Lobular neoplasia on core biopsy and risk factors to predict upstaging at surgical excision

Abstract #5009

Introduction: Lobular neoplasia (including atypical lobular hyperplasia and lobular carcinoma in-situ) identified on core biopsy (CB) is often recommended for surgical excision because the risk of upstaging to invasive carcinoma is documented to be 0-50%. We sought to identify risk factors to predict upstaging at surgical excisional biopsy.
 Methods: Retrospective chart review was used to identify women with CB revealing lobular neoplasia (LN) as highest risk pathological diagnosis. LN was defined as atypical lobular hyperplasia (ALH) and/or lobular carcinoma in situ (LCIS). Radiologic findings were correlated with pathology and excision results were recorded when available. Follow-up radiologic data was also recorded when available.
 Results: From 1997-2008, 45 women (age ranging from 33 to 81) underwent CB revealing LN. Ten had LCIS only, 34 had ALH only and 1 had both. Twenty five (56%) underwent surgical excision and 20 (44%) were followed clinically and mammographically. Core biopsy was recommended for mammographic microcalcifications (three with associated mass or focal asymmetry) in 29 pts (64%), while 14 CB (31%) were recommended for either mammographic mass or focal asymmetry only. Two CB (4%) were recommended for MRI abnormalities. For patients who underwent surgical excision, 8 (32%) were upstaged to invasive carcinoma or DCIS. Two of these 8 (25%) had LCIS on core biopsy and 6 (75%) had ALH only. Of the 6 pts with ALH only, the original core biopsy was done for focal asymmetry or mass in 3, abnormal MRI in 1 and microcalcifications in the remaining 2 (one with synchronous contralateral carcinoma). Patients not upstaged at surgical excision had original CB done for LCIS only in 5 (31%) and ALH only in 11 (69%). Of these 11 pts with ALH who were not upstaged, 8 underwent original CB for mass, focal asymmetry or MRI finding. Patients with LN on core biopsy done exclusively for mammographic microcalcifications underwent excision only 46% (13/28) of the time. Of those excised 4 were upstaged at surgical excision ( 3 with DCIS and 1 tubular carcinoma). Follow-up mammographic data was available for 65% (13/20) of patients who did not have surgical excision. At median follow-up of 16 months no new biopsies have been recommended and no new lesions have been identified for these patients.
 Conclusion :Of all patients who underwent surgical excision for LN found on core biopsy, 32% had a final diagnosis of either DCIS or invasive cancer. Of the 25 patients who underwent surgical excision, 24 were associated with one of the following risk factors: mass or focal asymmetry on mammogram, LCIS, synchronous contralateral carcinoma and non-concordant core biopsy. We did not identify any significant risk factors to predict upstaging at surgical excision, however, this may be due to selection bias. Further studies with larger number of patients are needed to identify risk factors to predict upstaging at surgical excision.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5009.

Use of whey permeate for cultivating Ganoderma lucidum mycelia

A novel approach to utilizing whey permeate, the cultivation of mycelia of the edible mushroom Ganoderma lucidum, is introduced. The major objective of this research was to use whey permeate as an alternative growth medium for the cultivation of mycelia of edible mushroom G. lucidum and to find an optimum condition for solid-state cultivation. Response surface analysis was applied to determine the combination of substrate concentration (25 to 45 g of lactose/L), pH (3.5 to 5.5), and temperature (25 to 35 degrees C) resulting in a maximal mycelial growth. The radial extension rates, estimated by measuring the diameters of growing colonies on the Petri dishes, were used as the growth of the mycelia at different conditions. In the model, pH and temperature significantly affected mycelial growth, but lactose concentration did not. The condition predicted to maximize the radial extension rate of 17.6 +/- 0.4 mm/d was determined to be pH 4.4 and temperature 29.4 degrees C. Therefore, the results suggest that whey permeate could be utilized as a growth substrate for the cultivation of mycelia from the edible mushroom G. lucidum, enhancing the use of this by-product by the cheese manufacturing industry.

