Isolated right pulmonary artery agenesis with agenesis of right upper lobe and bronchiectasis of right lower lobe with anomalous arterial supply from celiac axis with normal venous drainage

Isolated unilateral absence of pulmonary artery (UAPA) is a rare congenital anomaly. When detected in infancy, the condition is commonly associated with cardiovascular defects which are more frequently associated with left pulmonary artery agenesis. Patients with isolated right pulmonary artery agenesis survive into adulthood with minimal or no symptoms and are diagnosed incidentally on the chest radiographs. We report a case of a 19-year-old female patient who presented to us with recurrent haemoptysis. She was symptomatic since the age of four years. We report the rare occurrence of UAPA on right side, agenesis of right upper lobe and bronchiectasis of right lower lobe with anomalous arterial supply of right lung from coeliac axis in this patient.

The real-time intra-operative evaluation of sentinel lymph nodes in breast cancer patients using One Step Nucleic Acid Amplification (OSNA) and implications for clinical decision-making

INTRODUCTION

One Step Nucleic Acid Amplification (OSNA) method for the intraoperative analysis of sentinel lymph nodes (SLNs) in breast cancer, obviates a second operation to the axilla and thereby expedites progression to adjuvant therapy. Recent NICE guidelines have approved OSNA as a method of sentinel node diagnosis to support the above case.(1) METHOD: This is a single centre prospective cohort analysis of all patients undergoing breast cancer surgery including sentinel node biopsy from February 2010 to June 2012. Patients with negative SLN(s) on OSNA had no further axillary surgery. A validation phase was performed prior to using OSNA routinely. Those with micrometastases underwent a level 1 clearance, and >one SLN with macrometastases, underwent treatment by level 2 axillary dissection. The length of time from sentinel node retrieval to OSNA result was recorded.

RESULTS

Four hundred and forty nodes were analysed in 212 patients with a mean age of 55 years (range 24-98). The sensitivity and specificity of OSNA was 93% and 94% respectively in cases of macrometastases. The process required additional median anaesthesia time of 20 min (range -48 to +65 min). Non-sentinel node positivity was 5% and 48% for micrometastasis and macrometastasis respectively.

CONCLUSION

OSNA identified 62 of 212 patients with at least one positive sentinel node, thereby sparing 29% from a second procedure to clear the axilla subsequently. The median waiting time of 20 min for node results from completion of breast procedure is acceptable and allows for an efficient operating list. OSNA can be incorporated into routine practice and with improved methods of imaging preoperatively, can be an excellent adjunct to the breast cancer patient pathway of care.

Rituximab for ANCA-associated vasculitis in the setting of severe infection

OBJECTIVES

The combination of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV) and severe infection presents a challenge because current therapies with high-dose glucocorticoids and cyclophosphamide (CYC) are immunosuppressive and increase the risk of infection. Thus, coincident infection delays and complicates the introduction of treatment. Rituximab (RTX) is an alternative to CYC in AAV and may be preferable in the setting of severe infection.

METHOD

From 2005 to July 2011, 100 patients with AAV were treated with RTX at our institution and those who received RTX instead of CYC because of concomitant infection were studied.

RESULTS

Eight patients were identified. The mean follow-up was 12 months (range 6-30 months). All patients achieved remission by 6 months that was sustained to the end of follow-up. There were no deaths or further severe infections.

CONCLUSIONS

RTX can be considered for patients with generalized AAV and concomitant severe infection.

P3-07-23: Intraoperative Molecular Analysis of Sentinel Lymph Nodes in Breast Cancer Using One Step Nucleic Acid Amplification (OSNA)

Introduction: The OSNA method for the intra-operative analysis of sentinel lymph nodes (SLNs) in breast cancer has been introduced in 3 UK centres since 2007. The methodology uses a polymerase chain reaction to quantitate CK19, a cytokeratin specific to breast duct epithelial cells. OSNA provides “real-time” results on SLNs analysed as negative (−) or positive with either micro (+) or macrometastases (++).

Method: This is a single-centre prospective pilot study of all patients undergoing breast cancer surgery including sentinel node biopsy from February 2010 to May 2011. SLN identification was performed using a dual localization technique with peri-areolar Patente V blue dye and Tc99 radio-active isotope. SLNs were cut into 4 slices labeled as A, B, C and D, respectively after the removal of all perinodal fat. In all SLNs, slices A and C were processed in OSNA and slices B and D underwent histological assessment by H&E staining. Slices A and C were prepared for OSNA analysis with the required reagent (Lynorhag), followed by centrifugation and homogenization. Micro-pipetted samples were processed against control specimens, to produce normalized and quantitative curve results. The primary outcome measure was to correlate the results of OSNA with histopathology for each SLN. A negative SLN resulted in no further axillary surgery compared to a level I axillary sampling following the presence of micrometastases and a level II dissection following the detection of macrometastases. The total duration of OSNA for all SLNs was recorded in relation to delays in the completion of the intended breast surgery in each patient.

