Paravertebral block for breast surgery: a cost analysis

Abstract #6103

Background: Paravertebral block (PVB) is a form of regional block that has long been used in surgical procedures, including breast surgery. PVB provides intraoperative and postoperative analgesia, decreasing the need for narcotics (NA). It also decreases amounts of general anesthesia (GA) required. NA and GA contribute to postoperative nausea and vomiting, which is decreased with PVB. There has not been a modern cost analysis of PVB in breast surgery. The purpose of this study is to evaluate patient comfort and cost effectivness of PVB in breast surgery.
 Materials and Methods: A retrospective chart review of 461 breast cases was performed. Mastectomy with or without axillary staging and lumpectomy with axillary staging were included (n=188). Minor breast biopsies, lumpectomies alone, and combined reconstructions/other procedures were excluded. Data collected included whether or not PVB was performed (based on surgeon/patient/anesthesiologist preference), length of stay (LOS), postoperative requirements for NA and antiemetics (AE), and complications from PVB. Patients (pts) were scheduled as inpatient (IP) or outpatient (OP) based on procedure and comorbidities. The data was analyzed for IP and OP groups for LOS. Cost was calculated from NA and AE use and overnight stay.
 Results: 188 total procedures (125 IP; 63 OP). 88/125 IP had PVB (70%). 57/63 OP had PVB (90%). IP LOS < 24 hrs had 4/5 with PVB (80%); 1/5 without (20%). LOS 24-36 hrs had 46/63 with PVB (73%); 17/63 without (27%). 57 had LOS > 36 hrs; 38/57 with PVB (67%); 19/57 without (33%). OP LOS 0-2 hrs had 41 pts; 39/41 with PVB (95%); 2/41 without (5%). 22 had LOS > 2 hrs; 18/22 with PVB (82%); 4/22 without (18%). There was an overall shorter LOS for both IP and OP with PVB than without (p=0.0151). 152/188 pts required NA (81%). 112/152 received PVB (74%); 40/152 did not (26%). 36/188 did not require NA (19%). 32/36 received PVB (89%); 4/36 did not (11%). There was a difference between those who did and did not receive PVB and NA use (p=0.0257). 86/188 required antiemetics (46%). 59/86 received PVB (69%); 27/86 did not (31%). 102/188 did not require AE (54%). 86/102 received PVB (84%); 16/102 did not (16%). There was a difference between those who did and did not receive PVB and requirements for AE (p=0.0143). Number of doses of NA and AE were summarized as cost values per pt. The average cost for these medications for an IP with PVB was $184 vs $213 without. OP medicine costs with and without PVB was $39 and $111. Overall average cost difference was $29 for IP, $72 for OP. OP also saved $800 overnight charge. For all pts combined, there was a statistical cost difference (p=0.0085). 1/188 pts had a complication (pneumothorax).
 Discussion: PVB results in less use of postoperative NA and AE in breast surgery. Not only is this reflected in pt comfort, but also a statistically significant cost reduction for both IP and OP procedures and LOS.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6103.

Comparable efficacies between premenopausal and postmenopausal metastatic breast cancer patients by letrozole with and without goserelin as first line hormone therapy: a phase II parallel group study

