Abstract PS2-05: Genetic profiling for circulating tumor cell clusters to unveil molecular drivers of metastasis

Introduction: Although CTCs display the same spatial and temporal heterogeneity as the primary tumor, they represent a privileged window to disclose mechanisms of metastases. A portion of CTCs may form clusters that contain two or more CTCs bound together which were reported to have up to 50-fold of potential of forming distant metastasis in MBC as compared to individual CTCs (Aceto N. Cell, 2015). However, genomic characterization of CTCs-clusters compared to single CTCs remain largely unknown. We previously reported single CTC sequencing for HER2+ CTCs (2020 AACR #3120). Herein, we report a new finding of heterogeneity profiling for CTC-clusters compared to single CTCs, which would be helpful to evaluate the MBC metastasis capability and treatment in clinic. Methods: Whole blood sample (7.5ml/each) was collected from stage III/IV MBC patients before therapy. CTC enumeration was performed using the FDA-cleared CellSearch™ System (Menarini) targeting the EpCAM antigen for capturing CTCs which were then stained by Anti-CK-PE, DAPI, anti-CD45-APC and anti-HER2-FITC. The CTC-clusters and single CTCs were isolated using DEPArrayTM System (Menarini). DNA was isolated from CTC-clusters and single CTCs by ArcturusTM PicoPureTM DNA Extraction kit. The initial library was prepared by SMARTer® PicoPLEX® Gold Single Cell DNA-Seq Kit, and the exome capture was performed by Twist Human Core Exome EF Multiplex Complete Kit. The sequencing was prepared by NextSeq 500 mid output V2.5 kit and was performed on the NextSeq 500 (Illumina). It was a paired end run, 75×75 bps run with dual indexing. Results: We identified 107 CTCs by CellSearch™, including 93 single CTCs, 14 CTC-clusters and 145 WBCs. Autologous CTC-clusters (CK+DAPI+CD45-, Group 1), single CTCs (CK+DAPI+CD45-, Group 2), and leukocytes (CK-DAPI+CD45+, Group 3) were sequenced respectively. The sequencing data was processed following the GATK pipeline and annotated using SnpEff. There were 60,638 counts (6.77%) and 70,334 counts (8.20%) for exon variants in CTC-clusters and single CTCs respectively, 507,595 counts (56.69%) and 486,119 counts (56.69%) for intron variants, 194,026 (21.67%) and 175,819 counts (20.51%) for intergenic variants, 54,174 counts (6.05%) and 50,370 counts (5.87%) for downstream genes, 51,716 counts (5.78%) and 45,915 counts (5.36%) for upstream genes, and 3.04% and 3.37% of others variants in CTC-clusters and single CTCs respectively. Meanwhile, there was 0 count for exon and intron variants found in Group 3. There were 60 and 79 gene variants (SNP and Ins-Del) identified to have the highest impact effect (≥20) on CTC-clusters and single CTC exons respectively, which affect significantly on the functional proteins coding. Among the top 50 high impact gene variants in each group, there were 25 gene alteration sites were similar in Group 1 and 2, including XYLB, RAN, QPCT, HPGDS, HDAC8, GABBR2, CYP11B2 and CHKA. Specific to Group 1, there were 25 gene alterations which were primarily related to cellular proliferation and tumor promotion (AMD1), liver drug clearance (CES1), tissue remodeling (CHI3L1), immune cytokine signaling (JAK1) and metabolism (ASRGL1). Meanwhile, there are 25 specific gene alterations in Group 2 compared to Group 1, which were associated with nucleotide-excision repair (DDB1 and FAN1) chromosome positioning (KIF11), cell growth, differentiation, mitotic cycle, oncogenic transformation (PTPN3 and MAPK14), apoptosis (CASP1) and cell growth (CTNNB1). Conclusion: Genomic characterization of CTC-clusters compared to autologous single CTCs and leukocytes elucidated new specific gene alterations in CTC-clusters associated with most aggressive disease metastasis in MBC, which will help to gain new insights on the molecular mechanisms associated with the metastasis and find new molecularly driven therapies for disease metastasis.

