Whole joint MRI assessment of surgical cartilage repair of the knee: cartilage repair osteoarthritis knee score (CROAKS)

OBJECTIVE

To develop a magnetic resonance imaging (MRI) scoring system for follow-up of knee cartilage repair procedures integrating assessment of the repair site and the whole joint called Cartilage Repair OsteoArthritis Knee Score (CROAKS), and to assess its reliability.

DESIGN

MRI examinations of 20 patients that had undergone matrix-associated autologous chondrocyte transplantation (MACT) of the knee 12 months before were semi-quantitatively assessed for the repair site using features of the magnetic resonance observation of cartilage repair tissue (MOCART) system and for the whole joint based on experiences with the MRI Osteoarthritis Knee Score (MOAKS) instrument. Intra- and inter-observer reliability was calculated using weighted (w) kappa statistics for plates (medial/lateral tibia, medial/lateral femur, trochlea, patella), compartments (medial tibio-femoral, lateral tibio-femoral, patello-femoral) and the whole joint. For certain features with low prevalence the overall percent agreement was calculated in addition.

RESULTS

For cartilage, reliability on a plate level ranged between 0.48 (lateral femur) and 1.00 (medial femur). BML assessment showed comparable results ranging on a plate level between 0.46 and 1.00 with overall percent agreement between 83.3% and 100%. Meniscal morphology assessment ranged between 0.62 and 0.94. For repair site assessment reliability ranged from 0.41 (signal intensity inter-observer) to 1.00 (several features). Overall percent agreement was above 80% for 17 of 22 features assessed (intra- and inter-observer results combined).

CONCLUSIONS

Combined scoring of the repair site and whole joint assessment for common osteoarthritis features using CROAKS, which is based on experience with two established semi-quantitative scoring tools, is feasible and may be performed with good to excellent reliability.

Geographic disparities in surgery for breast and rectal cancer in Canada

Equitable access to appropriate cancer treatment is fundamental for achieving universal, high-quality cancer care [...]

Abstract P3-06-02: The use of imaging and tumor markers in the staging of patients age <65 years with early-stage breast cancer

Purpose

Guidelines from the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) recommend against the use of positron emission tomography (PET), computed tomography (CT), radionuclide bone scans (RBS) and tumor markers (TM) in the staging of early-stage breast cancer with a low risk for distant metastasis. No previous studies have described the use of these tests or identified factors associated with this practice in patients age <65 years.

Methods

We used the national employer-based claims database MarketScan to identify patients with a first diagnosis of breast cancer, age 20 to 64 years, who had undergone a mastectomy or a lumpectomy, and a sentinel lymph node biopsy between the years of 2005 and 2010. We excluded patients who had undergone an axillary lymph node dissection, as this may indicate advanced nodal disease for which staging tests may be recommended. We ascertained claims for PET, CT, RBS and TM during the period of 3 months before and 1 month after the date of surgery. We used a multivariable logistic regression model to identify factors associated with the use of these tests. The variables included in the model were: age at diagnosis, geographic region, year of diagnosis, type of surgery (lumpectomy vs. mastectomy), endocrine therapy (yes vs. no), radiation therapy (yes vs. no), and chemotherapy (trastuzumab-based, non-trastuzumab-based, vs. no).

Results

We identified 42,606 patients (median age 53 years) of whom 12% had at least one claim for a PET, 6.5% for a CT, and 2.5% for TM. In combination, 17% of the patients had at least one claim for a test. Among patients diagnosed in 2005, 14% had claims for tests, whereas between 2006 and 2010, this proportion ranged between 16% and 18% (test for trend p-value: 0.08). Among patients who had chemotherapy, 22% of those who received trastuzumab-based regimens and 21% of those who received non-trastuzumab-based regimens had claims for tests, compared to 14% of patients who did not receive chemotherapy. In the regression analysis, we observed geographic differences, where patients from the Northeast had increased odds of testing, compared to patients from the North Central region (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.34 - 1.59). Patients who underwent a lumpectomy had decreased odds of testing, compared to those who had a mastectomy (OR 0.62, 95% CI 0.57 - 0.66). Patients who received radiation therapy (OR 1.30; 95% CI 1.20 - 1.40) and chemotherapy (non-trastuzumab-based: OR 1.67, 95% CI 1.58 - 1.77; trastuzumab-based: OR 1.69, 95% CI 1.55 - 1.84) had increased odds of testing.

