Impact of Neoadjuvant Concurrent Chemoradiation (NACCRT) on Operability and Survival in Locally Advanced Inoperable Breast Cancer

PURPOSE/OBJECTIVE(S)

Inoperable locally advanced breast cancers (LABC) are treated with neoadjuvant chemotherapy (NACT). However, many patients remain inoperable after NACT due to an inadequate response. We, therefore, investigated the role of neoadjuvant concurrent chemoradiation (NACCRT) in this setting.

MATERIALS/METHODS

Patients with inoperable Stage III LABC were prospectively recruited in the study between May 2017 and December 2021. NACT consisted of 4 cycles of q3weekly Adriamycin (60 mg/m2) and Cyclophosphamide (600mg/m2), and 4 cycles of q3weekly Paclitaxel (175 mg/m2). Concurrent radiotherapy with 6 MV X-rays was given using a 3D conformal technique to a total dose of 46 Gy (2 Gy/fraction, 5 days/week) to the involved breast, axilla, supraclavicular fossa, and internal mammary chain (upper 3 intercostal spaces) along with the first two cycles of paclitaxel. A 0.5 cm bolus was used to boost the skin till the appearance of hyperpigmentation. All patients were assessed for surgery after the completion of the planned neoadjuvant treatment. Adjuvant treatments were given based on the receptor status. The impact of neoadjuvant CTRT on the pathological complete response (pCR), operability, and survival was analyzed. Event-free survival (EFS) and Overall Survival (OS) were analyzed using the Kaplan-Meier method.

RESULTS

The study enrolled 202 female patients with a median age of 52 years, with 23.7% having IIIA, 65.3% IIIB, and 10.8% having IIIC disease. Hormone-receptor (HR) positive disease was observed in 90/202 (44.6%) patients, triple-negative (TNBC) in 50/202 (24.8%) and Her2/neu positive in 62/202 (30.7%) patients. Modified radical mastectomy was performed in 88.1% of patients, with 8.5% remaining inoperable and 3.4% declining surgery due to clinical complete response (cCR). Among the patients who underwent MRM, 65/178 (32.2%) patients had a pCR. pCR was observed in 13/81 (16%) with HR-positive disease, 21/46 (45.6%) with TNBC, and 31/51 (60.7%) patients with Her2/neu-positive disease. Grade 3 skin reactions were observed in 39/202 (19.3%). Postoperative wound morbidity requiring hospitalization was observed in 19/178 (10.6%) patients. The median follow-up was 42 months, with 4-year EFS and OS of 63.8% and 71.5%, respectively. Six out of 7 patients who were in cCR and declined surgery are alive and remain in cCR. On subgroup analysis of Her 2 positive patients, pCR was significantly associated with improved EFS and OS (89.8% vs 33.3%, p = 0.001 and 89.1% vs 44.4%, p = 0.001 respectively).

CONCLUSION

Our study demonstrates the feasibility and efficacy of NACCRT in improving operability, pCR rates and survival outcomes in patients with inoperable LABC. The results suggest that NACCRT can be considered for use in clinical practice with careful patient selection. These findings contribute to the ongoing efforts to optimize treatment for this patient population and warrant further investigation in larger, randomized trials.

Hippocampus and its involvement in Alzheimer's disease: a review

Hippocampus is the significant component of the limbic lobe, which is further subdivided into the dentate gyrus and parts of Cornu Ammonis. It is the crucial region for learning and memory; its sub-regions aid in the generation of episodic memory. However, the hippocampus is one of the brain areas affected by Alzheimer's (AD). In the early stages of AD, the hippocampus shows rapid loss of its tissue, which is associated with the functional disconnection with other parts of the brain. In the progression of AD, atrophy of medial temporal and hippocampal regions are the structural markers in magnetic resonance imaging (MRI). Lack of sirtuin (SIRT) expression in the hippocampal neurons will impair cognitive function, including recent memory and spatial learning. Proliferation, differentiation, and migrations are the steps involved in adult neurogenesis. The microglia in the hippocampal region are more immunologically active than the other regions of the brain. Intrinsic factors like hormones, glia, and vascular nourishment are instrumental in the neural stem cell (NSC) functions by maintaining the brain's microenvironment. Along with the intrinsic factors, many extrinsic factors like dietary intake and physical activity may also influence the NSCs. Hence, pro-neurogenic lifestyle could delay neurodegeneration.

POS0400 METABOLIC CHANGES INDUCED BY ANTI-MALONDIALDEHYDE/MALINDIALDEHYDE-ACETALDEHYDE ANTIBODIES PROMOTE OSTEOCLAST DEVELOPMENT

Background:

Malondialdehyde (MDA) is a highly reactive compound generated during lipid-peroxidation in conditions associated with oxidative stress. MDA can irreversibly modify proteins (e.g. lysine, arginine and histidine residues). In addition, acetaldehyde can further react with MDA adducts to form malondialdehyde-acetaldehyde (MAA) modification. Such protein modifications can lead to immunogenic neo-epitopes that are recognized by autoantibodies. In fact, anti-MDA/MAA IgG antibodies are significantly increased in the serum of patients with autoimmune diseases, such as rheumatoid arthritis (RA) (1). Interestingly, anti-MDA/MAA antibodies have been shown to promote osteoclast (OC) differentiation in vitro suggesting a potential role for these autoantibodies in bone damage associated with RA (1).

Objectives:

Little is known about the molecular mechanisms activated by autoantibodies in RA. Here, we elucidate the pathways specifically triggered by anti-MDA/MAA autoantibodies in developing osteoclasts.

Methods:

Recombinant human monoclonal anti-MDA/MAA antibodies, which were previously cloned from single synovial B cells of RA patients, were added to different OC assays. OCs were generated from monocyte-derived macrophages in the presence of the cytokines RANK-L and M-CSF. OC development was monitored by light microscopy following tartrate-resistant acid phosphatase staining and by erosion assays using calcium phosphate-coated plates. Bone morphometrics were studied in anti-MDA/MAA-injected mice using X-ray microscopy. Cellular metabolism was analyzed by mass spectrometry, Seahorse XF Analyzer and a colorimetric L-Lactate assay.

