Humeral Retroversion in Children with Shoulder Internal Rotation Contractures Secondary to Upper-Trunk Neonatal Brachial Plexus Palsy

BACKGROUND

The most common sequela of neonatal brachial plexus palsy is an internal rotation contracture of the shoulder that impairs function and leads to skeletal deformation of the glenohumeral joint. Treatment options include release, transfers, and humeral osteotomy, all ultimately striving for better function through increased external rotation. Prior studies have shown that neonatal brachial plexus palsy alters humeral retroversion but with conflicting findings. We studied retroversion in children with internal rotation contractures from neonatal brachial plexus palsy to clarify its effect on version and surgical planning.

METHODS

Bilateral shoulder and elbow magnetic resonance imaging scans of 21 children with neonatal brachial plexus palsy were retrospectively analyzed. Retroversion referenced to the transepicondylar line at the elbow was measured with respect to 2 different proximal reference axes, the longest diameter of an axial cut of the proximal part of the humerus (the skew axis) and the line perpendicular to the articular surface (the humeral center line). Glenoid version and glenohumeral morphology type (concentric glenoid, posterior-concentric glenoid, biconcave, or pseudoglenoid) were also determined. All geometric variables were assessed for correlation with patient age and the severity of the internal rotation contracture.

RESULTS

Retroversion on the involved side was decreased at 6° compared with 19° (p = 0.003), as measured between the skew axis and transepicondylar line. Retroversion referenced to the humeral center line was also decreased at -2° (anteversion) compared with 20° (p < 0.001). Patient age was inversely correlated with retroversion, but was only significant for the skew axis (r = -0.497, p = 0.022), decreasing in linear regression by 2.4° per year (p = 0.038). Humeral retroversion did not correlate with the severity of the internal rotation contracture, glenoid version, or glenoid morphology type.

CONCLUSIONS

Humeral retroversion is likely to be less on the affected side in children with internal rotation contractures from upper trunk neonatal brachial plexus palsy and merits consideration in surgical planning.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Clinicopathologic Significance of Mismatch Repair Defects in Endometrial Cancer: An NRG Oncology/Gynecologic Oncology Group Study

PURPOSE

The clinicopathologic significance of mismatch repair (MMR) defects in endometrioid endometrial cancer (EEC) has not been definitively established. We undertook tumor typing to classify MMR defects to determine if MMR status is prognostic or predictive.

METHODS

Primary EECs from NRG/GOG0210 patients were assessed for microsatellite instability (MSI), MLH1 methylation, and MMR protein expression. Each tumor was assigned to one of four MMR classes: normal, epigenetic defect, probable mutation (MMR defect not attributable to MLH1 methylation), or MSI-low. The relationships between MMR classes and clinicopathologic variables were assessed using contingency table tests and Cox proportional hazard models.

RESULTS

A total of 1,024 tumors were assigned to MMR classes. Epigenetic and probable mutations in MMR were significantly associated with higher grade and more frequent lymphovascular space invasion. Epigenetic defects were more common in patients with higher International Federation of Gynecology and Obstetrics stage. Overall, there were no differences in outcomes. Progression-free survival was, however, worse for women whose tumors had epigenetic MMR defects compared with the MMR normal group (hazard ratio, 1.37; P < .05; 95% CI, 1.00 to 1.86). An exploratory analysis of interaction between MMR status and adjuvant therapy showed a trend toward improved progression-free survival for probable MMR mutation cases.

CONCLUSION

MMR defects in EECs are associated with a number of well-established poor prognostic indicators. Women with tumors that had MMR defects were likely to have higher-grade cancers and more frequent lymphovascular space invasion. Surprisingly, outcomes in these patients were similar to patients with MMR normal tumors, suggesting that MMR defects may counteract the effects of negative prognostic factors. Altered immune surveillance of MMR-deficient tumors, and other host/tumor interactions, is likely to determine outcomes for patients with MMR-deficient tumors.

Vita-Assay™ Method of Enrichment and Identification of Circulating Cancer Cells/Circulating Tumor Cells (CTCs)

The ability to capture, enrich, and propagate circulating cancer cells/circulating tumor cells (CTCs) for downstream analyses such as ex vivo drug-sensitivity testing of short-term cultures of CTCs, single cell sorting of CTCs by fluorescence activated cell sorting (FACS), animal injection tumor and/or metastasis formation studies, next generation sequencing (NGS), gene expression profiling, gene copy number determination, and epigenomic analyses is of high priority and of immense importance to both the basic research and translational/clinical research communities. Vitatex Inc.'s functional cell separation technology, constructed as Vita-Assay™ (AG6W, AN6W, AR6W) culture plates, is based on the preferential adhesion of invasive rare blood cells of tissue origin to a tissue or tumor microenvironment mimic-the so-called cell adhesion matrix (CAM), which has a demonstrated ability to enrich viable CTCs from blood up to one-million fold.The CAM-scaffold allows for the functional capture and identification of invasive CTCs (iCTCs) including invasive tumor progenitor (TP) cells from cancer-patients' blood. CAM-captured CTCs are capable of ingesting the CAM (CAM+) itself. Green and red fluorescent versions of Vita-Assay™ (AG6W and AR6W) allow for direct visualization of CAM-uptake by cancer cells. Vita-Assay™ CAM-enrichment has allowed for sensitive multiplex flow cytometric and microscopic detection of iCTCs from patients with cancers of the breast, ovary, prostate, pancreas, colorectum, and lung; it has also been successfully utilized for ex vivo drug-sensitivity testing of ovarian-cancer patient CTCs. The CAM enrichment method is equally suitable for the separation of iCTCs and TP cells in ascites and pleural fluid.

