Computational hemodynamics analysis of intracranial aneurysms treated with flow diverters: correlation with clinical outcomes

BACKGROUND AND PURPOSE

Recent studies have shown promising results regarding intracranial aneurysms treated with flow diverters. However, these have had adverse effects, including delayed aneurysm occlusion, posttreatment symptoms, and rupture. The hemodynamic profiles of aneurysms treated with flow diverters were analyzed to determine the ones associated with successful and failed treatments.

MATERIALS AND METHODS

Patient-specific computational fluid dynamics were used to simulate hemodynamic profiles, including the presence of jet flow, energy loss, volume flow, and wall shear stress in 4 successful occlusions of aneurysms and 4 failed cases after flow-diverter deployment. In these 4 failed cases, hemodynamic profiles were examined again after a hypothetic second intervention. This involved replacing the failed flow diverter with a hypothetic optimally deployed flow diverter or simulated placement of a second flow diverter within the first (double hypothetic optimally deployed).

RESULTS

Where successful occlusions were achieved, a marked obliteration of jet flow was observed. Flow entering the aneurysm sac was diverted via the center of the flow diverter and joined smoothly with the continuation of flow leaving the aneurysm sac into the parent arteries. These observations were supplemented by a reduction in the other hemodynamic profiles. Aneurysm neck geometry might influence the efficacy of the flow diverter.

CONCLUSIONS

Hemodynamic indices, as calculated by using computational fluid dynamics techniques, have close correlation with flow-diverter treatment outcome. Computational fluid dynamics could be potentially useful as a planning tool for neurointerventionists by simulating an optimized flow-diverter deployment strategy before the procedure and evaluating posttreatment outcome.

Correlation between fissured fibrous cap and contrast enhancement: preliminary results with the use of CTA and histologic validation

BACKGROUND AND PURPOSE

Previous studies demonstrated that carotid plaques analyzed by CTA can show contrast plaque enhancement. The purpose of this preliminary work was to evaluate the possible association between the fissured fibrous cap and contrast plaque enhancement.

MATERIALS AND METHODS

Forty-seven consecutive (men = 25; average age = 66.8 ± 9 years) symptomatic patients studied by use of a multidetector row CT scanner were prospectively analyzed. CTA was performed before and after contrast and radiation doses were recorded; analysis of contrast plaque enhancement was performed. Patients underwent carotid endarterectomy en bloc; histologic sections were prepared and evaluated for fissured fibrous cap and microvessel attenuation. The Mann-Whitney test was performed to evaluate the differences between the 2 groups. A multiple logistic regression analysis was performed to assess the effect of fissured fibrous cap and microvessel attenuation on contrast plaque enhancement. Receiver operating characteristic curve and area under the curve were also calculated.

RESULTS

Twelve patients had fissured fibrous cap. In 92% (11/12) of fissured fibrous cap-positive plaques, we found contrast plaque enhancement, whereas in 69% (24/35) of the plaques without fissured fibrous cap contrast plaque enhancement was found. The Mann-Whitney test showed a statistically significant difference between the contrast enhancement in plaques with fissured fibrous cap (Hounsfield units = 22.6) and without fissured fibrous cap (Hounsfield units = 12.9) (P = .011). On the regression analysis, both fissured fibrous cap and neovascularization were associated with contrast plaque enhancement (P = .0366 and P = .0001). The receiver operating characteristic curve confirmed an association between fissured fibrous cap and contrast plaque enhancement with an area under the curve of 0.749 (P = .005).

CONCLUSIONS

The presence of fissured fibrous cap is associated with contrast plaque enhancement. Histologic analysis showed that the presence of fissured fibrous cap is associated with a larger contrast plaque enhancement compared with the contrast plaque enhancement of plaques without fissured fibrous cap.

Effect of donor cell type on nuclear remodelling in rabbit somatic cell nuclear transfer embryos

Cloned rabbits have been produced for many years by somatic cell nuclear transfer (SCNT). The efficiency of cloning by SCNT, however, has remained extremely low. Most cloned embryos degenerate in utero, and the few that develop to term show a high incidence of post-natal death and abnormalities. The cell type used for donor nuclei is an important factor in nuclear transfer (NT). As reported previously, NT embryos reconstructed with fresh cumulus cells (CC-embryos) have better developmental potential than those reconstructed with foetal fibroblasts (FF-embryos) in vivo and in vitro. The reason for this disparity in developmental capacity is still unknown. In this study, we compared active demethylation levels and morphological changes between the nuclei of CC-embryos and FF-embryos shortly after activation. Anti-5-methylcytosine immunofluorescence of in vivo-fertilized and cloned rabbit embryos revealed that there was no detectable active demethylation in rabbit zygotes or NT-embryos derived from either fibroblasts or CC. In the process of nuclear remodelling, however, the proportion of nuclei with abnormal appearance in FF-embryos was significantly higher than that in CC-embryos during the first cell cycle. Our study demonstrates that the nuclear remodelling abnormality of cloned rabbit embryos may be one important factor for the disparity in developmental success between CC-embryos and FF-embryos.