Abstract #6134

Background: The use of goserelin in premenopausal patients(pts) is to produce castrated level of estradiol (E2), and the remaining peripheral E2 production is inhibited by letrozole, which would accomplish comparable clinical outcomes as in postmenopausal metastatic breast cancer (MBC) pts by letrozole alone.
 Methods: Hormone receptor positive pre- and postmenopausal pts with MBC were eligible. Letrozole 2.5 mg once a day was administered with goserelin 3.6 mg every 4 weeks in premenopausal pts and serial serum E2, FSH, LH were measured. Bone mineral density (BMD) and serum bone turnover markers were also checked (n=34).
 Results: Among total 78 pts enrolled, 32 pre- and 38 postmenopausal pts were assessed for efficacy and adverse events (AE). The median age was 42 years (range, 32–52) for pre- and 53 years (range, 33–70) for postmenopausal pts. Baseline characteristics were similar in the two groups, except for significantly longer disease free interval in postmenopausal pts (22.2 months vs. 41.2 months, P=0.01). Clinical benefit (CR+ PR+ SD ≥ 24 weeks) rates (62.5% vs. 68.4%, P=0.62), and objective response (CR + PR) rates (28.1 % vs. 23.7%, P=0.79) were comparable between the two groups. Median TTP was 8.6 months vs. 9.6 months (P=0.61) with a median follow-up of 11.6 months and 14.6 months, respectively. In multivariate analysis, strong ER status was significantly associated with clinical benefit rate (P=0.01), and HER2 positivity (P<0.001) and stage IV presentation (P=0.05) with shorter TTP. In premenopausal pts, the mean E2 level was dropped from 62.3 ± 81.8 pg/mL at baseline to 12.3 ± 2.2 pg/mL at week 2. AEs were mild with significantly more hot flushes in premenopausal pts. In premenopausal pts without bisphosphonate treatment, there was a trend of rising serum levels of osteocalcin (OC) (0% vs. 165%, P=0.065), bone alkaline phosphatase (bALP) (0% vs. 28%, P=0.055), and C-telopeptide (CTx) (0% vs. 108%, P=0.095), as well as a significant reduction in both lumbar spine (P=0.044) and femur (P=0.027) BMD. In contrast, in premenopausal pts with bone metastasis on bisphosphonate, there was no significant change in OC, bALP, CTx, and both BMD. In postmenopausal pts without bisphosphonate treatment, no significant change in OC, bALP, CTx, and femur BMD, while in pts with bone metastasis on bisphosphonate treatment, a significant decrease in OC (0% vs. -22%, P=0.050) and CTx (0% vs. -41%, P=0.020) and increase in both BMD (P=0.044, P=0.038 respectively) were observed.
 Conclusions: Clinical efficacies by letrozole and goserelin therapy in premenopausal MBC pts were comparable to those in postmenopausal pts by letrozole with mild AEs. While a modest increase in both bone formation and resorption especially in premenopausal pts, concurrent bisphosphonate therapy could stabilize bone metabolism in patients even with bone metastasis.
 Supported by NCC Grant No NCS-0610240-3. Letrozole for premenopausal group was supplied by Novartis.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6134.

The Effect on the Recovery Profile of a Change from Enflurane to Desflurane during the Latter Part of Anaesthesia

This study compared emergence and recovery characteristics after either enflurane anaesthesia or crossover from enflurane to desflurane anaesthesia. At an estimated 1 h prior to the end of operation, enflurane was either reduced (group E, n = 23) or replaced with desflurane (group X, n = 23). At the end of the operation, emergence and recovery characteristics of the two groups were compared. The crossover technique accelerated recovery compared with enflurane anaesthesia. The time taken for the eyes to open in response to painful pinching or a verbal command, and to regain awareness of age and name, were significantly shorter after crossover anaesthesia than after enflurane anaesthesia. The digit symbol substitution test and serial seven test scores were significantly better in patients subjected to crossover anaesthesia than in those subjected to enflurane anaesthesia. We conclude that, during surgery, the substitution of enflurane with desflurane in the latter part of anaesthesia can improve recovery.

Down-regulation of claudin-2 in breast carcinomas is associated with advanced disease

AIMS

Claudin 2 (CLDN2) is a family of integral membrane tight junctions. The aim was to determine the influence of CLDN2 expression on tumour behaviour and its role in breast carcinogenesis.