Combined Microsatellite Instability, MLH1 Methylation Analysis, and Immunohistochemistry for Lynch Syndrome Screening in Endometrial Cancers From GOG210: An NRG Oncology and Gynecologic Oncology Group Study

PURPOSE

The best screening practice for Lynch syndrome (LS) in endometrial cancer (EC) remains unknown. We sought to determine whether tumor microsatellite instability (MSI) typing along with immunohistochemistry (IHC) and MLH1 methylation analysis can help identify women with LS.

PATIENTS AND METHODS

ECs from GOG210 patients were assessed for MSI, MLH1 methylation, and mismatch repair (MMR) protein expression. Each tumor was classified as having normal MMR, defective MMR associated with MLH1 methylation, or probable MMR mutation (ie, defective MMR but no methylation). Cancer family history and demographic and clinical features were compared for the three groups. Lynch mutation testing was performed for a subset of women.

RESULTS

Analysis of 1,002 ECs suggested possible MMR mutation in 11.8% of tumors. The number of patients with a family history suggestive of LS was highest among women whose tumors were classified as probable MMR mutation (P = .001). Lynch mutations were identified in 41% of patient cases classified as probable mutation (21 of 51 tested). One of the MSH6 Lynch mutations was identified in a patient whose tumor had intact MSH6 expression. Age at diagnosis was younger for mutation carriers than noncarriers (54.3 v 62.3 years; P < .01), with five carriers diagnosed at age > 60 years.

CONCLUSION

Combined MSI, methylation, and IHC analysis may prove useful in Lynch screening in EC. Twenty-four percent of mutation carriers presented with ECs at age > 60 years, and one carrier had an MSI-positive tumor with no IHC defect. Restricting Lynch testing to women diagnosed at age < 60 years or to women with IHC defects could result in missing a substantial fraction of genetic disease.

Abstract LB-180: Prognostic analysis of invasive circulating tumor cells (iCTCs) to monitor epithelial ovarian cancer

Purpose:

Cancer antigen 125 (CA125) is recognized as the leading biomarker in monitoring Epithelial Ovarian Cancer (EOC). More recently, invasive circulating tumor cells (iCTCs) have been introduced as a biomarker for metastatic potential. The goal of this research is to compare this biomarker with CA125 to determine the response to surgery and chemotherapy.

Experimental Design:

We compared clinical parameters with serial assays for iCTCs and CA125 in 129 fresh blood and 169 serum samples, respectively, from 31 patients who were receiving surgery and chemotherapy. iCTCs were capable of ingesting matrices (Cell Adhesion Matrix CAM+) and identified using positive tumor markers, Epi (EPCAM and CA125 or seprase and CD44), and negative selection markers, which exclude Epi-positive hematopoietic lineage (HL) cells, and enumerated by flow cytometry. iCTCs and CA125 levels were measured at time point less than 3-days apart.

Results:

A significant correlation was identified between changes in iCTC counts and CA125 levels (r=0.67, P&lt;0.001) in the 83 samples collected prior to and after surgery and therapy. CA125 levels, but not iCTCs, were significantly reduced after surgery. During therapy, a significantly stronger concordance with clinical status was noted for decreasing values (specificity, 93.8% CA128; 90.6% iCTCs) compared with increasing values (sensitivity, 61.3% CA125; 83.9% iCTCs). Notably, increases in iCTCs, not CA125, were associated with increased risks for progressive disease (P&lt;0.001). In the 8 patients who had &gt;4 serial samples during therapy, changes in iCTC counts provided earlier measure of therapy response than CA125.

Conclusion:

This analysis showed that iCTC assay compared favorably with CA125 to monitor the response of chemotherapy in EOC patients, whereas changes of CA125 correlated better with reduced tumor burden after surgery.

Citation Format: Wen-Tien Chen, Huan Dong, Qiang Zhao, Jie Yang, QIAO ZHANG, Stanley Zucker, Michael L. Pearl. Prognostic analysis of invasive circulating tumor cells (iCTCs) to monitor epithelial ovarian cancer. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr LB-180. doi:10.1158/1538-7445.AM2014-LB-180

Extraesophageal Reflux in Patients Undergoing General Endotracheal Tube Anesthesia

Objectives:

Explore hypopharyngeal exposure to abnormally high or low pH during surgery performed under general endotracheal tube anesthesia and to compare results to published normative 24-hour data.

Methods:

Twenty volunteers for this prospective cohort study were recruited from June through September 2013. A wireless Dx-pH monitoring system was used during surgery. A drop from baseline to pH <5.5 was defined as a hypopharyngeal event, with thresholds pH 4.0, 4.5, and 5.0 also examined. Results were compared with supine events published by Chheda et al in 2009.

