Pre-navigation balloon technique: Distal emboli protection during stent retriever thrombectomy

OBJECTIVE

During stent retriever thrombectomy, a balloon guide catheter reduces distal emboli and consequently improves clinical outcomes. Because balloons are usually used before stent retrieval, these can affect the thrombus including the distal emboli while performing microcatheter navigation. This study aimed to evaluate the usefulness and safety of the pre-navigation balloon technique during microcatheter and microwire navigation.

METHODS

Patients who underwent stent retriever thrombectomy secondary to an anterior circulation large-artery occlusion were retrospectively evaluated. The pre-navigation balloon technique was used, and the number of retrievals, procedure time, final recanalization, presence of distal emboli, first-pass effect (FPE), symptomatic intracranial hemorrhage including procedure-related complications, and clinical outcomes at 3 months were evaluated.

RESULTS

In total 123 patients were analyzed, and occurrence of distal emboli was lesser in the pre-navigation balloon than in the non-preballoon group (4.4% vs. 11.5%, p = 0.02). No statistical difference was found in successful recanalization, mortality, and procedure-related complications. Moreover, the pre-navigation balloon group had a higher FPE than the non-balloon group (37.8% vs. 20.5%, p = 0.004). Although no statistical difference was found in the pre-navigation balloon group, a trend toward a higher rate of good clinical outcomes was observed (mRS 0-2 at 3 months, 55.6% vs. 48.7%, p = 0.09). For ICA occlusion(n = 35), significant effects were seen in decreasing distal embolism (0(0%) vs 3(16%), p = 0.01), increasing FPE (8(50%) vs 6(32%), p = 0.003), and improving clinical outcomes (mRS 0-2 at 3 months, 9(56%) vs 7(37%), p = 0.03) in the pre-navigation balloon group. In the multivariate analysis, lesser distal embolism (0.91 [0.80-1.00], p = 0.02), higher successful recanalization (3.52 [1.11-7.03], p = 0.016), and higher FPE (3.17 [1.83-7.37], p = 0.001) secondary to the procedure was a predictor of favorable clinical outcomes.

CONCLUSIONS

The pre-navigation balloon technique significantly reduced occurrence of distal embolism and increased the FPE.

Reducing contrast-agent volume and radiation dose in CT with 90-kVp tube voltage, high tube current modulation, and advanced iteration algorithm

Increasing utilization of computed tomography (CT) has raised concerns regarding CT radiation dose and technology has been developed to achieve an appropriate balance between image quality, radiation dose, and the amount of contrast material. This study was planned to evaluate the image quality and radiation dose in pancreatic dynamic computed tomography (PDCT) with 90-kVp tube voltage and reduction of the standard amount of contrast agent, compared with 100-kVp PDCT of the research hospital's convention. Total of 51 patients with both CT protocols were included. The average Hounsfield units (HU) values of the abdominal organs and image noise were measured for objective image quality analysis. Two radiologists evaluated five categories of image qualities such as subjective image noise, visibility of small structure, beam hardening or streak artifact, lesion conspicuity and overall diagnostic performance for subjective image quality analysis. The total amount of contrast agent, radiation dose, and image noise decreased in the low-kVp group, by 24.4%, 31.7%, and 20.6%, respectively (p < 0.001). The intraobserver and interobserver agreements were moderate to substantial (k = 0.4-0.8). The contrast-to-noise ratio (CNR), signal-to-noise ratio (SNR), and figure of merit of the almost organs except psoas muscle in the low-kVp group were significantly higher (p < 0.001). Except for lesion conspicuity, both reviewers judged that subjective image quality of the 90-kVp group was better (p < 0.001). With 90-kVp tube voltage, 25% reduced contrast agent volume with advanced iteration algorithm and high tube current modulation achieved radiation dose reduction of 31.7%, as well as better image quality and diagnostic confidence.

Safety and efficacy of trastuzumab biosimilar plus irinotecan or gemcitabine in patients with previously treated HER2 (ERBB2)-positive non-breast/non-gastric solid tumors: a phase II basket trial with circulating tumor DNA analysis

BACKGROUND

Human epidermal growth factor receptor 2 (HER2) (ERBB2)-directed agents are standard treatments for patients with HER2-positive breast and gastric cancer. Herein, we report the results of an open-label, single-center, phase II basket trial to investigate the efficacy and safety of trastuzumab biosimilar (Samfenet®) plus treatment of physician's choice for patients with previously treated HER2-positive advanced solid tumors, along with biomarker analysis employing circulating tumor DNA (ctDNA) sequencing.