Citation Format: Qiang Zhang, Lorenzo Gerratana, Paolo D'Amico, Andrew A. Davis, Saya Liz Jacob, Xinkun Wang, Zhe Ji, Zheng Cai, Elena Vagia, Wenan Qiang, Ami Shah, Youbin Zhang, Lisa Flaum, Firas Wehbe, Amir Behdad, William Gradishar, Leonidas Platanias, Massimo Cristofanilli. Genetic profiling for circulating tumor cell clusters to unveil molecular drivers of metastasis [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-05.

Abstract PS2-06: The detection and enumeration of circulating tumor cells (CTCs) and circulating endothelial cells (CECs) in metastatic breast cancer

Introduction: Circulating tumor cells (CTCs) are the roots of metastasis which is the main cause for death in metastatic breast cancer (MBC). CTCs enumeration is strongly prognostic in advanced disease and can stratify patients in two distinct disease, Stage IV aggressive and Stage IV indolent. In the former disease, the detection of CTC clusters and HER2-expression increase prognostic and predictive value. The metastatic cascade is a complex, regulated process involving immune cells and endothelial cells for progression and neoangiogenesis. Circulating endothelial cells (CECs) from the inner wall of blood vessels are shed into the blood stream during formation of blood vessels which is considered a sensitive marker of endothelial damage in pathological conditions such as cancer. CECs have been also studied as a biomarker for tumor progression and monitoring anti-angiogenic therapeutic effects in MBC. We evaluated the concomitant detection of CTCs and CECs in MBC patients, along with expression of HER2 in CTCs that may offer an interesting clue to elucidate the metastasis mechanisms. Methods: Whole blood samples (7.5ml/each) were collected from 14 stage IV MBC patients before systemic therapy. CTCs enumeration was performed in FDA approved CELLTRACKS System (Menarini) by using CTC Kit contains specific antibodies targeting the EpCAM for capturing CTCs, anti-CK-PE (for epithelial cells), DAPI (for nucleus), anti-CD45-APC (for leukocytes), and anti-HER-2/neu-FLU. The CTCs were classified as CK+, EpCAM+, DAPI+ and CD45-. Meanwhile, the same patients’ blood samples (4.0ml/each) were processed for CEC analyzed by using CEC kit which immunomagnetically captures CD146+ cells, and then stains the cells for CD105-PE (specific for protein endolgin), CD45-APC, nucleus-DAPI. The positive CECs were classified as CD 146+, CD105+, DAPI+ and CD45-. The associations between CTCs, HER2 expression and CECs were evaluated. Results: The average age of patients was 53.1. Subtypes of Luminal, HER2 positive and TNBC were 64.2% 7.2% and 28.6% respectively. Distant metastasis were found in 13 out of 14 patients, including bone (7), liver (5), Lymph nodes (5) and Pleura (2). CTCs were found positive (≥5, Stage IV aggressive) in 5 patients (range: 5-47, mean=24), and HER expression was identified in all 5 of these cases with a range of numbers between 1 and 7 (mean=4.2). The ratios of HER+ CTC/total ratios were 8.51%, 17.95%, 20%, 30.77%, and 33.33%. HER2 expression were defined officially in our lab according to the percentile of positive HER2 CTCs/Total CTCs and the expression intensity as - (<20%), + (20-39%), ++ (40-59%) and +++ (≥60%) respectively. There were 9 patients (%) were identified as CTCs negative (<5, Stage IV indolent) with the mean=1, and HER+ CTCs were found in only 2 patients with Stage IV indolent. Meanwhile, CECs were found in all 14 patients with a range of numbers between 4 to 115. There were an average of 33 CECs in Stage IV aggressive disease, compared to 53 CECs in Stage IV indolent. The average of CECs were 53.44, 12 and 37.25 in Luminal, HER2 positive and TNBC groups respectively. On the other hand, patients with HER2+ CTCs had an average of 50 CECs which is significantly higher than average of 41 CECs in patients without HER2+ CTCs. Moreover, there were average of 94.5, 56 and 40.22 CECs were found in groups when HER2 expression was ++/+++, above + and - respectively. The results demonstrated that although CTC enumeration have a reverse correlation with CECs numbers, HER2 expression in CTCs was significantly related with high CECs numbers. Conclusions: Our data provides the first evidence of potential association between CTCs and CECs in metastatic breast cancer. The association between HER2 expression and CECs offers a potential new insight to mechanism connections between CECs and disease metastasis in MBC.