Results:

The number and duration of hypopharyngeal events <15 minutes with pH below 4.0, 4.5, 5.0 and percentage of surgery time in hypopharyngeal events (from a pH = 5.5 to return to baseline) were similar to comparative data. However, including all duration events (> ≤ 15 minutes), the number and duration of events at all thresholds and the percentage of surgery time in hypopharyngeal events were consistently higher than comparative data. Most analyses with the potential predictive/confounding variables (ie, body mass index, Reflux Symptom Index, Voice Handicap Index-10) yielded nonsignificant results.

Conclusions:

Extended pharyngeal exposure to moderately reduced pH levels (greater than sleeping or resting in a supine position) were documented. Approximately 20% of surgical patients may experience extensive exposure to pH <5.5 (over 1 hour, >30% of surgery time) and an additional 20% may experience moderate exposure to pH <5.5 (5-20 minutes and/or 4% to 10% of surgery time). Additional studies are needed to predict which patients might be at elevated risk for this exposure as well as the impact of this exposure on clinical outcomes.

Assessing shoulder motion in children: age limitations to Mallet and ABC Loops

BACKGROUND

Shoulder ROM and function of the shoulder are difficult to evaluate in young children. There has been no determination of the age at which children can comply with the current assessment tools in use, but doing so would be important, because it gives us more accurate insight into the development and assessment of shoulder functional ROM in young children.

QUESTIONS/PURPOSES

We (1) determined whether age would limit the use of two different observational scales used to assess shoulder ROM and function in young children (the Mallet scale and the ABC Loops protocol); and (2) compared the two scales in terms of intra- and interobserver reliabilities.

METHODS

Sixty-five able-bodied children (32 boys, 33 girls; mean age, 3.9 years; range, 0.5-7.0 years) were recruited from local preschools and evaluated using the Mallet scale and ABC Loops protocol. Children were assessed on their ability to complete the examinations and time to completion for each measurement protocol. Intra- and interobserver reliability was tested by percentage agreement. Forty-eight children (mean age, 4.4 years; SD, 1.3 years) were able to complete the Mallet and ABC Loops measurement protocols; 17 children (mean age, 2.3 years; SD, 1.1 years) failed to complete either test.

RESULTS

Younger children had more difficulty completing the examinations; there was a strong negative correlation between age and failure: probability of failure increased with decreasing age (Pearson r = -0.601, p < 0.001). Children who were able to complete one test were able to complete the other. Interobserver and intraobserver agreement was very high for both scales (in excess of 95% for all comparisons), and with the numbers available, there were no differences between the scales.

CONCLUSIONS

The Mallet scale and ABC Loops protocol have high reliability metrics in children younger than 6 years, but very young children (those younger than 3 years) generally will not be able to complete the examinations. The ABC Loops test took longer to perform than the Mallet scale but may more comprehensively evaluate a child's functional capabilities. We therefore state that both assessment tools can be reliably used in children older than 3 years; we believe the ABC Loops gives a more accurate assessment of shoulder ROM.

Geometry of the proximal humeral articular surface in young children: a study to define normal and analyze the dysplasia due to brachial plexus birth palsy

BACKGROUND

Little is known regarding the morphology of the proximal humerus in growing children. This study reports bilateral magnetic resonance imaging measurements in children with internal rotation contractures from birth palsy, hypothesizing that dysplasia alters normal humeral sphericity and symmetry.

METHODS

We studied 25 children with unilateral internal rotation contractures (mean age, 3.7 years) for humeral shape by bilateral magnetic resonance imaging studies at the mid-glenoid level. Local radii of curvature were compared for symmetry and orientation.

RESULTS

Neither side showed uniform radii (sphericity), but normal humeri showed symmetry lost in dysplasia. Internal rotation contractures were correlated with flattening of the anterior humeral head (P = .0002). All heads were flatter in the region of articular contact. The skew axis (the largest cross-sectional diameter of the proximal humerus) was collinear with the articular surface centerline in normal humeri, an alignment often lost with dysplasia, resulting in a skew axis angle. The severity of glenoid deformity correlated with progressive posterior displacement of the humeral head center (P < .0003).

CONCLUSION

The normal humeral articular surface in the young child is not spherical and is flatter in the middle than at the periphery but is symmetric about its central axis. Internal rotation contractures result in loss of this symmetry with characteristic flattening of the anterior humeral head and development of a skew axis angle.

CLINICAL RELEVANCE

Posterior displacement of the humeral head center of rotation beyond 50% of the calculated head radius warrants vigilance and possibly surgical intervention because there is a high likelihood for development of a pseudoglenoid.

Abstract LB-73: Circulating tumor cells with the invasive phenotype predict progression free survival and overall survival in preoperative patients diagnosed with advanced epithelial ovarian cancer

Purpose: Circulating tumor cells (CTCs) might function as prognostic markers for monitoring and assessing therapy efficacy ex vivo. This study aimed to measure overall population of CTCs based on expression of epithelial lineage (Epi) markers and the subpopulation of CTCs with the invasive phenotype (iCTCs) in preoperative patients for prognosis of advanced Epithelial Ovarian Cancer (EOC).