Results:

Anti-MDA/MAA antibodies induced a robust OC differentiation in vitro and bone loss in vivo. The anti-MDA/MAA antibodies acted on developing OCs by increasing glycolysis via an Fcγ receptor I-mediated pathway and the upregulation of the transcription factors HIF-1α, Myc and CHREBP. Such regulation of cellular metabolism was exclusively observed in the presence of the osteoclastogenic anti-MDA/MAA clones, whereas other RA-associated autoantibodies (anti-MDA/MAA or anti-citrullinated protein antibodies) had no effect on metabolism. The anti-MDA/MAA treatment induced a shift in the tricarboxylic acid (TCA) cycle activity in developing OCs, leading to the accumulation of citrate and aconitate.

Conclusion:

We described a novel type of autoantibody-induced pathway in RA, which might contribute to increased OC activation and a consequent bone loss. Anti-MDA/MAA antibodies promoted osteoclast development by increasing glycolysis and by modulating the TCA cycle through a signaling pathway that included Fcγ receptor I and a network of transcription factors acting on glycolysis. A TCA cycle bias towards citrate production suggests that the anti-MDA/MAA antibodies might stimulate OCs via increasing lipid biosynthesis in the cells.

References:

[1]Grönwall C. et al. J. Autoimmunity 84 (2017): 29-45.

Acknowledgements:

This Project has received funding from FOREUM, Foundation for Research in Rheumatology, from the European Research Council (ERC) grant agreement CoG 2017 - 7722209_PREVENT RA, the EU/EFPIA Innovative Medicine Initiative grant agreement 777357_RTCure, the Konung Gustaf V:s och Drottning Victorias Frimurarestiftelse and Knut and Alice Wallenberg Foundation.

Disclosure of Interests:

Koji Sakuraba: None declared, Akilan Krishnamurthy: None declared, Alexandra Circiumaru: None declared, Vijay Joshua: None declared, Heidi Wähämaa: None declared, Marianne Engström: None declared, Meng Sun: None declared, Xiaowei Zheng: None declared, Cheng Xu: None declared, Khaled Amara: None declared, Vivianne Malmström Grant/research support from: collaboration with Pfizer, unrelated to the abstract, Sergiu-Bogdan Catrina: None declared, Caroline Grönwall: None declared, Bence Réthi: None declared, Anca Catrina Grant/research support from: collaboration with BMS and Pfizer, unrelated to the present abstract

OP0326 ACPA-INDUCED PAIN-BEHAVIOR, BONE LOSS AND TENDON INFLAMMATION IN MICE: A NOVEL MODEL FOR THE PRE-DISEASE PHASES OF ACPA-POSITIVE RHEUMATOID ARTHRITIS

Background:

In rheumatoid arthritis (RA), anti-citrullinated protein antibodies (ACPAs) are associated with bone loss and pain. Recently, tenosynovitis has been suggested as a predicting factor for arthritis progression in individuals at-risk for RA.

Objectives:

We aimed to investigate if transfer of human ACPAs into mice could induce tenosynovitis and/or subclinical inflammation.

Methods:

Monoclonal ACPA (1325:04C03 and 1325:01B09) and control (1362:01E02) antibodies (mAbs) were generated from synovial plasma or memory B cells of RA patients. 2mg of combination of monoclonal ACPAs or control antibody were injected in BALB/c female mice (age 12-16 weeks) (n= 9). Pain-like behavior was monitored by measuring mechanical hypersensitivity using von Frey filaments every 3 days and estimation by up-down Dixon method. Bone morphometrics was analyzed by micro-CT. Using specially designed mobilization casts, dedicated mouse MRI coils, and gadolinium enhanced contrast medium, the hind limbs of these mice were scanned in a 9.4 T scanner and resulting T1-weighted images were evaluated for signs of soft tissue joint inflammation. The MRI images were scored for the presence of joint involvement and tendon inflammatory changes by 3 readers in a blinded manner.

Figure 1.

NAPA performed on healthy donor mo-DCs incubated with native, PAD2-citrullinated, and PAD4-citrullinated fibrinogen. Alpha, beta, and gamma chains of fibrinogen are shown separately. Each colored line represents a unique peptide. Nested peptides with a common core motif are shown in the same color. Grey bar denotes peptides with identical core motif between samples.

Results:

ACPAs (1325:04C03 and 1325:01B09) induced pain-like behavior (lasting for at least 4 weeks) and reduction of the trabecular and cortical bone thickness in the hind limbs as compared to control monoclonal antibodies (p<0.05). While no macroscopic or MRI signs of synovial inflammation were detected, MRI subclinical inflammation of the tendon sheaths was present in mice injected with ACPAs, but not in those injected with control mAb. Semi-quantitative scoring of the inflammatory tendon changes showed significant higher values in mice injected with ACPA (median of 1, range 0 to 2) than those injected with control mAb (median of 0, range 0 to 1).

Conclusion:

We show that ACPA induces pain-like behavior, bone loss and tendon sheath inflammation in mice, a model that mimics the preclinical state of ACPA positive RA.

