by clinical guidelines. Moreover, it could be demonstrated that EP is prognostic for early and late metastasis [5, 11].The EPclin score was also directly compared to purely clinical risk classifications (like St. Gallen, German S3, and NCCN) and found to be superior to these classifiers [11]. The objective of this study was to compare the concordance of EndoPredict results in 40 ER-positive/HER2-negative breast carcinomas which were previously tested with MammaPrint and categorized as low-risk (20 patients) or high-risk (20 patients). We further evaluate TargetPrint (Agendia Laboratories), a commercially available mRNA-based gene expression test that quantitatively determines gene expression levels of ER, PgR, and HER2. MATERIALS AND METHODS Patients and tumor samples This study involved 40 patients with ER-positive/HER2-negative early-stage breast carcinoma. All patients underwent surgery between March 2012 and December 2015 at the University Hospital La Paz, Madrid, Spain. Data on age and tumor characteristics were collected for all patients. The surgical specimens were fixed in 10% buffered formalin and embedded in paraffin. Four- µm thick sections were stained with hematoxylin-eosin for histological diagnosis. Sections (10 µm) with at least 40% of tumor cellularity were selected for the study. Immunohistochemistry for ER/PR/HER2 and Ki67 and Fluorescence in situ Hybridization (FISH) for HER2 All cases were reviewed by two breast pathologist (DH and LY) to assess tumor grade (using the Nottingham histological three-tier grading system), tumor size, nodal status, ER, PgR, HER-2, and Ki67 expression. The expression of ERÃŽ ± (clone EP1; Dako, Glostrup, Denmark, prediluted), PgR (clone PgR1294; Dako, prediluted), and Ki67 (clone MIB1; Dako, prediluted) were determined by immunohistochemistry (IHC) during routine pathologic examination. ER and PgR status was determined based on the percentage of positive nuclei in the invasive neoplastic compartment of the tissue. Tumors were classified as ER- or PgR-positive when ≠¥1% invasive tumor cells showed definite nuclear staining, regardless of staining intensity. Ki67 was evaluated as the percentage of positively stained nuclear cancer cells (regardless of staining intensity). HER2 expression was evaluated with the HercepTest kit (Dako) and scored as 0, 1+, 2+, or 3+, according to the FDA scoring system. Tumors scored as 2+ wer e re-tested with FISH using the HER2 IQFISH PharmDx kit (Dako). Mammaprint Test The MammaPrint test was performed on representative paraffin blocks at the centralized Agendia Laboratories (Amsterdam, The Netherlands) blinded for clinical and histological data as part of routine care of the patients included in this study. Additionally to MammaPrint, TargetPrint assay, an additional test that is an alternative measurement of ER, PgR, and HER2 to IHC/FISH assessment, was also performed. EndoPredict Test The same tumor tissue block used for MammaPrint testing in each case was used for EP test. RNA extraction was performed as previously described [9]. Total RNA was extracted from one 10- µm whole formalin-fixed, paraffin-embedded tissue section using a silica-coated magnetic bead-based method with Tissue Preparation Reagents (Sividon Diagnostics). Expression of eight genes-of-interest (AZGP1, BIRC5, DHCR7, IL6ST, MGP, RBBP8, STC2, UBE2C), three normalization genes (CALM2, OAZ1, RPL37A) as well as the amount of residual genomic DNA (HBB) were assessed by the EP assay (Sividon Diagnostics). Gene expression was assessed by one-step RT-qPCR using the SuperScript III PLATINUM One-Step Quantitative RT-PCR System with ROX (Invitrogen, Karlsruhe, Germany) according to manufacturers instructions in a VERSANT ® kPCR Molecular System (Siemens Healthcare Diagnostics, Erlangen, Germany). EP and EPclin scores were determined as published earlier [8, 9] using the EndoPredict Report Generator sof tware which is available online (www1.endopredict.com). The predefined cut-offs for diagnostic decisions were applied to stratify patients into low- or high-risk groups: EP low-risk (

ALS Disease Psychological Aspects

This paper explores the psychological profile of patients with Amyotrophic lateral sclerosis (ALS). Aside from the physical challenges experienced by patients, they also have to endure psychological changes such as depression and denial. There are several factors that may contribute to the psychosocial profile of a patient such as degree of severity, age, onset of disease, time span, and dependence on machines like respirator.This paper examines the psychological features of ALS patients and how it affects the family and support team. Amyotrophic lateral sclerosis (ALS), commonly known as Lou Gehrig’s disease is a progressive degenerative disease attacking the brain and spinal cord. The destruction of the nerve cells, called neurons, in the body’s upper and lower motor neurons leads to the inability