Experimental Design: CTCs and iCTCs enriched by the Cell Adhesion Matrix (CAM)-coated devices from 122 preoperative patients were identified as Epi+ nucleic acid (NA)+ hematopoietic lineage (HL)- cells and CAM uptake (CAM+) Epi+ NA+ HL- cells, respectively. CTCs and iCTCs were enumerated using multiplex flow cytometry, validated by microscopy, and correlated with overall survival (OS) and progression-free survival (PFS).

Results: iCTCs were detected in 0/39 (0%) benign patients, 5/11 (45.5%) Stage I, 2/4 (50%) Stage II, 41/43 (95.3%) Stage III and 16/16 (100%) stage IV patients (P-value &lt;0.001). However, healthy (n=48) and benign women had noticeable CTCs (mean=10 and 3 CTCs/1.0-mL blood, respectively), and large variation (IQR=24.5 and 30 CTCs/1.0-mL blood, respectively), although CTCs were significantly different across different stage groups. Kaplan-Meier estimates of OS at 5 years in the iCTC positive and negative groups were 15.4% (95% CI, 7.2% to 26.3%) and 94% (95% CI, 82.5% to 98%), respectively. The PFS in the iCTC positive group was also significantly lower than that in the negative group (P-value &lt;0.001). In multivariable Cox models, iCTCs were independently predictive of OS (P-value &lt;0.001) and provided predictive power for disease recurrence independent of diagnostic disease stages, age, debulking status and platinum sensitivity.

Conclusion: CTCs show the expression of heterogeneous epithelial antigens with potential biologic relevance. Co-expression of epithelial antigens and invasiveness of iCTCs in preoperative patients provides prognosis of advanced EOC that could help tailor appropriate therapy.

Citation Format: Wen-Tien Chen, Qiang Zhao, Huan Dong, Jie Yang, Qiao Zhang, Tina Fan, Marc G. Golightly, Whitney C. Dessio, Stefan Madajewicz, Melissa Henretta, Michael L. Pearl. Circulating tumor cells with the invasive phenotype predict progression free survival and overall survival in preoperative patients diagnosed with advanced epithelial ovarian cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr LB-73. doi:10.1158/1538-7445.AM2013-LB-73

Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study

PURPOSE

The primary objective was to establish noninferiority of laparoscopy compared with laparotomy for recurrence after surgical staging of uterine cancer.

PATIENTS AND METHODS

Patients with clinical stages I to IIA disease were randomly allocated (two to one) to laparoscopy (n = 1,696) versus laparotomy (n = 920) for hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. The primary study end point was noninferiority of recurrence-free interval defined as no more than a 40% increase in the risk of recurrence with laparoscopy compared with laparotomy.

RESULTS

With a median follow-up time of 59 months for 2,181 patients still alive, there were 309 recurrences (210 laparoscopy; 99 laparotomy) and 350 deaths (229 laparoscopy; 121 laparotomy). The estimated hazard ratio for laparoscopy relative to laparotomy was 1.14 (90% lower bound, 0.92; 95% upper bound, 1.46), falling short of the protocol-specified definition of noninferiority. However, the actual recurrence rates were substantially lower than anticipated, resulting in an estimated 3-year recurrence rate of 11.4% with laparoscopy and 10.2% with laparotomy, or a difference of 1.14% (90% lower bound, -1.28; 95% upper bound, 4.0). The estimated 5-year overall survival was almost identical in both arms at 89.8%.

CONCLUSION

This study previously reported that laparoscopic surgical management of uterine cancer is superior for short-term safety and length-of-stay end points. The potential for increased risk of cancer recurrence with laparoscopy versus laparotomy was quantified and found to be small, providing accurate information for decision making for women with uterine cancer.

Randomized phase III trial of tamoxifen versus thalidomide in women with biochemical-recurrent-only epithelial ovarian, fallopian tube or primary peritoneal carcinoma after a complete response to first-line platinum/taxane chemotherapy with an evaluation of serum vascular endothelial growth factor (VEGF): A Gynecologic Oncology Group Study

PURPOSE

To compare progression-free survival (PFS), overall survival (OS) and toxicities of thalidomide versus tamoxifen and to evaluate serum vascular endothelial growth factor (VEGF) in biochemical-recurrent epithelial ovarian cancer, primary peritoneal cancer or fallopian tube carcinoma (EOC/PPC/FTC).

METHODS

Biochemical recurrence was defined as a rising CA-125 exceeding twice the upper limit of normal without evidence of disease as defined by RECIST 1.0 criteria. Women with FIGO stages III and IV, histologically confirmed EOC/PPC/FTC who were free of disease following first-line chemotherapy were randomized to oral thalidomide 200mg daily with escalation to a maximum of 400 mg or tamoxifen 20mg orally twice daily for up to 1 year, progression or adverse effect prohibited further treatment. VEGF was quantified by ELISA in pre and post-treatment serum.

RESULTS

Of the 139 women randomized, 138 were eligible. Interim analysis showed that thalidomide did not reduce the recurrence rate relative to tamoxifen, and the trial was closed. Thalidomide versus tamoxifen was associated with a similar risk of progression (HR = 1.31, 95% confidence interval [CI] = 0.93-1.85), an increased risk of death (HR = 1.76, 95% CI = 1.16-2.68) and more grades 3 and 4 toxicities (55% versus 3%). The most common grades 3 and 4 toxicities were constitutional (12%), somnolence (12%), pulmonary (9%), venous thromboembolism (VTE) (6%) and peripheral neurologic (6%) for thalidomide, with VTE (1.4%) and gastrointestinal (1.4%) for tamoxifen. Serum VEGF was not associated with clinical characteristics, treatment, PFS or OS.