Citation Format: Qiang Zhang, Paolo D'Amico, Jeannine Donahue, Lorenzo Gerratana, Andrew A. Davis, Saya Liz Jacob, Zheng Cai, Elena Vagia, Wenan Qiang, Ami N. Shah, Katy Kerby, Lisa Flaum, Youbin Zhang, Firas Wehbe, Amir Behdad, William Gradishar, Leonidas Platanias, Massimo Cristofanilli. The detection and enumeration of circulating tumor cells (CTCs) and circulating endothelial cells (CECs) in metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-06.

Abstract PS2-20: Prognostic value of baseline circulating tumor cells (CTCs) enumerations is for stage III and stage IV breast cancer

Introduction: Prognosis of metastatic breast cancer (MBC) is initially predicted by the cancer’s characteristics based on AJCC TNM system, including the size of the cancer tumor, invasion into nearby tissue, lymph nodes and other parts of the body beyond the breast. Although additional information including hormone-receptor status, HER2 status, and possibly Oncotype DX score contributed to improve prognostic evaluation, predicting clinical outcomes and treatment benefit for MBC is still a challenge in clinic because of the clinical and biologically heterogeneous condition. We recently reported that CTCs enumeration can classify MBC in two distinct prognostic groups independently of clinical and molecular characteristics (Crit Rev Oncol Hematol. 2019). Moreover, our group reported that CTCs is associated with HER2 expression in MBC which may indicate more aggressive tumor (2019 AACR #1919). Here we compared CTCs enumeration of Stage III and Stage IV, which would be helpful to evaluate the MBC metastasis capability and treatment in clinic. Methods: The study included 38 specimens prospectively collected under IRB-approved protocol from 38 patients with Stage III MBC, and 254 specimens from 254 patients with stage IV MBC who received standard systemic treatments based on disease subtypes at NMH (2016-2020). Duplicate whole blood samples (7.5ml/each) were collected in EDTA tubes from these patients who were longitudinally characterized for CTCs before therapy (baseline). CTCs enrichment and enumeration were performed in FDA approved semi-automated fluorescence CELLTRACKS ANALYZERII® System (Menarini) by using CELLSEARCH® CXC Kit contains antibodies targeting the Epithelial Cell Adhesion Molecule (EpCAM) antigen for capturing CTCs, anti-CK-PE which is specific for the intracellular protein cytokeratin in epithelial cells, DAPI for staining the cell nucleus, anti-CD45-APC is specific for leukocytes (2019 ASCO #1036). The CTCs were classified based on morphology and correct phenotype as CK+, DAPI+ and CD45-. Kruskal-Wallis test was used for statistics. Results: Patients were classified as Luminal, HER2 positive and TNBC disease subtypes in 46.6%, 46.7% and 6.7% respectively in Stage III patients, and 54%, 18% and 28% respectively in Stage IV patients. The patients at age above 50 were 26.% in Stage III group and 68% in Stage IV group respectively. IBC patients represented 61.5% and 33.5% of Stage III and Stage IV patients respectively. Metastasis in liver, lung and bone were diagnosed in 40.7%, 40.2% and 62.8% in Stage IV patients. CTC negative (<5 CTCs) and positive (≥5CTCs) patients were identified in 32/38 (84.22%, group 1) and 6/38 (15.78%, group 2) respectively in Stage III patients, and 149/254 (59%, Stage IV indolent ) and 105/254 (41%, Stage IV aggressive ) respectively in Stage IV patients. Patients in Group 1 have a significantly less recurrence probability than patients in Group 2 (p=0.015). Correspondingly, patients with Stage IV indolent also had significantly longer survival than patients with Stage aggressive disease (p=0.0021). When comparing the all population, Group 1 patients still have the highest survival probability (p=0.00057) within 47 months follow-up survey. More interesting, there was no any CTC-clusters found in all Stage III patients when there were 28 out of 254 stage IV patients (11.02%) were detected with CTC-clusters, who had the worst prognosis in compared to either Stage IV patients without CTC-clusters or Stage III patients (p=0.00035). Conclusions: In this study, we showed that enumeration of baseline CTC and CTC-clusters correlated with worse prognosis even the patients were pathologically diagnosed for the same stage, which provided an additional measure to predict disease recurrence after systemic therapies especially for Stage III MBC patients.