METHODS

Patients with HER2-positive unresectable or metastatic non-breast, non-gastric solid tumors who failed at least one prior treatment were included in this study conducted at Asan Medical Center, Seoul, Korea. Patients received trastuzumab combined with irinotecan or gemcitabine at the treating physicians' discretion. The primary endpoint was the objective response rate as per RECIST version 1.1. Plasma samples were collected at baseline and at the time of disease progression for ctDNA analysis.

RESULTS

Twenty-three patients were screened from 31 December 2019 to 17 September 2021, and 20 were enrolled in this study. Their median age was 64 years (30-84 years), and 13 patients (65.0%) were male. The most common primary tumor was hepatobiliary cancer (seven patients, 35.0%), followed by colorectal cancer (six patients, 30.0%). Among 18 patients with an available response evaluation, the objective response rate was 11.1% (95% confidence interval 3.1% to 32.8%). ERBB2 amplification was detected from ctDNA analysis of baseline plasma samples in 85% of patients (n = 17), and the ERBB2 copy number from ctDNA analysis showed a significant correlation with the results from tissue sequencing. Among 16 patients with post-progression ctDNA analysis, 7 (43.8%) developed new alterations. None of the patients discontinued the study due to adverse events.

CONCLUSIONS

Trastuzumab plus irinotecan or gemcitabine was safe and feasible for patients with previously treated HER2-positive advanced solid tumors with modest efficacy outcomes, and ctDNA analysis was useful for detecting HER2 amplification.

Quantitative ultrasound for non-invasive evaluation of subclinical rejection in renal transplantation

OBJECTIVES

This study aimed to investigate the predictive efficacy of shear-wave elastography, superb microvascular imaging (SMI), and CEUS for allograft rejection in kidney transplants without graft dysfunction.

METHODS

From January 2021 to November 2021, 72 consecutive patients who underwent both allograft biopsy and ultrasound were evaluated. Blood test results were obtained within a week of the ultrasound examinations, which were performed before the protocol biopsy. Resistive index (RI), tissue viscoelasticity, vascular index, and quantitative CEUS parameters were measured. Patients were divided based on biopsy results into the rejection and non-rejection groups.

RESULTS

Among the 72 patients, 21 patients had pathological characteristics of acute rejection. RI of allograft was significantly higher in the rejection group (p = 0.007), compared to the non-rejection group. There were no significant between-group differences in vascular indices of SMI, mean elasticity, and mean viscosity. Meanwhile, among the parameters obtained by the time-intensity curve on CEUS, the cortical and medullary ratios of average contrast signal intensity, peak enhancement, wash-in area AUC, wash-in perfusion index, wash-out AUC, and wash-in and wash-out AUC were significantly different between the two groups (p < 0.05). In the receiver operating characteristic curve analysis for predicting allograft rejection, the AUC was 0.853 for the combination of six CEUS parameters, RI, and blood urea nitrogen.

CONCLUSIONS

Among non-invasive quantitative ultrasound measurements, CEUS parameters are the most useful for diagnosing subclinical allograft rejection. Furthermore, the combination of CEUS parameters, RI, and blood urea nitrogen may be helpful for the early detection of renal allograft rejection.

KEY POINTS

• Among non-invasive quantitative ultrasound measurements, CEUS parameters are the most useful for the diagnosis of subclinical allograft rejection. • On CEUS, the C/M ratios of MeanLin, PE, WiAUC, WiPI, WoAUC, and WiWoAUC are significantly lower in the rejection group; the combination of these showed reliable predictive performance for rejection. • The combination of CEUS parameters, RI, and BUN has a high predictive capability for subclinical allograft rejection.

Contrast Agent Selection to Prevent Recurrent Severe Hypersensitivity Reaction to Iodinated Contrast Media Based on Nationwide Database

OBJECTIVE

To investigate the incidence of severe iodinated contrast media (ICM)-related hypersensitivity reaction (HSR) and to find the optimal alternative ICM to reduce the risk of severe HSR recurrence.

METHODS

We retrospectively reviewed 23,383,183 cases of ICM administration between January 2015 and December 2019 from the nationwide health insurance database. We classified ICMs based on generic profiles and the presence of N-(2,3-dihydroxypropyl) carbamoyl side chains. The incidence of severe and recurrent severe HSRs was calculated, and χ2 tests were performed to compare the prevalence of severe HSR according to ICM groups. In addition, logistic regression analyses were used to assess differences between ICM groups.

RESULTS

The incidence of severe HSRs was 1.92% (450,067 of 23,282,183). Among 1,875,245 individuals who received ICM twice on different days, severe HSR occurred in 40,850 individuals, and severe HSR recurred in 3319 individuals (8.12%). The risk of recurrence significantly decreased when the ICM changed (9.24% vs 7.08%, P < 0.001), especially when the ICM changed to one with a different side chain (6.74%, P < 0.001). In addition, compared with the reuse of the culprit agent, using combinations of iobitridol/iohexol (odds ratio [OR], 0.696; P = 0.04), iohexol/iopamidol (OR, 0.757; P = 0.007), iopamidol/iohexol (OR, 0.447; P < 0.001), and ioversol/iohexol (OR, 0.683; P = 0.04) reduced the risk of recurrence of severe HSR.

