Prognostic value of changes in spinal cord signal intensity on magnetic resonance imaging in patients with cervical compressive myelopathy

BACKGROUND CONTEXT

Signal intensity on preoperative cervical magnetic resonance imaging (MRI) of the spinal cord has been shown to be a potential predictor of outcome of surgery for cervical compressive myelopathy. However, the prognostic value of such signal remains controversial. One reason for the controversy is the lack of proper quantitative methods to assess MRI signal intensity.

PURPOSE

To quantify signal intensity and to correlate intramedullary signal changes on MRI T1- and T2-weighted images (WIs) with clinical outcome and prognosis.

STUDY DESIGN

Retrospective case study.

PATIENT SAMPLE

Patients (n=148; cervical spondylotic myelopathy, n=102 and ossified posterior longitudinal ligament, n=46) who underwent surgery for cervical compressive myelopathy and had high signal intensity change on sagittal T2-WI MRI before surgery between 2006 and 2010.

OUTCOME MEASURE

Neurologic assessment was conducted with the Japanese Orthopedic Association (JOA) scoring system for cervical myelopathy. The rate of neurologic improvement was calculated with the use of preoperative and postoperative JOA scores.

METHODS

Quantitative analysis of MRI signal on both T1- and T2-WIs via use of the signal intensity ratio (SIR; signal intensity of lesion relative to that at C7-T1 disc level) was performed. Correlations between SIR on T1- and T2-WIs and preoperative JOA score, JOA improvement rate, disease duration, and MRI morphologic classification (cystic or diffuse type) were analyzed. Multivariate regression analysis for JOA improvement rate was also analyzed. In a substudy, 25 patients underwent follow-up MRI starting from 6 months after surgery to analyze the relationship between changes in SIR on follow-up MRI and clinical outcome.

RESULTS

SIR on T1-WIs, but not SIR on T2-WIs, correlated with postoperative neurologic improvement. The disease duration correlated negatively with SIR on T1-WIs and JOA improvement rate but not with SIR on T2-WIs. SIR on T2-WIs of "cystic type" was significantly greater than of "diffuse type," but SIR on T1-WI and JOA improvement rate were not different in the two types. Stepwise multivariate regression analysis indicated that SIR on T1-WIs and long disease duration were significant predictors of postoperative neurologic outcome. SIR on follow-up T1-WI and changes in SIR on T1-WI after surgery correlated positively with postoperative improvement rate. SIR on follow-up T2-WI and changes on T2-WI correlated negatively with postoperative neurologic improvement.

CONCLUSIONS

Our results suggest that low intensity signal on preoperative T1-WIs but not T2-WIs correlated with poor postoperative neurologic outcome. Furthermore, decreased signal intensity on postoperative T1-WIs and increased signal intensity on postoperative T2-WIs are predictors of poor neurologic outcome.

Molecular Cloning and Sequencing of the Extracellular Pectate Lyase II Gene fromErwinia carotovoraEr

Erwinia carotovora Er produces three extra-cellular pectate lyases (PL I, II, and III). The gene for pectate lyase II (pelII) of E. carotovora Er was cloned and expressed both in Escherichia coli and E. carotovora Er. Localization experiments in E. coli showed that PL II was exclusively in the cytoplasmic space, while PL II was excreted into the culture medium. The complete nucleotides of the pelII gene were sequenced and found to include one open reading frame of 1122 bp coding for a protein of 374 amino acid residues. From comparison of the N-terminal amino acid sequence between the purified PL II and the deduced protein from the nucleotide sequence we reached the conclusion that the mature protein is composed of 352 amino acids with a calculated molecular weight of 38,169 and is preceded by a typical signal sequence of 22 amino acid residues. PL II had 90.1% and 82.9% homologies with PL I and PL III in amino acid sequence, respectively.

RET-rearranged non-small-cell lung carcinoma: a clinicopathological and molecular analysis

BACKGROUND

To elucidate clinicopathological characteristics of non-small-cell lung carcinoma (NSCLC) cases carrying RET rearrangements causing oncogenic fusions to identify responders to therapy with RET tyrosine kinase inhibitors.

METHODS

We investigated 1874 patients with carcinomas, including 1620 adenocarcinomas (ADCs), 203 squamous cell carcinomas (SCCs), 8 large cell carcinomas, and 43 sarcomatoid carcinomas (SACs). Fluorescence in situ hybridisation (FISH) and/or reverse transcription-PCR (RT-PCR) were performed to detect RET gene rearrangement.

