The Pellegrini-Stieda Lesion of the Knee: An Anatomical and Radiological Review

The Pellegrini-Stieda lesion is a calcification on the medial side of the knee. The origin of this tissue is controversial. The purpose of our study is to investigate the origin of the Pellegrini-Stieda lesion using conventional radiography as to recreate the circumstances in which Pellegrini and Stieda had to study this pathology. Six nonpaired fresh-frozen cadaveric knees were used. A surgical approach to the medial side of the knee was performed using the layered approach. The origin of the gastrocnemius muscle (GM) (n = 3) or the superficial medial collateral ligament (sMCL) (n = 3) were marked with a radio-opaque fluid. X-ray analysis was performed by measuring the distance from the proximal part of the marking to the medial tibial plateau, multilayer views, and comparison to the original X-rays by Pellegrini-Stieda. Two out of three markings in both the GM and sMCL group were matched with the correct structure. The images were digitally processed so that the osseous structures became partly transparent. After overlaying the images, we found a random distribution of the markings. The Stieda/GM group had no overlap of the markings at all. Compared with the original images from the publications by Pellegrini and Stieda, no comparable position could be found between the original lesions and the markings in our specimens. Conventional X-ray of the knee could not reproduce a distinction between the sMCL and GM as origins for the Pellegrini-Stieda lesion as suggested by Pellegrini and Stieda.

Pattern of failure in anaplastic glioma patients with an IDH1/2 mutation

PURPOSE

The current study aimed to assess patterns of failure (PoF) in anaplastic glioma (AG) patients managed with intensity-modulated radiation therapy (IMRT) and their relationship to molecular subtype.

METHODS

The outcomes of AG patients managed between 2008 and 2014 and entered into a prospective database were assessed, including PoF. AG was initially defined using the WHO 2007 classification, but for analysis, patients were subsequently recategorised based on WHO 2016 as anaplastic oligodendroglioma (AOD), astrocytoma isocitrate dehydrogenase (IDH) mutant (AAmut) or astrocytoma IDH wildtype (AAwt). Management involved IMRT and temozolomide (TMZ), including from 2011 patients with an IDH mutation (IDHmut) planned with 18F-fluoroethyltyrosine (FET) and 18F-fluorodeoxyglucose (FDG) positron-emission tomography (PET). PoF was local, marginal or distant in relation to the IMRT volume. Relapse-free survival (RFS) was calculated from the start of IMRT.

RESULTS

A total of 156 patients were assessed, with median follow-up of 5.1 years. Of these patients, 75% were IDHmut, 44% were managed at first or later relapse and 73% received TMZ. Relapse occurred in 68 patients, with 6‑year RFS of 75.0, 48.8 and 2.5% for AOD, AAmut and AAwt, respectively (p < 0.001). There was a component of local relapse in 63%, of marginal relapse in 19% and of distant relapse in 37% of relapses. Isolated local, marginal and distant relapse was evident in 51, 9 and 22%, respectively. A distant relapse pattern was more frequent in IDHmut compared to IDHwt patients (26% vs. 45%, p = 0.005), especially within the first 2 years post-IMRT. In multivariate analysis, distant relapse remained associated with AAmut (p < 0.002) and delayed IMRT until the second relapse (p < 0.001).

CONCLUSION

Although patients with IDH-mutated AG have improved outcomes, there was a higher proportion of distant relapses occurring during the 2 years after IMRT.

Abstract P1-12-12: Bubble packaging of adjuvant endocrine therapy:updated analysis of compliance and survival

Introduction: Adherence to endocrine therapy is a long recognized problem despite efficacy of these drugs with reported compliance rates of 89% in first year and 50% in fourth year. Most of our knowledge of noncompliance is observational and retrospective. This final analysis of the Bubble Study reports the compliance rate of adjuvant endocrine therapy among women with early stage breast cancer using “bubble” packaging. We previously reported adherence rates of 97% with bubble packaging. This updated analysis includes disease free survival (DFS) and overall survival (OS) at 5 years.

Methods: The Bubble study is a non-blinded, prospective observational cohort study, which enrolled 86 patients between August 2012 and April 2014. Demographic and clinical data were collected prospectively including age, race, insurance, duration of therapy, stage, treatment, comorbidities, recurrence and survival. Duration of therapy was divided into 3 cohorts: &lt;12 months, 12-36 months, and 37-60 months. All patients received routine prescriptions in a “bubble” pack or daily blister pack. Patients returned all used bubble packs at follow up appointments for review and kept a diary of missed doses for analysis. DFS and OS data were obtained at 78 months. Compliance was defined as &gt;90% adherence. We calculated institutional DFS and OS for breast cancer patients treated within a similar time frame from the tumor registry.

Results: 53 patients were included in the analysis. The remaining patients withdrew from the study prior to data collection or were deemed ineligible. The overall compliance rate was 97%; however, only 72% of enrolled patients were continued in the analysis. None of the variables examined (race, age, insurance status and stage) had an impact on compliance. Only duration of endocrine therapy had a marginal effect on compliance (p value = 0.06). The latest cohort (duration of therapy 37-60 months) was least likely to be compliant at 89.53%. Our 5-year DFS is 92% and 5-year OS is 96%. There is no statistically significant difference in DFS and OS between patients with compliance&gt;90% and &lt;90%. For ER+ breast cancer patients treated during similar timeframe at our institution outside the trial, 5-year DFS is 94% and 5-year OS is 90%.