CONCLUSIONS

Changing the culprit ICM to that with a different side chain can reduce severe HSR recurrence. The optimal choice of an alternative ICM depends on the causative agent.

Nomenclature and Lymphatic Drainage Patterns of Abdominal Lymph Nodes

The lymphatic system provides a route for the spread of inflammation and malignancies. The identification of nodal stations and lymphatic pathways of tumor spread is important for tumor staging, choice of therapy, and the prediction of the prognosis of patients with malignant diseases. Because lymph node metastasis is common in primary intra-abdominal malignant tumors, its detection is essential for radiologists to understand the pattern of disease spread. Using schematic pictures and color-coded CT images, this pictorial essay describes the locations and nomenclature of the abdominal lymph nodes. Furthermore, the lymphatic drainage pathways of the upper and lower gastrointestinal tracts, liver, gallbladder, bile duct, and pancreas have been highlighted. In addition, lymph nodes belonging to the regional lymph nodes in malignant tumors arising from each organ are described, and certain cases are presented with images from patients.

Prognostic implication of residual inflammatory risk according to disease status in patients treated with percutaneous coronary intervention

Background

Compared with stable angina, acute myocardial infarction (AMI) phenotype is related with the elevated inflammatory activity. However, time-dependent change of inflammatory level and its prognostic implication has not been fully understood according to the disease entity.

Methods

We enrolled total 4,263 patients who underwent percutaneous coronary intervention (PCI) with serial measurement of high-sensitivity C-reactive protein (hsCRP) at on-admission and 1-month post-PCI. The risks of MACE (a composite of death, MI or stroke), and major bleeding were evaluated up to 4 years after procedure.

Results

Compared with the non-AMI group (n=1,887), the AMI group (n=2,376) showed the significant decrease of hs-CRP during 1 month (∇0.5 vs. ∇0.1 mg/L; P&lt;0.001). However, 1-month hs-CRP value still was higher in the AMI group than in the non-AMI group (median: 1.0 vs. 0.9 mg/L; P=0.001). During 1-month follow-up, high vs. low inflammatory risk (upper vs. lower tertile of hs-CRP) was significantly associated with increased rate of MACE in the AMI group (HR: 7.66; 95% CI: 2.29–25.59; P&lt;0.001), but not in the non-AMI group (HR: 0.74; 95% CI: 0.12–4.40; P=0.736). From 1-month to 4-years, patients with high inflammatory risk showed the greater rate of MACE compared to those with low inflammatory risk, in both the AMI (HR: 2.40; 95% CI: 1.73–3.45; P&lt;0.001) and non-AMI (HR: 2.67; 95% CI: 1.80–3.94; P&lt;0.001) groups.

Conclusion

In PCI-treated patients, patients presented with AMI showed the greater values of inflammatory activity and its prognostic implication during the early phase, but combined inflammatory risk appeared similar across the disease entity during the late phase. This result may support that clinical benefit of post-PCI anti-inflammatory treatment would be constant regardless of the disease entity during the stabilized phase.

Funding Acknowledgement

Type of funding sources: None.

Early line-probe assay using DNA specimens in patients with pulmonary TB

BACKGROUND: We investigated the feasibility of early line-probe assay (LPA) using remnant DNA of Mycobacterium tuberculosis from polymerase chain reaction (PCR) test.METHODS: M. tuberculosis DNA specimens with cycle threshold (Ct) values reported and collected from patients with known results for both LPA with culture isolates and phenotype drug susceptibility testing (pDST) were selected. The diagnostic performance of DNA-based LPA according to the Ct value was investigated.RESULTS: A total of 143 respiratory specimens were included. For isoniazid resistance, the accuracy in subgroups with Ct value <25, 25-29 and ≥29 was respectively 96.8%, 65.7% and 13.3%. For rifampicin resistance, accuracy in subgroups with Ct values <29 and ≥29 was respectively 87.8% and 13.3%. When compared to the pDST results, sensitivity, specificity, positive predictive value and negative predictive value in specimens with Ct values <25 was respectively 1.00 (95% CI 0.69-1.00), 0.95 (95% CI 0.76-1.00), 0.91 (95% CI 0.59-1.00) and 1.00 (95% CI 0.83-1.00) for isoniazid resistance. For rifampicin resistance, corresponding values in subgroups with Ct values <29 were respectively 0.89 (95% CI 0.52-1.00), 0.98 (95% CI 0.91-1.00), 0.80 (95% CI 0.50-0.94) and 0.99 (95% CI 0.92-1.00).CONCLUSIONS: DNA-based early LPA with remnant DNA from respiratory samples was feasible and accurate when the Ct values were low.