Citation Format: Qiang Zhang, Zheng Cai, Lorenzo Gerratana, Paolo D'Amico, Andrew A. Davis, Saya Liz Jacob, Elena Vagia, Ami N Shah, Lisa Flaum, Youbin Zhang, Wenan Qiang, Firas Wehbe, Amir Behdad, William Gradishar, Leonidas C Platanias, Massimo Cristofanilli. Prognostic value of baseline circulating tumor cells (CTCs) enumerations is for stage III and stage IV breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-20.

Abstract PS2-11: Ctc-her2+ a novel subset in stage IVaggressive: Molecular correlations, outcome and clinical characteristics in metastatic breast cancer

Background The enumeration of Circulating Tumor Cells (CTCs) in the peripheral blood of patients (pts) with metastatic breast cancer (MBC) showed prognostic value independent of clinic-pathological characteristics and proposed as a new tool for Stage IV stratification. Molecular characterization of CTCs with analysis of standard HER2 and estrogen-receptor (ER) status provides additional predictive value. The presence of HER2 positive CTCs (CTCs-HER2+) has been documented in pts with HER2 negative MBC and suggestive of tumor heterogeneity. The molecular features associated with the detection of these cells and the clinical significance of CTCs-HER2+ remains of unclear clinical significance. The lack of validated prospective trials limits the use of this immunophenotypic characterization as a prognostic and predictive factor. We conducted an analysis of a large cohort of patients with MBC evaluated for CTCs enumeration (CTCs+), molecular analysis of CTCs (CTCs-HER2+) and ctDNA. Methods The IRB-approved study prospectively analyzed blood samples of pts with MBC enrolled before starting a new line of therapy. Samples were collected from pts treated at Northwestern University (Chicago, IL) between 2016 and 2020. ctDNA was analyzed using the Guardant360 NGS assay (Guardant Health) with a specific focus on the detection of ERBB2 mutations. CTCs were enumerated through CellSearch™ (Menarini Silicon Biosystems, Bologna, Italy), and characterized for HER2 expression using the CellSearch CXC Kit. HER2+ CTCs were divided in 4 different categories (0,1+,2+,3+), leaning on fluorescence intensity, as previously reported by Riethdorf et al. Pts with <5 CTCs (stage IV indolent ) were excluded from the analysis. The cHER2 ratio, defined as the sum of 2+ CTCs and 3+ CTCs divided by the total number of HER2+ CTCs was used to split the remaining pts in 2 different subgroups: cHER2 ratio> 0.75 (cHER2high), cHER2 ratio<0.75 (cHER2low). Pts' characteristics and genomic alterations were compared between these two subgroups and a long-rank test was performed to analyze the outcome (progression-free survival, PFS). Results A total of 247 pts with MBC about to start new therapy were enrolled. 136 patients (55%) demonstrated CTCs count ≥ 5 (stage IV aggressive). Of these, 111 pts had a blood sample bearing HER2+ CTCs. 88 pts were classified as cHER2low, while 32 were allocated in the second subgroup (cHER2high). The clinic subtype distribution of the two groups was as follows: 65% ER+, 19% HER2+ and 16% TNBC among cHER2low, compared to 55% ER+, 38% HER2+ and 7% TNBC among cHER2high pts. The HER2+ subtype was significantly more represented in the cHER2high group (p<0.05), along with ERBB2 mutations (p<0.05). We observed a total of 89 events (progression to treatment), 67 and 22 respectively. The median PFS was 87 days in the cHER2low and 209 days among cHER2high pts (log Rank test, p<0.001). Conclusion This study shows a significant association between the cHER2 ratio and outcome in pts with Stage IV aggressive disease, suggesting a potential predictive/prognostic role of this biomarker among MBC pts bearing CTC-HER2+. cHER2high pts, in which blood was collected a prevalent number of CTC-HER2+ 2+ and 3+, were more likely to have a HER2 FISH amplification by tissue biopsy and ERBB2 gene alteration by ctDNA. These findings, taken together, suggest a potential role of these subsets of CTC-HER2+ in the characterization of the HER2+ metastatic disease. The cHER2low is intrinsically characterized by a higher percentage of CTC-HER2+ 1+. This CTC-HER2+ subset of cells is commonly detected among all subtypes but, more frequently in ER+ disease and their significance remains unclear. Exploring the underlying biological nature of the CTC-HER2+ 1+ could allow to better understand the role these cells in the natural evolution of the MBC.