Increased cochlear fluid-attenuated inversion recovery signal in patients with vestibular schwannoma

BACKGROUND AND PURPOSE

Elevated protein levels have been reported in perilymph of patients with vestibular schwannoma. Fluid-attenuated inversion recovery (FLAIR) imaging is sensitive to high protein contents in fluids. The purpose of this study was to investigate if in patients with unilateral vestibular schwannoma, cochlear FLAIR signal intensity on the affected side is increased compared with the unaffected side and control subjects.

MATERIALS AND METHODS

Fifteen patients with unilateral vestibular schwannoma and 25 age-matched control subjects (without a history of hearing loss) were retrospectively evaluated. All patients and controls had routine 5-mm FLAIR and T1- and T2-weighted imaging of the brain. The signal intensity of both cochleae was evaluated by placing a small region of interest on FLAIR images. The signal intensity of the brain stem was also determined by placing a second region of interest. A ratio of cochlear signal intensity to brain stem signal intensity (CIBI ratio) was determined. A t test was used to compare the CIBI ratios.

RESULTS

In patients, the mean CIBI ratio of the affected side was 0.89 +/- 0.18, and that of the unaffected side was 0.57 +/- 0.12. In control subjects, it was 0.51 +/- 0.07. The CIBI ratio of the affected side was significantly higher compared with the unaffected side (P < .001) and compared with control subjects (P < .001).

CONCLUSION

Patients with vestibular schwannoma have increased cochlear FLAIR signal intensity on the affected side compared with the unaffected side and healthy subjects.

Small-sized liver graft does not increase the risk of hepatocellular carcinoma recurrence after living donor liver transplantation

PURPOSE

Following implantation into adult recipients, living donor liver grafts usually undergo liver regeneration. This regeneration process may provoke the growth of occult hepatocellular carcinoma (HCC) cells in the recipient body. To assess the risk of HCC recurrence, we analyzed the influence of graft-recipient weight ratio (GRWR).

METHODS

The 181 recipients with HCC within the University of California at San Francisco (UCSF) criteria were divided into four groups according to GRWR: low GRWR (<0.8; n = 30), mid GRWR (0.8-1.0; n = 65), high GRWR (>1.0; n = 64), and whole liver graft group (>1.5; n = 22).

RESULTS

There were no differences in overall patient survival (P = .105) and recurrence-free survival (P = .406) among these four groups. GRWR <0.8 was not a significant risk factor for HCC recurrence. Similar outcomes were obtained in HCC patients who met the Milan criteria (n = 170).

CONCLUSIONS

We think that small living donor liver graft and subsequent liver regeneration do not increase the risk of posttransplant HCC recurrence when HCC is within the Milan or UCSF criteria.

Bevacizumab and irinotecan in patients (pts) with recurrent glioblastoma multiforme (GBM)

2078

Background: Primary GBM exhibits overexpression or amplification of the epidermal growth factor gene. The effectiveness of bevacizumab and irinotecan in pts with relapsed GBM was first reported in 2005 (Stark-Vance, et al, Neuro-Oncol, 2005). In this report, we assess the effects of combination of bevacizumab and irinotecan on overall responses, toxicity, cognitive function and functional status in recurrent GBM pts. Methods: From August 2005 to December 2006, 22 consecutive GBM pts failed > 1 prior chemotherapy with measurable disease on MRI were included. Each patient received bevacizumab 5mg/kg IV and irinotecan 125mg/m2 IV infusion every 2 weeks until disease progression or developed unacceptable toxicity. The response was determined by MRI every 2 cycles. Cognitive function was assessed by Blessed Orientation-Memory-Concentration Test (BOMC) and functional status was assessed by Karnofsky performance status (KPS), Barthel Index (BI) and Instrumental Activities of Daily Living (IADL) prior to each cycle of treatment. Descriptive statistics analysis was used. Results: All pts failed temozolomide and radiation therapy; 1 pt had prior BCNU and 2 pts had prior irinotecan treatment. The median (M) age was 55 years (37-77) with pre treatment M KPS 80 (40–80), BOMC 7 (0–28), BI 85 (10–100) and IADL 6 (0–17); 12 pts exhibited mild (3 pts), moderate (7 pts) to severe (2 pts) cognitive impairment. The M number of cycles received was 8 (2–27); 21 pts are evaluable for MRI responses with 95.2% response rate (2CR’s + 14PR’s + 4 minimal responses). Seven pts have expired; the M length of survival was 4.6 months (range 1.1–15.4+) and the M time to progression was 3 months (0.5–13.8+). There were only two grade 3 thrombocytopenia and one grade 3 neutropenia. Improvement in BOMC score was seen in 15 pts (62%) with M improvement of 7 point. Improvement in functional status was seen in 18 pts (85.7%) with M improvement in KPS by 10 point, BI by 8 points and IADL by 2 point. Conclusions: The combination of bevacizumab and irinotecan is well tolerated and safe. The overall response rate was 95.2% and significant improvements in cognitive functional and functional status were demonstrated. The longer follow up will determine the impact of this most active combination.

