Chronic coccydynia in adolescents. A series of 53 patients

BACKGROUND

Little is known about coccydynia in adolescents.

AIM

The aim of this study was to explore causes, clinical and imaging features and response to treatment of chronic coccydynia in adolescents.

DESIGN

This was a cohort study.

SETTING

The study included patients followed up at a specialized consultation in a university hospital.

METHODS

A series of 53 adolescent patients with chronic coccydynia were followed for 1-4 years. Investigations included dynamic X-ray films, with a magnetic resonance imaging scan of the coccyx in 26/53. Treatment was by coccygeal steroid injection or non-steroidal anti-inflammatory drugs (NSAIDs). Amitriptyline or coccygectomy were used as second-line treatment. Outcomes were assessed at a consultation two months after the treatment, then between one to four years later, by telephone interview, questionnaires and by a visual analogue scale (VAS). Fifty-one adult patients with coccydynia formed the control group.

RESULTS

In 20 cases (37.7%) the coccydynia was subsequent to trauma. Obesity was not a risk factor. Abnormal mobility was rarer and spicules more frequent compared to adult patients (P<0.001); 11/27 MRI scans showed a hypersignal within the disc or adjacent bone and 6/27 a hypersignal surrounding the tip of the coccyx (bursitis). Initial treatment was a coccygeal steroid injection for 41 patients and NSAIDs for 12. Ten were given amitriptyline and 3 a coccygectomy. At final assessment, there was no pain or almost no pain in 32/53 (60.4%), moderate pain and functional impairment in 12/53 (22.6%) and severe pain and functional impairment in 9/53 (17%).

CONCLUSION

Coccydynia in adolescents differs from coccydynia in adults. A MRI scan is helpful and should be obligatory for diagnosis. Prognosis is relatively good.

CLINICAL REHABILITATION IMPACT

Our results should help clinicians manage this rare and debilitating condition.

Intraoperative Determination of Axillary Node Metastasis: Meta-Analysis of Diagnostic Accuracy Assessment Studies for Frozen Section, Imprint Cytology and Molecular Assays

Background: Sentinel lymph node status is highly predictive of overall axillary lymph node involvement. Intraoperative assessment potentially enables completion of axillary dissection at the same setting. The most commonly used methods are frozen section histology and imprint cytology. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) assays have been recently developed.Objectives: To obtain summary estimates of the diagnostic accuracy of intraoperative tests for the detection of metastases in lymph nodes of patients with breast cancer.Selection criteria: Cross-sectional studies assessing the diagnostic accuracy of at least one index test for the detection of metastases in lymph nodes of patients with breast cancer were selected. Index tests included frozen section, touch imprint cytology or RT-PCR with the One-Step Nucleic Acid Amplification (OSNA) technique (Sysmex) or GeneSearch™ Breast Lymph Node (BLN) Assay (Veridex, LCC). The reference standard was permanent section H&E analysis.Search strategy: We searched MEDLINE and EMBASE up to April 2009 with both controlled vocabulary and freetext words corresponding to 'breast cancer' and 'lymph node' and 'intraoperative test'. We also searched SABCS and ASCO annual meeting proceedings from 2006 to 2008 as well as Sysmex, Veridex and FDA websites. We checked the reference lists of selected studies and review articles for additional studies.Data collection and analysis: Two review authors independently applied the selection criteria to identify references and reached consensus at each step. Both independently assessed quality according to the QUADAS checklist and extracted data from selected studies. Meta-analysis was performed using a bivariate mixed-effect model. Per-patient and per-node combined sensitivity and specificity were calculated.Results: Among 560 screened references from MEDLINE or EMBASE, 100 references were selected (43 pending decisions because of availability or translation issues). We identified 29 additional articles or abstracts from other sources. Of these, 3 independent studies (667 nodes) assessed GeneSearch™ BLN Assay accuracy on a per-node basis: combined sensitivity was 0.86, 95%CI:0.63-0.96 and combined specificity 0.94, 95%CI:0.92-0.96. Six independent studies (2091 nodes) assessed OSNA accuracy on a per-node basis: combined sensitivity was 0.93, 95%CI:0.86-0.96 and combined specificity 0.95, 95%CI:0.92-0.97. In 5 studies reporting data corrected for sampling bias, sensitivity was 0.94, 95%CI:0.86-0.97 and specificity 0.96, 95%CI:0.94-0.97.Conclusion: Our preliminary results indicate that RT-PCR yields high per-node sensitivity and specificity. OSNA tends to show a nonsignificantly higher accuracy than GeneSearch™ BLN Assay. Updated results, including frozen section, imprint cytology and subgroup analyses, will be presented at the congress.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1005.

