Abstract P3-02-02: Predictive value of breast MRI in detecting mammographically occult contralateral breast cancer: Can we target women more likely to have contralateral breast cancer based on primary tumor clinicopathologic factors?

Background: Use of preoperative magnetic resonance imaging (MRI) staging in newly diagnosed breast cancer increases detection of synchronous contralateral breast cancer (CBC) over other screening modalities; however, it is associated with a high false positive rate, additional biopsies, extensive surgical procedures, and possibly increased psychological morbidity.

Specific Aims: To determine predictors of synchronous, mammographically-occult but MRI-detected CBC in women newly diagnosed with breast cancer.

Methods: We performed a retrospective review of patients at Allina Health, Abbott Northwestern Hospital who had preoperative breast MRI prior to surgical resection of their breast cancer from 2010–2014. We collected patient demographic and clinicopathologic data. To determine the association between MRI-detected CBC versus benign findings based on clinicopathologic data, we performed univariate analysis (p<0.05). Multivariate Logistic Regression was used to adjust for covariates and factors predictive of CBC. Area under the Receiver Operating Characteristic Curve provided a measure of model accuracy.

Findings: 1894 patients had pre-operative MRI during the study period. Of those, 201 had suspicious findings on contralateral breast MRI requiring biopsy (table 1). Overall 3% (60/1894) had synchronous CBC (invasive carcinoma or DCIS) detected on MRI. The majority of CBCs (n=60) were stage 0 or IA (85%), ER/PgR+ (98%), HER2- (89%), and low/intermediate grade (80%). Women more likely to have mammographically-occult CBC were older (p<0.001), had lobular versus ductal index cancer (p=0.03), and had ER positive (p=0.027) or PgR positive (p=0.002) tumors. On multivariate logistic regression analysis (ROC area=0.75), PgR positive status (p=0.022), and older age (p=0.004) were predictive of CBC. With each year of additional age, odds of CBC increased by 5%. No CBC was identified in women < age 45 with high risk index cancers (ER- or HER2 +). CBC was 11 times more likely when PgR status was positive versus negative. CBCs were diagnosed significantly more frequently in patients with index cancers that were hormone receptor positive and HER2 negative compared to HER2 positive or triple negative invasive index cancers (Fisher's exact test; p=0.041).

Risk of CBC by Index Cancer TypeIndex CancerCBC n (%)DCIS (n=51)15 (29)Invasive carcinoma (n=150)45 (30)ER+/HER2- (n=121)41 (34)HER2 positive (n=18)3 (17)Triple Negative (n=11)1 (9)Total (n=201)60 (30)

Conclusions: Preoperative MRI is effective in detecting mammographically-occult early stage, hormone receptor positive CBC in older women. MRI-detected CBC is more common in patients originally presenting with hormone receptor positive and HER2 negative index cancers. Our results suggest that it may be possible to determine a subset of patients who are less likely to benefit from a preoperative breast MRI, an important implication in an era of increasing healthcare cost utilization awareness.

Citation Format: Susnik B, Lillemoe TJ, Swenson KK, Tsai ML, Finkelstein MJ, Schneider L, Braatz CM, Krueger JL, Rueth N. Predictive value of breast MRI in detecting mammographically occult contralateral breast cancer: Can we target women more likely to have contralateral breast cancer based on primary tumor clinicopathologic factors? [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-02-02.

Anatomical and functional evaluation of diaphyseal femoral fractures in children under 6 years old

Objective : The aim of this study is to evaluate both the anatomical and functional consequences of our treatment protocol of diaphyseal femoral fractures in children under 6 years old Methods : We conducted a retrospective analysis of a series containing 50 children in Strasbourg University Hospital whom had traumatic diaphyseal femoral fractures and underwent conservative treatment by traction followed by casting with a mean follow-up period of 25 months. Results : All fractures healed without complications i.e. gait disorders, back pain and limitation of activity. Results showed a significant correlation between the initial varus angulation and shortening which could influence the final remodeling result within the first 24 months. Using the Receiver Operating Characteristic curve, we developed the Initial Displacement Index on Traction (IDIT) which is the sum of both the initial varus in degrees and the initial shortening in millimeters. Conclusion : The treatment by initial traction followed by a cast for childrens ≤ 6 years old gives clinical and radiological results comparable with those reported for immediate casting method. The hospitalization period is longer in the traction method but with less exposure to general anesthesia (GA) and risks of secondary displacements.