Metabolic Stress Index Including Mitochondrial Biomarker for Noninvasive Diagnosis of Hepatic Steatosis

BACKGROUND

Mitochondrial dysfunction with oxidative stress contributes to nonalcoholic fatty liver disease (NAFLD) progression. We investigated the steatosis predictive efficacy of a novel non-invasive diagnostic panel using metabolic stress biomarkers.

METHODS

Altogether, 343 subjects who underwent magnetic resonance imaging-based liver examinations from a population-based general cohort, and 41 patients enrolled in a biopsy-evaluated NAFLD cohort, participated in the development and validation groups, respectively. Serologic stress biomarkers were quantitated by enzyme-linked immunosorbent assay.

RESULTS

Multivariate regression showed that waist-to-hip ratio, fibroblast growth factor (FGF) 21, FGF19, adiponectin-to-leptin ratio, insulin, albumin, triglyceride, total-cholesterol, and alanine-aminotransferase were independent predictors of steatosis (rank-ordered by Wald). The area under receiver-operator characteristics curve [AUROC (95%CI)] of the metabolic stress index for steatosis (MSI-S) was 0.886 (0.85-0.92) and 0.825 (0.69-0.96) in development and validation groups, respectively. MSI-S had higher diagnostic accuracy (78.1%-81.1%) than other steatosis indices. MSI-S notably differentiated steatosis severities, while other indices showed less discrimination.

CONCLUSION

MSI-S, as a novel non-invasive index, based on mitochondrial stress biomarker FGF21 effectively predicted steatosis. Furthermore, MSI-S may increase the population that could be excluded from further evaluation, reducing unnecessary invasive investigations more effectively than other indices.

Impact of active and stable cancer on survival in patients undergoing percutaneous coronary intervention

Background

With advances in treatment of ischemic heart disease and cancer treatment, use of percutaneous coronary intervention (PCI) in cancer survivors and patients with active cancer (AC) is expanding.

Objectives

The purpose of this study was to determine the impact of cancer on survival and major cardiovascular events (MACE) in a long-term, single-center cohort of patients treated with PCI.

Methods

Patients treated with PCI between January 2010 and December 2017 were grouped as follows: controls (patients without cancer), stable cancer (SC), and AC. AC was included patients with cancer diagnosed within the past 6 months, patients who had cancer-related therapy within the past 6 months, active metastatic disease, or active recurrence of the cancer. The primary endpoints were 5-year survival and a secondary endpoint was 5-year MACE.

Results

A total of 6,743 patients (age 66±12 years, 68.4% men) treated with PCI were included: 6,404 (95.0%) controls, 245 (3.6%) SC, and 94 (1.4%) AC. Predominant malignancies were gastrointestinal (37.4%), lung (22.7%), and genitourinary cancer (14.7%). No differences were observed between patients with AC, SC and controls regarding 5-year MACE (total MACE, 33.2% vs. 28.1% vs. 17.5%, p=0.072; cardiac death, 13.6% vs. 9.1% vs. 6.7%, p=0.066; non-fatal myocardial infarction, 2.9% vs. 7.5% vs. 7.8%, p=0.820; revascularization, 17.9% vs. 17.6% vs. 11.6%, p=0.794, respectively). Patients with AC and SC had reduced 5-year survival compared with controls (62.0% vs. 81.5% vs. 89.8%, p&lt;0.001) (Figure). AC was associated with a 1.76 (95% CI 1.22 to 2.54, p=0.002) fold increased risk of all-cause 5-year mortality in multivariable adjusted models.

Conclusions

Cumulative incidence of 5-year survival was discriminated by concurrent status of cancer following PCI. Individualized decision making is needed in the routine practice of PCI regarding concurrent cancer-specific treatment and prognosis.

Funding Acknowledgement

Type of funding sources: None.

Effect of hepatic steatosis on native T1 mapping of 3T magnetic resonance imaging in the assessment of T1 values for patients with non-alcoholic fatty liver disease

PURPOSE

This study investigated whether T1 values in native T1 mapping of 3T magnetic resonance imaging (MRI) of the liver were affected by the fatty component.