CONCLUSION

Thalidomide was not more effective than tamoxifen in delaying recurrence or death but was more toxic. VEGF was not prognostic in this cohort.

Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2

PURPOSE

The objective was to compare laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer.

PATIENTS AND METHODS

Patients with clinical stage I to IIA uterine cancer were randomly assigned to laparoscopy (n = 1,696) or open laparotomy (n = 920), including hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. The main study end points were 6-week morbidity and mortality, hospital length of stay, conversion from laparoscopy to laparotomy, recurrence-free survival, site of recurrence, and patient-reported quality-of-life outcomes.

RESULTS

Laparoscopy was initiated in 1,682 patients and completed without conversion in 1,248 patients (74.2%). Conversion from laparoscopy to laparotomy was secondary to poor visibility in 246 patients (14.6%), metastatic cancer in 69 patients (4.1%), bleeding in 49 patients (2.9%), and other cause in 70 patients (4.2%). Laparoscopy had fewer moderate to severe postoperative adverse events than laparotomy (14% v 21%, respectively; P < .0001) but similar rates of intraoperative complications, despite having a significantly longer operative time (median, 204 v 130 minutes, respectively; P < .001). Hospitalization of more than 2 days was significantly lower in laparoscopy versus laparotomy patients (52% v 94%, respectively; P < .0001). Pelvic and para-aortic nodes were not removed in 8% of laparoscopy patients and 4% of laparotomy patients (P < .0001). No difference in overall detection of advanced stage (stage IIIA, IIIC, or IVB) was seen (17% of laparoscopy patients v 17% of laparotomy patients; P = .841).

CONCLUSION

Laparoscopic surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay. Follow-up of these patients will determine whether surgical technique impacts pattern of recurrence or disease-free survival.

Phase II evaluation of pemetrexed in the treatment of recurrent or persistent platinum-resistant ovarian or primary peritoneal carcinoma: a study of the Gynecologic Oncology Group

PURPOSE

To estimate the antitumor activity of pemetrexed in patients with persistent or recurrent platinum-resistant epithelial ovarian or primary peritoneal cancer and to determine the nature and degree of toxicities.

PATIENTS AND METHODS

A phase II trial was conducted by the Gynecologic Oncology Group. Patients must have had cancer that had progressed on platinum-based primary chemotherapy or recurred within 6 months. Pemetrexed at a dose of 900 mg/m(2) was to be administered as an intravenous infusion over 10 minutes every 21 days. Dose delay and adjustment was permitted for toxicity. Treatment was continued until disease progression or unacceptable adverse effects.

RESULTS

From July 6, 2004, to August 23, 2006, 51 patients were entered. A total of 259 cycles (median, four; range one to 19 cycles) of pemetrexed were administered, with 40% of patients receiving six or more cycles. Overall, the treatment was well tolerated. More serious toxicities (grade 3 and 4) included neutropenia in 42%, leukopenia in 25%, anemia in 15%, and constitutional in 15% of patients. No treatment-related deaths were reported. One patient (2%) had a complete and nine patients (19%) had partial responses, with a median duration response of 8.4 months. Seventeen patients (35%) had stable disease for a median of 4.1 months. Eighteen patients (38%) had increasing disease. Three patients (6%) were not assessable. Median progression-free survival was 2.9 months, and overall survival was 11.4 months.

CONCLUSION

Pemetrexed has sufficient activity in the treatment of recurrent platinum-resistant ovarian cancer at the dose and schedule tested to warrant further investigation.

Clinical significance of circulating tumor cells detected by an invasion assay in peripheral blood of patients with ovarian cancer

OBJECTIVES

The invasive growth of circulating tumor cells (CTCs) propagates cancer metastasis. The aims of this study were to evaluate the association of invasive CTCs, detected by a novel cell invasion assay, with disease stage, CA-125 level and patient survival.

METHODS

Peripheral blood samples from 71 patients undergoing evaluation for ovarian malignancy were assessed for the presence of invasive CTCs using a cell invasion assay that enriches and identifies tumor cells with a cell adhesion matrix (CAM). Invasive CTCs were identified as cells exhibiting CAM invasion (CAM+) and expressing standard epithelial markers (Epi+).

RESULTS

43 (60.6%) patients had detectable CTCs: 0/5 benign patients, 1/10 (10%) early stage, 39/52 (73.1%) late stage and 3/4 (75%) unstaged patients (p-value <0.001). CTC counts ranged from 0-149 CTCs/ml with stage III/IV patients exhibiting significantly higher mean counts (41.3 CTCs/ml) than stage I/II patients (6.0 CTCs/ml) and benign patients (0 CTCs/ml, p-value=0.001). A positive correlation between CTC count and CA-125 level was observed (Spearman correlation coefficient r=0.309, p-value=0.035). Kaplan-Meier curves revealed a significant decrease in disease-free survival in patients with detectable CTCs (median survival 15.0 months vs. 35.0 months, log-rank p-value=0.042). Tumor grade and tumor histology did not influence CTC detection.