Popliteal artery dissection presented 12 hours after admission for a Salter III fracture of proximal tibia

A 16-year-old boy sustained a salter III fracture of the upper tibia following a motorcycle accident. Except for well localized knee pain, the patient did not have any other symptom. Repeated clinical examination did not reveal any absent peripheral pulse. Given the state of the fracture, anatomical reduction and screw fixation was planned in the operating room.  Twelve hours after admission the patient was taken to the operating room. During the period preceding surgery he continued to have normal vascular clinical examinations. Further clinical assessment was performed in the operating room and remained to be normal. However after induction and upon extension of the lower limb, peripheral pulses in the affected side were abruptly lost. Urgent vascular exploration of the area showed a popliteal artery dissection necessitating a bypass graft to restore blood flow.  We present a review of the literature alongside a case report showing how popliteal artery pathology in a similar context can present late and be for a period of time clinically undetectable.

Incidence, risk factors and clinical implications of chyle leak after pancreatic surgery

Background

Chyle leak is a well known but poorly characterized complication after pancreatic surgery. Available data on incidence, risk factors and clinical significance of chyle leak are highly heterogeneous.

Methods

For this cohort study all patients who underwent pancreatic surgery between January 2008 and December 2012 were identified from a prospective database. Chyle leak was defined as any drainage output with triglyceride content of 110 mg/dl or more. Risk factors for chyle leak were assessed by univariable and multivariable analyses. The clinical relevance of chyle leak was evaluated using hospital stay and resolution by 14 days for short-term outcome and overall survival for long-term outcome.

Results

Chyle leak developed in 346 (10·4 per cent) of 3324 patients. Pre-existing diabetes, resection for malignancy, distal pancreatectomy, duration of surgery 180 min or longer, and concomitant pancreatic fistula or abscess were independent risk factors for chyle leak. Both isolated chyle leak and coincidental chyle leak (with other intra-abdominal complications) were associated with prolonged hospital stay. Some 178 (87·7 per cent) of 203 isolated chyle leaks and 90 (70·3 per cent) of 128 coincidental chyle leaks resolved with conservative management within 14 days. Initial and maximum drainage volumes were associated with duration of hospital stay and success of therapy by 14 days. Impact on survival was restricted to chyle leaks that persisted at 14 days in patients with cancer undergoing palliative surgery.

Conclusion

Chyle leak is a relevant complication, with an incidence of more than 10 per cent after pancreatic surgery, and has a major impact on hospital stay. Drainage volume is associated with hospital stay and success of therapy.

[Linked Prosthesis for the Proximal Interphalangeal Joint: 17-Year Long-Term Results]

BACKGROUND/PURPOSE

Joint replacement is a widely used procedure to treat painful osteoarthritis of the proximal interphalangeal joint. From 1996 to 1999, 16 patients received 19 hinged, piston-based DIGITOS prostheses in our department. In 2007, the 7-year clinical course of 14 patients (17 devices) was published in this journal. Now 12 of these patients (15 devices) have been followed with an average history of 17 years, and the preoperative data has been compared with the results after 7 and 17 years, respectively.

PATIENTS AND METHODS

The patients were 10 women and 2 men, whose average age at the time of the preoperative examination was 63 (48-69) years. Replacements were performed on the index (6), middle (6), and ring finger (3). There were 14 idiopathic osteoarthritic changes and 1 posttraumatic osteoarthritic change. Follow-up included a clinical (range of motion in the proximal interphalangeal joint, extension lag, pain) and radiological examination. In addition, the DASH score was obtained and the patients were asked whether or not they would undergo the same surgery again. The results after 7 and 17 years were reviewed for statistically significant differences.

RESULTS

While there were significant changes regarding extension lag and flexion in the first 7 years after replacement of the proximal interphalangeal joint, only minor changes were observed between 7 and 17 years after surgery. While the prosthesis was in its correct position in the first 2 years after implantation, all prostheses exhibited radiolucent lines after 4 years and periprosthetic osteophytes after 5 years. 17 years after surgery, the radiolucent lines had not increased at all and the osteophytes had increased insignificantly compared with the 7-year findings. None of the patients reported pain; all of them said that they would undergo the same surgical procedure again.