METHODS

This prospective study involved 340 participants from a population-based cohort study between May 8, 2018 and August 8, 2019. Data obtained included: (1) hepatic stiffness according to magnetic resonance elastography (MRE); (2) T1 value according to T1 mapping; (3) fat fraction and iron concentration from multi-echo Dixon; and (4) clinical indices of hepatic steatosis including body mass index, waist circumference, history of diabetes, aspartate aminotransferase, alanine aminotransferase, gamma-glutamyl transpeptidase, and triglycerides. The correlations between T1 value and fat fraction, and between T1 value and liver stiffness were assessed using Pearson's correlation coefficient. The independent two-sample t-test was used to evaluate the differences in T1 values according to the presence or absence of hepatic steatosis, and the one-way analysis of variance was used to evaluate the difference in T1 value by grading of hepatic steatosis according to MRI-based proton density fat fraction (PDFF). In addition, univariate and multivariate linear regression analyses were performed to determine whether other variables influenced the T1 value.

RESULTS

T1 value showed a positive correlation with the fat fraction obtained from PDFF (r = 0.615, P < 0.001) and with the liver stiffness obtained from MRE (r = 0.370, P < 0.001). Regardless of the evaluation method, the T1 value was significantly increased in subjects with hepatic steatosis (P < 0.001). When comparing hepatic steatosis grades based on MRI-PDFF, the mean T1 values were significantly different in all grades, and the T1 value tended to increase as the grade increased (P < 0.001, P for trend <0.001). On multiple linear regression analysis, the T1 value was influenced by MRI-PDFF, calculated liver iron concentration, liver stiffness, and serum aspartate aminotransferase level.

CONCLUSION

The T1 value obtained by current T1 mapping of 3T MRI was affected by the liver fat component and several other factors such as liver stiffness, iron concentration, and inflammation.

P3637Relationship between serial measurements of NT-proBNP and cardiovascular events in patients with acute coronary syndrome

Background

Increased level of natriuretic peptides has been known as an important predictors of adverse cardiovascular (CV) outcomes in patients with acute coronary syndrome (ACS). We sought to evaluate clinical implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) measured at initial and follow-up periods.

Methods

Serial NT-proBNP levels (on-admission and one-month post-PCI) were measured in ACS patients undergoing PCI (n=2,290). High NT-proBNP levels were determined according to the predefined age-specific criteria. Patients were stratified into 4 groups according to NT-proBNP levels (on-admission & one-month): (1) normal-normal group (n=1234, 53.9%); (2) high–normal group (n=257, 11.2%); (3) normal-high group (n=376, 16.4%); and (4) high-high group (n=423, 18.5%). Clinical events were defined as all-cause death and MACE (a composite of CV death, non-fatal MI, and ischemic stroke).

Results

With a median follow-up of 35.9 (IQR: 16.8, 54.5) months, all-cause death and MACE were occurred in 4.1% and 7.2%, respectively. NT-proBNP on-admission vs. at one-month did not differ significantly (median 391.6 [IQR: 143.9, 1402.3] vs. median 619.1 [IQR 240.1, 1616.1]; p=0.622), but the prevalence of high NT-proBNP was increased over time (25.3% to 34.9%; p<0.001). The rates of all-cause death and MACE significantly increased only in the high-high group compared with other groups (log-rank test, all p values <0.001, Figure). After adjustment, the high-high group remained significantly risky in terms with the occurrence of all-cause death (HR, 2.99; 95% CI, 1.65 to 5.41; p<0.001) and MACE (HR, 1.96; 95% CI, 1.28 to 3.01; p=0.002).

Figure 1

Conclusion

Serial measurements of NT-proBNP at on-admission and follow-up can help to stratify the risks of all-cause death and adverse CV events following PCI in ACS patients. About two-fifths of patients having high NT-proBNP level during hospitalization can be classified into the low-risk group for all-cause death and adverse CV events.

Acknowledgement/Funding

None

Abstract P4-01-11: Genomic alterations of cell-free DNA in early breast cancer patients with recurrence

Cell-free DNA (cfDNA), as a non-invasive strategy, provides substantial benefit to overcome tumor heterogeneity. Surveillance of recurrence after standard treatment in early breast cancer (BC) using cfDNA, enables to detect minimal residual disease (MRD), also to identify genomic alterations driving recurrences. We aimed to assess the role of cfDNA in detecting MRD by investigating genomic alterations of 1)primary, recurred tumor and 2)cfDNA at time of recurrence using deep targeted sequencing. Fifty-four early BC patients were enrolled prospectively between 2014 and 2017 at time of recurrence. Median disease free interval was 28.5 months (rage 6.2-49.8). 62.7% (32/51) were hormone receptor (HR) positive (28 HRpos/HER2neg, 4 HRpos/HER2pos), 11.8% (6/51) were HRneg/HER2pos and 25.5% (13/51) were triple negative BCs. 59.3% (32/54) patients developed loco-regional recurrence (15 local recurrence only, 13 regional only, 4 with both) and distant metastasis was observed among 40.7% (22/54) patients. Cell-free DNA was extracted from 5cc blood at time of recurrence. Deep targeted sequencing was performed using customized NGS panel –encompassing 426 cancer-related target coding region, 242 fusion and amplification-related region- of cfDNA and FFPE(formalin fixed paraffin embedded) tumor samples archived from surgical resection or biopsy. Deep targeted sequencing data was successfully performed in 72.1% (31/43) plasma samples and sequencing yield was significantly lower when stored for more than 2yrs (46.2% vs 83.3%).