Conclusion

Despite current ASCO and NCCN guidelines, the use of imaging tests and TM in the staging of early-stage breast cancer remains common, and there is no clear trend of a change of this non-recommended practice over time. Subsets of patients with early-stage breast cancer had an increased probability of undergoing tests not recommended for staging purposes. The use of imaging tests and TM may be increased in those patients who are perceived to be at a higher risk for metastasis during diagnosis, as there was a significant association of this practice with mastectomy (over lumpectomy), radiation therapy and chemotherapy.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-06-02.

Abstract P5-08-09: Synergistic cytotoxicity of digoxin and 5-fluorouracil in doxorubicin-resistant breast cancer cell lines

BACKGROUND: Metastatic breast cancer is the leading cause of cancer death for women in the US. Cytotoxic chemotherapy remains one of the most important systemic treatment options for breast cancer patients. To enhance the tumor response to chemotherapy, attention has been focused on agents that reverse multidrug resistance (MDR) and increase the sensitivity of tumor cells to chemical drugs. Although many reversal drugs have been identified in vitro, their clinical application has been limited due to their own toxicity. It was reported that 5 years after mastectomy, the recurrence rate of breast cancer among patients on cardiac glycoside therapy, namely digoxin or digitoxin, was almost 10 times lower as compared with those who were not on cardiac glycoside therapy. Digoxin has also been shown to inhibit hypoxia-inducible factors (HIF) and block lung metastasis in a breast cancer model. Interestingly, digoxin was demonstrated to stimulate cell death in various cell lines including breast cancer. Therefore the aim of this study was to examine the reversal effect of combined digoxin and 5-fluorouracil (5-FU) on MDR resistance in human breast cell lines MCF-7 and MDA-MB-231 in vitro, as well as its mechanism of action.

METHODS: Wild-type and doxorubicin-resistant ER-positive (MCF-7 and MCF-7/DoxR) and triple negative (MDA-MB-231 and MDA-231/DoxR) breast cancer lines were used for this study. We have previously shown that both doxorubicin-resistant cell lines are also cross-resistant to 5-FU. Cell viability of both resistant cancer cell lines to 5-FU, digoxin, and both 5-FU with digoxin were compared to control at 96 hours of incubation both in normoxia and hypoxia using MTT assay. Western blot was used to quantify the level of HIF-1α and p-glycoprotein (P-gP).

RESULTS: In both doxorubicin-resistant cell lines, sub-IC50 concentration of digoxin together with 5-FU significantly decreased the cell viabilities at 96 hours compared to single agent digoxin and 5-FU. Under both normoxic and hypoxic conditions, the same synergistic cytotoxic effects were demonstrated. Western blot revealed that HIF-1α and P-gP were decreased in both doxorubicin-resistant breast cancer cells treated with the digoxin and 5-FU combination compared to single agent digoxin or 5-FU.

CONCLUSION: The combination of digoxin and 5-FU demonstrates a synergistic cytotoxic effect in doxorubicin-resistant breast cancer cell lines that is maintained under hypoxic conditions. This is, at least in part, via the inhibitory effects on both HIF-1α and P-gP. The combination of digoxin and 5-FU could be an effective clinical treatment strategy to overcome MDR in breast cancer. A phase II clinical trial is ongoing to test this hypothesis in patients with doxorubicin-resistant metastatic breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-08-09.

Abstract P5-08-10: Upregulation of microRNA-181a promotes metastasis of breast cancer cells following chemotherapy

Recent studies indicated that genotoxic treatment may promote cancer cell invasion. Moreover, resistance to chemotherapy highly correlates with high metastatic potential in breast cancer patients. Nevertheless, the molecular mechanisms linking chemotherapeutic resistance to metastasis remain poorly understood. Here, we show that microRNA-181a (miR-181a) plays an important role in promoting chemodrug-induced breast cancer metastasis. Treatment with genotoxic drugs increases miR-181a expression in triple-negative breast cancer cells, which is dependent on NF-kB activation by DNA damaging agents. Genotoxic NF-κB activation upregulates IL-6 expression and secretion in breast cancer cells, which leads to STAT3 (signal transducer and activator of transcription 3) phosphorylation and activation. Activated STAT3 translocates onto miR-181a gene promoter region and enhances its transcription in response to genotoxic treatments. Interestingly, chemodrug treatment also induces epigenetic modifications, such as increased histone H3 Ser28 phosphorylation and decreased H3 Lys27 trimethylation, at miR-181a promoter region, which are also required for miR-181a up-regulation. In addition, we found overexpression of miR-181a in breast cancer cells significantly enhanced cell invasion and metastasis, while inhibiting miR-181a reduced cell aggressiveness upon genotoxic exposure. We further show that miR-181a directly suppresses the expression of ataxia telangiectasia mutated (ATM) in breast cancer cells, which plays a pivotal role in DNA damage response and cancer progression. Therefore, our findings support a critical role of DNA damage-induced miR-181a in promoting breast cancer metastasis following chemotherapeutic treatment. Further exploration of molecular mechanisms regulating miR-181a induction and miR-181a-driven aggressive behaviors of breast cancer cells in response to chemotherapy may reveal novel approaches to reduce metastasis and improve therapeutic response in breast cancers by targeting miRNAs.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-08-10.