References:

[1]Harre, U. et al. J Clin Invest (2012)

[2]Krishnamurthy, A. et al. Ann Rheum Dis (2016, 2019), JI 2019

[3]Wigerblad, G. et al. Ann Rheum Dis (2016, 2019)

[4]KleyerA, Seminars in Arthritis and Rheumatism (2016)

Disclosure of Interests:

Akilan Krishnamurthy: None declared, Yogan Kisten: None declared, Alexandra Circiumaru: None declared, Koji Sakurabas: None declared, Patrik Jarvolli: None declared, Juan Jimenez Jimenez Andrade: None declared, Peter Damberg: None declared, Heidi Wähämaa: None declared, Vivianne Malmström Grant/research support from: VM has had research grants from Janssen Pharmaceutica, Lars Klareskog: None declared, Camilla Svensson: None declared, Bence Réthi: None declared, Anca Catrina: None declared

SAT0017 METABOLIC CHANGES INDUCED BY ANTI-MALONDIALDEHYDE/MALINDIALDEHYDE-ACETALDEHYDE ANTIBODIES PROMOTE OSTEOCLAST DEVELOPMENT

Background:

Malondialdehyde (MDA) is a highly reactive compound produced by lipid-peroxidation in situations associated with oxidative stress. MDA can irreversibly modify proteins residues such as lysine, arginine and histidine. In addition, MDA adducts can further react with acetaldehyde to generate malondialdehyde-acetaldehyde (MAA) modifications. Such modifications can give rise to immunogenic neo-epitopes that are recognized by autoantibodies. In fact, anti-MDA/MAA IgG antibodies are significantly increased in the serum of patients with autoimmune diseases, such as rheumatoid arthritis (RA) (1) and systemic lupus erythematosus (2). Recently, we have shown that anti-MDA/MAA IgG antibodies are able to promote osteoclast (OC) differentiationin vitro(1).

Objectives:

To investigate the molecular mechanisms triggered by anti-MDA/MAA autoantibodies during osteoclastogenesis.

Methods:

OCs were generated from monocyte-derived macrophages in the presence of the cytokines RANK-L and M-CSF. The development of OCs was monitored by light microscopy following tartrate-resistant acid phosphatase (TRAP) staining and erosion area on synthetic calcium phosphate-coated plates. Three different recombinant human monoclonal anti-MDA/MAA antibodies, cloned from single synovial B cells of RA patients, control antibodies and Fab fragments of the antibodies were added to OC cultures. Glycolysis was inhibited by 2-deoxyglucose, and Fc-gamma receptor I or II by anti-CD64 or anti-CD16 neutralizing antibodies. IL-8 levels were measured by enzyme linked immunosorbent assay. Cellular metabolism was monitored using Seahorse XF Analyzer (extracellular acidification rate and oxygen consumption) and a colorimetric L-Lactate assay.

Results:

Lactic acid production correlated with the osteoclastogenetic effect of some but not all anti-MDA/MAA antibodies on OCs (R=0.4758, p=0.0252) suggesting an antibody-mediated regulation of glycolysis. Further, extracellular acidification (ECAR) and oxygen consumption (OCR) rate of the developing OCs were increased by the osteoclastogenic anti-MDA/MAA clones (maximum increase of 54% for the ECAR and 78% for the OCR by clone 146+:01G07, and maximum increase of 28% for the ECAR and 39% for the OCR by clone 1103:01H05), but not by the non-osteoclastogenetic anti-MDA/MAA clones or control antibodies. The glycolysis inhibitor 2-deoxyglucose completely abolished the osteoclastogenetic effect of the anti-MDA/MAA clones at drug concentrations that did not influenced baseline OC development. Fab2 fragments of the osteocalstogenetic anti-MDA/MAA clones had no effect on OC development and metabolism. In accordance with this, Fc-gamma receptor I neutralizing antibodies completely abolished the osteocalstogenetic effect of the anti-MDA/MAA clones. The osteoclastogenetic effect of the anti-MDA/MAA antibodies was independent of IL-8 production. In contrast to anti MDA/MAA antibodies, ACPA-mediated osteoclastogenesis was independent of glycolysis and Fc-gamma receptors but dependent on IL-8.

Conclusion:

Our results describe a novel glycolysis-dependent mechanism by which anti-MDA/MAA antibodies promote osteoclast development that is different from the one previously described for ACPA.

References:

[1] C. Grönwall et al. Journal of Autoimmunity 84 (2017) 29-45.

[2] C. Wang et al. Arthritis and Rheumatism 62 (2010) 2064-2072

Disclosure of Interests:

Koji Sakuraba: None declared, Akilan Krishnamurthy: None declared, Alexandra Circiumaru: None declared, Meng Sun: None declared, Vijay Joshua: None declared, Marianne Engström: None declared, Xiaowei Zheng: None declared, Cheng Xu: None declared, Khaled Amara: None declared, Vivianne Malmström Grant/research support from: VM has had research grants from Janssen Pharmaceutica, Sergiu-Bogdan Catrina: None declared, Caroline Grönwall: None declared, Bence Réthi: None declared, Anca Catrina: None declared

FRI0005 DIVERSITY OF ANTI-CITRULLINATED PROTEIN ANTIBODY COMPOSITIONS INFLUENCE SYNOVIAL FIBROBLAST REACTIVITY

Background:

Anti-citrullinated protein antibodies (ACPAs) play an important role in rheumatoid arthritis (RA) pathogenesis. We hypothesized that the effect of these antibodies is mediated by their binding to synovial fibroblasts and inducing an increased mobility of fibroblasts1.

Objectives:

In our study, we analyzed and compared fibroblast modulation by ACPA pools obtained from different patients or by a set of monoclonal ACPAs with different fine specificity that were obtained from different tissue sites.

Methods:

Synovial fibroblasts were isolated from RA patients synovial tissue biopsies. Individual polyclonal ACPA and control IgGs were purified from sera of four ACPA-positive RA patients by affinity purification on protein G and CCP-2 columns. Monoclonal antibodies were derived from memory B cell isolated from blood2, synovial fluid or bronchoalveolar lavage of RA patients. Whole antibodies and F(ab’)2 fragments were tested in fibroblast migration using IncuCyte live-cell analysis. Blocking experiments were performed with soluble citrullinated proteins in SF migration. Cross-reactivity of the antibodies to citrullinated and acetylated epitopes was tested using PAD inhibitors (Cl-amidine and GSK199), histone acetyltransferases (anacardic acid) and deacetylases (trichostatin A). Binding patterns of monoclonal ACPAs, both whole and F(ab’)2 fragments were analyzed in synovial biopsies obtained from both healthy donors and RA patients.