Mutations of cfDNA and tumor (primary, recurred) were analyzed. Mean sequencing depth of cfDNA and FFPE were x425.7 and x777.6 respectively. Median number of pathogenic mutations found in primary tumor, cfDNA and recurred tumor were 27(range 12-99), 25(range 8-85) and 9(range 0-23). Among mutations found in primary tumor, 27.4% were shared mutations (range 8.1%-72.7%) with recurred tumor and 26.1% were shared mutations (range 4.7%-69.2%) observed in cfDNA sample. Among mutations found in recurred tumor, 40.9% were observed in cfDNA (range 17.7-87.5%). In primary tumor, median number of mutations with allelic fraction (MAF)&gt;10% were 12 (range 4-21) and at least one mutation was found in cfDNA at time of recurrence. Among mutations with MAF&gt;10%, 59.4% and 69.1% were found in cfDNA and recurred tumor. Known oncogenic mutations of PIK3CA, TP53, GATA3, AKT1, ESR1, RELN, ERBB2, ERBB3, BRCA1 mutation were found. PIK3CA gene (p.H1047R) was found in two cases both in primary tumor and cfDNA at recurrence (MAF 11.4% vs 5.3% and 12.3% vs 15.4%) suggesting de novo driver mutation. One patient developed regional recurrence during adjuvant aromatase inhibitor with ESR1 V392I mutation in both cfDNA and recurred tumor (MAF 48.1 and 54.5%), while another patient's recurred tumor during aromatase inhibitor harbored ESR1 D538G mutation exclusively in recurred tumor with MAF &lt;1%. Both patients had no ESR1 hotpot mutation in primary tumor.

Our data showed sequencing yield of 83.3% in plasma samples within 2yr. Pathogenic mutations in primary tumor, especially when MAF&gt;10%, half of them was observed in cfDNA at time of recurrence. ESR1 mutation should be included in cfDNA surveillance for patients undergoing endocrine therapy even absent in primary tumor.

Citation Format: Kim J, Jo WK, Kim KY, Kim BJ, Lee SB, Lee HJ, Yu JH, Kim HJ, Chung IY, Ko BS, Kim S-B, Jung KH, Ahn JH, Chang S, Lee JW, Son BH, Ahn SH. Genomic alterations of cell-free DNA in early breast cancer patients with recurrence [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-01-11.

Varices on computed tomography are surrogate of clinically significant portal hypertension and can predict survival in compensated cirrhosis patients

BACKGROUND AND AIM

To investigate prognostic value of varices on computed tomography (CT) and redefine surrogate criteria for clinically significant portal hypertension (CSPH).

METHODS

We retrospectively enrolled 241 patients with compensated cirrhosis who underwent hepatic venous pressure gradient (HVPG) measurement from 2008 to 2013. Using CT and upper endoscopy findings obtained within 3 months from HVPG measurement, patients were classified into three groups: presence of standard surrogate for CSPH, defined as presence of varices on upper endoscopy and/or splenomegaly associated with thrombocytopenia (Group 1, n = 139); varices on CT without standard surrogate for CSPH (Group 2, n = 41); and free from both (Group 3, n = 61). HVPG value and overall survival (OS) rates were compared among three patient groups. Revised surrogate for CSPH was defined as presence of standard surrogate and/or presence of varices on CT (i.e. both Group 1 and Group 2).

RESULTS

Mean HVPG value in Group 2 was significantly higher than that in Group 3 (10.3 mmHg vs 6.5 mmHg, P < 0.001), but significantly lower than that in Group 1 (10.3 mmHg vs 13.1 mmHg, P < 0.001). Seven-year OS rates in Group 2 was similar to those in Group 1 (57.0% vs 62.7%, P = 0.591), but significantly poorer than those in Group 3 (57.0% vs 84.0%, P = 0.015). The presence of revised surrogate for CSPH was a significant predictive factor for OS (P = 0.025, Hazard ratio = 2.71 [1.14-6.45]) on multivariate analysis whereas standard surrogate for CSPH was not (P = 0.849).

CONCLUSION

The presence of varices on CT was a significant sign for CSPH, predicting poor OS outcome in patients with compensated cirrhosis.