Obesity, alexithymia and psychopathology: a case-control study

OBJECTIVE

The relationship between psychopathology and alexithymia in obese patients is uncertain. The present study was performed to evaluate this relationship in a clinical sample of patients attending a centre for the diagnosis and treatment of obesity compared to a matched sample of non-obese subjects.

METHODS

293 consecutive obese patients (48 males, 245 females, mean age 45, 41±13.55 yrs; mean BMI 35.60±6.20) were compared with a control group made of 293 non-obese subjects (48 males, 245 females, mean age 45, 66±13.86 yrs; mean BMI 21.8±2.06); all subjects were interviewed by means of SCID I and SCID II together with several self-evaluation instruments including the TAS-20 (Toronto Alexithymia Scale) and SCL-90 (Symptom Check List, Revised).

RESULTS

Alexithymia was significantly more frequent among obese patients compared to "normal" controls (12.9% vs 6.9%, p=0.010); moreover obese patients achieved significantly higher mean scores on subscales 1 and 2 and on overall scale of the Toronto Alexithymia Scale; comorbidity with axis I/II disorders, in particular Binge Eating Disorder, was associated with a significantly higher frequency of alexithymic traits and higher scores at TAS.

CONCLUSIONS

Alexithymia and psychopathology are strongly correlated among obese patients seeking treatment. Routine evaluation of personality traits and comorbid psychopathology may be relevant in treatment of obesity.

Relapse of amoebic infection 10 years after the infection

A 52-year-old man with schizophrenia, who had a history of amoebic liver abscess treated with combination antimicrobial agents, presented 10 years later with severe rectal bleeding. Diagnosis of amoebic colitis was confirmed by histological examination of endoscopic biopsy. Doctors treating patients with amoebic infection should be aware of the risk of eradication failure. Post-treatment stool testing, preferably by antigen testing or polymerase chain reaction, should be performed after antimicrobial treatment.

Hepatocarcinogenesis of regenerative and dysplastic nodules in Chinese patients

OBJECTIVES

To determine the development rate of hepatocellular carcinoma and survival of patients diagnosed to have regenerative, and low-grade and high-grade dysplastic liver nodules.

DESIGN

Retrospective descriptive study.

SETTING

Acute public hospital, Hong Kong.

PATIENTS

Patients with non-malignant liver nodules confirmed by imaging-guided liver biopsy between January 1997 and December 2008.

MAIN OUTCOME MEASURES

Rates of hepatocellular carcinoma development and survival.

RESULTS

A total of 147 patients with non-malignant liver nodules were followed up over a median duration of 29 months. The initial histological diagnosis included regenerative nodules (n=74), low-grade dysplastic nodules (n=34), and high-grade dysplastic nodules (n=39). The respective cumulative hepatocellular carcinoma development rate during the first, second, third, and fourth year were 3%, 5%, 9% and 12% for simple regenerative nodules, 29%, 35%, 38% and 44% for low-grade dysplastic nodules, and 38%, 41%, 51% and 51% for high-grade dysplastic nodules. The hepatocellular carcinoma development rate was highest in those with high-grade dysplastic nodules. Multivariate analysis showed that histological dysplastic changes were associated with increased alpha-fetoprotein levels and advanced age, which were both independent predictors of hepatocellular carcinoma development. Histological dysplastic changes, male sex, advanced age, prolonged prothrombin time, and ultrasound appearances were independent predictors of mortality.

CONCLUSION

The presence of dysplastic change in liver nodules increased the risk of hepatocellular carcinoma development and death.

Abstract P1-01-19: Comparison of Ultrasound-Guided Fine Needles Aspiration Cytology and Ultrasound Guided Core Biopsy in Pre-Operative Axillary Staging for Early Breast Cancer

Introduction: Pre-operative axillary staging is now widely accepted as a prerequisite in surgical management of the axilla for patients newly diagnosed with early breast cancer. For those patients having breast tumour excision who are found to have nodal involvement, axillary clearance can be performed at the same time without prior sentinel node biopsy. Ultrasound (US) alone has low sensitivity, but can be used to direct needle biopsy. We assessed and compared the sensitivity and specificity of US-guided core biopsies (USCB) and US-guided fine needle cytology (USFNAC) used in our unit.

Patients and methods: A retrospective and prospective data collection was performed between November 2007 and May 2010 on all newly diagnosed breast cancer patients in our unit since the introduction of routine pre-operative axillary US. Patients whose nodes looked benign or normal on US were offered sentinel node biopsy (SNB). Patients found to have suspicious nodes were offered USFNAC or USCB, according to the individual preference of the radiologists. Patients with positive cytology or histology underwent axillary node clearances (ANC), those with benign cytology or histology were offered SNB. The final histology results were reviewed and correlated to their pre-operative histology or cytology.