Results:

Three out of four tested individual ACPA were able to promote fibroblast migration. Five out of nine tested monoclonal ACPAs stimulated fibroblast migration. One of these antibodies, clone 1325:01B09 is characterized by cross-reactivity to citrullinated, homocitrullinated and acetylated targets. The effect of 1325:01B09 on fibroblast migration was completely abolished by Cl-amidine or by pre-incubating the antibody with citrullinated fibrinogen or histone but not citrullinated enolase or vimentin. Despite the cross-reactivity to acetylated epitopes, neither anacardic acid nor trichostatin A could modulate the 1325:01B09 effect on fibroblast migration. F(ab’)2 fragments of this antibody stimulated fibroblast migration and labelled podoplanin-positive fibroblasts in inflamed RA synovium similarly to the intact antibody, indicating an Fc-independent effect.

Conclusion:

The effect on fibroblast mobility was likely to be mediated by binding to citrullinated epitopes but not through Fc receptors. Detection of fibroblast modulating ACPAs in majority of RA patients indicated that fibroblasts might be key cellular targets in disease pathogenesis, although individual variability might exist in the composition of ACPA cellular targets.

References:

[1]Sun M, Rethi B, Krishnamurthy A, et al. Anticitrullinated protein antibodies facilitate migration of synovial tissue-derived fibroblasts. Ann Rheum Dis 2019;78(12):1621-31. doi: 10.1136/annrheumdis-2018-214967 [published Online First: 2019/09/05]

[2]Amara K, Lena Israelsson, Ragnhild Stålesen, et al. A Refined Protocol for Identifying Citrulline-specific Monoclonal Antibodies from Single Human B Cells from Rheumatoid Arthritis Patient Material. Bio-protocol 2019;9(16)

Disclosure of Interests:

Meng Sun: None declared, Bence Réthi: None declared, Akilan Krishnamurthy: None declared, Vijay Joshua: None declared, Alexandra Circiumaru: None declared, Marianne Engström: None declared, Caroline Grönwall: None declared, Vivianne Malmström Grant/research support from: VM has had research grants from Janssen Pharmaceutica, Khaled Amara: None declared, Lars Klareskog: None declared, Heidi Wähämaa: None declared, Anca Catrina: None declared

Advanced buffer materials for indoor air CO2 control in commercial buildings

In this study, we evaluated solid sorbents for their ability to passively control indoor CO₂ concentration in buildings or rooms with cyclic occupancy (eg, offices, bedrooms). Silica supported amines were identified as suitable candidates and systematically evaluated in the removal of CO₂ from indoor air by equilibrium and dynamic techniques. In particular, sorbents with various amine loadings were synthesized using tetraethylenepentamine (TEPA), poly(ethyleneimine) (PEI) and a silane coupling agent 3-aminopropyltriethoxysilane (APS). TGA analysis indicates that TEPA impregnated silica not only displays a relatively high adsorption capacity when exposed to ppm level CO₂ concentrations, but also is capable of desorbing the majority of CO₂ by air flow (eg, by concentration gradient). In 10 L flow-through chamber experiments, TEPA-based sorbents reduced outlet CO₂ by up to 5% at 50% RH and up to 93% of CO₂ adsorbed over 8 hours was desorbed within 16 hours. In 8 m³ flow-through chamber experiments, 18 g of the sorbent powder spread over a 2 m² area removed approximately 8% of CO₂ injected. By extrapolating these results to real buildings, we estimate that meaningful reductions in the CO₂ can be achieved, which may help reduce energy requirements for ventilation and/or improve air quality.

Atezolizumab: A novel PD-L1 inhibitor in cancer therapy with a focus in bladder and non-small cell lung cancers

In recent years, immunotherapy has come to the forefront as a major development in cancer treatment. Evasion of the immune system by tumor cells has been identified as one of the hallmarks of cancer and multiple therapies have been developed to counter this process. Programmed cell death 1 ligand 1 (PD-L1), a ligand to programmed cell death protein 1 (PD-1), is expressed by many cancer cells and the binding of PD-L1 to PD-1 results in the suppression of T-cell-mediated immune response against cancer cells. Atezolizumab is a monoclonal antibody that binds to PD-L1 and blocks its interaction with PD-1, thereby enhancing T-cell activity against tumor cells. Atezolizumab has been shown to be well tolerated with no dose-limiting toxicities in phase I trials. Atezolizumab was approved by the U.S. Food and Drug Administration in 2016 for the treatment of platinum-resistant metastatic non-small cell lung cancer (NSCLC) and urothelial cancer based on phase II and preliminary phase III studies that have shown significant improvement in objective response rate and median overall survival. There are 117 ongoing clinical trials of atezolizumab currently. Given its efficacy in NSCLC and urothelial carcinoma, atezolizumab holds much potential in the future of cancer therapeutics.

Incidence of Accessory Phrenic Nerve and its Clinical Significance: A Cadaveric Study

The description of accessory phrenic nerve (APN) in the standard textbooks and available literature is vague and sometimes limited to few lines. The incidence of APN varies a great deal from 17.6 % to 80.9 % in the available literature. The aim of the present study was to calculate the incidence and variation of APN in Indian population. Material and methods: Forty five adult formalin-fixed cadavers (35 male, 10 female; 90 sides) used for gross anatomy dissection for undergraduates; during the 2 year period 2006–2007 were considered. Findings were recorded at different stages of the dissection. Results: Out of 90 body sides studied, the APN was present in 48 sides (53.3 %). In 17 of the above sides the APN was confined to the cervical region (Cervical type) and in 31 sides the APN entered the thorax (Thoracic type), all anterior to the subclavian vein (SV). In eleven specimens the APN was found bilaterally. Conclusion: The incidence of APN, with its course and relation to the various structures in cervical and thoracic region will help the surgeons while performing internal thoracic artery (ITA) grafting and other radical neck surgery.