CONCLUSIONS

Invasive CTCs can be detected in a majority of epithelial ovarian cancer patients and may predict shorter disease-free survival. Furthermore, higher CTC counts may reflect later stage disease and higher CA-125 levels.

Phase II multicenter open-label study of karenitecin in previously treated epithelial ovarian and primary peritoneal cancer: a Gynecologic Oncology Group Study

The topoisomerase I agents are established as a therapy in recurrent ovarian cancer. Karenitecin, an analog of topotecan with solubility and pharmacologic advantages, was tested in a phase II trial in previously treated patients with recurrent or persistent ovarian cancer. The drug was administered intravenously over 1 h at a dose of 1.0 mg/m(2) daily for 5 days every 21 days. Patients were treated until disease progression, intolerable toxicity, or voluntary withdrawal. Response was evaluated according to modified RECIST criteria. Twenty-seven patients were entered into the study. One patient was inevaluable for not receiving any treatment. Of the 26 evaluable patients, there were two partial responses and one complete response for a total response rate of 12%. This response rate was insufficient to justify accrual to the second stage. The most common grade 3 or 4 toxicities were neutropenia (19%) and gastrointestinal (15%). Karenitecin is a well-tolerated topoisomerase compound but has minimal activity in extensively pretreated ovarian cancer with the dose-schedule employed.

A Phase II Study of Weekly Docetaxel for Patients with Advanced or Recurrent Cancer of the Cervix

BACKGROUND/AIMS

A phase II study was conducted to assess the activity and toxicity of weekly docetaxel in patients with advanced or recurrent cancer of the cervix.

METHODS

Eligible patients were required to have measurable disease with adequate performance status, bone marrow, renal and hepatic function. Patients were allowed to receive chemosensitization and not more than one prior chemotherapy regimen excluding taxanes. Docetaxel 35 mg/m2 was administered intravenously weekly for 3 weeks followed by 1 week off until disease progression or adverse effects prohibited further therapy.

RESULTS

Ten patients were entered into this study, all of who were evaluable for toxicity and response. A median of 2 cycles (range 2-6) were administered. The most frequent drug-related toxicities were anemia and fatigue. There were no objective responses. Three patients had stable disease up to 6 cycles. One patient died of exsanguination from a known vaginal metastasis after completing her second cycle. The median progression-free interval was 1.7 months (range 0.9-5.8) and overall survival was 6.9 months (1.6-23.7).

CONCLUSIONS

Docetaxel has limited activity in patients with recurrent cancer of the cervix at the dose and schedule tested.

Pilot Phase 2 Trial of 4 Months of Maintenance Pegylated Liposomal Doxorubicin in Patients with Advanced Ovarian Cancer after Complete Response to Platinum and Paclitaxel-Based Chemotherapy

BACKGROUND/AIMS

Stages III and IV ovarian and peritoneal cancer patients are commonly treated with combination chemotherapy after surgical debulking. This phase II trial investigated the use of pegylated liposomal doxorubicin as consolidation chemotherapy for these patients.

METHODS

Women with stage III or IV ovarian or primary peritoneal carcinoma demonstrating no clinical evidence of disease after primary therapy were eligible for enrollment. Patients received 4 cycles of 40 mg/m(2) IV of pegylated liposomal doxorubicin every 28 days.

RESULTS

Twelve patients were enrolled. There were 6 stage IIIC and 6 stage IV patients. Ten patients received 4 cycles. Two patients had dose limiting skin toxicity manifest as hand-foot syndrome and received only 3 cycles. Forty-six of a planned 48 cycles were administered. Median disease-free survival from registration is 10 months with a mean of 18 months. Median overall survival has not yet been reached. Four patients are disease-free, two have relapsed and six have died from disease progression.

CONCLUSION

Pegylated liposomal doxorubicin is a well-tolerated choice for consolidation chemotherapy in patients with ovarian or primary peritoneal carcinoma.

Arthroscopic release and latissimus dorsi transfer for shoulder internal rotation contractures and glenohumeral deformity secondary to brachial plexus birth palsy

BACKGROUND

Internal rotation contractures due to external rotation weakness secondary to brachial plexus birth palsy frequently lead to glenohumeral deformity and impaired shoulder function. Our surgical approach to treat these contractures relies on arthroscopic release for young children (less than three years old) and combines arthroscopic release with latissimus dorsi transfer for older children. We report the results for the first thirty-three children followed for a minimum of two years after such treatment.

METHODS

Nineteen children with a mean age of 1.5 years (all younger than three years of age) underwent arthroscopic contracture release as the only primary procedure, and fourteen children with a mean age of 6.7 were also treated with a latissimus dorsi transfer. Passive external rotation with the arm at the side and passive and active elevation were measured for all patients preoperatively. Passive and active external rotation, internal rotation, and elevation were measured for all patients postoperatively. Magnetic resonance imaging was performed preoperatively and postoperatively to evaluate the status of the glenohumeral joint.