Transoesophageal echocardiographic evaluation of central venous catheter positioning using Peres' formula or a radiological landmark-based approach: a prospective randomized single-centre study

BACKGROUND

The lower superior vena cava (SVC), near its junction with the right atrium (RA), is considered the ideal location for the central venous catheter tip to ensure proper function and prevent injuries. We determined catheter insertion depth with a new formula using the sternoclavicular joint and the carina as radiological landmarks, with a 1.5 cm safety margin. The accuracy of tip positioning with the radiological landmark-based technique (R) and Peres' formula (P) was compared using transoesophageal echocardiography.

METHODS

Real-time ultrasound-guided central venous catheter insertion was done through the right internal jugular or subclavian vein. Patients were randomly assigned to either the P group (n=93) or the R group (n=95). Optimal catheter tip position was considered to be within 2 cm above and 1 cm below the RA-SVC junction. Catheter tip position, abutment, angle to the vascular wall, and flow stream were evaluated on a bicaval view.

RESULTS

The distance from the skin insertion point to the RA-SVC junction and determined depth of catheter insertion were more strongly correlated in the R group [17.4 (1.2) and 16.7 (1.5) cm; r=0.821, P<0.001] than in the P group [17.3 (1.2) and 16.4 (1.1) cm; r=0.517, P<0.001], with z=3.96 (P<0.001). More tips were correctly positioned in the R group than in the P group (74 vs 93%, P=0.001). Abutment, tip angle to the lateral wall >40°, and disrupted flow stream were comparable.

CONCLUSIONS

Catheter tip position was more accurate with a radiological landmark-based technique than with Peres' formula.

CLINICAL TRIAL REGISTRATION

Clinical Trial Registry of Korea: https://cris.nih.go.kr/cris/index.jsp KCT0001937.

Rational Design of Low Cost and High Energy Lithium Batteries through Tailored Fluorine-free Electrolyte and Nanostructured S/C Composite

We report a new Li-S cell concept based on an optimized F-free catholyte solution and a high loading nanostructured C/S composite cathode. The Li₂ S₈ present in the electrolyte ensures both buffering against active material dissolution and Li⁺ conduction. The high S loading is obtained by confining elemental S (≈80 %) in the pores of a highly ordered mesopores carbon (CMK3). With this concept we demonstrate stabilization of a high energy density and excellent cycling performance over 500 cycles. This Li-S cell has a specific capacity that reaches over 1000 mA h g^-1 , with an overall S loading of 3.6 mg cm^-2 and low electrolyte volume (i.e., 10 μL cm^-2 ), resulting in a practical energy density of 365 Wh kg^-1 . The Li-S system proposed thus meets the requirements for large scale energy storage systems and is expected to be environmentally friendly and have lower cost compared with the commercial Li-ion battery thanks to the removal of both Co and F from the overall formulation.

Preparedness of Young Male Physicians for Biological Terrorism and Warfare in South Korea

Introduction

The events of 11th September 2001, and the subsequent anthrax attacks in the United States brought the threat of bioterrorism to the forefront of concern for public health departments. Moreover, the rising confrontation between North and South Korea emphasizes the possibility of aggression with biological weapons and our vulnerability to bioterrorism. While the importance of physicians' interests and management ability is becoming more critical, no studies have yet been undertaken in Korea to assess whether primary care physicians are well informed and capable of managing bioterrorism. This study evaluates the awareness and response of young male physicians to potential bioterrorism in South Korea.

Method

A total of 692 young male physicians completed the knowledge and awareness survey during the education period of military service on 9th April 2005.

Results

Forty-five percent of the participants responded that the possibility of biological warfare in Korea was high. The level of bioterrorism knowledge, however, was low. Eighty-seven percent acknowledged the necessity of education and training for bioterrorism, and 69.9% were willing to accept education and training in bioterrorism preparedness.

Conclusion

These findings suggest that young physicians should receive continuous education and training to improve preparedness for biological terrorism and warfare in South Korea.

Clinical Characteristics of Patients with Pseudo-Subarachnoid Haemorrhage who were Successfully Resuscitated from Out-of-Hospital Cardiopulmonary Arrest

Introduction

Pseudo-subarachnoid haemorrhage (PSAH) is a rare neuroradiological finding seen in patients with diffuse cerebral edemas. We investigated clinical characteristics and risk factors for the development of PSAH.

Method

The successfully resuscitated patients in emergency department were classified into two groups: those with pseudo-SAH [PSAH (+)] and those without pseudo-SAH [PSAH (-)]. Clinical variables were analysed.