Results: 251 SLNs were analysed in 112 patients (mean age of 55 years). Comparisons between OSNA and histopathology were made in 116 nodes (34 SLNs analysed by OSNA only). SLN positivity was evident in 30 nodes (26%) comprising either macrometastases (n=13) or micrometastases (n=17). The OSNA sensitivity and specificity of was 93% and 89%, respectively. Accounting for a tissue allocation bias in the presence of micrometastases only, the specificity rose to 94% if these cases were excluded in the analysis. There was no correlation between SLN positivity and tumour grade, size or receptor status. The time to OSNA results were analysed in 75 patients undergoing 45 wide local excisions (WLE), of which 18 were wire localized; 23 mastectomies and 22 SLNB alone. The mean time for OSNA was 40.5, 51.8, 54 and 61.5 minutes for 1,2,3, and 4 sentinel lymph nodes respectively. Operation time was prolonged by a median of 20 minutes (range −48 to +65 minutes) WLEs were delayed by the greatest time Exclusions: Nodes that were not available for histological comparison i) nodes weighing <0.05g (n=34) were processed whole. ii) Departmental agreement from mid March 2011 to process nodes whole via OSNA (n=51); 6 had micro or macrometastases.

Conclusion: OSNA prevented staged axillary surgery in 24 (21%) of patients. A median time of 20 minutes for the OSNA procedure is comparable with acceptable operating times. Current experience supports the use of OSNA for each individual whole SLN analysis. The pilot data has resulted in a prescribed change in policy to analyse the whole SLN using this technique.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-23.

P2-16-01: A Multi-Centre Prospective Cohort Study Evaluating Health Related Quality of Life after Types of Immediate Latissimus Dorsi (LD) Breast Reconstruction

Introduction: Evidence for the clinical effectiveness of breast reconstruction based on Patient Reported Outcome Measures (PROMS) is lacking. Methodology evaluating PROMS after types of breast reconstruction has been poor with respect to study design, statistics, missing data and absence of prospective documentation of pre-defined complication data in a systematic review of all studies since 19781. Furthermore, there is no reliable data on the effects of associated radiotherapy (RT) in this context. As a prelude to a proposed randomised trial in breast reconstruction, our aim was to conduct a ‘robust’ cohort study evaluating the effects of either implant-assisted LD (LDI) or tissue only (ALD) LD flap reconstruction in relation to key determinants including clinico-pathological parameters, complications and treatment schedules over a 36 month period.

Methods: An MREC approved prospective longitudinal cohort study involving 6 centres commenced in early 2007. Serial PROMS using the EORTC QLQ-C30, BR-23, FACT-B, BIS and HADS, were completed pre-operatively and at 3, 6, 12, 24 and 36 months after surgery. Data up to 12 months were included in this analysis as data were sparse beyond this point; follow-up is ongoing. Demographic and clinical data were compared between the surgical groups. Generalised estimating equations were used to investigate demographic and clinical predictors of HRQL over time.

Results: A total of 189 patients (107-ALD, 82-LDI) were recruited, with a mean age of 50 years (range 22–70). Baseline questionnaires were completed by 149 (79%) women, with 167 (88%) available at 12 months. Patients in the ALD group had a higher BMI (mean 27.3 versus 25.2 in LDI, p=0.001) and a greater likelihood of post-mastectomy RT (52% versus 30% in LDI, p=0.004).

Only role functioning (p=0.001) and pain (p=0.003) were significantly adversely affected in the ALD v LDI group, with no statistically significant effects from PMRT on HRQL, although chemotherapy impaired global QoL (p<0.001) and social functioning (p=0.001), and increased fatigue (p=0.007). Early complications (< 3 months) significantly impaired HRQL in general, as did poor baseline scores (p<0.01 for various subscales). Significant improvements over time were noted for global QoL, role and social functioning, fatigue, pain and breast symptoms (p<0.001 for all).

Conclusion: There is increasing evidence of clinical equipoise between types of LD breast reconstruction and despite acknowledged cosmetic disadvantages the overall effects of PMRT on HRQL are minimal. The identification of important variables that may affect HRQL is crucial in all studies evaluating the effects of surgery on PROMS. Their integration into study results is essential for correct interpretation of clinically based assessments. This remains a challenging aspect in cohort studies, and emphasises the need for pragmatism in design of trials in the field.

1. Winters ZE, Benson JR, Pusic AL. Annals of Surgery 2010;252(6):929–42

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-01.