Optimizing the size variation threshold for the CT evaluation of response in metastatic renal cell carcinoma treated with sunitinib

BACKGROUND

In metastatic renal cell carcinoma (mRCC), antiangiogenic treatments rarely achieve a reduction of -30% in the sum of longest diameters (SLD) of target lesions required by RECIST for an 'objective response', although they objectively improve progression-free survival (PFS). We sought to determine a threshold for the computed tomography evaluation of these patients' best reflecting patient outcome.

PATIENTS AND METHODS

In 334 mRCC patients treated with sunitinib, we tested thresholds from -45% to +10%. We classified patients as 'responders' when the best relative variation of the sum of longest diameters (DeltaSLD) reached the tested threshold and as 'nonresponders' otherwise. For each tested threshold, the median PFS of the two groups were compared. Receiver operating characteristic (ROC) analysis was also carried out among the 103 patients that progressed during follow-up. Finally, the 'optimal' threshold was retested on an independent cohort of 39 patients.

RESULTS

The DeltaSLD threshold of -10% gave the most significant difference. It divided patients into 256 responders and 78 nonresponders (median PFS 11.1 and 5.6 months). The same -10% threshold was found using the ROC analysis. Results were confirmed on the external validation cohort.

CONCLUSION

A variation of -10% in the SLD accurately and rapidly identifies mRCC patients benefiting from sunitinib.

Impact of sentinel lymph node biopsy on staging of early cervical cancer: Results of a prospective, multicenter study

CRA5506

Background: 10% to 15% of patients with pN0 early cervical cancer experience recurrences. This may be related either to nodes missed by the dissection or located outside the dissection field or to failed diagnosis of node metastases. The objective of this study was to measure the benefits from sentinel node (SN) detection in terms of nodes collected from unusual territories and of detected micrometastases and isolated tumor cells (ITCs). Methods: 145 patients who had stage Ia1-Ib1 epidermoid cancer or adenocarcinoma or adenosquamous cancer were included in a multicenter study (January 2005 - June 2007). Noninclusion criteria were age<18 years, pregnancy, and previous treatment. SNs were identified by combined technetium and blue-dye labeling in the pelvic and para-aortic territories. Slices were cut 200 μm apart. At each level, HES staining and labeling with anti-cytokeratin antibodies (AE1-AE3) were performed. SNs in an unusual territory were defined as SNs outside the ilio-obturator region. ITC was defined as size <0.2 mm, micrometastasis as size 0.2 to 2mm, and macrometastases as size >2 mm. The study was funded by the French National Institute of Cancer and reviewed by an IRB. Results: 17 patients were excluded for major protocol deviations, leaving 128 patients for the per protocol analysis. One or more SNs were detected in 98.4% of patients (95%CI, 94.4 to 99.9%). The 430 detected SNs were located as follows: external iliac, 80.5 %; common iliac, 8.6%; presacral and paraaortic, 5.5%; and parametrial, 4.9 %. SN detection identified at least one SN in an unusual territory in 48/128 (37.5%) patients. There were 26 positive SNs in 21(16.4%) patients of whom 8 (38%) had macrometastases, 7 (33%) micrometastases, and 6 (29%) ITCs. Of these 26 nodes, 7 (27%) were detected only by immunohistochemistry (6/128 patients: 4.6%). There was no false-negative No node metastases were found in 104/128 (81.2%) patients. Conclusions: SN detection supplied additional information in 39.8% of patients (51/128), either showing that drainage occurred via unusual pathways or detecting cancer spread via immunohistochemistry. Node dissection could have been avoided in the 104/128 patients with negative nodes, potentially decreasing treatment-associated morbidity.

No significant financial relationships to disclose.

Impact of sentinel lymph node biopsy on staging of early cervical cancer: Results of a prospective, multicenter study

CRA5506

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.