CONCLUSION

While there were significant clinical and radiological changes in the first 7 years after replacement of the proximal interphalangeal joint by a linked DIGITOS prosthesis, only minor changes were observed between 7 and 17 years after surgery.

Contamination risk of stable isotope samples during milling

RATIONALE

Isotope analysis of wood is an important tool in dendrochronology and ecophysiology. Prior to mass spectrometry analysis, wood must be homogenized, and a convenient method involves a ball mill capable of milling samples directly in sample tubes. However, sample-tube plastic can contaminate wood during milling, which could lead to biological misinterpretations.

METHODS

We tested possible contamination of whole wood and cellulose samples during ball-mill homogenization for carbon and oxygen isotope measurements. We used a multi-factorial design with two/three steel milling balls, two sample amounts (10 mg, 40 mg), and two milling times (5 min, 10 min). We further analyzed abrasion by milling empty tubes, and measured the isotope ratios of pure contaminants.

RESULTS

A strong risk exists for carbon isotope bias through plastic contamination: the δ(13) C value of polypropylene deviated from the control by -6.77‰. Small fibers from PTFE filter bags used during cellulose extraction also present a risk as the δ(13) C value of this plastic deviated by -5.02‰. Low sample amounts (10 mg) showed highest contamination due to increased abrasion during milling (-1.34‰), which is further concentrated by cellulose extraction (-3.38‰). Oxygen isotope measurements were unaffected.

CONCLUSIONS

A ball mill can be used to homogenize samples within test tubes prior to oxygen isotope analysis, but not prior to carbon or radiocarbon isotope analysis. There is still a need for a fast, simple and contamination-free sample preparation procedure. Copyright © 2016 John Wiley & Sons, Ltd.

Dolutegravir as monotherapy in HIV-1-infected individuals with suppressed HIV viraemia

BACKGROUND

Reducing drug burden is a key challenge for achieving lifelong suppressive HIV therapy. Dolutegravir, with a high potency, long half-life and high genetic barrier, offers potential for monotherapy.

METHODS

This observational single-centre study enrolled all patients with HIV RNA (viral load) <50 copies/mL for at least 12 months, with CD4 >350 cells/mm(3) and with no failure under integrase inhibitor therapy who had switched from suppressive ART to dolutegravir monotherapy (50 mg/day). Primary outcome was proportion of patients with viral load <50 copies/mL at week 24.

RESULTS

Twenty-eight patients treated for a median ART duration of 17 years (IQR 11-20), virally suppressed for a median of 79 months (IQR 42-95) and with a median CD4 count of 624 cells/mm(3) (IQR 524-761), were enrolled. Baseline ART consisted of a three-drug (n = 10), two-drug (n = 10) or single-drug (n = 8) regimen with integrase inhibitor exposure in 13 patients. The proportion of patients maintaining viral load <50 copies/mL was 96% (95% CI 79%-100%) at week 4, 100% (95% CI = 85%-100%) at week 8, 93% (95% CI 76%-99%) at week 12 and 92% (75-99) at week 24. Three patients (3.70%; 95% CI 3.4%-10.8%) with prior integrase inhibitor experience had HIV RNA rebound with the presence of resistance mutations. Genotyping of HIV DNA using the Sanger method or ultradeep sequencing showed no integrase inhibitor resistance-associated mutations (RAMs) except for the mutation 74I in a patient on a suppressive elvitegravir regimen. The median within- and between-subject variability of dolutegravir C24 was 25% and 34%, respectively. Nine patients with a year of follow-up remained virally suppressed.

CONCLUSIONS

Dolutegravir has the potency to be further investigated as a single ART in randomized studies, particularly in patients with no prior exposure to integrase inhibitors.

Upregulation of inflammasome activity and increased gut permeability are associated with obesity in children and adolescents

BACKGROUND

Immune activation contributes to the persistent state of inflammation associated with metabolic dysfunction in obesity. The specific immune receptors that sense metabolic stress signals and trigger inflammation are nevertheless largely unknown, and little is known on inflammatory and immune gene regulation in obesity.