P2-16-06: A Systematic Review of Standardised Clinical Outcomes and Patient Reported Outcome Measures (PROMS) in Breast Reconstruction

Introduction: Failure to prospectively define and report surgical complications across a range of study designs is a confounding factor that fundamentally compromises the interpretation of data on health-related quality of life (HRQL) and PROMS. The UK National Mastectomy and Breast Reconstruction audit on 5000 breast reconstruction patients found higher than expected levels of complications (including rates of reoperation and levels of infection). We aimed to analyze the reporting of complications in a systematic review of all studies evaluating PROMS in breast reconstruction since 19781.

Methods: Efficace criteria for HRQL methodology were used to assess the inclusion eligibility for each study1. Two out of 34 eligible studies were excluded due to overlapping patient datasets and small numbers (n<5) of breast reconstruction cases. Two reviewers examined the reporting of complications. The study designs comprised: 2 randomised controlled trials (RCT); 10 prospective longitudinal studies (PLS) and 20 retrospective studies (RS). RCTs and PLS were evaluated for predefined complications, their grading according to Clavien-Dindo2 and their integration into the evaluation of PROMS results. RS were evaluated for the reporting of complications and their statistical methodology.

Results: A total of 3213 patients were included in the 32 studies. The type of reconstruction was only recorded in 71% of patients. The majority of patients in these studies underwent abdominal flap reconstruction, compared to implant only techniques (32%), and less than 10% comprising Latissimus dorsi flaps. Only 19% of studies recorded complications with the majority (81%) failing to report any complications. Only 3 studies provided details of the numbers and level of complications amongst a total of 44 patients (1.4% of the total number of patients). Reported complications were graded and classified either as major (requiring surgical intervention) or minor comprising 55% and 45%, respectively. None of the RCT or PLS studies defined either the type or level of complications a priori, nor stratified complications based on risk factors such as age, body mass index, smoking and diabetes.

Conclusion: There is a significant under estimation of the contribution of complications to HRQL and PROMS reporting. This fact diminishes the current evidence on the effects of breast reconstruction on PROMS. There should be collective efforts to improve the standards of documentation for clinical outcomes in breast reconstruction. This together with standardized reporting of PROMS will consolidate clinical evidence upon which decision-making and provision of patient information can be confidently based.

1. Winters ZE, Benson JR, Pusic AL. Annals of Surgery 2010;252(6):929–42

2. Dindo D et al. Annals of Surgery 2004;240(2):205–213

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-16-06.

Endothelial progenitor cells correlate with lesion volume and growth in acute stroke

OBJECTIVES

Circulating endothelial progenitor cells (EPC) are markers of vascular injury and their numbers decrease in acute stroke. However, the relation of EPC levels to stroke severity has not been quantified. MRI measurements of lesion volume provide an objective method for stroke severity assessment and outcome prediction. This cross-sectional study aims to determine whether EPC are correlated with lesion volume at baseline, lesion growth, and final lesion volume.

METHODS

Seventeen patients (median age 63 years, NIH Stroke Scale score 7) were selected from 175 patients with imaging-confirmed acute ischemic stroke. EPC were quantified by flow cytometry using CD34, CD133, and VEGFR2 surface markers. Brain MRI was performed at baseline and at days 1 and 5 after the stroke onset. Stroke lesion volumes were quantified.

RESULTS

Larger lesion volumes measured on diffusion-weighted images (DWI) at baseline were associated with low EPC levels, while smaller lesion volumes and less lesion growth were linked with high levels of EPC subsets (CD34+CD133+, CD133+VEGFR2+, and CD34+ CD133+VEGFR2+). Similar results were observed with DWI lesion volumes and EPC (CD34+CD133+) on day 1. Lesion growth volume, represented as a difference between final lesion volume and baseline DWI, was larger in patients with lower day 1 EPC (CD133+VEGFR2+). After adjustments for age and admission glucose (model 1), mean arterial pressure and white blood cells (model 2), INR and hematocrit (model 3), the CD34+CD133+ subset remained predictive of baseline and day 1 lesion volumes, while CD133+VEGFR2+ predicted baseline lesion volume and growth of lesion volume.

CONCLUSIONS

Higher EPC levels were indicative of smaller volumes of acute lesion, final lesion, and lesion growth, and may serve as markers of acute phase stroke severity. However, a larger prospective study is needed to confirm our findings.

