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[Background] Non-small cell lung cancer (NSCLC) is the most common cause of cancer-related deaths worldwide and is primarily treated with radiation, surgery, and platinum-based drugs like cisplatin and carboplatin. The major challenge in the treatment of NSCLC patients is intrinsic or acquired resistance to chemotherapy. Molecular markers predicting the outcome of the patients are urgently needed., [Methods] Here, we employed patient-derived xenografts (PDXs) to detect predictive methylation biomarkers for platin-based therapies. We used MeDIP-Seq to generate genome-wide DNA methylation profiles of 22 PDXs, their parental primary NSCLC, and their corresponding normal tissues and complemented the data with gene expression analyses of the same tissues. Candidate biomarkers were validated with quantitative methylation-specific PCRs (qMSP) in an independent cohort., [Results] Comprehensive analyses revealed that differential methylation patterns are highly similar, enriched in PDXs and lung tumor-specific when comparing differences in methylation between PDXs versus primary NSCLC. We identified a set of 40 candidate regions with methylation correlated to carboplatin response and corresponding inverse gene expression pattern even before therapy. This analysis led to the identification of a promoter CpG island methylation of LDL receptor-related protein 12 (LRP12) associated with increased resistance to carboplatin. Validation in an independent patient cohort (n = 35) confirmed that LRP12 methylation status is predictive for therapeutic response of NSCLC patients to platin therapy with a sensitivity of 80% and a specificity of 84% (p, [Conclusions] Using an epigenome-wide sequencing approach, we find differential methylation patterns from primary lung cancer and PDX-derived cancers to be very similar, albeit with a lower degree of differential methylation in primary tumors. We identify LRP12 DNA methylation as a powerful predictive marker for carboplatin resistance. These findings outline a platform for the identification of epigenetic therapy resistance biomarkers based on PDX NSCLC models., This work was supported by the Volkswagenstiftung (Lichtenberg program to MRS), the German Federal Ministry of Education and Research (0316190A (EPITREAT), the Center for Molecular Medicine Cologne (CMMC), the state of North Rhine-Westphalia (EFRE-0800397), and the German Research Foundation (DFG KFO286).

Cardiac anaesthesia continues to develop as a specialized discipline within the wide field of clinical anaesthesia. A comprehensive knowledge of cardiovascular physiology and its improved monitoring with modern invasive and non-invasive devices is the basis for the pharmacological treatment of complex cardiovascular disorders. Excellent skills in intraoperative transoesophageal echocardiography have become essential. Rapid developments in cardiopulmonary bypass techniques and surgical devices have resulted in the speedy introduction of new surgical techniques which anaesthesia has to embrace. The developments in the field of (left) ventricular assist devices are expansive. By changing the paradigm of the indication of implantation from ‘bridging to heart transplantation’ to ‘destination therapy’, particularly in the large group of elderly patients with end-stage heart failure, these complex operations are no longer restricted to the small group of heart centres performing heart transplantation. This chapter provides a comprehensive review of modern cardiac anaesthesia in the contemporary world of quickly evolving cardiac surgery. The basics of anaesthesia management for the ‘cardiac’ patient are described and principles of extracorporeal circulation as well as diagnostic and treatment strategies of disturbances of the haemostatic system are highlighted. Pharmacological strategies to treat left- and right-heart failure and strategies for temporary mechanical support are outlined. Further areas of focus are the anaesthetic implications of modern less or minimally invasive procedures such as off-pump coronary artery bypass grafting and minimally invasive valve implantation/surgery and anaesthesia for implantation of ventricular assist devices and heart transplantation.

SummaryBackground Anesthesia for pediatric cardiac surgery requires a high level of expert knowledge. There are currently no recommendations and standards for anesthetic management for congenital cardiac surgery in Germany. Aim The aim of the present study was to assess the current status of structural and personnel anesthetic standards at pediatric cardiac surgery centers in Germany. Method All cardiac surgical centers in Germany were reviewed for an active program for congenital heart surgery. Centers with an active program were invited to respond to an online survey. The questionnaire containing 55 items in 16 categories assessed current practice in pediatric cardiac anesthesia. Results An active program for pediatric cardiac surgery was identified at 27 centers. The response rate to the survey was 96.3%. A specialized group of anesthesiologists for pediatric cardiac anesthesia was reported from 26 centers (92.3%). The mean size of this group was 4.8 anesthesiologists per center. However, the annual case load of centers and relative annual case load per specialized anesthesiologist varied considerably between 12.5 and 250. Nonanesthesiologists performed sedation and general anesthesia for diagnostic and therapeutic interventions outside the operating theater in children with congenital heart diseases in 24 centers (77%). Although special equipment, for example, pediatric TEE, near-infrared spectroscopy, and devices for mechanical auto transfusion were available in most centers, their routine use was not always part of standard operating procedures. The proposal for mean adequate training in pediatric cardiac anesthesia as estimated by the participating centers was 10.8 months. Conclusion The present study represents the current structural situation for anesthesia at German pediatric cardiac surgery centers.

