Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores

Background and Purpose—

The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion.

Methods—

Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy.

Results—

We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30–4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59–5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32–6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22–4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71–3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%; P <0.05).

Conclusions—

Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores.

Registration—

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02419794.

Impact of Endovascular Therapy in Patients With Large Ischemic Core

Background and Purpose—

Endovascular therapy (EVT) is strongly recommended for acute cerebral large vessel occlusion with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of the internal carotid artery or M1 segment of the middle cerebral artery. However, the effect of EVT for patients who have ischemic core with ASPECTS ≤5 (0–5) was not established. The purpose of this study was to elucidate the outcomes of EVT for patients with large ischemic core.

Methods—

Based on the data of The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2, patients with internal carotid artery or M1 segment of the middle cerebral artery occlusion and pretreatment ASPECTS 0 to 5 on noncontrast CT or diffusion-weighted image were extracted, and the outcomes by EVT were analyzed. Primary end point was defined as a good functional outcome (modified Rankin Scale score of ≤2) after 90 days.

Result—

Among 2420 registered patients, 504 patients were with internal carotid artery or M1 segment of the middle cerebral artery occlusion and ASPECTS 0 to 5. Among these 504 patients, 172 (34.1 %) were treated with EVT (EVT group) and 332 (65.9 %) without (no-EVT group). In the no-EVT group, elderly patients, females, poor prestroke modified Rankin Scale, high National Institutes of Health Stroke Scale, low ASPECTS, and late admission were significantly more observed. Good functional outcomes were significantly more observed in the EVT group than in the no-EVT group (19.8 % versus 4.2 %; P <0.0001; adjusted odds ratio, 2.33; 95% CI, 1.10–4.94). The incidences of symptomatic intracranial hemorrhage within 72 hours did not significantly different between the EVT group and the no-EVT group (3.7 % versus 4.9%; P =0.55; adjusted odds ratio, 0.50; 95% CI, 0.14–1.73).

Conclusions—

Although outcomes in this group of patients were usually poor, the data suggested EVT may increase the likelihood of a good functional outcome.

Abstract OT2-01-05: A randomized controlled trial comparing post-operative intensive follow-up with standard follow-up in high-risk breast cancer patients (JCOG1204: INSPIRE)

Background: The standard follow-up after surgery for breast cancer includes periodic interviews, clinical examinations, and mammography, but many institutions are conducting intensive follow-up including periodic computed tomography(CT), magnetic resonance imaging(MRI), and bone scintigraphy in the world, despite the lack of evidence to support this approach. While intensive follow-up may contribute to prolonged survival through earlier diagnosis and treatment of relapse, it has the disadvantages of high effort and costs placed on patients(pts) and healthcare workers, radiation exposure for imaging examinations, and overtreatment owing to false-positive results. Although past two randomized trials could not show significant difference in overall survival (OS), as imaging methods have remarkably improved, leading to the earlier detection of relapse, and medical therapies have remarkably improved in recent years, randomized controlled trials are needed to confirm whether intensive follow-up can really prolong survival sufficiently to offset these disadvantages in high-risk breast cancer pts.

Trial design: This study is a multi-institutional two-arm open label randomized controlled phase III trial being conducted with the participation of 42 hospitals belonging to the Breast Cancer Study Group of Japan Clinical Oncology Group. Eligible pts are randomized either to the intensive follow-up group or to the standard follow-up group; the former will undergo physical examination, bone scintigraphy, chest and abdominal CT, brain MRI/CT and frequent tumor markers, whereas the latter will undergo physical examination at the same frequency and tumor markers will be evaluated once a year. Mammography once a year is planned for both groups. This trial has been registered at the UMIN Clinical Trials Registry as UMIN000012429.

Eligibility criteria: High-risk breast cancer pts, who are expected to have recurrence rates of over 30% within 5 years after surgery. The main inclusion criteria are as follows: four or more axillary nodal metastases in the estrogen receptor (ER) positive pts without neoadjuvant chemotherapy(NC)., axillary node metastases in ER-negative pts without NC, axillary nodal metastases in ER-positive pts with NC, histologically proven residual invasive cancer in the breast or axilla in ER-negative with NC.

Specific Aims: The primary endpoint is OS, and secondary endpoints are disease-free survival, relapse-free survival, distant metastasis–free survival, OS in intrinsic subtypes, actual number of implemented examinations, compliance with pre-specified examinations, and adverse events.

Statistical methods: The primary endpoint will require a total of 538 events to be assessed in order to obtain a statistical power of 80% with a one-sided significance level of 0.05. Thus, the planned sample size to compare the two survival curves is set at 1500 pts, assuming an accrual time of 6 years and a follow-up time of 7 years according to the Schoenfeld and Richter's method.

Present accrual and target accrual: The trial was activated in November 2013. 773 pts have been enrolled by the end of June 2018.