RESULTS

In all, 22 cases (1.2%) showed RET rearrangements; all cases were of ADC histology. Of the 22 patients, 19 possessed KIF5B-RET fusion genes, whereas 3 possessed CCDC6-RET fusion genes. The RET-rearranged tumours were significantly more common in younger patients (P=0.038) and tended to occur in patients with no history of smoking (P=0.051). In addition, RET rearrangements were not associated with gender, occupational history (particularly radioactive exposure), tumour size, lymph node status, tumour stage, or patient survival. The predominant growth pattern in RET-rearranged ADCs was lepidic in 6 cases, papillary in 9 cases, acinar in 2 cases, micropapillary in 1 case, and solid in 4 cases. Cells with cytoplasmic mucin production were at least focally present in 12 of the 22 (54.5%) RET-rearranged ADC cases. Among the 21 analysed RET-rearranged tumours, RET immunopositivity was observed in 15 cases (71.4%), and was significantly associated with RET rearrangement (P<0.001).

CONCLUSIONS

The RET rearrangements were observed in 1.2% of NSCLCs. All cases of RET rearrangement were ADCs. The RET rearrangements were more likely to be observed in younger patients. Although cytoplasmic mucin production was at least focally present in 54.5% of RET-rearranged ADCs, specific histological features were not detected.

Gender differences in the incidence and progression of diabetic retinopathy among Japanese patients with type 2 diabetes mellitus: a clinic-based retrospective longitudinal study

A clinic-based retrospective longitudinal study conducted for 5.8 ± 2.5 years, including 383 (M/F 245/138) Japanese patients with type 2 diabetes mellitus showed that females exhibit a significantly higher prevalence of proliferative diabetic retinopathy (DR) at baseline and that female gender is an independent risk factor for the development of DR.

Perioperative patient safety indicators and hospital surgical volumes

Background

Since the late 1990s, patient safety has been an important policy issue in developed countries. To evaluate the effectiveness of the activities of patient safety, it is necessary to quantitatively assess the incidence of adverse events by types of failure mode using tangible data. The purpose of this study is to calculate patient safety indicators (PSIs) using the Japanese Diagnosis Procedure Combination/per-diem payment system (DPC/PDPS) reimbursement data and to elucidate the relationship between perioperative PSIs and hospital surgical volume.

Methods

DPC/PDPS data of the Medi-Target project managed by the All Japan Hospital Association were used. An observational study was conducted where PSIs were calculated using an algorithm proposed by the US Agency for Healthcare Research and Quality. We analyzed data of 1,383,872 patients from 188 hospitals who were discharged from January 2008 to December 2010.

Results

Among 20 provider level PSIs, four PSIs (three perioperative PSIs and decubitus ulcer) and mortality rates of postoperative patients were related to surgical volume. Low-volume hospitals (less than 33rd percentiles surgical volume per month) had higher mortality rates (5.7%, 95% confidence interval (CI), 3.9% to 7.4%) than mid- (2.9%, 95% CI, 2.6% to 3.3%) or high-volume hospitals (2.7%, 95% CI, 2.5% to 2.9%). Low-volume hospitals had more deaths among surgical inpatients with serious treatable complications (38.5%, 95% CI, 33.7% to 43.2%) than high-volume hospitals (21.4%, 95% CI, 19.0% to 23.9%). Also Low-volume hospitals had lower proportion of difficult surgeries (54.9%, 95% CI, 50.1% to 59.8%) compared with high-volume hospitals (63.4%, 95% CI, 62.3% to 64.6%). In low-volume hospitals, limited experience may have led to insufficient care for postoperative complications.

Conclusions

We demonstrated that PSIs can be calculated using DPC/PDPS data and perioperative PSIs were related to hospital surgical volume. Further investigations focusing on identifying risk factors for poor PSIs and effective support to these hospitals are needed.

RET-rearranged non-small-cell lung carcinoma: a clinicopathological and molecular analysis

Background:

To elucidate clinicopathological characteristics of non-small-cell lung carcinoma (NSCLC) cases carrying RET rearrangements causing oncogenic fusions to identify responders to therapy with RET tyrosine kinase inhibitors.

Methods:

We investigated 1874 patients with carcinomas, including 1620 adenocarcinomas (ADCs), 203 squamous cell carcinomas (SCCs), 8 large cell carcinomas, and 43 sarcomatoid carcinomas (SACs). Fluorescence in situ hybridisation (FISH) and/or reverse transcription–PCR (RT–PCR) were performed to detect RET gene rearrangement.