Citation Format: Paolo D'Amico, Qiang Zhang, Lorenzo Gerratana, Youbin Zhang, Ami Shah, Carolina Reduzzi, Andrew Davis, Saya Jacob, Firas Wehbe, Amir Behdad, Giuseppe Curigliano, Massimo Cristofanilli. Ctc-her2+ a novel subset in stage IVaggressive: Molecular correlations, outcome and clinical characteristics in metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS2-11.

Pharmacological management of male breast cancer

INTRODUCTION

Despite its rarity, male breast cancer shows a steadily rising incidence. Given the absence of ad hoc prospective randomized clinical trials, treatment strategies are based on extrapolation from female breast cancer recommendations or solely on population-based data.

AREAS COVERED

This review discusses the current treatment landscape for male breast cancer in the adjuvant and in the metastatic setting. The authors also discuss the biology and genomic landscape of male breast cancer. Original research and review articles, relative to the period 2010-2019, were included in the review of the literature.

EXPERT OPINION

There is a major medical need to include male patients with breast cancer in prospective clinical trials. The call to equality in breast cancer care can be pursued via two divergent paths: (i) a gender-neutral delivery of breast cancer information and (ii) the creation of separate sections, for the more common female breast cancer and for the rare male ones. We propose to differentiate male breast cancer care, acknowledging unique onco-sexual and social needs that can be only partially shared.

Preclinical models of breast cancer: Two-way shuttles for immune checkpoint inhibitors from and to patient bedside

The Food and Drug Administration has lately approved atezolizumab, anti-programmed death ligand 1 (PD-L1), to be used together with nanoparticle albumin-bound (nab) paclitaxel in treating patients with triple negative breast cancer (BC) expressing PD-L1. Nonetheless, immune checkpoint inhibitors (ICIs) are still challenged by the resistance and immune-related adverse effects evident in a considerable subset of treated patients without conclusive comprehension of the underlying molecular basis, biomarkers and tolerable therapeutic regimens capable of unleashing the anti-tumour immune responses. Stepping back to preclinical models is thus inevitable to address these inquiries. Herein, we comprehensively review diverse preclinical models of BC exploited in investigating ICIs underscoring their pros and cons as well as the learnt and awaited lessons to allow full exploitation of ICIs in BC therapy.