No significant financial relationships to disclose.

Radiographic evaluation of recurrent glioblastoma multiforme (GBM) in patients treated with bevacizumab and irinotecan

12512

Background: Recurrent GBM carries a poor prognosis after first-line therapies have been exhausted, even in the setting of gross total resection. Bevacizumab and Irinotecan have shown promising results in patients with recurrent GBM (Stark-Vance, et al. Neuro- Oncol, 2005). We sought to retrospectively document the short-term effects of this chemotherapeutic regimen on recurrent GBM, as evidenced by comparative MRI brain scans obtained prior to, and one-month following initiation of treatment. Methods: We collected brain MRI data from August 2005 to December 2006, in which post-contrast spin-echo T1-weighted images demonstrated measurable enhancement and/or GBM tumor mass. Having failed temozolomide and radiation therapy, 14 consecutive patients’ MRI scans were available for review at this institution by a neuro-radiologist, in which both pre- and post-treatment hard and/or soft copy MR images were available for direct measurement. Each was treated with Bevacizumab 5 mg/kg IV and Irinotecan 125 mg/m2 IV infusion every 2 weeks until disease progression, or development of unacceptable toxicity. We measured pre- and post-treatment recurrent GBM bulk tumor in anteroposterior, transverse, and cranio-caudad dimensions, and calculated volumetric data, assuming an ellipsoid tumor configuration. Results: Pre-treatment MRI scans were performed 2 weeks prior to initiation of therapy (Mean: 13 days; Median: 10 days). Post-treatment scans were performed at approximately one month following initial treatment (Mean: 30 days; Median: 28 days). All patients witnessed significant decrease in tumor bulk volume ranging from 15.3 to 89.8%, having received an average of two cycles of chemotherapy. We observed a mean decrease in tumor volume of 46.6% (SD = 22.6%; SEM = 6.0%; 95% CI = 33.6 - 60.0 % decrease). Conclusions: We report 46.6% mean reduction in recurrent GBM tumor bulk at an average of 1-month post-treatment in patients treated with an average of two cycles of Bevacizumab and Irinotecan therapy. These promising initial results necessitate further long-term prospective evaluation of this chemotherapy.

No significant financial relationships to disclose.

Outcome of patients with huge hepatocellular carcinoma after primary resection and treatment of recurrent lesions

BACKGROUND

Tumour recurrence is common after hepatic resection of hepatocellular carcinomas (HCCs) greater than 10 cm in diameter. This study evaluated the outcome of patients with huge HCC after primary resection and treatment of recurrent lesions.

METHODS

A retrospective review was undertaken of clinical data for 100 patients with huge HCC who underwent liver resection.

RESULTS

Mean(s.d.) tumour diameter was 13.3(3.0) cm; 80 per cent were single lesions. Systematic and non-systematic resections were performed in 80 and 20 per cent of patients respectively, with R0 resection achieved in 86 per cent. Overall 1-, 3- and 5-year disease-free survival rates were 43, 26 and 20 per cent respectively. Risk factors for HCC recurrence were resection margin less than 1 cm and macrovascular invasion. Extensive tumour necrosis of 90 per cent or more after preoperative transarterial chemoembolization was not a prognostic factor. Some 85 per cent of patients with recurrence received various treatments, and these patients had a longer post-recurrence survival than those who were not treated. Overall 1-, 3- and 5-year survival rates were 66, 44 and 31 per cent respectively.