Results

Pseudo-SAH was found in 31.6% of patients. PSAH was more common in males (p=0.042). The mean age was 39.9±10.3 years in the PSAH (+) group and 54.4±22.0 years in the PSAH (-) group (p=0.038). Outcomes measured by Cerebral Performance Category score were also significantly different between the two groups (p=0.037). Logistic regression analysis found that serum lactate concentration and duration of anoxia were associated with the development of PSAH (with odds ratios and p values of 1.92, p=0.01 and 1.13, p=0.02, respectively).

Conclusions

PSAH itself is a phenomenon that could be seen in post-resuscitation encephalopathy as a consequence of severe anoxic insult.

Bilateral simultaneous unicompartmental knee arthroplasty versus unilateral total knee arthroplasty: A comparison of the amount of blood loss and transfusion, perioperative complications, hospital stay, and functional recovery

BACKGROUND

Unicompartmental knee arthroplasty (UKA) is a good alternative treatment option to total knee arthroplasty (TKA) for single compartment knee osteoarthritis. Several recent reports suggest that UKA results in more rapid functional recovery than TKA, together with fewer complications. Few performed a comparison of bilateral simultaneous UKA and unilateral TKA.

HYPOTHESIS

Bilateral simultaneous UKA would result in fewer perioperative complications, less blood loss, less transfusion and faster recovery of short-term clinical outcomes, compared with unilateral TKA patients.

MATERIAL AND METHODS

In a retrospective trial, the bilateral simultaneous UKA (bUKA) cases were matched one to one with a cohort of unilateral TKA (uTKA) cases according to age, body mass index, gender, Kellgren-Lawrence grade of knee osteoarthritis and American Society of Anesthesiologists score. In bilateral simultaneous UKA group, patients had KL grade 4 of bilateral knee osteoarthritis, and in unilateral TKA group, patients had KL grade 4 of unilateral knee osteoarthritis. The transfusion requirements, estimated blood loss (EBL), duration of hospital stay, incidence of complications, and knee clinical scores of the bUKA and uTKA groups were compared at the 6-month short-term follow-up.

RESULTS

Patients were categorized into the bUKA group (n=52) and uTKA group (n=52). The number of patients requiring transfusion and the amount of EBL was smaller in the bUKA group (P<0.001 for transfusion and P=0.043 for EBL). The duration of hospital stay was shorter and the number of complications was smaller in the bUKA group (P<0.001 for hospital stay and P=0.028 for complications). The clinical outcomes were also superior in the bUKA group (P<0.001).

CONCLUSIONS

Bilateral simultaneous UKA shows fewer perioperative complications, less blood loss, less transfusion, and better functional outcomes at 6 months postoperatively than unilateral TKA. The data suggest that bilateral simultaneous UKA can be performed safely, and results in acceptable clinical outcomes.

LEVEL OF EVIDENCE

III, case-control study.

Differentiation between gallbladder cancer with acute cholecystitis: Considerations for surgeons during emergency cholecystectomy, a cohort study

PURPOSE

Gallbladder cancer (GBCA) is an uncommon malignancy with vague and non-specific symptoms. GBCA is sometimes diagnosed after emergency cholecystectomy for acute cholecystitis. We investigated the differential diagnosis between GBCA with acute cholecystitis.

MATERIALS AND METHODS

Thirteen patients were diagnosed with GBCA after emergency cholecystectomy carried out for acute cholecystitis. A radiologist who was blinded to the final diagnoses retrospectively reviewed the computed tomography (CT) scans of the patients with GBCA and 25 patients with acute cholecystitis. We retrospectively reviewed the medical records of these patients and compared the clinical characteristics and CT findings between patients with GBCA and those with acute cholecystitis. We also investigated the prognostic factors in patients with GBCA who underwent emergency cholecystectomy.

RESULTS

Gallbladder (GB) stones were found more often in patients with acute cholecystitis (n = 17, 68%) than in patients with GBCA (n = 7, 53.8%) (p = 0.486). Patients with GBCA showed typical GB masses or focal enhanced wall thickening when compared to diffuse wall thickening in patients with acute cholecystitis. Some GBCA patients showed irregular mural thickening and GB enhancement. Differentiating carcinoma from acute cholecystitis might sometimes not possible, but the latter group of patients had significantly lower C-reactive protein (CRP) levels (p = 0.033) and less regional fat stranding (p = 0.047). Survival was significantly affected by aggressive tumor characteristics (lymphatic invasion [p = 0.025], depth of tumor invasion [p = 0.004]) or R0 resection (p = 0.013) rather than bile spillage (p = 0.112).

CONCLUSIONS

Surgeons deciding on emergency cholecystectomy for elderly patients with acute cholecystitis must suspect GBCA in patients with a low CRP level, irregular mural thickening or enhancement of GB without regional fat stranding.