Conclusion: There was no difference in OS or DFS based on compliance to oral anti-estrogens. Given the high overall compliance rate in this small patient population, the lack of OS and DFS difference is not surprising. However, the compliance rate of bubble packaging (&gt;90%) is higher than expected based on current literature. Although this may suggest improved compliance with bubble packaging, more studies are necessary to confirm this given small sample size and high trial dropout rate. Trial withdrawal likely altered analysis of adherence rates as it selects for a largely compliant group of patients.This bias may also explain the lack of difference in compliance rate among race, insurance status and/ or age, which contradicts our current knowledge of high-risk groups.There was a trend towards lower DFS in the bubble cohort, but overall better survival when comparing to institutional rate. Studies are ongoing to confirm bubble packaging adherence rates and compare this to established strategies to improve adherence.

Citation Format: Bhandari S, Ngo PT, Mandadi M, Wu X, Brown C, Rai S, Riley EC. Bubble packaging of adjuvant endocrine therapy:updated analysis of compliance and survival [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-12-12.

No incidence of glenohumeral joint dislocation in a review of 220 paediatric proximal humerus fractures

PURPOSE

Proximal humerus fractures in adults are approached with a high suspicion for potential associated glenohumeral dislocation. Axillary views of the shoulder can be painful and possibly even lead to dynamic angulation of the proximal humerus fracture. The incidence of associated glenohumeral dislocation in the paediatric population is unclear and it would be useful to determine whether children with proximal humerus fracture require specific axillary view imaging to rule out dislocation.

METHODS

We retrospectively reviewed 220 proximal humerus fractures in 218 total children. Imaging and follow-up clinic notes were reviewed for potential glenohumeral dislocation.

RESULTS

Average patient age was 9.8 years SD 3.8 with 55% of the patients male and a wide variety of mechanisms of injury. None of the 220 fractures evaluated showed radiographic evidence of a shoulder dislocation, and all 218 children had a follow-up appointment at least 21 days after the injury without any clinical concern of a missed shoulder dislocation.

CONCLUSION

No paediatric patients presenting with proximal humerus fractures had a corresponding glenohumeral joint dislocation in our relatively large series. We recommend obtaining this additional imaging only in cases with higher energy mechanisms, if there is suspicion of subluxation or dislocation on anteroposterior and scapular-Y views or if there is clinical concern.

LEVEL OF EVIDENCE

Level III Diagnostic.

Skeletal response to treatment with teriparatide (TPD) after bisphosphonate in post-menopausal women with osteoporosis and a high prevalence of secondary risk factors in real-life setting of a metabolic bone clinic; effect of age and vitamin D status

PURPOSE

Teriparatide (TPD) is a skeletal anabolic agent used in patients with severe post-menopausal osteoporosis (PMO) and steroid-induced osteoporosis who are at hish risk of fracture. Predictors of therapeutic response to teriparatide in real-life setting are not well characterised. We investigated potential factors associated with teriparatide response in post-menopausal women with established osteoporosis.

METHODS

We carried out a retrospective survey of 48 women, aged 73.2 [7.5] years with severe osteoporosis and prevalent fractures treated with TPD according to the NICE criteria. BMD was measured at baseline, 6-12 and 18-24 months at the lumbar spine (LS), total hip (TH) and femoral neck (FN). Bone turnover markers, serum 25 (OH)vitamin D were determined at 3-12 and 12-24 months.

RESULTS

BMD increased at 6-12 months (% change mean [SEM] 6.5 [1.1] p = 0.004) and 18-24 months (8.45 % [1.2] p<0.001) at the LS. A significant increase in BMD was observed at FN (3.1 [1.3] % p = 0.02). Changes in BMD at the TH was higher in patients younger than 73 years compared to older women (% change in BMD 4.13 [1.64] % v/s -1.7 [1.1] p = 0.007). Baseline 25 (OH) vitamin D correlated with change in P1NP at 3-12 months (r = 0.45 p = 0.049).

CONCLUSIONS

TPD-induced changes in BMD at the TH appears may be dependent on age. Vitamin D status may influence the early anabolic effect to TPD. Our data suggest that these factors may be important considerations when initiating and optimising treatment with TPD, although further larger studies are needed to confirm these findings.

Perioperative cognitive protection

There is significant evidence that many older surgical patients experience at least a transient decrease in cognitive function. Although there is still equipoise regarding the degree, duration, and mechanism of cognitive dysfunction, there is a concurrent need to provide best-practice clinical evidence. The two major cognitive disorders seen after surgery are postoperative delirium and postoperative cognitive dysfunction. Delirium is a public health problem; millions of dollars are spent annually on delirium-related medical resource use and prolonged hospital stays. Postoperative cognitive dysfunction is a research construct that historically signifies decline in performance on a neuropsychiatric test or group of tests and begins days to weeks after surgery. This review focuses on the current state of information gathered by several interdisciplinary stakeholder groups. Although there is still a need for high-level evidence to guide clinical practice, there is an emerging literature that can guide practitioners.