The increasing challenge of never smokers with adenocarcinoma lung: Need to look beyond tobacco exposure

BACKGROUND

Lung cancer continues to remain as one of the leading causes of morbidity and mortality worldwide, despite the decreasing trends in smoking prevalence worldwide. An earlier study from the authors' institute reported the increasing trends of "Nonsmoking associated lung cancers."

MATERIALS AND METHODS

All consecutive histologically confirmed patients with lung cancer who presented to the outpatient department over a year (November 2014-October 2015) were included in this current prospective study.

RESULTS

Seven hundred and thirteen patients presented with clinicoradiologically suspicious findings of lung cancer in the said period. A pathological confirmation of lung cancer could be ascertained in 495 patients, and this cohort was further analyzed. The mean age of presentation was 57.76 years; the male to female ratio was approximately 2.5:1. Interestingly, 55.35% of the patients were nonsmokers. Adenocarcinoma (63%) was the predominant histology. Never smokers, both among men (P = 0.02) and women (P = 0.001), presented more frequently with adenocarcinoma histology. Further, 84.9% (45/53) of rural and 76.1% (19/25) of urban women who were never smokers reported exposure to indoor air pollution (secondhand smoke/fuel used for cooking purposes) which was significantly associated with adenocarcinoma histology.

CONCLUSION

Our study confirmed our initial observation of the changing epidemiology of lung cancer in the Indian subcontinent, paralleling the global trends of rise in adenocarcinoma. Lung cancer in never smokers outnumbering that among smokers was another interesting observation. The take-home message for both the clinicians as well as the policymakers is to study factors beyond tobacco exposure to understand the direction of the current lung cancer epidemic.

Chemotherapy delivery for resected colorectal cancer liver metastases: Management and outcomes in routine clinical practice

BACKGROUND

International guidelines recommend peri-operative chemotherapy for patients with resectable colorectal cancer liver metastases (CRCLM). Chemotherapy delivery in routine practice is not well described.

METHODS

All cases of CRC who underwent resection of LM in 2002-2009 were identified using the population-based Ontario Cancer Registry. Electronic treatment records identified chemotherapy delivered within 16 weeks before or after hepatectomy. All pathology reports were reviewed to describe extent of LM. Modified Poisson regression was used to evaluate factors associated with chemotherapy delivery. Cox proportional hazards model and propensity score analysis were used to explore the association between post-operative chemotherapy and cancer-specific (CSS) and overall (OS) survival.

RESULTS

We identified 1310 patients. Sixty-two percent of cases (815/1310) received peri-operative chemotherapy; 25% (200/815) pre-operative, 45% (366/815) post-operative, and 31% (249/815) pre- and post-operative. Utilization of chemotherapy increased over time from 51% in 2002 (57/112) to 73% in 2009 (157/216, p < 0.001). Fifty-four percent of patients received FOLFOX, 41% FOLFIRI, and 10% 5-FU monotherapy. Factors that were independently associated with greater utilization of post-operative chemotherapy included younger age (p < 0.001), female sex (p = 0.050), shorter disease-free interval (p = 0.006), and no prior adjuvant chemotherapy (p < 0.001). Utilization of chemotherapy varied substantially across geographic regions (from 24% to 71%, p = 0.001). Post-operative chemotherapy was associated with improved CSS (HR 0.58, 95%CI 0.44-0.76) and OS (HR 0.49, 95%CI 0.38-0.61); results were consistent in propensity score analysis.

CONCLUSION

Utilization of chemotherapy for resected CRCLM in routine practice has evolved with emerging evidence. Post-operative chemotherapy is associated with improved survival in the general population.

Morphology and topography of the parietal emissary foramina in South Indians: an anatomical study

The objectives of the present study were to study the prevalence of the parietal emissary vein in adult South Indian population and to study the distance of foramen from the sagittal suture. There were 58 adult human skulls in the present study which were available at the anatomy department of our institution. The study included 116 parietal bones which have been observed macroscopically for the number, prevalence and topography of the emissary foramen. The emissary foramen was present in 83 parietal bones (71.5%) of the present study. It was present at the junction between the middle 1/3 and posterior 1/3 region of the parietal bone. The foramen was observed solitary in 73 parietal bones (62.9%), double in 8 bones (6.9%), and triple in 2 parietal bones (1.7%). The foramen was not observed in 33 parietal bones (28.4%). The bilateral absence of parietal emissary foramen was seen in 7 skulls (12.1%). It was absent unilaterally in 19 skulls (32.7%). The accessory foramina were seen in only 8 skulls (13.8%). The mean distance of the foramen from the sagittal suture was 6.7±2.9 mm and 6.8±2.8 mm on the right and left sides respectively. The prevalence of parietal emissary vein in the present study was 71.5%. The present study has observed important data about the morphology and morphometry of the parietal emissary vein in South Indian population. The identification of parietal emissary veins and accessory veins is important in the operation room to prevent the blood loss.

The Paracondylar Skull Base: Anatomical Variants and Their Clinical Implications

AIM

The knowledge of the vasculature around the paracondylar region is important in neurosurgical procedures such as the paracondylar and lateral supracondylar approaches. The objectives of the present study were to determine the prevalence of paracondylar emissary foramina in the adult skull bases and to study the morphology of condylar canals and hypoglossal canals.

MATERIAL AND METHODS

The present study included 48 adult human skulls that were obtained from the gross anatomy laboratory of our institution. The paracondylar region was macroscopically observed for the variant foramina, canals and grooves.