RESULTS

Preoperative passive external rotation averaged -2 degrees for the children who underwent arthroscopic contracture release only and -24 degrees for those who also were treated with a latissimus dorsi transfer. Arthroscopic release achieved a marked increase in passive external rotation and a centered position of the glenohumeral joint at the time of surgery in all but the oldest child in the series, who had severe deformity. The contracture recurred in four of the younger children who had an isolated release, and this was treated with a repeat arthroscopic release and a secondary latissimus dorsi transfer. None of the children who had a primary latissimus dorsi transfer had recurrence of the contracture. At the time of follow-up, the mean passive external rotation was increased by 67 degrees (p < 0.005) in the fifteen children with a successful arthroscopic release, 81 degrees (p < 0.005) in those treated with a primary latissimus dorsi transfer, and 78 degrees in the four patients who were treated with a late latissimus dorsi transfer because the isolated arthroscopic release failed. The mean active elevation increased 12 degrees , 3 degrees , and 10 degrees , respectively, in the three groups. Internal rotation was not measured consistently preoperatively, but when it had been it was found to have decreased substantially postoperatively. Magnetic resonance imaging performed prior to the surgery showed a pseudoglenoid deformity in eighteen of the children. At two years, magnetic resonance images were available for fifteen of those children, and twelve of the images showed marked remodeling of the deformity.

CONCLUSIONS

In children who are younger than three years of age, arthroscopic release effectively restores nearly normal passive external rotation and a centered glenohumeral joint at the time of surgery. In most of these children, external rotation strength is sufficient to maintain this range of motion and to improve glenoid development when preoperative deformity was present. The addition of a latissimus dorsi transfer in older children predictably results in similar improvements. Gains in active elevation are minimal. All children have a loss of internal rotation, which is moderate in most of them but is severe in some.

Proximal humeral anatomy in shoulder arthroplasty: Implications for prosthetic design and surgical technique

Resurfacing arthroplasty of the glenohumeral joint has been established for several decades as a means to restore comfort and function of the shoulder for many afflictions that derange the normal anatomy. Rigorous study of shoulder anatomy in terms relevant to prosthetic geometry, however, did not begin until the 1990s. It has become apparent that normal anatomy is highly variable from individual to individual and that it is aligned somewhat differently than the early modular prosthetic devices. Multiple studies have shown that retroversion is markedly variable, not only between individuals but also between the left and right sides of the same individual, ranging from 0 degrees to 55 degrees . The inclination of the proximal humeral articular surface relative to the shaft (head shaft angle) is also variable, ranging from 30 degrees to 55 degrees. The center of rotation is variably offset in 3 dimensions. The radius of curvature ranges from 20 to 30 mm and is smaller in women than in men. The thickness of the articular surface, head height, is equally variable but shows a striking proportionality to the radius of curvature. The last decade has seen a proliferation of humeral implants aiming to serve a better understanding of shoulder anatomy and function. A modern understanding of shoulder anatomy and contemporary design features is paramount for surgeons performing shoulder arthroplasty. Head size selection is dependent on multiple factors, the most important of these, other than the patient's original head size, are the osteotomy performed by the surgeon and the inclination angle(s) of the prosthetic system. Systems with variable inclination angles instruct the surgeon to resect the humeral head along the anatomic neck as best possible and then provide either adjustable or variable prosthetic geometries to match the resultant inclination angle. Other prosthetic systems have a fixed inclination angle somewhere within the normal range and instruct the surgeon to make an osteotomy at this inclination, adjusting the fit with additional preparation of the canal and revising the osteotomy as necessary. Over the last decade, most systems have offered heads that are offset by 3 to 4 mm, allowing the surgeon to dial in the most suitable position for the head on the stem. Component design and surgical technique are inextricably intertwined. Most surgeons with experience using modern systems feel a greater sense of predictability in achieving their surgical goals when using these systems as compared with earlier ones. How these developments impact implant longevity will only be known with time and further follow-up.

Evaluation of vinorelbine in persistent or recurrent nonsquamous carcinoma of the cervix: a Gynecologic Oncology Group Study

OBJECTIVE

The Gynecologic Oncology Group (GOG) has studied a number of drugs to determine their activity in patients with previously treated squamous and nonsquamous cancer arising in the uterine cervix. A Phase II study with intravenous vinorelbine was initiated for this purpose in patients with Stage IVB, recurrent, or persistent nonsquamous carcinomas who had received one prior chemotherapy or were not eligible for other studies.

METHODS

Eligible patients had to have measurable disease, GOG performance status of 0-2 and adequate bone marrow, liver, and renal function. The treatment consisted of vinorelbine 30 mg/m(2) on days 1 and 8, repeated every 21 days. Tumor measurements and toxicities were recorded every treatment cycle.

RESULTS

Thirty patients were enrolled with 28 patients deemed eligible and evaluable. Only two confirmed partial responses (7.1%) were noted. Neutropenia was the most common toxicity with 9 of 28 (32%) experiencing either grade 3 or 4 changes. Anemia was severe in seven. Neuropathy was more than mild in three patients. Severe events, such as fatigue, hypertension, or pulmonary changes attributed to drug administration, occurred only in one or two instances.

CONCLUSION

With the dose schedule and assessment criteria employed, vinorelbine had only minimal activity in nonsquamous cancer of the cervix.