// Uwe Schirmer 1 , Kai Doberstein 1 , Anne-Kathleen Rupp 1 , Niko P. Bretz 1 , Daniela Wuttig 2 , Helena Kiefel 1 , Christian Breunig 5 , Heidi Fiegl 3 , Elisabeth Muller-Holzner 3 , Robert Zeillinger 4 , Eva Schuster 4 , Alain G. Zeimet 3 , Holger Sultmann 2 and Peter Altevogt 1 1 Department of Translational Immunology, German Cancer Research Center; 2 Working Group Cancer Genome Research, German Cancer Research Center; 3 Department of Gynecology and Obstetrics, Medical University of Innsbruck, A-6020 Innsbruck, Austria, 4 Medical University Vienna, Vienna, Austria; 5 Division of Molecular Genome Analysis, German Cancer Research Center, Heidelberg, Germany Correspondence: Peter Altevogt, email: // Key words : miR-34a, endometrial carcinoma, L1CAM, ovarian carcinoma Received : November 4, 2013 Accepted : January 12, 2014 Published :January 12, 2014 Abstract L1CAM promotes cell motility, invasion and metastasis formation in various human cancers and can be considered as a driver of tumor progression. Knowledge about genetic processes leading to the presence of L1CAM in cancers is of considerable importance. Experimentally, L1CAM expression can be achieved by various means. Overexpression of the transcription factor SLUG or treatment of cells with TGF-β1 can induce or augment L1CAM levels in cancer cells. Likewise, hypomethylation of the L1CAM promoter on the X chromosome correlates with L1CAM expression. However, presently no mechanisms that might control transcriptional activity are known. Here we have identified miR-34a as a suppressor of L1CAM. We observed that L1CAM positive endometrial carcinoma (EC) cell lines HEC1B and SPAC1L lost L1CAM protein and mRNA by treatment with demethylating agents or knock-down of the DNA-methyltransferase-1 (DNMT1). Concomitantly, several miRNAs were up-regulated. Using miRNA profiling, luciferase reporter assays and mutagenesis, we identified miR-34a as a putative binder to the L1CAM-3’UTR. Overexpression of miR-34a in HEC1B cells blocked L1CAM expression and inhibited cell migration. In ECC1 cells (wildtype p53) the activation of p53 caused miR-34a up-regulation and loss of L1CAM expression that was miR-34a dependent. We observed an inverse correlation between L1CAM and miR-34a levels in EC cell lines. In primary tumor sections areas expressing high amounts of L1CAM had less miR-34a expression than those with low L1CAM levels. Our data suggest that miR-34a can regulate L1CAM expression by targeting L1CAM mRNA for degradation. These findings shed new light on the complex regulation of L1CAM in human tumors.

Circulating DNA released from cancerous tissues has been found to harbour tumour-associated alterations and to represent the molecular composition of the tumour. Recent advances in technologies, especially in next-generation sequencing, enable the analysis of low amounts of circulating DNA from body fluids. These “liquid biopsies” allow tumour genotyping and therapy monitoring without invasive procedures and offer the potential for early cancer detection.