RESULTS

It was observed that the paracondylar emissary foramen was present in 16 skulls (33.3%). The foramen was found bilaterally in 7 skulls (14.6%) and unilaterally in 9 skulls (18.7%). The hypoglossal canal was single in 35 (72.9%) skulls, double in 11 skulls (22.9%), and triple in 2 skulls (4.2%). The paracondylar process (2.1%) and the paracondylar groove (2.1%) were seen in 1 skull each. The posterior condylar canal was found to be patent in 19 (39.6%) skulls.

CONCLUSION

The present study observed that, the paracondylar emissary vein is not rare in occurrence as it is observed in 33.3% of cases. The identification of the paracondylar emissary veins and accessory vessels is important to avoid dangerous bleeding during the surgery. The morphological knowledge of the foramina around the paracondylar region is enlightening to the chiropractors, neurosurgeons and radiologists.

Etanercept decreases synovial expression of tumour necrosis factor-α and lymphotoxin-α in rheumatoid arthritis

OBJECTIVES

Etanercept is an effective tumour necrosis factor (TNF)-α inhibitor drug with the unique ability to block not only TNF-α but also lymphotoxin (LT)-α, at least in vitro. We aimed to investigate the in vivo effect of etanercept on synovial expression of TNF-α and LT-α.

METHOD

Synovial biopsies from 12 rheumatoid arthritis (RA) patients started on etanercept and 11 RA patients started on infliximab were obtained at baseline and 8 weeks after treatment initiation. Synovial expression of TNF-α and LT-α was evaluated by immunohistochemistry followed by computer-assisted image analysis. Differences between paired samples were analysed by the Wilcoxon test and between groups by the Mann-Whitney test. A p-value < 0.05 was considered statistically significant.

RESULTS

Six out of the 12 of the patients started on etanercept achieved an American College of Rheumatology (ACR)50 response. Macroscopic evaluation of the joints during arthroscopy revealed a significant decrease of local inflammation mainly in good ACR50 responders. Synovial expression of both LT-α and TNF-α decreased but the differences did not reach statistical significance at a group level. By contrast, a significant decrease in both LT-α and TNF-α was observed when only good ACR50 responders were analysed. Despite higher levels of baseline synovial TNF-α in the good responders, neither baseline LT-α nor TNF-α could predict clinical response after 8 weeks. A decreasing trend of the synovial levels of LT-α was also observed in good responders to infliximab, but the difference did not reach statistical significance.

CONCLUSIONS

Etanercept treatment modulates the synovial expression of both TNF-α and LT-α in vivo, a mechanism that might partly explain its clinical efficacy in RA.

Effect of sildenafil-induced nitric oxide on the histomorphology of cardiomyocytes in male rats

Introduction:

Although sildenafil citrate, one of the selective phosphodiesterase-5 (PDE5) inhibitors, is considered the best treatment for erectile dysfunction, studies have shown that it has also a beneficial effect on a variety of cardiovascular conditions. In spite of reports of a significant protective effect of sildenafil against necrosis in intact hearts, there are also contradictory reports regarding its beneficial effect on the heart. Since there are not enough reports regarding the histomorphological changes in the cardiomyocytes after exposure to sildenafil citrate, the present study was conducted to observe the same along with other biochemical parameters.

Materials and Methods:

Adult male albino rats of Wistar strain were used in the present study. The animals were divided into a control group and two experimental groups containing six rats each. The animals were treated with a solution of sildenafil citrate dissolved in distilled water. Histomorphological changes were observed by light microscopy and the levels of nitric oxide (NO) and PDE in the heart were measured by spectrophotometry.

Results:

It was observed that animals treated with sildenafil citrate showed a highly significant increase in NO and a decrease in PDE level, but the histological architecture of the cardiomyocytes did not show much change other than a slightly elongated and swollen nucleus.

Conclusions:

This study shows that sildenafil citrate at low dosage is well tolerated by cardiac muscle cells, but as dosage increases, it may become detrimental through its NO and PDE activity.

Bilateral arterial variation in the upper extremity--an anatomical case report

We report a case of bilateral arterial variation in the upper extremities of a male cadaver. In the left upper extremity, it was observed that the ulnar artery was arising from axillary artery. This ulnar artery was superficial throughout its course at the medial aspect of the arm and forearm. It was highly tortuous and did not have any branches either in the arm or forearm. It ended as the superficial palmar arch in the palm. However the brachial artery entered the cubital fossa and divided into radial and common interosseus arteries. In contrast, the right upper extremity was having normal brachial artery which was terminated into the ulnar and radial arteries at the cubital fossa. However, there was an accessory brachial artery present at the arm and ended at the cubital fossa. We believe that these anatomical variations are because of abnormal developmental vascular pattern in the region. In clinical practice, accurate knowledge of the arterial variations of upper extremity is of considerable importance in case of reparative surgeries and fracture management. They are of interest to the vascular and plastic surgeons.

Incomplete discoid lateral meniscus: a case report

The variations of lateral meniscus include pathologic entities which vary in size, shape and attachment. In this manuscript, we report a case of discoid lateral meniscus which was observed in an embalmed fetal cadaver. It was an incomplete variety of the discoid meniscus and observed on the right side knee. The clinical implication of this discoid meniscus has been emphasized along with the review of literature. The morphological and embryologic details of the discoid lateral menisci are discussed.

Morphological analysis and morphometry of the foramen magnum: an anatomical investigation

AIM

The objectives were to study the morphology of the foramen magnum in dry skulls and to evaluate its antero-posterior diameter, transverse diameter and the foramen magnum index.

MATERIAL AND METHODS

The foramen magna of 53 dry human cadaver skulls that were obtained from the neuroanatomy laboratory were examined. Different shapes of the foramen magnum were macroscopically noted and classified. The antero-posterior and transverse diameters were measured and the average foraminal index was calculated.