CONCLUSION

In patients with huge HCC, hepatic resection combined with active treatment for recurrence resulted in longer-term survival. Frequent protocol-based follow-up appears to be beneficial for the early detection and timely treatment of recurrence.

Suitable whole blood levels 2 hours after neoral in liver transplant patients: experiences at a single center

Whole blood levels 2 hours after Neoral (C2) administration were observed to correlate better with area under the curve (AUC(0-4)) than trough levels (C0), suggesting that C2 may be the best single time point predictor of Neoral absorption. Owing to concerns about drug toxicity due to excessive immunosuppression, C2 adjustments to target blood levels may represent an advance. The present study measured C2 and levels to determine which correlated more closely with AUC(0-4).

METHODS

Between August 2003 and July 2004, 40 adult liver transplantations were performed in our center. All patients received Neoral twice daily. They were maintained at a C0 level of about 200 ng/mL. C0 levels were measured daily. C2 levels were estimated on postoperative days 3, 5, 7, 14, and 28. AUC(0-4) performed on postoperative days 3, 7, and 28 was calculated using the trapezoidal rule.

RESULTS

The mean AUC(0-4), C0, C1, C2, C3, and C4 were 1100.3 +/- 484.8 ng/mL, 197.1 +/- 84.7 ng/mL, 240.7 +/- 166.2 ng/mL, 307.8 +/- 162.6 ng/mL, 302.8 +/- 138.9 ng/mL, and 300.3 +/- 142.8 ng/mL, respectively. C2 correlated with AUC(0-4) (R2 = 0.868: P < .05) better than C0 (R2 = 0.245: P < .05), C1 (R2 = 0.604: P < .05), or C4 (R2 = 0.583: P < .05).

CONCLUSIONS

Neoral dose monitoring according to a mean C2 range of 307.8 +/- 162.6 ng/mL correlated better with AUC(0-4). Further studies are required to determine suitable C2 levels in liver transplant patients.

Reappraisal of seventh-day syndrome following living donor liver transplantation

Seventh-day syndrome (7DS) is characterized by sudden failure of a liver graft that had been working normally at about 1 week after transplantation, without an identifiable cause. A nonnegligible percentage of cadaveric liver transplants have shown this type of acute graft failure, whereas 7DS has not been reported after living donor liver transplantation (LDLT). Among 580 adult LDLT recipients in our institution between 1997 and 2003, 3 (0.5%) showed clinical sequences typical of 7DS. All three recipients showed similar but unique clinical sequences, consisting of initial uneventful recovery, dramatic rise of serum liver enzyme levels about 1 week later despite potent antirejection therapy, and subsequent graft loss. Liver biopsy findings were compatible with massive hemorrhagic necrosis. Sustained fever lasting for 2 days preceded deterioration of liver function. All three patients died prior to the opportunity for retransplantation. Our findings suggest that, as in cadaveric donor liver transplantation, 7DS can also occur following LDLT and that a preceding episode of sustained fever may be a prodrome of 7DS although its pathogenesis is yet poorly understood.

Pulmonary complications following adult liver transplantation

PURPOSE

Pulmonary complications frequently occur after liver transplantation, but the risk factors associated with them have not been fully determined. We therefore sought to identify risk factors for pulmonary complications among adult liver transplant recipients.

METHODS

We retrospectively reviewed the medical records of 128 consecutive adult patients who underwent 131 liver transplantations during 2001. We evaluated the incidence, time of onset, and outcome of radiographically determined pulmonary complications, as well as the factors predictive of infectious complications.

RESULTS

Postoperative chest roentgenograms detected 68 cases of pulmonary complications, including pleural effusion (n = 50), atelectasis (n = 6), pneumonia (n = 6), pulmonary edema (n = 5), and acute respiratory distress syndrome associated with pneumonia (n = 1). Of the seven patients with pneumonia, five died. On univariate analysis the risk factors predictive for pneumonia were high serum creatinine and total bilirubin, hemodialysis at the time of occurrence, and history of acute rejection and on multivariate analysis increased total bilirubin and history of acute rejection. Pulmonary complications were dependent on the medical condition at the time of occurrence rather than on the preoperative condition.