Value of International Prognostic Score (IPS) in predicting need for bone marrow biopsy (BMB) in Hodgkin's lymphoma (HL)

e19531

Background: BMB is frequently performed during the staging of patients (pts) with HL. Previous data suggested routine use of this procedure may be unnecessary. The Ann Arbor classification is currently used to detect pts requiring BMB. Despite sensitivity (sen) of 100%, specificity (spec) is only 40%. We sought to determine whether IPS [as developed by Hasenclever and Diehl (1998)] would yield greater spec while maintaining good sen. Methods: We retrospectively reviewed charts of 1215 histologically proven HL pts from Jan 2000-Dec 2008 at Cleveland Clinic Taussig and Fairview Moll Cancer Centers. Of 1215 pts, 1089 had BMB (90%). 876 pts were included in our study. 213 were excluded due to un-interpretable BMB or missing data. The IPS is calculated as the number of poor risk features present based on male sex, age ≥45, albumin (alb) <4 g/dL, hemoglobin (hem) <10.5 g/dL, stage IV, white blood cell (WBC) ≥15,000/mm3, lymphocyte (lymph) <600/mm3 and/or <8% of total WBC. Multivariable logistic regression was initially used to assess the association between BMI and each factor in the IPS. All 7 factors were significant (p<.001 for sex, age, albu, hem, stage and lymph; .07 for WBC); and therefore recursive partioning algorithm was used to identify a cutoff for determining bone marrow involvement (BMI). Results: 88 pts (10%) had BMI. Using an IPS of >3 to predict BMI, sen was 97% and spec 87%. BMI by histology was 4% lymphocyte-rich, 5% nodular sclerosis, 20% mixed-cellularity and 21% lymphocyte-depleted. Using the IPS>3 cutoff sen and spec were similar across all types of histologies; ranging from 94–100% and 86–89% respectively. Conclusions: using an IPS of >3 for predicting BMI in HL doubled the spec associated with Ann Arbor classification with little loss of sen. The implementation of IPS is a practical and reliable tool that will allow physicians to predict BMI in HL pts. It may, therefore eliminate painful BMB in many Pts.

No significant financial relationships to disclose.

Acute compartment syndrome--a life and limb threatening surgical emergency

Acute compartment syndrome is a life and limb threatening condition. Clinical assessment is the diagnostic cornerstone of compartment syndrome but pressure monitoring also has a role in equivocal cases, in unconscious or uncooperative patients, and in patients with nerve blocks and other forms of regional and epidural anesthesia. A high degree of suspicion and early decompression of all compartments at risk are important for a satisfactory outcome.

Hormone therapy – who takes it – the rich or the poor?

Abstract #5093

Introduction: In the UK, hormone therapy is provided to all breast cancer patients for a standard NHS prescription charge (approximately USD13 per month). Previous studies in the USA and the UK have shown that only 60% of patients comply fully with prescribed therapy. This study examines the effects of age, drug type, prognosis and social deprivation on hormone therapy compliance.&#x2028; Method: During scheduled outpatient appointments data was collected from patients as part of their routine follow-up. Parameters included: age, name of drug, time on drug, drug compliance (full; deviation – missing &lt;1 pill/week; holiday – missing pills &gt; 1 week; stopped), and side effects (subjective – mild; moderate; severe). Prognostic information was derived using the Nottingham Prognostic Index (NPI). The patients' home postal codes were collected and allocated to the correct electoral ward (small geographical areas with average population of 5500). Using data from the UK National Census in 2000, information on social status was derived from the patients' postal codes and given as the Index of Multiple Deprivation (ID2000). The ID2000 has both an ID2000 score and ID2000 ranking (1 to 8414) for different electoral wards across England & Wales. Low ID2000 scores and high ID2000 rankings correspond to areas of affluence. Patients in ID2000 rankings &lt;4212 were assigned as 'deprived' and &gt;4212 as 'affluent'. The predominant social grade for each ward was recorded (AB, C1, C2, D and E).&#x2028; Results: To date, 117 patients have been analysed. The ID2000 ranks ranged from 1033 to 8297. Ninety two (89%) of patients were fully compliant, 5 (5%) deviated, 2 (2%) took a holiday and 4 (4%) stopped taking their hormone treatment. Compliance was significantly better for those taking an aromatase inhibitor (AI) (96.7%) than tamoxifen (80.5%) (Chi2 test Chi2 = 7.147. p = 0.0075). Compliance is unaffected by affluence (92.5%) v deprivation (80.9%) (Chi2 test Chi2 = 2.486, p=0.11). Compliance is also unaffected by NPI (Mann Whitney U test p=0.84) and age (Mann Whitney U test p=0.78).&#x2028; Conclusion: These early data suggest that hormone drug compliance in our centre is higher than previously reported. Compliance is significantly higher for aromatase inhibitors than tamoxifen; currently there is no discernable difference between individual AIs. Compliance appears higher in affluent patients; however this is not statistically significant. Compliance appears to be independent of age, duration of therapy and prognosis. This study is ongoing and further work comparing different areas is recommended.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5093.