METHOD AND RESULTS

Thirty-seven invasive breast carcinomas and corresponding normal breast tissues were examined for CLDN2 protein and mRNA expression using Western blotting and semiquantitative reverse transcriptase-polymerase chain reaction. The expression of CLDN2 protein in 118 cases of breast carcinoma was further studied with immunohistochemistry and related to various clinicopathological parameters. CLDN2 protein expression was significantly down-regulated (0.4-fold) in tumours compared with corresponding normal breast tissue (P < 0.0001). Down-regulation of CLDN2 was significantly associated with lymph node metastasis (P = 0.047) by Western blot analysis, and with high clinical stage (P = 0.040) by immunohistochemistry. The expression levels of CLDN2 mRNA in high clinical stages (stages II and III) were lower than those in low clinical stage (stage I) and normal tissue, but not statistically significantly so.

CONCLUSIONS

These results suggest that CLDN2 is implicated in the progression as well as the development of breast carcinoma, indicating that CLDN2 is a possible tumour suppressor gene product.

Tissue classification for MRI of thigh using a modified FCM method

Fuzzy C-means (FCM) has been frequently used to image segmentation in order to separate objects. The most used segmentation attribute is grey level of pixels. Nevertheless, this method can not identify complex image objects because grey level can not take into account all visual information. This paper describes a modified FCM method for tissue classification which integrates separation and fusion operation of partition tree with expert knowledge. Our method has been applied to 26 MRI (Magnetic Resonance Imaging) images of thigh for localizing four main anatomical tissues: muscle, adipose tissue, cortical bone, and spongy bone. A testing dataset of 6500 representative points has been created by an expert. Using our method, we obtain a high classification rate (95.73%) in the test dataset, which largely improved the classification results obtained from existing methods.

Identification of a novel HLA-G allele, HLA-G*010113, in a Korean individual

In the present study, a novel human leucocyte antigen-G allele, G*010113, was identified via direct sequencing from donor gDNA in a Korean population. This allele differs from G*01010201 by a single nucleotide substitution, C to T, in codon 169 of exon 3 but did not result in any amino acid change.

Low-grade endometrial stromal sarcoma: a single center's experience with 22 cases

The aim of this retrospective study was to evaluate the clinical behavior and management outcome of low-grade endometrial stromal sarcoma (LGESS). From September 1994, to March 2007, 22 patients with histologically proven stage I LGESS were included in this study. Clinicopathologic variables, recurrence, and management outcomes were reviewed retrospectively. The median age of the 22 patients was 43 years. The most common presenting symptom was abnormal vaginal bleeding. All patients underwent a hysterectomy and had stage I disease. Six patients had adjuvant therapy after the hysterectomy. The median follow-up period was 77 months (range 12-202 months). Ten patients had disease recurrence. The median disease-free survival period was 111 months (range 6-182 months). The pelvis (eight cases) was the most common site of recurrence followed by the lung (four cases) and the liver (one case). Recurrent disease was treated with surgery (one case), surgery plus chemotherapy (five cases), chemotherapy (two cases), and surgery plus radiotherapy (two cases). Two patients died after 25 and 54 months after disease recurrence. Treatment with a bilateral salpingo-oophorectomy or adjuvant chemoradiation did not affect the disease-free interval. LGESS is usually a slow-growing neoplasm with an indolent clinical course. Surgery is the primary treatment for recurrent endometrial stromal sarcoma when feasible. Adjuvant treatment (radiotherapy, chemotherapy, or both) had no effect on the prognosis of patients with stage I disease.

Recent developments of bio-molecular motors as on-chip devices using single molecule techniques

The integration of microfluidic devices with single molecule motor detection techniques allows chip based devices to reach sensitivity levels previously unattainable.

Measurements of the proton elastic-form-factor ratio mu pG p E/G p M at low momentum transfer

High-precision measurements of the proton elastic form-factor ratio, mu pG p E/G p M, have been made at four-momentum transfer, Q2, values between 0.2 and 0.5 GeV2. The new data, while consistent with previous results, clearly show a ratio less than unity and significant differences from the central values of several recent phenomenological fits. By combining the new form-factor ratio data with an existing cross-section measurement, one finds that in this Q2 range the deviation from unity is primarily due to G p E being smaller than expected.