Contribution of indirect computed tomographic venography to the diagnosis of postpartum venous thromboembolism

BACKGROUND

The diagnostic value of indirect computed tomographic venography (CTV), following thoracic computed tomographic angiography (CTA), has not been specifically evaluated in postpartum patients with suspected pulmonary embolism.

OBJECTIVES

To assess the diagnostic value of CTV in postpartum venous thromboembolism.

METHODS

We reviewed all CTA and CTV procedures performed during the last 7 years in our institution for suspected pulmonary embolism during the postpartum period. We focused on the quality of CTA, the rates of positive CTA and isolated positive CTV findings, and alternative diagnoses provided by CTV.

RESULTS

Fifty-five CTA and 33 CTV procedures were performed for suspected pulmonary embolism in 47 patients referred between 24 h and 2 months after Cesarean (34 patients) or vaginal (13 patients) delivery. Of the 33 patients who had both CTA and CTV, seven had positive CTA findings and four had isolated positive CTV findings. Thus, the absolute increase in the venous thromboembolism detection rate following CTV was 12.1% [95% confidence interval (CI) 4.0-29.1]. Subcapsular hematoma of the liver or spleen was found on CTV in another two patients without venous thromboembolism. Consequently, CTV had a direct impact on clinical management in six of 33 patients (18%).

CONCLUSION

Our results suggest that postpartum patients with suspected pulmonary embolism have a significant rate of pelvic vein thrombosis and that the use of CTV leads to a 31% relative increase in the detection rate of venous thromboembolism as compared to CTA alone in these patients.

Diagnostic strategy for growth hormone deficiency: relevance of IGF-1 determination as a screening test

BACKGROUND

Adult growth hormone (GH) deficiency must be diagnosed before prescribing therapeutic recombinant human GH. We studied the clinical relevance of a diagnostic strategy for growth hormone deficiency (GHD) using IGF-1 determination as a first step.

METHODS

In 2000 and 2001, we tested 142 adult patients with hypothalamo-pituitary disorders for somatotropic function using Insulin Tolerance Test (ITT), the reference test for the diagnosis of GHD, with concomitant Insulin-like growth factor-1 (IGF-1) determination, a marker of somatotropic function. Patients were classified as GHD (peak GH concentration<3 ng/ml with the ITT) or normal.

SETTING

Monocenter prospective study in a tertiary referral center.

RESULTS

GHD was diagnosed in 61 subjects. Using a ROC curve, a threshold IGF-1 concentration of 175 ng/ml yielded a negative predictive value of 89+/-5%. A diagnostic strategy with IGF-1 determination as the first step followed by ITT for patients with an IGF-1 concentration below 175 ng/ml missed five of the 61 GHD patients, avoided 46/142 ITT and reduced the cost of diagnosis by 15%.

CONCLUSION

We propose the use of a strategy consisting of IGF-1 determination followed, if below 175 ng/ml by confirmatory ITT to diagnose GHD in adults.

[Evaluating the knowledge of nasal polyposis in patients, GPs, and ENT specialists]

OBJECTIVES

To evaluate education for adults with nasal polyposis (NP) and compare their knowledge and opinions on NP to those of a group of general practitioners and a group of ENT specialists.

MATERIAL AND METHODS

Prospective study conducted on 87 consecutive subjects (33 patients with NP, 20 GP, and 34 ENT) using a questionnaire to evaluate the knowledge on NP (general, medical, and surgical information).

RESULTS

The results obtained from the three groups of subjects (patients, GP, ENT) differed significantly on "overall knowledge of the disease." Patients and GPs showed similar results. The ENT group had significantly better results.

CONCLUSION

Education in a this type of chronic disease of the upper respiratory tract seems necessary for the management of NP. This study also underscores the need for information transfer on NP from ENT specialists and GPs.

[Obesity and high blood pressure in French West Indies women, some difference according to definition of obesity; BMI or abdominal obesity]

OBJECTIVES

To compare prevalence of abdominal obesity with obesity defined as BMI >or=30 kg/m2 in a West Indies population, and to define the relation between obesity and hypertension.

METHODS

A cross-sectional study of 2420 consecutive unemployed subjects referred for check-up in the two health centres of Guadeloupe, a French Caribbean island. Height and weight were measured and the body mass index (BMI) was calculated as weight/height2 (kg/m2). Obesity was defined as BMI >or=30 kg/m2 and excess weight as BMI >or=25 kg/m2 and<30 kg/m2. Abdominal obesity was defined as waist measurement more than 88 cm for women and more than 102 cm for men.