Results:

In all, 22 cases (1.2%) showed RET rearrangements; all cases were of ADC histology. Of the 22 patients, 19 possessed KIF5B–RET fusion genes, whereas 3 possessed CCDC6–RET fusion genes. The RET-rearranged tumours were significantly more common in younger patients (P=0.038) and tended to occur in patients with no history of smoking (P=0.051). In addition, RET rearrangements were not associated with gender, occupational history (particularly radioactive exposure), tumour size, lymph node status, tumour stage, or patient survival. The predominant growth pattern in RET-rearranged ADCs was lepidic in 6 cases, papillary in 9 cases, acinar in 2 cases, micropapillary in 1 case, and solid in 4 cases. Cells with cytoplasmic mucin production were at least focally present in 12 of the 22 (54.5%) RET-rearranged ADC cases. Among the 21 analysed RET-rearranged tumours, RET immunopositivity was observed in 15 cases (71.4%), and was significantly associated with RET rearrangement (P<0.001).

Conclusions:

The RET rearrangements were observed in 1.2% of NSCLCs. All cases of RET rearrangement were ADCs. The RET rearrangements were more likely to be observed in younger patients. Although cytoplasmic mucin production was at least focally present in 54.5% of RET-rearranged ADCs, specific histological features were not detected.

Projections from the dorsal peduncular cortex to the trigeminal subnucleus caudalis (medullary dorsal horn) and other lower brainstem areas in rats

This study has revealed direct projections from the dorsal peduncular cortex (DP) in the medial prefrontal cortex (mPfC) to the trigeminal brainstem sensory nuclear complex and other lower brainstem areas in rats. We first examined the distribution of mPfC neurons projecting directly to the medullary dorsal horn (trigeminal subnucleus caudalis [Vc]) and trigeminal subnucleus oralis (Vo) which are known to receive direct projections from the lateral prefrontal cortex (insular cortex). After injections of the retrograde tracer Fluorogold (FG) into the rostro-dorsomedial part of laminae I/II of Vc (rdm-I/II-Vc), many neurons were labeled bilaterally (with an ipsilateral predominance) in the rostrocaudal middle level of DP (mid-DP) and not in other mPfC areas. After FG injections into the lateral and caudal parts of laminae I/II of Vc, or the Vo, no neurons were labeled in the mPfC. We then examined projections from the mid-DP by using the anterograde tracer biotinylated dextranamine (BDA). After BDA injections into the mid-DP, many axons and terminals were labeled bilaterally (with an ipsilateral predominance) in the rdm-I/II-Vc, periaqueductal gray and solitary tract nucleus, and ipsilaterally in the parabrachial nucleus and trigeminal mesencephalic nucleus. In addition, the connections of the mid-DP with the insular cortex were examined. Many BDA-labeled axons and terminals from the mid-DP were also found ipsilaterally in the caudalmost level of the granular and dysgranular insular cortex (GI/DI). After BDA injections into the caudalmost GI/DI, many axons and terminals were labeled ipsilaterally in the mid-DP. The projections from the mid-DP to the rdm-I/II-Vc and other brainstem nuclei suggest that mid-DP neurons may regulate intraoral and perioral sensory processing (including nociceptive processing) of rdm-I/II-Vc neurons directly or indirectly through the brainstem nuclei. The reciprocal connections between the mid-DP and caudalmost GI/DI suggest that this regulation may involve mid-DP interactions with the caudalmost GI/DI neurons.

Abstract P3-14-10: Conversion to node-negative after neoadjuvant chemotherapy is a surrogate prognostic marker in patients with hormone receptor-positive breast cancer

Background: While pathologic complete response (pCR) after neoadjuvant chemotherapy (NAC) improves patients’ survival with HER2-positive and triple-negative (TN) breast cancers, it has been reported not to be the same for patients with hormone receptor (HR)-positive breast cancer. However, it is not well known whether chemosensitivity presented by change in tumor stage or nodal status after NAC contributes to improve the prognosis with HR-positive breast cancer. The aim of this study was to evaluate the impact of change in tumor stage or nodal status after NAC on prognosis in patients with primary breast cancer.

Patients and Methods: We assessed retrospectively 599 consecutive patients with primary breast cancer (a median age of 49 years, ranging 26-79 years) who underwent surgical resection after NAC between 2001 and 2008. HR (ER and PR) statuses were determined by immunohistochemistory (IHC). HER2 status was determined by IHC and/or fluorescent in situ hybridization assays. ER-positive and PR-positive patients were 426 (71.1%) and 353 patients (58.9%), respectively. HER2 status was positive in 130 patients (21.7%). HR-positive subtype was defined as ER and/or PR-positive and HER2 negative. We compared the patients with respect to disease-free survival (DFS) and overall survival (OS) based on change in tumor stage and nodal status after NAC. pCR was defined as no residual invasive tumor and ypN0.