CONCLUSIONS

Although the incidence of pneumonia in liver recipients was relatively low, the mortality rate in patients who developed this complication was high. High-risk patients undergoing liver transplantation thus require early diagnosis and intensive treatment to diminish the morbidity and mortality associated with pulmonary complications.

Multi-segment foot motion analysis on hallux valgus patients

In this study, a multi-segment foot motion analysis on hallux valgus patients were performed using the 9-segment foot model and then compared with the results from normal subjects. Results showed that there were no significant differences in hindfoot motions between normal subjects and HV patients. However, noted in HV patients were hyperexternal rotation in the talocrural joint, an excessive eversion of the subtalar joint during early stance and lack of dynamic motion in hallux MP and medial MP joints especially during terminal stance. In spite of limitation in this study due to the small number of HV patients, the current multi-segment foot model would be feasible to diagnose and treat patients with various foot diseases, combined with further studies in the future.

Analysis of relation between coronary perfusion pressure and the extracted parameters from a ventricular fibrillation ECG signal

This work presents an alternative return of spontaneous circulation (ROSC) estimate using indirectly induced presumption that coronary perfusion pressure (CPP) correlates with the extracted parameter from the ventricular fibrillation (VF) ECG signal. In past studies, it is revealed that successful cardiopulmonary resuscitation (CPR) needs at least 30 approximately 40 mmHg CPP during the aortic diastolic period. In 360 segments derived from 18 test dogs with experimental cardiac arrest of cardiac cause, we analyzed the ability of 4 spectral features of VF before countershock to discriminate or not between segments that correspond to CPP. The median frequency (MF), peak frequency (PF), average segment amplitude (ASA) and maximum segment amplitude (MSA) were studied. After preprocessing the raw data acquired from the specific experimental setup and protocol, we verified CPP is a serious estimate of ROSC, and then we analyzed the extracted parameters corresponding to CPP by multiple regression. In the specific conditional frequency domain (MF: 9.42 approximately 12.42 Hz, PF: 8.71 approximately 13.08 Hz, ASA: > 0.19 mV), CPP is correlated to the extracted parameter with 0.71 +/- 0.05 coefficient of multiple determination (R(2)). The combination of MF, PF, and ASA achieved a 79.47 +/- 3% sensitivity and 41.67 +/- 4% specificity in testing.

Efficacy of 6-Month Pretransplant Abstinence for Patients With Alcoholic Liver Disease Undergoing Living Donor Liver Transplantation

PURPOSE

Questions have been raised regarding the ethics of liver transplantation in patients with alcoholic liver disease (ALD), including the fairness of cadaveric organ allocation to individuals who abuse alcohol and the efficacy of transplantation in these patients, many of whom may relapse. Living donor liver transplantation (LDLT) for ALD patients raises the similar ethical issues. ALD candidates for cadaveric liver transplants are required to abstain from alcohol for 6 months before being listed, but the efficacy of 6 months of abstinence in ALD patients receiving LDLT is not known.

METHODS

We therefore determined the efficacy of 6 months of pretransplant abstinence in 15 ALD patients who underwent LDLT from February 1997 to December 2003.

RESULTS

The Model for End-stage Liver Disease score was 24 +/- 10, and mean pretransplant abstinence period was 15 +/- 13 months, with 11 (73.3%) patients being abstinent for at least 6 months. Four patients received dual grafts, making the number of living donors 19: 12 children, two wives, one brother, three nephews, and one aunt. There were no unrelated donors. Three patients showed a relapse to alcohol drinking. The overall 1-, 3-, and 5-year survival rates were 100%, 100%, and 87.5%, respectively, and the cumulative 1-, 3-, and 5-year relapse rates were 6.7%, 20%, and 20%, respectively. The relapse rates in patients who did and did not maintain 6 months of abstinence were 9.1% and 50%, respectively; this difference was not significant (P = .154), likely due to the small sample size. Younger recipient age was a significant risk factor for alcohol relapse (40 +/- 8 years versus 53 +/- 6 years; P = .004).

CONCLUSIONS

Pretransplant abstinence of 6 months seemed to be beneficial. For ethical reasons, a 6-month abstinence rule should be strictly observed in LDLT.