Contains fulltext : 124525.pdf (Publisher’s version ) (Closed access) BACKGROUND: Despite the excellent prognosis of Federation Internationale de Gynecologie et d'Obstetrique (FIGO) stage I, type I endometrial cancers, a substantial number of patients experience recurrence and die from this disease. We analyzed the value of immunohistochemical L1CAM determination to predict clinical outcome. METHODS: We conducted a retrospective multicenter cohort study to determine expression of L1CAM by immunohistochemistry in 1021 endometrial cancer specimens. The Kaplan-Meier method and Cox proportional hazard model were applied for survival and multivariable analyses. A machine-learning approach was used to validate variables for predicting recurrence and death. RESULTS: Of 1021 included cancers, 17.7% were rated L1CAM-positive. Of these L1CAM-positive cancers, 51.4% recurred during follow-up compared with 2.9% L1CAM-negative cancers. Patients bearing L1CAM-positive cancers had poorer disease-free and overall survival (two-sided Log-rank P < .001). Multivariable analyses revealed an increase in the likelihood of recurrence (hazard ratio [HR] = 16.33; 95% confidence interval [CI] = 10.55 to 25.28) and death (HR = 15.01; 95% CI = 9.28 to 24.26). In the L1CAM-negative cancers FIGO stage I subdivision, grading and risk assessment were irrelevant for predicting disease-free and overall survival. The prognostic relevance of these parameters was related strictly to L1CAM positivity. A classification and regression decision tree (CRT)identified L1CAM as the best variable for predicting recurrence (sensitivity = 0.74; specificity = 0.91) and death (sensitivity = 0.77; specificity = 0.89). CONCLUSIONS: To our knowledge, L1CAM has been shown to be the best-ever published prognostic factor in FIGO stage I, type I endometrial cancers and shows clear superiority over the standardly used multifactor risk score. L1CAM expression in type I cancers indicates the need for adjuvant treatment. This adhesion molecule might serve as a treatment target for the fully humanized anti-L1CAM antibody currently under development for clinical use.

Introduction The development and implementation of practice guidelines might be an important tool to evaluate the different practices and to consider different local strategies. Methods A postal questionnaire with 37 questions was sent to the leading physicians of 80 intensive care units in Germany, treating patients after cardiothoracic surgery. The survey covered the same core questions on current practice of hemodynamic monitoring, volume replacement, inotropic/vasopressor support, and transfusions before and after the publication of an S3 guideline. Results A total of 77.5 % of the completed questionnaires were returned. Monitoring changed to increased use of central venous oxygen saturation (ScvO2) in 55.1% (2005: 20.9%), end-tidal CO2-monitoring 36.2% (2005: 24.3%), and decreased use of the left atrial pressure with 12.3% (2005: 23.3%) and pulmonary artery catheter 47.5% (2005: 58.2%). For volume therapy, there is a decreased use of Hydroxyethyl starch (HES) with 38.7% (2005: 63.4%) and an increased use of crystalloids 41.9% (2005: 22.4%). For inotropes, there is a trend to a decreased use of dopamine with 9.7% (2005: 29.1%, P = 0.074). The clinical relevance of the guidelines was judged ‘high’ by 43.5% and ‘medium’ by 50% of the responding physicians; however, change of treatments was reported by one quarter of respondents. Conclusion Despite ongoing variability in the use of monitoring devices, volume replacement and vasopressor/inotrope use in cardiac surgery patients, there have been some changes in the therapy of these patients after publication of the guidelines. Because the guideline has been considered as clinically relevant, further interdisciplinary development and implementation support should be considered.

Long-lasting success in lung cancer therapy using tyrosine kinase inhibitors (TKIs) is rare since the tumors develop resistance due to the occurrence of molecularly altered subclones. The aim of this study was to monitor tumors over time based on the quantity of mutant plasma DNA and to identify early indications for therapy response and tumor progression. Serial plasma samples from lung adenocarcinoma patients treated with TKIs were used to quantify EGFR and KRAS mutations in circulating DNA by digital PCR. Mutant DNA levels were compared with the courses of responses to treatment with TKIs, conventional chemotherapy, radiotherapy, or combinations thereof. Variations in plasma DNA mutation levels over time were found in 15 patients. We categorize three major courses: First, signs of therapy response are associated with a fast clearing of plasma DNA mutations within a few days. Second, periods of stable disease are accompanied by either absence of mutations or fluctuation at low levels. Finally, dramatic increase of mutational load is followed by rapid tumor progression and poor patient survival. In summary, the serial assessment of EGFR mutations in the plasma of NSCLC patients allows conclusions about controlled disease and tumor progression earlier than currently available methods.