Provincial rates and time trends in pancreatic cancer outcomes

Pancreatic cancer, often called the “silent killer,” is the twelfth most common cancer in Canada, with an estimated 4600 new cases in 2012. [...]

New chart review data validate administrative data-based indicator for guideline-recommended treatment of locally advanced non-small-cell lung cancer and shed light on reasons for non-referral and non-treatment

The 2012 Cancer System Performance Report is the 4th annual report on the Canadian cancer control system produced by the System Performance initiative at the Canadian Partnership Against Cancer, in collaboration with its provincial and national partners. [...]

Efficacy and safety of continuous 4-year telbivudine treatment in patients with chronic hepatitis B

In the phase-III GLOBE/015 studies, telbivudine demonstrated superior efficacy vs lamivudine during 2-year treatment in HBeAg-positive and HBeAg-negative chronic hepatitis B (CHB). After completion, 847 patients had an option to continue telbivudine treatment for further 2 years. A total of 596 (70%) of telbivudine-treated patients, who were serum HBV DNA positive or negative and without genotypic resistance to telbivudine at the end of the GLOBE/015 trials, were enrolled into a further 2-year extension study. A group of 502 patients completed 4 years of continuous telbivudine treatment and were included in the telbivudine per-protocol population. Amongst 293 HBeAg-positive patients, 76.2% had undetectable serum HBV DNA and 86.0% had normal serum ALT at the end of 4 years. Notably, the cumulative rate of HBeAg seroconversion was 53.2%. Amongst 209 HBeAg-negative patients, 86.4% had undetectable HBV DNA and 89.6% had normal serum ALT. In patients who had discontinued telbivudine treatment due to HBeAg seroconversion, the HBeAg response was durable in 82% of patients (median 111 weeks of off-treatment follow-up). The cumulative 4-year resistance rate was 10.6% for HBeAg-positive and 10.0% for HBeAg-negative patients. Most adverse events were mild or moderate in severity and transient. Renal function measured by estimated glomerular filtration rate (eGFR) increased by 14.9 mL/min/1.73 m(2) (16.6%) from baseline to 4 years (P < 0.0001). In conclusion, in HBeAg-positive and HBeAg-negative CHB patients without resistance after 2 years, two additional years of telbivudine treatment continued to provide effective viral suppression with a favourable safety profile. Moreover, telbivudine achieved 53% of HBeAg seroconversion in HBeAg-positive patients.

Co-occupant's exposure to exhaled pollutants with two types of personalized ventilation strategies under mixing and displacement ventilation systems

Personalized ventilation (PV) system in conjunction with total ventilation system can provide cleaner inhaled air for the user. Concerns still exist about whether the normally protecting PV device, on the other hand, facilitates the dispersion of infectious agents generated by its user. In this article, two types of PV systems with upward supplied fresh air, namely a chair-based PV and one kind of desk-mounted PV systems, when combined with mixing ventilation (MV) and displacement ventilation (DV) systems, are investigated using simulation method with regard to their impacts on co-occupant's exposure to the exhaled droplet nuclei generated by the infected PV user. Simulation results of tracer gas and particles with aerodynamic diameter of 1, 5, and 10 μm from exhaled air show that, when only the infected person uses a PV, the different PV air supplying directions present very different impacts on the co-occupant's intake under DV, while no apparent differences can be observed under MV. The findings demonstrate that better inhaled air quality can always be achieved under DV when the adopted PV system can deliver conditioned fresh air in the same direction with the mainly upward airflow patterns of DV.