of the voluntary muscles to function normally (National Institute of Neurological Disorders and Stroke, 2008).With the death of the muscles, ALS patients will have impaired use of their arms and legs. Loss of control is the trademark of ALS. As the disease progresses, the patient will have trouble accomplishing day-to-day activities like eating, tooth brushing and putting on clothes (Olney, 2005, p. 8). Furthermore, the patient’s breathing will suffer and in the end, a ventilator will be needed (2005). Although the disease is debilitating, it does not impinge on the patient’s senses- sight, taste, and smell, hear and touch (2008).There are three diagnostic factors in ALS: clinical features such as â€Å"weakness and involuntary muscle contractions†, having positive results of electromyography (EMG), MRI and blood tests) and ruling out other disorders (Amyotrophic Lateral Sclerosis Society of Canada, n. d. p. 1). Not only is the etiology of ALS unknown but there is also no cure for it, which makes the disease more frustrating. The drugs and treatments currently available are targeted only to mitigate ALS symptoms.Given the complexit y of the disease, it is not surprising to find that ALS-afflicted patients endure physical symptoms as well as cognitive and behavioral changes like memory and speech problems and emotional distress (Levine, n. d. ). Another study reports the onset of depression and denial in ALS patients (Houpt, Gould, and Norris, 1977). Given the grim prognosis that accompanies the disease, there are ALS cases when the patient undergoes severe psychological/ social/ spiritual distress. After all, ALS is a â€Å"life-changing event for an individual and his/her loved ones† (Ciechoski, 2002, p. 9).Typically an individual facing the end of life undergoes what psychiatrist Elisabeth Kubler-Ross the five stages of dying: denial, anger, bargaining, depression and acceptance (Morris and Maisto, 2002, p. 437). The same phases may also apply in patients with ALS (Ciechoski, 2002, p. 12). In an ALS Patient Profile project, it was found that ALS patients experience greater bouts with depression- 60% c ompared to the 16 -20% exhibited by the normal and fit population (McDonald, 1992). This can be construed as a sign that the ALS patient is overwhelmed with sadness, apathy and feelings of worthlessness.Depression, after all, is a normal reaction in individuals diagnosed with a life-threatening disease (Ciechoski, 2002, p. 15). Another study concurs with finding, adding that aside from depression; ALS patients are also more to go through denial as a response pattern (Houpt, Gould, and Norris, 1977). Denial, as Kubler-Ross suggests, is the first in a sequence people undertake as they await death. It means that the individual refuses to accept the diagnosis and swears that everything is all right. The study conducted by Drs. Houpt, Gould, and Norris reports that 22.5 percent of ALS patients are â€Å"major deniers† (1977). Again, this is something common to an individual coping with changes. For example, an ALS patient may refrain using a wheelchair even though he/she is clearl y demonstrating difficulty being mobile. It may take some time before the patient finally accepts the situation and resorts to using a wheelchair. However, this does denote giving up or succumbing to the disease but merely a sign that the patient is looking after his/ her well-being. In doing so, the patient will have a â€Å"sense of control† (p. 17).Yet, another research shows that ALS-afflicted patients suffer from behavioral instability- displaying polarity in emotions, from being overly reactive and exaggerated to being extremely reticent and dull (Levine, n. d. ). There is also an increased chance of the patient becoming withdrawn, becoming less interactive and shying away from interaction with others, as well as professing â€Å"lack of insight† (n. d. ). Likewise, the patient may start having troubles making decision. Decision making in a serious ailment such as ALS is crucial, thus is requires a great amount of â€Å"flexibility and creativity† (Ciechos ki, 2002, p.18). Among the issues that need to be addressed by the patient are living accommodations, employing caregiver services, use of ventilator and feeding tube, family and work life, and even the subject of creating a living will (p. 21). Decision making should be consulted with the family, medical and support group but ultimately it must be stressed that it is the patient that makes the final decision (p. 22). Despite the torrents of emotions experienced by the patient, it is not suffice to conclude that ALS patients have a predictable psychosocial profile.There have been studies indicating that some ALS patients only go through mild depression or none at all (McDonald, 1992). There are several factors that contribute to the psychosocial profile of an ALS patient- the onset of the disease, age of acquisition, seriousness of