Circulating cell-free DNA (cfDNA) released from cancerous tissues has been found to harbor tumor-associated alterations and to represent the molecular composition of the tumor. Recent advances in technologies, especially in next-generation sequencing, enable the analysis of low amounts of cfDNA from body fluids. We analyzed the exomes of tumor tissue and matched serum samples to investigate the molecular representation of the tumor exome in cfDNA. To this end, we implemented a workflow for sequencing of cfDNA from low serum volumes (200 μl) and performed whole-exome sequencing (WES) of serum and matched tumor tissue samples from six non-small cell lung cancer (NSCLC) patients and two control sera. Exomes, including untranslated regions (UTRs) of cfDNA were sequenced with an average coverage of 68.5x. Enrichment efficiency, target coverage, and sequencing depth of cfDNA reads were comparable to those from matched tissues. Discovered variants were compared between serum and tissue as well as to the COSMIC database of known mutations. Although not all tissue variants could be confirmed in the matched serum, up to 57% of the tumor variants were reflected in matched cfDNA with mutations in PIK3CA, ALK, and PTEN as well as variants at COSMIC annotated sites in all six patients analyzed. Moreover, cfDNA revealed a mutation in MTOR, which was not detected in the matched tissue, potentially from an untested region of the heterogeneous primary tumor or from a distant metastatic clone. WES of cfDNA may provide additional complementary molecular information about clinically relevant mutations and the clonal heterogeneity of the tumors.

Objectives The relationship between the transfusion of red blood cell (RBC) units and outcomes in patients undergoing cardiac surgery is the subject of intense debates. In this study, we investigated the relationship between the transfusion of 1-2 leucocyte-depleted (LD) RBC units and outcomes in patients undergoing open-heart valve surgery. Methods The investigation encompassed consecutive patients undergoing open-heart valve surgery at our institution between July 2009 and March 2015 who received no (RBC- group) or 1-2 units of LD RBC (RBC+ group). End-points were 30-day mortality (primary), the incidence of in-hospital major organ dysfunctions and 1-year mortality (secondary). Propensity score (PS)-adjusted statistical analysis was used to assess the effect of RBC transfusion on end-points. Results Thirty-day mortality rate was 0.2% (3/1485) in the RBC- group and 0.4% (6/1672) in the RBC+ group, with a PS-adjusted odds ratio (OR) for 30-day mortality of 1.00 (95% CI: 0.21-4.83;P = 0.99). The two groups showed no significant differences in PS-adjusted ORs for major complications, such as stroke, low cardiac output syndrome, thoracic wound infection and prolonged mechanical ventilation (>24 h). The PS-adjusted ORs for prolonged intensive care unit stay (>48 h) were, however, significantly higher in the RBC+ group (OR = 1.34 [95%CI: 1.04-1.72; P = 0.02]) than in the RBC- group. One-year mortality was comparable between groups (PS-adjusted hazard ratio for the RBC+ group: 0.85 [95% CI: 0.42-1.72; P = 0.65]). Conclusions Our data do not provide evidence that in patients undergoing valve surgery with cardiopulmonary bypass, transfusion of 1-2 units of LD RBC increases operative mortality, the incidence of postoperative complications or 1-year mortality.

Background Sparse data are available on the prevalence of right ventricular dysfunction and/or pulmonary arterial hypertension in patients scheduled for cardiac surgery in Germany as well as on the intensity and modalities used for diagnosis, perioperative monitoring, and treatment of these comorbidities. Methods A postal survey including questions on the prevalence of preoperative right ventricular dysfunction and/or pulmonary arterial hypertension in patients undergoing cardiac surgery in 2009 was sent to 81 German heart centers. Total 47 of 81 (58%) heart centers returned the questionnaires. The centers reported data on 51,095 patients, and 49.8% of the procedures were isolated coronary artery bypass grafting. Results Data on the prevalence of preoperative pulmonary hypertension and/or right ventricular dysfunction were not available in 54% and 64.6% of centers. In the remaining hospitals, 19.5% of patients presented right heart dysfunction and 10% pulmonary arterial hypertension. Preoperative echocardiography was performed in only 45.3% of the coronary artery bypass grafting cases. Preoperative pharmacologic treatment of pulmonary hypertension or right ventricular dysfunction with oral sildenafil, inhaled prostanoids, or nitric oxide was initiated in 71% and 95.7% of the centers, respectively. Intra- and postoperative treatment was most frequently accomplished with phosphodiesterase-III inhibitors. Conclusion The prevalence of preoperative right heart dysfunction and pulmonary arterial hypertension in cardiac surgical patients in Germany seems to be substantial. However, in more than 50% of the patients, no preoperative data on right ventricular function and pulmonary arterial pressure are available. This may lead to underestimation of perioperative risk and inappropriate management of this high-risk population.