Three-dimensional turbo spin-echo magnetic resonance imaging (MRI) and semiquantitative assessment of knee osteoarthritis: comparison with two-dimensional routine MRI

PURPOSE

The aim of this study was to evaluate three-dimensional (3D) turbo spin-echo (TSE) magnetic resonance imaging (MRI) for semiquantitative assessment of knee OA.

MATERIALS AND METHOD

Twenty subjects fulfilling the American College of Rheumatology clinical criteria of knee OA underwent both two-dimensional (2D) and 3D MRIs on the same day. The 2D MRI protocol included triplanar fat-suppressed (FS) intermediate-weighted (Iw) TSE. For the 3D TSE technique, a sagittal FS Iw sequence was acquired and triplanar reformations were constructed. 2D and 3D MRIs were read separately by two radiologists using the Whole-Organ Magnetic Resonance Imaging Score (WORMS) system. Agreement was determined using weighted kappa statistics and percentage of overall agreement. The diagnostic performance of WORMS readings using 3D TSE MRI to detect the presence or absence of features was assessed using readings from 2D TSE images as a reference.

RESULTS

Agreement for the scored features ranged between 0.62 (osteophytes (OS)) and 0.94 (meniscal extrusion). The sensitivity of WORMS readings using the 3D TSE technique ranged between 80% (periarticular cysts) and 100% (several features), the specificity ranged between 62.3% (OS) and 100% (several features), and accuracy ranged between 77.2% (OS) and 99.3% (subchondral cysts).

CONCLUSIONS

Semiquantitative assessment of knee OA can be reliably performed using 3D TSE MRI, showing substantial to almost perfect agreement and high accuracy when compared to routine 2D TSE MRI. 3D TSE MRI also takes less time, which is important for large OA studies.

Thrombotic risk factors in Chinese Budd-Chiari syndrome patients. An observational study with a systematic review of the literature

In Western countries, thrombotic risk factors for Budd-Chiari syndrome (BCS) are very common, including factor V Leiden mutation, prothrombin G20210A mutation, myeloproliferative neoplasms, paroxysmal nocturnal haemoglobinuria, etc. However, the data regarding thrombotic risk factors in Chinese BCS patients are extremely limited. An observational study was conducted to examine this issue. A total of 246 BCS patients who were consecutively admitted to our department between July 1999 and December 2011 were invited to be examined for thrombotic risk factors. Of these, 169 patients were enrolled. Neither factor V Leiden mutation nor prothrombin G20210A mutation was found in any of 136 patients tested. JAK2 V617F mutation was positive in four of 169 patients tested. Neither MPL W515L/K mutation nor JAK2 exon 12 mutation was found in any of 135 patients tested. Overt myeloproliferative neoplasms were diagnosed in five patients (polycythemia vera, n=3; essential thrombocythemia, n=1; idiopathic myelofibrosis, n=1). Two of them had positive JAK2 V617F mutation. Both CD55 and CD59 deficiencies were found in one of 166 patients tested. This patient had a previous history of paroxysmal nocturnal haemo-globinuria before BCS. Anticardiolipin IgG antibodies were positive or weakly positive in six of 166 patients tested. Hyperhomocysteinaemia was found in 64 of 128 patients tested. 5,10-methylenetetrahydrofolate reductase C677T mutation was found in 96 of 135 patients tested. In conclusion, factor V Leiden mutation, prothrombin G20210A mutation, myeloproliferative neoplasms, and paroxysmal nocturnal haemoglobinuria are very rare in Chinese BCS patients, suggesting that the etiological distribution of BCS might be different between Western countries and China.

A retrospective chart review validates indicator results and provides insight into reasons for non-concordance with evidence-based guidelines

As part of the system performance initiative of the Canadian Partnership Against Cancer, indicators measuring treatment practice patterns across the country relative to evidence-based guidelines were first published in 2010 and are updated annually. Among the treatment indicators examined is the percentage of resected stage ii and iii rectal cancer patients receiving neoadjuvant (preoperative) radiation therapy (RT), the treatment approach recommended for locally advanced rectal cancer

Elevated tibiofemoral articular contact stress predicts risk for bone marrow lesions and cartilage damage at 30 months

OBJECTIVE

As cartilage loss and bone marrow lesions (BMLs) are associated with knee joint pain and structural worsening, this study assessed whether non-invasive estimates of articular contact stress may longitudinally predict risk for worsening of knee cartilage morphology and BMLs.