Liver toxicity in the era of immune checkpoint inhibitors: A practical approach

Immune checkpoint inhibitors have revolutionized the cancer treatment with an approved efficacy in different solid tumors and hematologic malignancies. These agents are increasing the indication in cancer treatment, but can be associated with serious immune-related adverse effects (IRAEs). Dermatologic and gastrointestinal toxicities are the most common IRAE followed by endocrinopathies with a different time of occurrence. Rarely cases of gastrointestinal toxicities are observed almost 2 years after initiation of the therapy. In this review we focus on liver toxicity related to these immunotherapeutic agents for which the largest amount of safety data is available. The management of drug-induced liver toxicity is very complicated and in same cases may take a long period of time to be resolved. A prompt recognition of liver IRAEs and an appropriate management of this event, requiring close collaboration with other specialist figures, could improve its treatment with evident implication on the efficacy of the therapy.

Thyroid Function in Patients with Cancer of the Breast

In 47 patients with operable cancer of the breast the thyroid activity has been studied with the following tests: a) radioactive iodine uptake, 3 and 24 hours after the administration of 50 μc of I131; b) conversion rate; c) hormonal index, i. e. the quantity of protein bound radioiodine in 1 liter of plasma, evaluated as a percentage of the administered dose. The thyroid function was studied immediately before Halstead operation as well as one, three, and twelve months later. From the data obtained it appears that a) breast cancer patients show a thyroid radioiodine uptake higher than the controls, either at the 3rd or at the 24th hour, b) after the removal of the breast, the uptake decreases, reaching normal values 12 months after the operation, c) the conversion rate does not show any difference from the controls either before or after the operation, d) the hormonal index is considerably higher than normal values before operation, and in spite of a lowering after radical mastectomy, it is still higher one year later. The data seem to show that breast cancer patients have a higher metabolic activity of the thyroid gland, without clinical signs of hyperthyroidism. After removal of the carcerous breast the thyroid activity slowly decreases. However, the conversion rate is not modified as compared to the control patients. Further confirmation of the present preliminary results should be obtained by a comparative evaluation of the results either in patients with other types of tumors, or in patients subjected to surgical procedures for non-tumorous lesions.

Targeting the microenvironment in solid tumors

Tumorigenesis is a complex and dynamic process involving different cellular and non-cellular elements composed of tumor microenvironment (TME). The interaction of TME with cancer cells is responsible for tumor development, progression and drug resistance. TME consists of non malignant cells of the tumor such as cancer associated fibroblasts (CAFs), endothelial cells and pericytes composing tumor vasculature, immune and inflammatory cells, bone marrow derived cells, and the extracellular matrix (ECM) establishing a complex cross-talk with tumor. These interactions contribute towards proliferation and invasion of the tumor by producing growth factors, chemokines and matrix-degrading enzymes. ECM is a complex system containing macromolecules with distinctive physical, biochemical and biomechanical properties. During tumorigenesis this system is deregulated favoring the generation of tumorigenic microenvironment enhancing tumor-associated angiogenesis and inflammation. An important step of anticancer treatment is the identification of the biological alterations present in TME in order to target these key molecular players. Multitargeted approaches, providing a simultaneous inhibition of TME components, may offer a more efficient way to treat cancer. In this manuscript we overview the function of each components of TME and the treatments targeting the key players.