METHODS

The study includes a cross-sectional and a longitudinal arm. Forty children and adolescents were enrolled: 22 obese subjects and 18 age-matched normal weight controls. Obese subjects participated in an 18-month therapeutic protocol, based on intensive lifestyle modification (dietary regimen, physical activity and behavioral interventions). Expression of genes involved in the inflammasome pathway, plasma concentration of the inflammasome-associated pro-inflammatory cytokines (interleukin (IL)-1β and IL-18) and indexes of microbial translocation (lipopolysaccharide (LPS), soluble CD14 (sCD14) and intestinal fatty acid-binding protein) were analyzed at baseline in obese subjects compared with controls, and after 18 months in obese subjects.

RESULTS

Cross-sectional analyses showed that the LPS-induced expression of genes involved in inflammasome (NLRP3, caspase 5 and NAIP), Nod-like receptors (NLRX1 and NOD1), downstream signaling (P2RX7, RAGE, RIPk2, TIRAP and BIRC2) and effector molecules (IFN-γ, IL-12β, IL-1β, CCL2, CCL5, IL-6 and TNFα) was significantly increased in obese subjects at baseline as compared with normal weight controls. The baseline plasma concentration of inflammasome-related cytokines (IL-1β and IL-18) and of microbial translocation markers (LPS and sCD14) was augmented in obese subjects as compared with controls as well. Longitudinal analyses indicated that intensive lifestyle modification resulted in a normalization of parameters in subjects with a significant reduction of BMI after 18 months.

CONCLUSIONS

In children and adolescents, obesity is characterized by the activation of the inflammasome and by an alteration of gut permeability. Successful lifestyle modification is effective in reducing inflammation, suggesting that inhibition of the inflammasome may be a potential therapeutic strategy in obesity.

Risk of pancreatic fistula after enucleation of pancreatic tumours

Background

Enucleation is used increasingly for small pancreatic tumours. Data on perioperative outcome after pancreatic enucleation, especially regarding the significance and risk factors associated with postoperative pancreatic fistula (POPF), are limited. This study aimed to assess risk-dependent perioperative outcome after pancreatic enucleation, with a focus on POPF.

Methods

Patients undergoing enucleation for pancreatic lesions between October 2001 and February 2014 were identified from a prospective database. A detailed analysis of morbidity was performed. Risk factors for POPF were assessed by univariable and multivariable analyses.

Results

Of 166 enucleations, 94 (56·6 per cent) were performed for cystic and 72 (43·4 per cent) for solid lesions. Morbidity was observed in 91 patients (54·8 per cent). Severe complications occurred in 30 patients (18·1 per cent), and one patient (0·6 per cent) died. Reoperation was necessary in nine patients (5·4 per cent). POPF was the main determinant of outcome and occurred in 68 patients (41·0 per cent): grade A POPF, 34 (20·5 per cent); grade B, ten (6·0 per cent); and grade C, 24 (14·5 per cent). Risk factors independently associated with POPF were: cystic tumour, localization in the pancreatic tail, history of pancreatitis and cardiac co-morbidity. Only cystic morphology was independently associated with clinically relevant POPF (grade B or C), occurring after enucleation in 25 (27 per cent) of 94 patients with cystic tumours versus nine (13 per cent) of 72 patients with solid tumours. Tumour size and distance to the main duct were not associated with risk of POPF.

Conclusion

Enucleation is a safe procedure in appropriately selected patients with a low rate of severe complications. POPF is the main determinant of outcome and is more frequent after the enucleation of cystic lesions.

Vitamin D levels and cytokine profiles in patients with systemic lupus erythematosus

OBJECTIVES

To evaluate the expression of Th1, Th2, and Th17 cytokines in patients with systemic lupus erythematosus (SLE), and verify the association between serum cytokine levels and vitamin D concentration.

METHODS

The sample consisted of 172 patients with SLE. 25-Hydroxyvitamin D (25(OH)D) levels were measured by chemiluminescence and 25(OH)D levels <20 ng/mL were considered to reflect vitamin D deficiency. Serum cytokine levels were measured in once-thawed samples, using a Th1/Th2/Th17 CBA (cytometric beads array) kit.

RESULTS

One hundred and sixty-one (93.6%) patients were women and 128 (74.4%) were of European descent. Mean patient age was 40.5 ± 13.8 years, and mean age at diagnosis was 31.5 ± 13.4 years. At the time of study entry, patients had a median (IQR) SLEDAI of 2 (1-4) and SLICC of 0 (0-1). Mean 25(OH)D concentration was 25.4 ± 11.04 ng/mL. Fifty-nine (34.3%) patients had a vitamin D deficiency. No statistically significant associations were identified between cytokine and vitamin D levels. The most significant finding was a positive correlation between INF-α levels and SLEDAI (r(s) = 0.22, p = 0.04).