RESULTS

[table: see text]

CONCLUSION

A high prevalence of obesity was observed in this Caribbean population suggesting the interest of primary prevention in The Caribbean. In women, abdominal obesity (waist measurement>88 cm) was more frequent than obesity defined as BMI>30 kg/m2). In a multivariate analysis, obesity is an independent risk factor of hypertension (Odds-ratio=3), however the definition of obesity.

[Impact of the surgical route on staging and outcome of early borderline ovarian tumors]

OBJECTIVE

To assess the impact of the surgical route on the management and outcome of early borderline ovarian tumors (BOT).

PATIENTS AND METHODS

We have retrospectively analysed BOT operated on between January 1st 1985 and December 31st 2001. We included cases with clinical stages Ia to Ic. We compared the prevalence of deleterious acts according to the surgical access, as well as the quality of staging. Univariate and multivariate analysis assessed the impact of factors on quality of staging. Survival was also compared according to the initial surgical access. Data were computed and analysed using SPPS 7.5 and STATA 8.

RESULTS

118 cases have been included, 48 (41%) have been operated on by laparoscopy, 54 (45%) by laparotomy and 16 (14%) had a conversion. A conservative treatment has been done in 57% of patients, with increased frequency in case of laparoscopy (P<0.05) and in aged patients (P<0.001). A tumor rupture occurred in 9% of cases, without difference between accesses (P=0.1). A bag was used for the specimen delivery in only 40% of cases of laparoscopy. Most of patients (73%) had an incomplete staging. Year of treatment, and a radical treatment were associated with a better staging. Survival curves showed no detrimental effect of laparoscopy.

DISCUSSION AND CONCLUSION

Despite an incomplete staging, this series does not show any detrimental effect of laparoscopy on the outcome of early BOT.

Reducing the burden of arterial hypertension: what can be expected from an improved access to health care? Results from a study in 2420 unemployed subjects in the Caribbean

High prevalence and poor control of hypertension have been observed in populations with low-socioeconomic status. Comparing an unemployed population with another employed population sharing the same culture, and another employed population living in another environment might enlighten the effects of factors accessible to primary prevention on the one hand and access to health care on the other hand. The objectives are, first, to describe blood pressure (BP) prevalence and control in an unemployed Caribbean population benefiting from State financial support and good access to health care and second, compare the results in this population with those observed, with the same methodology in two employed populations, one in the Caribbean and one in metropolitan France. A cross-sectional study of 2420 consecutive unemployed subjects referred for check-up in the two health centres of Guadeloupe, a French Caribbean island. Hypertension prevalence was 25.2% in men and 22.1% in women. BP was controlled in 17.3% of men and 37.2% of women receiving antihypertensive medication. Among women, 58% were overweight and 29% obese. Prevalence of hypertension was higher among the unemployed and employed Caribbean population, than among an employed metropolitan French population. A high prevalence of obesity was observed in the two Caribbean populations suggesting the interest of primary prevention in the Caribbean. Burden of hypertension in a population relates to the development of hypertension (primary prevention) and control of hypertension (secondary prevention). Identifying hypertensive patients and controlling blood pressure are both important to reduce the disease burden.

Evaluation of a new disinfection procedure for ultrasound probes using ultraviolet light

Following 183 ultrasound examinations, a randomized trial was conducted to compare three procedures for disinfection of probes under routine conditions: dry wiping with a soft, dry, non-sterile paper towel, antiseptic wiping with a towel impregnated with disinfectant spray and dry wiping followed by a 10 min ultraviolet C (UVC) cycle in a disinfection chamber. After ultrasonography, swabs were taken from transducer heads before and after cleaning and streaked onto plates that were then cultured. The number of colonies per plate was counted and organisms identified. The median microbial reduction was 100% for UVC, 98.4% for antiseptic wiping and 87.5% for dry wiping (P<0.001). The percentage of negative specimens was 88% for UVC, 16% for antiseptic wiping and 4% for dry wiping (P<0.0001). Microbial flora was isolated from 12 probes (6.6%) before cleaning, whereas specimens obtained after cleaning contained no pathogens except in one case after antiseptic wiping. UVC disinfection of ultrasound probe may provide a useful method for reducing the bacterial load under routine conditions.