Clinical efficacy of ribociclib as a first-line therapy for HR-positive, advanced breast cancer

INTRODUCTION

Breast cancer (BC) remains the most frequently diagnosed cancer and the most common cause of cancer death among women of all races worldwide. Over 80% of BC cases are hormone receptor (HR)-positive, comprised of luminal A and luminal B per molecular subtypes, imposing an urgent need to fully understand the mechanisms behind progression. Ribociclib is a selective cycline-dependent kinase 4 and 6 inhibitor. A phase 1 and a phase 3 trial have established a definitive role of ribociclib as frontline in the treatment of endocrine-sensitive advanced BC. Areas covered: Herein, the authors provide an overview of the data on ribociclib covering all aspects of the drug from its pharmacokinetics to efficacy and safety. The authors also provide their perspectives for the future. Expert opinion: Ribociclib is offering an opportunity to explore a new compound at the crossroads of different molecular activity and cell targets, which focus on endocrine-resistance reversal in multiple settings including early BC. Moreover, its activity against different subtypes of BC is being studied as is its immune-modulating effect. One cautionary note is that, in a market of concomitant similar competitors, a financial discussion will be mandatory.

Orthofile®: a new approach for mechanical interproximal reduction : a scanning electron microscopic enamel evaluation

PURPOSE

The aim of this in vitro study was to evaluate the stripping achieved on different teeth (incisors, canines, and premolars) by two grades of abrasive strips used for the first and tenth time. Our second aim was to test the efficacy of these strips by calculating the time necessary to perform interproximal reductions of 0.10, 0.20, and 0.30 mm.

METHODS

Four models were constructed using extracted teeth affixed in wax. The upper and lower arches were set on plaster bases and fixed in wax, carefully creating contact points. All model mouths were treated with artificial saliva (Oral Balance®) in order to simulate the biological conditions in the oral cavity. We then tested specific air-rotor strips of different grades and degrees of wear (15-µm-grain and 25-µm-grain Orthofile® strips). Afterwards the teeth from all samples were cut lengthwise in half, and each mesial and distal portion was gold-plated and observed under SEM at incremental magnification (30, 60, and 100 µm).

RESULTS

The 25-µm-grain strip was more effective than the 15-µm-grain strip, irrespective of the tooth involved. Second, the finishing phase with specific polishing strips after interproximal reduction was fundamental in reducing the number of abrasions and irregularities created by stripping, in particular after using the 25-µm-grain strip. To achieve the best result, the entire abraded area must be polished.

CONCLUSION

This system permits a rapid and effective stripping procedure in direct proportion to the strip's grain and in inverse proportion to the wear from its use. Further research will enable us to compare this system with similar procedures.

MRI of the small-bowel: how to differentiate primary neoplasms and mimickers

MRI of the gastrointestinal tract is gaining clinical acceptance and is increasingly used to evaluate patients with suspected small-bowel diseases. MRI may be performed with enterography or enteroclysis, both of which combine the advantages of cross-sectional imaging with those of conventional enteroclysis. In this paper, MRI features of primary small-bowel neoplasms, the most important signs for differential diagnosis and the diseases that can be considered as mimickers of small-bowel neoplasms, are discussed.

Patient-oriented assessment of back pain in pregnancy

Back pain is a common symptom in women during the last period of pregnancy. Only a few studies using validated patient-oriented tools have been undertaken on this topic. We report on a multicenter study on back pain in women during the last period of pregnancy, which involved seven Italian institutions. Seventy-six women in their 8th and 9th months were studied using the Italian validated version of the Roland questionnaire -- a disease-specific patient-oriented tool for low back pain. Sixty-two percent of the women had gone through at least one previous pregnancy, and clinical data concerning both the period before all pregnancies and the period before the current pregnancy were acquired. The study found that 31% of the women had no back pain symptoms (Roland score 0), 40% scored from 1 to 4, 21% scored from 5 to 10, and 8% scored more than 10. With regard to the predictive factor, history of back pain and sciatica before the pregnancy were found to be associated with occurrence of back pain symptoms during pregnancy. Unexpectedly, our results showed that male sex of the fetus seems to be related to occurrence of back pain symptoms during pregnancy. However, back pain was not associated with having gone through previous pregnancies, nor was the Roland score related to the weight before pregnancy or to increment of weight during pregnancy. Evaluation of the patient's perspective made it possible to identify predictive factors for occurrence of back pain, thereby furnishing important information for the clinical approach to pregnancy.