Results: Of 559 Axillary ultrasound scans performed in our department between November 2007 and May 2010, 229 patients had pre-operative US scans of the axilla for newly diagnosed, clinically node-negative breast cancer. Of these 46 had USFNAC, 44 had USCB and 139 had normal/benign US. The USFNAC and USCB groups had similar proportions of positive results on postoperative histology, namely 70% and 79% respectively, allowing direct comparisons to be made. Of the 46 USFNAC patients, 17 (37%) had positive cytology (all confirmed by axillary clearance final histology). The 29 USFNAC patients with negative cytology had 15 (52%) with positive histology on sentinel node biopsy. The sensitivity of USFNAC was 53% and the specificity 100%. Of the 44 USCB patients, 26 (59%) were positive (all confirmed by axillary clearance final histology). Of the 18 USCB-negative patients, 7 (39%) were found to be positive on axillary clearance. The sensitivity of USCB was 79% and the specificity 100%. Of the 139 patients with normal US, 42 (30%) were found to be positive on sentinel node biopsies. For US alone, sensitivity was 61% and specificity was 80%.

Conclusion: US staging of the axilla is superior to clinical staging. However, there is still a high incidence of false negative results, making US a crude way of assessing the axilla and confirming the necessity for sentinel node biopsy in US-negative axillae. For patients with axillae that are indeterminate on US, our data supports routine use of ultrasound core biopsy (USCB) over Ultrasound fine needle aspiration cytology (USFNAC) for preoperative staging of the axilla, where technically feasible.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-19.

A pilot study to compare FXR expression in normal and malignant tissue in receptor-positive early-stage breast cancer

e14645

Background: Farnesoid X receptor (FXR), a nuclear receptor, is a ligand dependent transcriptional factor regulating cholesterol and carbohydrate metabolism. Recently, FXR was shown to have a contributing role in colorectal cancer. We hypothesize that FXR expression changes from normal to premalignant to malignant tissue in patients with breast cancer. Methods: We identified 16 paired formaldehyde fixed, paraffin embedded tissue (normal, premalignant, and malignant) from patients with receptor positive, early stage breast cancer. Clinical information was extracted from a prospective database initiated in 2006 under institutional approval. Immunohistochemical staining of FXR using a validated polyclonal antibody was completed with appropriate positive and negative controls. The slides were graded independently by two investigators using an agreed upon scale to detect the percentage of positively stained cells to the nearest 10th percentile. Statistical analysis was performed by ANOVA and Student's t-test. A p-value of 0.05 was considered significant in all analyses. Results: Normal tissue and invasive cancer was identified in all 16 patient specimens. Of the 16 invasive cancers, 12 were ductal and 4 were lobular. 8/16 (50%) of the specimens also contained non-invasive cancer. 5/16 patients (31%) had N1 disease. FXR expression did not correlate with grade, histology, stage, or lymph node status. However, FXR expression increases with malignant transformation of the breast cancer cell. The mean percentage of cells staining positive for FXR in normal breast tissue was 58%, non-invasive 72% and invasive 79%. FXR staining in normal breast tissue was significantly less when compared to both invasive and noninvasive cancer (p< 0.007). Conclusions: FXR expression is upregulated in breast cancer when compared with expression in normal tissue and appears to progressively increase along the continuum of malignancy. Our pilot study results warrant further evaluation into FXR as a predictive biomarker for breast cancer, given the ability to target FXR via development of non-toxic oral ligands.

No significant financial relationships to disclose.

Robotic surgery for gastrointestinal malignancies

BACKGROUND

This report describes our initial experience with the use of robotic-assisted surgery for the treatment of gastrointestinal (GI) malignancies.

METHODS

Between November 2004 and July 2007, 73 robotic procedures (26 female, 47 male) for GI cancer were performed and retrospectively reviewed. Procedures included 25 oesophagectomies, 11 gastrectomies and 37 rectal resections. The median body mass index (BMI) for this patient population was 26.

RESULTS

The median operative times for rectal, oesophageal and gastric resections were 285, 482 and 430 min, respectively. There were three conversions. Major postoperative morbidity was 16% for rectal, 32% for oesophageal and 9% for gastric procedures. The leak rate was 11% for rectal, 16% for oesophageal and 9% for gastric anastomoses. Median length of stay was 4, 11 and 5 days, respectively. The median number of lymph nodes harvested was 13, 22, and 26 for rectal, oesophageal and gastric lymphadenectomies, respectively. At a median follow-up of 9 months, one patient developed a port site recurrence; 30 day mortality was zero.

CONCLUSION

This initial experience suggests that the robotic approach is safe and feasible for a variety of radical oncological surgical procedures.