Results: After NAC, 84 (14.0%) patients had pCR. Two hundred ninety one (48.6%) decreased tumor stage and 308 (51.4%) did not decrease tumor stage. Regarding nodal status, 190 (31.7%) had cN0 and 409 (68.3%) had cN+ before NAC, and 286 had ypN0 (47.7%) and 313 had ypN+ (52.2%). For patients with TN breast cancer, patients with pCR had excellent prognosis compared to those with residual tumor in either the breast or lymph node (non-pCR) (DFS, p&lt;0.01, and OS, p = 0.035, respectively). Among the non-pCR group, patients with ypN0 also have longer DFS and OS than patients with ypN+ (p&lt;0.01, and p = 0.031, respectively). However, for ypN0 patients with TN breast cancer, patients with residual primary tumor had significantly shorter DFS and OS than patients with ypT0. For HR-positive breast cancer patients, there was a trend that patients with pCR had better DFS than patients with non-pCR (p = 0.069). In terms of OS, there was no significant difference between pCR and non-pCR (p = 0.285). Patients with ypN0 had significantly longer DFS and OS than those with ypN+ regardless of residual tumor stage (p&lt; 0.001 and p = 0.01, respectively). Change in tumor stage itself did not contribute to improve patients’ survival.

Conclusions: Our results revealed that HR-positive breast cancer patients with conversion to lymph nodes metastasis after NAC have a good prognosis even if they have residual tumor in the breast, while TN breast cancer patients require pCR to have a good prognosis. It indicated that conversion to node-negative after neoadjuvant chemotherapy might be a surrogate prognostic marker in patients with HR-positive breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-14-10.

Clinicopathological features of nonsmall cell lung carcinomas with BRAF mutations

BACKGROUND

Recently, driver tyrosine kinase gene mutations have been detected in malignant tumors, including lung tumors. Notwithstanding their attractiveness as targets for molecular therapy, limited information is available regarding BRAF-mutated lung carcinomas.

MATERIALS AND METHODS

BRAF mutation status was determined in 2001 surgically resected nonsmall-cell lung cancer (NSCLC) cases using high-resolution melting analysis (HRMA) followed by Sanger sequencing and/or deep sequencing using next generation sequencer.

RESULTS

BRAF mutations were detected in 26 (1.3%) of 2001 NSCLC cases (25 adenocarcinomas and 1 squamous cell carcinoma). In the 26 cases, 13 mutation genotypes were identified, including V600E (8 of 26; 30.8%), G469A (6 of 26; 23.1%), K601E (4 of 26; 15.4%), and other residual mutations (1 of 26; 0.04%). Of the 13 genotypes, 4 genotypes (G464E, G596R, A598T, and G606R) had not been previously reported in lung cancer. The overall survival rate was not significantly different between patients with wild-type BRAF and those with V600E or non-V600E BRAF mutations (P = 0.49 and P = 0.15, respectively). Histomorphological analysis revealed that focal clear cell changes were present in 75% of V600E-mutated tumors. All V600E BRAF-mutated tumors were negative for other driver gene alterations including epidermal growth factor receptor (EGFR) and KRAS mutations and the anaplastic lymphoma kinase gene translocation, whereas five tumors with non-V600E BRAF mutations (four G469A and one G464E/G466R) showed concomitant EGFR mutations.

CONCLUSION

The frequency of BRAF mutations in lung cancer was low in an Asian cohort. Furthermore, BRAF mutation status lacked prognostic significance in this patient population.

Evaluation of matrix-assisted laser desorption ionization-time of flight mass spectrometry for species identification of Acinetobacter strains isolated from blood cultures

The clinical relevance of Acinetobacter species, other than A. baumannii, as human pathogens has not been sufficiently assessed owing to the insufficiency of simple phenotypic clinical diagnostic laboratory tests. Infections caused by these organisms have different impacts on clinical outcome and require different treatment and management approaches. It is therefore important to correctly identify Acinetobacter species. Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has been introduced to identify a wide range of microorganisms in clinical laboratories, but only a few studies have examined its utility for identifying Acinetobacter species, particularly those of the non-Acinetobacter baumannii complex. We therefore evaluated MALDI-TOF MS for identification of Acinetobacter species by comparing it with sequence analysis of rpoB using 123 isolates of Acinetobacter species from blood. Of the isolates examined, we identified 106/123 (86.2%) to species, and 16/123 (13.0%) could only be identified as acinetobacters. The identity of one isolate could not be established. Of the 106 species identified, 89/106 (84.0%) were confirmed by rpoB sequence analysis, and 17/106 (16.0%) were discordant. These data indicate correct identification of 89/123 (72.4%) isolates. Surprisingly, all blood culture isolates were identified as 13 species of Acinetobacter, and the incidence of Acinetobacter pittii was unexpectedly high (42/123; 34.1%) and exceeded that of A. baumannii (22/123; 17.9%). Although the present identification rate using MALDI-TOF MS is not acceptable for species-level identification of Acinetobacter, further expansion of the database should remedy this situation.