Carpal tunnel syndrome: relationship between clinical and patient-oriented assessment

Clinical diagnosis of carpal tunnel syndrome usually is easy and sensitive, but frequently, it is based on history and referred symptoms when no motor or sensory deficits are observed during examination. In patients with carpal tunnel syndrome, a dissociation between the severity of the disease reported by the patient and the deficits clinically evaluated by the physician often are observed. The Italian Carpal Tunnel Syndrome Study Group did a multicenter study on 740 patients (1123 hands) with carpal tunnel syndrome to assess the aspects of dissociation between the patient's and the physician's quantification of the disease severity and the ability of the patients with carpal tunnel syndrome to do daily activities. Validated patient-oriented parameters assessing symptoms and hand functional status were used. The relationship between the physician's and the patient's measurements is strong with a linear significant correlation when analyzing the functional status of the hand but not so clear and simple when analyzing the symptoms. Patients with mild-to-moderate carpal tunnel syndrome seemed to function well, although severe symptoms may be reported by the patient; however, when nerve impairment becomes severe, the patient's hand function is extremely impaired although symptoms may be milder. The data show that the patient's point of view is reliable. Carpal tunnel syndrome seems to be an ideal model to evaluate the importance of patient-oriented measurements.

A new clinical scale of carpal tunnel syndrome: validation of the measurement and clinical-neurophysiological assessment

OBJECTIVE

To validate a new clinical scale of carpal tunnel syndrome (CTS). The scale is based on clinical history and physical examination findings and includes two figures. The first is a score determined by clinical history and objective findings. The second evaluates the presence/absence of pain as a dichotomous categorical score.

METHODS

One hundred and sixty-eight consecutive idiopathic CTS hands were studied in two centers (Rome, Siena). We compare the results of the historical-objective scale (Hi-Ob scale) with the results of other validated measurements of CTS severity: (1) the Italian version of the Boston Carpal Tunnel Questionnaire, (2) the neurophysiological classification adopted by the Italian CTS study group. Furthermore, for the Hi-Ob scale the intra-observer and inter-observer evaluations were assessed.

RESULTS

The main Hi-Ob parameter was positively related to the conventional validated measurements. Conversely, the category 'PAIN' of the Hi-Ob scale appeared unrelated to the other clinical and electrophysiological parameters. Intra- and inter-observer evaluation showed the reproducibility of the Hi-Ob assessment.

CONCLUSIONS

Our data show that the Hi-Ob scale is a reliable measurement which may be useful in CTS evaluation either for clinical or for scientific purposes.

Multiperspective assessment of peripheral nerve involvement in diabetic patients

To assess the relationship between peripheral nerve involvement and the patient's perception of his own quality of life, we studied 36 consecutive out-patients affected by insulin-dependent diabetes mellitus without other diabetic complications other than neuropathy (20 men, 16 women; mean age 39.1 years). We used clinical (Semmes-Weinstein, vibration perception threshold, muscle strength, osteotendinous reflexes), neurophysiological (sural, peroneal and ulnar nerves), metabolic (glycosylated haemoglobin) and patient-oriented (SF-36 and NASS questionnaires) measurements. Patient-oriented physical scores were significantly related to: (1) neurophysiological findings of the inferior limbs; (2) conventional measurements of sensitivity; (3) metabolic assessment. Conversely, patient-oriented mental scores were significantly related only to metabolic assessment. The patient-oriented measure provided an important perspective of the severity of the disease often closely related with the biological parameters and suggested new ways of interpreting conventional biological measurements. In particular, the peripheral nerve picture appeared strictly related with the physical aspects of the patients' quality of life, while the metabolic picture appeared related with both the mental and physical aspects of the quality of life.