ALS, extent of the disease, reliance on respirator and other medical machines, and rate of deterioration (1992). It was found that the onset of the sympt oms do no factor in the patient’s psychosocial status (1992). It will also be a factor when there are unresolved issues on the patient’s part prior to diagnosis.On the other hand, age contributes to the patient’s well-being. ALS patients that are diagnosed during late adulthood (over 65 years old) tend to be more depressed and hopeless than those diagnosed in their younger years (1992). While ALS may not primarily be the root of depression, if one is to follow Kubler-Ross’ stages of dying, depression is a normal reaction when the subject of end-of-life id talked. An ALS diagnosis will only aggravate the fear. In addition, when a patient exhibits an acute presentation of ALS, the probability of it affecting the individual’s psychosocial status intensifies.The same assumption, on the other hand, does not apply to the length of ALS. When one is faced with ALS, the prognosis is grim, giving the patient a time life of 3-5 years (1992). However, current data shows that there are ALS patients, roughly 18-42%, outliving the five year mark (1992). Thus, it can be deduced that it is not age but the patient’s will and family support that help him/her uplift his/her psychosocial welfare. When an ALS patient suffers rapid deterioration, his/ her psychosocial profile is also affected.Furthermore, it was found that the longer the patient has been diagnosed with ALS, the more distressed he/she can be (1992). The same is applied to patients whose symptoms have worsened, thus have the need to rely on respirators and other machines. Such individuals may feel more helpless, affecting their attitudes and behaviors. As with any illness, ALS affects relationships- between spouses, siblings, children, friends, family, colleagues and other support system. Family, especially first-degree members are inclined to report periods of depression and denial (McDonald, 1992).One study reports that an astounding 47% of spouses experience stress during a n ALS diagnosis (1992). An ALS diagnosis changes the role play in a family, sometimes the wife become the breadwinner or the children take on the role of main caretaker, depending on who gets ill. Aside from family, the patients’ relationship with friends and work colleagues may also suffer, depending on the degree of closeness experienced. Furthermore, the patient’s relationship with the health care professional is important. The better the line of communication between the patient and the health care team, the better outcome there will be.The health care professional may help the patient deal with depression by prescribing medication and counselling, whichever is appropriate. The psychological characteristics of ALS patients vary in patients. Some may be depressed while others may be hopeful. Coping with a difficult illness like ALS is difficult not only for the patient but the family and support group as well. Worsening of symptoms may hinder their psychological wel l-being. Thus, it is important for everybody concerned to remember that ALS is a disease not to be battled alone.With help and support from everyone involved, patients will be able to live full lives. References Amyotrophic Lateral Sclerosis Society of Canada. (n. d. ). A guide to all ALS patient care for primary care physicians [PDF file]. Retrieved Mary 12, 2009 from Amyotrophic Lateral Sclerosis Society of Canada Website: http://www. als. ca Ciechoski, M. (2002). Coping with change [PDF file]. Retrieved May 12, 2009 from The ALS Association Website: http://www. alsa. org/files/cms/Resources/ALS_manual2. pdf. Houpt, J. , Gould, B. and Norris, F. (1977). Psychological characteristics of patients withamyotrophic lateral sclerosis (ALS) [PDF file]. Retrieved May 12, 2009 from Psychosomatic Medicine Website: http://www. psychosomaticmedicine. org. Levine, S. W. (n. d. ). Neurocognitive, behavioral and psychological changes associated with ALS [PDF file]. Retrieved May 12, 2009 from AL S Connection Website: http://www. alsconnection. com/Neurocognitive_Testing_vers_2. pdf McDonald, E. (1992). Psychological aspects of ALS patients and their primary caregivers. Retrieved May 12, 2009 from American Holistic Health Association Website: http://www. ahha. org/articles/McDonald2.htm Morris, C. and Maisto, A. (2002). Psychology an introduction 11th ed. New Jersey: Prentice Hall. National Institute of Neurological Disorders and Stroke (2008). NINDS amyotrophic lateral sclerosis information page. Retrieved May 12, 2009 from National Institute of Neurological Disorders and Stroke Website: http://www. ninds. nih. gov/ Olney, A. (2005). Daily activities made easier for people with amyotrophic lateral sclerosis [PDF file]. Retrieved May 12, 2009 from The ALS Association Website: http://www. alsa. org/files/cms/Resources/OT_Manual_2006. pdf.