DESIGN

This was a longitudinal cohort study of adults aged 50-79 years with risk factors for knee osteoarthritis. Baseline and follow-up measures included whole-organ magnetic resonance imaging score (WORMS) classification of knee cartilage morphology and BMLs. Tibiofemoral geometry was manually segmented on baseline magnetic resonance imaging (MRI), and three-dimensional (3D) tibiofemoral point clouds were registered into subject-specific loaded apposition using fixed-flexion knee radiographs. Discrete element analysis (DEA) was used to estimate mean and peak contact stresses for the medial and lateral compartments. The association of baseline contact stress with worsening cartilage and BMLs in the same subregion over 30 months was assessed using conditional logistic regression.

RESULTS

Subjects (N = 38, 60.5% female) had a mean ± standard deviation (SD) age and body mass index (BMI) of 63.5 ± 8.4 years and 30.5 ± 3.7 kg/m2 respectively. Elevated mean articular contact stress at baseline was associated with worsening cartilage morphology and worsening BMLs by 30 months, with odds ratio (OR) [95% confidence interval (CI)] of 4.0 (2.5, 6.4) and 6.6 (2.7, 16.5) respectively. Peak contact stress also was significantly associated with worsening cartilage morphology and BMLs {1.9 (1.5, 2.3) and 2.3 (1.5, 3.6)}(all P < 0.0001).

CONCLUSIONS

Detection of higher contact stress 30 months prior to structural worsening suggests an etiological role for mechanical loading. Estimation of articular contact stress with DEA is an efficient and accurate means of predicting subregion-specific knee joint worsening and may be useful in guiding prognosis and treatment.

Defining physiologically "normal" vitamin D in African Americans

The relationship between serum 25(OH)D and intact parathyroid hormone (iPTH) was evaluated in the Multicenter Osteoarthritis Study (MOST). No further change in iPTH was observed for African Americans with 25(OH)D levels above 20 ng/ml, suggesting that compared to Caucasians, lower vitamin D targets for sufficiency may be appropriate for African Americans.

INTRODUCTION

Vitamin D levels ≥30 ng/ml are commonly considered "normal" based upon maximal suppression of iPTH; however, this has recently been challenged and the optimal 25(OH)D level among non-Caucasians is unclear. We evaluated the cross-sectional relationship between serum 25(OH)D and iPTH in a sample of Caucasian and African American adults.

METHODS

We used baseline serum samples of participants from the Multicenter Osteoarthritis Study (MOST) for this analysis and used three methods to model the relationship between 25(OH)D and iPTH: ordinary least squares regression (OLS), segmented regression and Helmert contrasts.

RESULTS

Among Caucasians (n = 1,258), 25(OH)D and iPTH ranged from 4 to 51 ng/ml and 2 to 120 pg/ml and from 3 to 32 ng/ml and 3 to 119 pg/ml in African Americans (n = 423). We observed different thresholds between African Americans and Caucasians using each analytic technique. Using 25(OH)D as a categorical variable in OLS, iPTH was statistically higher at lower 25(OH)D categories than the 24-32 ng/ml referent group among Caucasians. However, in African Americans, the mean iPTH was only significantly higher at 25(OH)D levels below 15 ng/ml. Using segmented regression, iPTH appeared to stabilize at a lower 25(OH)D level in African Americans (19-23 ng/ml) compared to in Caucasians (>32 ng/ml). Helmert contrasts also revealed a lower threshold in African Americans than Caucasians.

CONCLUSION

Among MOST participants, the 25(OH)D thresholds at which no further change in iPTH was observed was approximately 20 ng/ml in African Americans versus approximately 30 ng/ml in Caucasians, suggesting optimal vitamin D levels in Caucasians may not be applicable to African Americans.

Inter-flat airflow and airborne disease transmission in high-rise residential buildings

1. A virus-spread mechanism is related to inter-flat or interzonal airflow through open windows caused by buoyancy effects. 2. Both on-site measurements and numerical simulations quantify the amount of the exhaust air that exits the upper part of the window of a floor and re-enters the lower part of the open window of the immediately upper floor. 3. Ventilation air could contain up to 7% (in terms of mass fraction) of the exhaust air from the lower floor.4. In high-rise buildings, windows flush with the façade are a major route for the vertical spread of pathogen-containing aerosols, especially those<1 μm in diameter.