Decision making in contemporary shoulder arthroplasty

Clinical experience with humeral implants has evolved over the past decade, along with a better understanding of shoulder anatomy and function. There is no question that surgeons are getting better at restoring normal anatomic relationships than in preceding decades. Whether or not this impacts implant longevity will only be known with time and further follow-up. Even over the short term, it is difficult to ascertain whether new prosthetic designs have improved patient function as well as has been implied by the related biomechanical studies. Most surgeons with experience using old and new systems realize a greater sense of predictability in achieving their surgical goals when using more modern implants. Concerns over the durability of prosthetic systems with multiple moving parts and hand-tightened locking mechanisms have almost been forgotten in shoulder arthroplasty, but time will also reveal their importance. New glenoid designs have been less exciting, the major problem being one of developing appropriate materials. Polyethylene does not behave like normal cartilage, and its wear is constant and unforgiving. Surgeons now better understand how to reconstruct the normal glenoid position and achieve more secure early fixation than in the past, but this does not promise long-term durability and freedom from complications.

Evaluation of irofulven (MGI-114) in the treatment of recurrent or persistent endometrial carcinoma: A phase II study of the Gynecologic Oncology Group

OBJECTIVE

This multi-center phase II trial was conducted by the Gynecologic Oncology Group to evaluate the activity and toxicity of irofulven in patients with previously treated adenocarcinoma of the endometrium.

METHODS

Eligible patients had documented recurrent or persistent endometrial carcinoma after receiving definitive locoregional therapy, and were required to have measurable disease, performance status of 0-2, and adequate bone marrow, hepatic and renal functions prior to study entry. Patients were allowed one prior chemotherapy regimen. The initial dose of irofulven was 11 mg/m(2)/day for four days administered intravenously. Cycles were repeated every 28 days. Doses were escalated or reduced based on previous cycle toxicity.

RESULTS

Twenty-five patients were enrolled onto the trial. There was one (4%) confirmed complete response. Seven (28%) patients had stable disease, with a median duration of 10.4 (range: 4.4-21.6) months. Patients received a median of one (range: 1-5) cycle of protocol treatment. There were three early treatment-related deaths due to renal failure and severe electrolyte disturbances. Two patients experienced grade 4 hematologic adverse effects.

CONCLUSION

Irofulven administered at the dose and schedule used in this trial was minimally active and resulted in significant toxicity.

Choosing abdominal incision and closure techniques: a review

This review summarizes contemporary concepts of abdominal surgical incision creation and closure. The Ovid computerized database was searched for articles published in English from 1996 to 2003 using keywords pertaining to the specific topic of interest (e.g., suture, drain, surgical technique, fascia). Human prospective, randomized trials; meta-analyses; and evidence-based-focused reviews were assessed and data abstracted. Several earlier and animal-based studies on specific issues were included. The data indicate that: (1) the direction of the incision should be based upon obtaining adequate exposure; (2) hair should either be left in place or clipped at the time of surgery; (3) a single dose of prophylactic antibiotics should be given 30 minutes prior to surgery; (4) using a "deep" scalpel is unnecessary; (5) a scalpel and electrocautery are comparable for deepening the incision; (6) minimal peritoneal lavage with non-antibiotic containing solutions is adequate; (7) the peritoneum should not be routinely closed; (8) the fascia should be loosely approximated by a continuous mass closure using a slowly absorbable, monofilament suture with the smallest possible caliber and a suture:wound length ratio of at least 4:1; (9) retention sutures, subcutaenous sutures and drains do not appear to reduce the risk of wound complications; and (10) the skin may be closed in a variety of methods, but a semiocclusive dressing should be applied. As scientific evidence accumulates to refute traditional dogma, management of the surgical patient has undergone substantial changes. Surgeons should now be able to create and close an abdominal wound based upon sound scientific principles rather than simply "doing what I always do."

Glenohumeral deformity in children with internal rotation contractures secondary to brachial plexus birth palsy: intraoperative arthrographic classification

PURPOSE

To evaluate, with intraoperative arthrography, joint morphology in children undergoing surgical treatment of residual paralysis of the shoulder resulting in brachial plexus birth palsy and to correlate the morphology with the degree of passive external rotation.

MATERIALS AND METHODS

In 64 children (age range, 7 months to 13 years 6 months), an orthopedic surgeon performed intraoperative arthrography and measured passive external rotation while the patient received a general anesthetic. The orthopedic surgeon and three radiologists reviewed arthrograms and in consensus classified glenohumeral joints in one of four categories: concentric, with the humeral head well centered on the glenoid fossa; flat, with flattening of the posterior glenoid; biconcave, with the humeral head in articulation with the posterior of two concavities, which were in the same plane; and pseudoglenoid, with the humeral head in articulation with the more posterior of two concavities, with retroversion and in a plane different from that of the anterior concavity. Kruskal-Wallis test was used to compare preoperative external rotation with four appearances of glenoid.

RESULTS

Twenty-one children had concentric glenohumeral joints; seven children, flat glenohumeral joints; 19 children, biconcave glenoid; and 17 children, pseudoglenoid. Median passive external rotation was -20 degrees for patients with pseudoglenoid, -10 degrees for those with flat or biconcave glenoids, and 0 degrees for those with concentric glenoids. Presence and type of glenoid deformity were significantly associated with severity of internal rotation contracture (P <.001).

CONCLUSION

Consistent patterns of glenohumeral joint deformity in brachial plexus birth palsy were identified and correlated with severity of internal rotation contracture.