RESULTS

The foramen magnum shapes were determined as a round shape in 22.6% of cases, egg shape in 18.9%, tetragonal in 18.9%, oval in 15.1%, irregular in 15.1%, hexagonal in 5.6% and pentagonal in 3.8% of the cases. In 20.7% of skulls, the occipital condyle was observed to protrude into the foramen. The mean antero-posterior and transverse diameter of the foramen magnum was determined as 31 ± 2.4 mm and 25.2 ± 2.4 mm respectively. The average foramen magnum index was 1.2 ± 0.1.

CONCLUSION

The present study has determined the various shapes of foramen magnum and its morphometry. The data obtained may be of useful to the neurosurgeon in analyzing the morphological anatomy of craniovertebral junction. The findings are also enlightening for the anthropologists, morphologists and clinical anatomists.

Bone morphometry

OBJECTIVES

To compare anatomical measurements with that of radiological measurements.

BACKGROUND

The radiological measurements are commonly used in clinical practice. It is well known that the anatomical measurements are more accurate than radiological. The comparison of anatomicoradiological measurements is not reported hitherto.

METHODS

One human adult cadaveric femur bone was used for the present study. It was measured both anatomically and radiologically.

RESULTS

In digital X- ray measurements, the length from the upper lip of fovea capitis to the most prominent part of greater trochanter was 87.2 mms, from the upper most part of greater trochanter to the isthmus it was 147.9 mms, mediolateral width of medullary cavity at the isthmus was 8.9 mms, the mediolateral width at the distal root of lesser trochanter was 18.5 mms, anteroposterior width of medullary cavity at the isthmus was 11.5 mms, the anteroposterior width at the distal root of lesser trochanter was 16.8 mms. The same measurements were 91.2 mms, 154.6 mms, 11.8 mms, 19.7 mms, 11.9 mms and 18.5 mms when taken anatomically using the digital vernier caliper.

CONCLUSION

The present study showed that in all the parameters measured the radiological values were slightly lesser than the anatomical values. Considering the variations in the values, the implants can be designed for a particular case in orthopedic surgery. We believe that this study adds an important reference in the scientific literature (Tab. 1, Fig. 2, Ref. 5).

Clinically oriented morphometric study of medial and lateral menisci of the knee joint in adult cadavers

PURPOSE

The objective was to analyze the peripheral and inner border lengths of the medial and lateral menisci and the distance between anterior and posterior horns.

MATERIALS AND METHODS

The menisci from 23 adult knee joints (46 menisci) of the formalin fixed cadaver lower limbs were used. The peripheral and inner borer lengths of the menisci were measured with a non elastic cotton thread and the distance between the horns were measured with the vernier caliper of 0.02 mm accuracy.

RESULTS

The mean peripheral lengths of the medial and lateral menisci were 99.06 +/- 11.21 and 90.25 +/- 9.36 mm respectively. The inner border lengths for the same were determined as 55.44 +/- 8.37 and 50.63 +/- 5.33 mm respectively. The distances between the anterior and posterior horns were 24.13 +/- 4.19 and 11.31 +/- 3.86 mm for the same. The peripheral length and inter horn distance of the medial meniscus was more than the lateral, the statistically significance was observed (*p<0.05). The other parameters obtained were statistically not significant.

CONCLUSION

The present study had determined some important anatomical data which may be of importance to the orthopaedic literature. The findings are also enlightening for the anthropologists and clinical anatomists.

A morphometric study of foramen ovale

AIM

To note the morphological variations and morphometric details of foramina ovale in dry adult skulls of Indian origin.

MATERIAL AND METHODS

82 dry adult human skulls of unknown sex and of Indian origin were obtained and variations in appearance and number of foramen ovale were noted. The length and width of the foramina ovale of both sides were determined using digital Vernier calipers and area (A) was also calculated and analyzed.

RESULTS

Out of 82 adult skulls, the values for the right side was 7.64 ± 1.194 mm, 5.128 ± 0.827 mm and 30.808 ± 7.545 mm2 and for the left side the values was 7.561 ± 1.123 mm, 5.244 ± 0.950 mm and 31.310 ± 8.262 mm2 respectively, for the mean length, width and area of the foramen ovale. The shape of foramen was typically ovale in most of the skulls (56.70%) with some bony variations such as spine, tubercles etc.

CONCLUSION

There was no statistically significant difference between the two sides in length, width and area of foramen ovale and there was a positive correlation between lengths and areas of both sides.

COMMUNICATION BETWEEN THE MUSCULOCUTANEOUS AND MEDIAN NERVE: OCCURRENCE ON BOTH SIDES

Communications between musculocutaneous nerve and median nerve may be of considerable significance to neurologists and orthopaedicians when dealing with patients of nerve entrapment syndromes of the upper limb. Many authors have mentioned about an occurrence of such a variation previously, but the presence of a communication between the two nerves in both the arms has not been cited to the best of our knowledge. During routine dissection on a 72 year old male cadaver for the under graduate students in the Department of Anatomy at K.S. Hegde Medical Academy, we encountered an anomalous communication between musculocutaneous and median nerve in both the upper limbs. The communicating branch arose from the musculocutaneous nerve at a distance of 12.6 cm and 12.5 cm from the tip of coracoid process on right and left side and joined the median nerve 16.2 cm from the same bony point. Communications between nerves like this may explain abnormal debilities in certain cases of trauma of the upper arm. Lack of awareness of such variations with different patterns of communications between musculocutaneous and median nerve might complicate surgical repair of the nerves.

Morphometric analysis of clavicle in nepalese population

BACKGROUND

Determining the sex of deceased is easy when a complete skeleton is available for examination. On the whole, the bones are heavier, larger and markings of muscular attachments are more pronounced in the male than in the female.

OBJECTIVE

The purpose of this study was attempted to evolve an easily applied formula to enable the assessment of sex in an unknown clavicles and to know about comparative differences between the right and left clavicles, from certain metrical parameters.

METHODS

The study was an observational, cross-sectional and descriptive in nature. The present study was conducted on 257 adult clavicles out of which, 135 were of the right side and 122 of left side. The maximum length of the clavicle (in mm) was taken.