CONCLUSION

Although vitamin D deficiencies are highly prevalent in patients with SLE, vitamin D levels were not significantly associated with patient cytokine profiles. The positive correlation between IFN-α levels and SLEDAI showed in this study corroborates other findings in the literature. The present results did not replicate those of in vitro studies of the effect of vitamin D levels on cytokine profiles. Placebo-controlled intervention trials of the effect of vitamin D on cytokine profiles are still required before any definitive conclusions can be drawn regarding the association between these variables.

Low frequency electric current noise in glioma cell populations

Measuring the electrical activity of large and defined populations of cells is currently a major technical challenge to electrophysiology, especially in the picoampere-range. For this purpose, we developed and applied a bidirectional transducer based on a chip with interdigitated gold electrodes to record the electrical response of cultured glioma cells. Recent research determined that also non-neural brain glia cells are electrically active and excitable. Their transformed counterparts, e.g. glioma cells, were suggested to partially retain these electric features. Such electrophysiological studies however are usually performed on individual cells and are limited in their predictive power for the overall electrical activity of the multicellular tumour bulk. Our extremely low-noise measuring system allowed us to detect not only prominent electrical bursts of neuronal cells but also minute, yet constantly occurring and functional, membrane capacitive current oscillations across large populations of C6 glioma cells, which we termed electric current noise. At the same time, tumour cells of non-brain origin (HeLa) proved to be electrically quiescent in comparison. Finally, we determined that the glioma cell activity is primarily caused by the opening of voltage-gated Na⁺ and K⁺ ion channels and can be efficiently abolished using specific pharmacological inhibitors. Thus, we offer here a unique approach for studying electrophysiological properties of large cancer cell populations as an in vitro reference for tumour bulks in vivo.

Rapid plasma viral suppression in naive HIV-infected patients with high CD4 cells and low viraemia initiating a dual nucleoside reverse transcriptase inhibitor strategy: a proof-of-concept study

OBJECTIVES

To evaluate whether a dual nucleoside reverse transcriptase inhibitor (NRTI) strategy can control HIV replication in antiviral therapy (ART)-naive HIV-infected patients with a high CD4 cell count and a low viral load (VL).

METHODS

This observational study included all HIV-infected treatment-naive patients with a CD4 cell count >300 cells/mm(3), a plasma HIV RNA between 1000 copies/mL and 30,000 copies/mL and wild-type virus who initiated dual NRTI ART between January 2008 and December 2012. HIV RNA and CD4 cell count were assessed at Day 0, Week (W) 4, W12, W24 and W48. The primary endpoint was the proportion of patients with a plasma VL (pVL) <50 copies/mL at W24.

RESULTS

Twenty patients were included. The median (IQR) baseline characteristics were: time since HIV diagnosis, 25 months (8-66 months); CD4 cell count, 592 cells/mm(3) (405-798 cells/mm(3)); HIV RNA, 10,395 copies/mL (4106-16,566 copies/mL); and HIV DNA, 464 copies/10(6) peripheral blood mononuclear cells (195-1168 copies/10(6) PBMC). Nineteen patients received tenofovir/emtricitabine and one patient received abacavir/lamivudine. At W12, 88% of the patients with available data (n = 16/18, 95% CI 0.65-0.99) had a pVL <50 copies/mL. Overall, the proportion of patients with a pVL <50 copies/mL was 100% (n = 20/20, 95% CI 0.83-1.0) at W24 and 95% (n = 18/19, 95% CI 0.74-0.99) at W48 (with one patient lost to follow-up and one patient with poor treatment compliance). The median increase in CD4 cells was 83 cells/mm(3) (40-310 cells/mm(3)). There was no discontinuation of antiretroviral therapy for any reason such as lack of efficacy or toxicity.

CONCLUSIONS

This pilot study suggests that, in patients with a high CD4 cell count and a low VL, a dual NRTI strategy may represent a potentially effective treatment strategy to control HIV replication. This needs to be confirmed in larger controlled clinical studies.