Facebook vs. Twitter Essay

Of all the many social media outlets out there today, Facebook and twitter are the most popular in my opinion. These two social media phenomenas have several comparisons and differences in various ways. Facebook ranked number one in most used social network world wide, twitter isn’t to far behind on the list. This two social networks are appealing to billions of people all over the world because it helps you get connected with friends and you are able to communicate with them as well through tweets or Facebook chats. Which social network is better? That is for you to answer, however the social network is more beneficial to you may influence which network you prefer to use. First of all, the majority of people seem to think Facebook to be more popular than twitter. The main reason Mark Zuckerberg created Facebook was for people to connect with friends, current friends or friends from high school that you wish to get back in touch with. You can potentially connect with new friends through Facebook as well and meet different people from all of the country. The installed user base for Facebook hit one billion users at the end of september which considered by many to be a milestone that no other social network will surpass anytime soon. The reason users may not be a fan of Facebook or like twitter more is due to the fact that navigation and updates to Facebook or rather difficult and you invest more time into it. When you message somebody on Facebook it’s unlikely that you will get an immediate response from that person unless they are currently on and get notified they have a new message. On the other hand, Twitter’s popularity comes from how easily you can interact with people and you receive rapid response. People like the simplicity of twitter’s navigation and being able to send tweets whenever, if you tweet at someone and that person has the mobile app they will be notified immediately with the ability to respond quickly. Twitter’s similarities with texting are popular with the young crowd such as myself and other students all over the world. Unlike Facebooks large user base that attracts people, unfortunately twitter can’t compete with that, they are known for a much smaller user base. When sending tweets you are limited to only 140 characters, so you must be to the point when sending a tweet. Among these two social networks differences there are also several similarities. You can download both of the networks mobile app to your smart phone and access the network from your phone. Facebook and twitter both allow you to upload pictures on your profile for people and friends to view. Tweets and statuses are similar in the sense users can see what you posted on the news feed, and the popularity and growth of both networks are the biggest similarity the two have in common. Which one do you pick? I have both Facebook and twitter, I enjoy both of them and they are beneficial to my life. In the end I tend to like Facebook just a little bit more due to the interactiveness the network offers. Each network has its pros, cons and attracts people depending on the type of person you are. One person may like twitter better than Facebook, that’s fine and dandy as well, the user has there personal preference based on who they are. At the end of the day both social networks; Facebook and Twitter succeed to curb my enthusiasm.

The Course Of English 102 With Professor Lyn Has...

The overall course of English 102 with Professor Lyn has impacted my writing and me as an individual. Not only did the course help me improve my writing, but it helped me think of the ideas and norms that we ascribe to in the world as more complex. This portfolio shows how some of the learning objectives of English 102 reflects my growth as a writer and thinker. The papers that are included in this portfolio demonstrate my mastery of the learning objectives of this course. There are first drafts to show where I began in my writing process and final drafts to demonstrate my understanding of what was wrong in my first submissions. My ability to edit and recognize errors in my paper shows my improvement of writing. The different types of writing and audiences the papers are intended for impacted my approach of writing these papers. One of the papers included in this portfolio is the essay on Perfect Peace. The type of writing for this essay was argumentative. The intended audience are those who read the book and could not understand the complexities that child abuse can cause to one psychologically. I demonstrate my mastery of the learning objectives of English 102 in this paper by thinking outside of the â€Å"box†. The â€Å"box† is the prison that society puts us into by encouraging that the patriarchal norms are correct and the only way to live. I thought outside of the prison by not thinking that Emma Jean is simply wrong for what she did and that she’s not justifiable. I