RESULTS

The length of the right clavicles varies from 108 mm to 178 mm with an average of 143.21 mm ± 11.13 mm S.D. The length of the left clavicles varies from 111 mm to 181 mm with an average 145.53 mm ± 11.04 mm S.D. It has been observed that the left clavicle was longer than the right clavicle by 2.32 mm. There was no such single character which can determine the sex of all clavicles. Depending on the length alone, the sex can be decided in 13.33% male and 4.44% female right clavicles and 16.39% male and 9.83% female bones if the left clavicle is considered.

CONCLUSION

The left clavicle was longer than the right clavicle. The determination of sex from the clavicle has a great medico legal significance to the toxicologists. It also helps the anthropologists in their study of evolution of mankind and migration of races.

Aberrant deep flexor muscles of the forearm associated with the accessory origin of first lumbrical muscle

Objective

To find out variations in the deep forearm flexors that are associated with anomalous origin of the first lumbrical muscle.

Introduction

Muscular anomalies of the upper extremity could cause peripheral nerve disorders. Although variations in the attachments of lumbrical muscles have been commonly studied, muscle with an additional origin in the proximal aspect of the forearm from the deep flexors is not much discussed.

Methods

Fifty-three formalin-fixed upper limbs were dissected to assess the aberrant origin of the first lumbrical from the deep forearm flexors. The measurement, shape, origin, insertion and innervation of aberrant deep forearm flexors were noted and photographed.

Results

In two (3.77%) out of 53 upper limbs unilateral aberrant deep forearm flexors were found giving accessory anomalous origin to the first lumbrical muscle. In 11 cases (20.75%) the presence of accessory head of flexor pollicis longus was seen, and found co-existing with the aberrant deep forearm flexor in one (1.89%) limb.

Discussion

The clinical implication of these muscular anomalies, such as aberrant origins and hypertrophy of the first lumbrical, in nerve entrapments, especially in the aetiology of carpal tunnel syndrome, is considered. The awareness and identification of the muscular variations of the antebrachial and carpal regions will facilitate safe surgery of cases of median nerve entrapment syndromes.

Foramina on the zygomatic bone: its clinical significance

AIM

To study the anatomy of zygomatico-orbital, zygomatico-facial and zygomatico temporal foramina in south Indian population.

MATERIALS AND METHODS

50 dry adult skulls of south Indian origin were studied. The number of ZO, ZF and ZT were recorded on each side. The distances of these foramina to the nearest palpable bony points, infero-lateral angle of the orbit and infra-orbital foramen were measured using Vernier's calipers.

RESULTS

Variable number of ZO and ZF foramina, ranging from 0 to 4 was seen. Single ZO foramen in 56% and 44%, double in 6% and 12%, absent in 38% and 44% on right and left sides were seen. Distance of ZO foramen from inferolateral angle of orbit was 9+2.51 mm and 7.8+1.74 mm on right and left side respectively. The mean distance from infraorbital foramen was 29.93+2.76 mm and 30.19+ 3.52 mm on right and left side respectively. Single ZF foramen in 40% and 42%, double in 10% and 8%, 3 in 4% on right side and 4 in 2% on left sides were seen. In the remaining 46% and 48% of bones, the ZF foramen was absent. Mean distance from inferolateral angle of orbit was 8.05+2.68 and 9.15+2.11 mm respectively on the right and left side. Mean distance from infraorbital foramen was 25.45+4.35 mm and 25.42+4 mm respectively on right and left side.

CONCLUSION

The location of ZO and ZF foramen can be population specific and knowledge of its location is important during stabilization of zygomatic fractures, in endoscopic subperiosteal facelift.

Bilateral anomaly of rectus capitis posterior muscles in the suboccipital triangle and its clinical implication

Rectus capitis posterior muscles are located in the suboccipital triangle and function in extension and lateral rotation of the head and neck. There are two of these muscles on each side: the rectus capitis posterior major and the rectus capitis posterior minor. In the present case we observed bilateral double rectus capitis posterior major muscle and bilateral absence of rectus capitis posterior minor muscle. The additional rectus capitis posterior major may put more strain to the spine of the axis and mean time the bilateral absence of rectus capitis posterior minor muscles will result in muscular in coordination in the suboccipital region while balancing the head. The present variation should be considered in the aetiology of cervicogenic headache.

Prediction of postoperative pulmonary reserve in lung resection patients

We performed Ventilation/Perfusion scans for patients planned for thoracotomy with resection of the primary or metastatic lung tumors. We predicted the post-operative FEV1 (Forced Expiratory Volume in first second) using Differential Lung Analysis software.

METHODS

34 patients were evaluated with Ventilation/Perfusion (V/Q) scans. Ventilation scan was performed with Tc-99m DTPA Aerosol and Perfusion Scan with Tc99m MAA, on 2 different days. The numbers of counts in anterior and posterior views of V/Q scans were calculated individually. Anterior and posterior arithmetical mean was calculated and post-operative FEV1 was predicted with the use of Differential Lung Analysis software. In most of the patients, the counts in the ventilation scan were lower and they were related to preoperative FEV1. Depending on the volume of lung resection, i.e. Upper, Middle and Lower zones or Total Pneumonectomy, FEV1 was calculated. Whenever FEV1 was >0.8 (L), the patient was taken up for resection (and if there were no other risk factors, such as cardiac complications, chronic obstructive pulmonary diseases, and any other pathological conditions involving the contralateral lung).

RESULTS

Most of the 34 patients were taken up for lung resection based on our FEV1 predictions. In 7 patients, repeat spirometry (i.e. pulmonary function test) was done at varying intervals after surgical procedures and the variation between preoperative FEV(1) and postoperative FEV(1) was only ±15%, at the most.

CONCLUSION

Postoperative FEV(1) based on V/Q scan and pulmonary function tests helped us to proceed with lung resection after assessment of the pulmonary reserve.