Contact: Principal investigator Takashi Hojo MD tahojo@east.ncc.go.jp

Citation Format: Hojo T, Masuda N, Shibata T, Mizutani T, Shien T, Kinoshita T, Iwatani T, Kanbayashi C, Kitagawa D, Tsuneizumi M, Iwata H. A randomized controlled trial comparing post-operative intensive follow-up with standard follow-up in high-risk breast cancer patients (JCOG1204: INSPIRE) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT2-01-05.

Abstract P3-13-06: Tailored neoadjuvant endocrine and chemo-endocrine therapy for postmenopausal patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative primary breast cancer

Aims We investigated the efficacy and safety of initial neoadjuvant endocrine therapy with exemestane (EXE) alone followed by subsequent tailored treatment with EXE alone for responders or EXE plus oral metronomic cyclophosphamide (CPA) for non-responders.

Methods In this multicenter open-label phase II study, we enrolled postmenopausal patients with primary invasive estrogen receptor (ER)-positive, HER2-negative, stage I–IIIA (T1c–T3 N0–2 M0) breast cancer and Ki67 index ≤ 30%. Patients first received EXE 25mg/day for 12 weeks. Based on clinical response and change in Ki67 index in response to the initial therapy, patients who achieved complete response (CR), partial response (PR) with Ki67 index ≤5% after treatment, or stable disease (SD) with Ki67 index ≤5% both before and after treatment were defined as responders. Non-responders were defined as patients with PR and Ki67 index &gt;5% after treatment, or SD and Ki67 index &gt;5% before or after treatment. For the subsequent 24 weeks, responders continued the EXE monotherapy (continued EXE group), whereas non-responders switched to combination therapy with EXE plus CPA 50mg/day (EXE+CPA group). The primary endpoint was clinical response (CR and PR) at weeks 24 and 36.

Results A total of 59 patients (median age 69 years, range 53–86 years) were enrolled between January 2011 and July 2015. After exclusion of 3 (2 with progressive disease, 1 with an adverse event, AE) who discontinued treatment in the initial 12-week EXE monotherapy period, 56 remained enrolled to receive subsequent treatment. After 8–12 weeks of the initial EXE monotherapy, 14 patients were classified as responders (9 with PR and Ki67 index ≤5% after treatment; 5 with SD and Ki67 index ≤5% before and after treatment), whereas 42 were classified as non-responders (3 with PR and Ki67 index &gt;5% after treatment; 39 with SD and Ki67 index &gt;5% before or after treatment). Clinical response rates at weeks 24 and 36 were 85% (12/14, 95%CI 57.2–98.2%) and 76% (10/13, 95%CI 46.2–95.0%), respectively, in the continued EXE group, and 56% (23/41, 95%CI 39.7–71.5%) and 76% (30/39, 95%CI 60.7–88.9%), respectively, in the EXE+CPA group. At week 36, no significant difference was found in median Ki67 index between the continued EXE and EXE+CPA groups (3.5% and 4.0%, respectively). The proportion of patients with preoperative endocrine prognostic index (PEPI) 0 was also similar between the continued EXE and EXE+CPA groups (21.4% and 23.8%, respectively). The breast-conserving surgery rate was 71.4% and 69.0%, respectively. Grade 3 AEs were elevated liver enzymes (1 patient) in the continued EXE group, and gastritis, hypertriglyceridemia, and bone mineral density loss (1 patient each) in the EXE+CPA group.

Conclusion Switching from EXE monotherapy to EXE+CPA combination therapy based on clinical response and biological response (change in Ki67 index) to initial therapy improved subsequent clinical response in non-responders. Favorable clinical response to EXE alone was maintained in responders. Tailored neoadjuvant endocrine and chemo-endocrine therapy was shown to be effective in postmenopausal ER-positive breast cancer patients. (JBCRG-11CPA; UMIN000004751)

Citation Format: Masuda N, Sato N, Morimoto T, Ueno T, Kanbayashi C, Kaneko K, Yasojima H, Saji S, Sasano H, Morita S, Ohno S, Toi M. Tailored neoadjuvant endocrine and chemo-endocrine therapy for postmenopausal patients with estrogen receptor-positive human epidermal growth factor receptor 2-negative primary breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-13-06.

Solid papillary carcinoma of the breast: report of two cases

Two cases of solid papillary carcinoma of the breast were pathologically studied. Subjects included two female patients: a 76-year-old (Case 1) and a 43-year-old (Case 2). Both cases showed solid and papillary proliferation of spindle cells in expanded ducts, perivascular pseudorosettes, eosinophilic fine granules in an abundant cytoplasm, intracellular mucin production, and positivity for chromogranin A. Case 1 showed an aggregation form involving multiple ducts, admixture of signet-ring like cells, mucin pools, and small and large electron-dense granules and flocculent granules in electron microscopy. Case 2 showed a solitary and compact form in a dilated duct and an interlacing bundle pattern.

Vitamin B2 activity of 7,8-dimethyl-10-(2,3,4-trihydroxy-4-formylbutyl)isoalloxazine in Lactobacillus casei

The microbial activities of vitamin B2-aldehyde and vitamin B2-acid, produced by Schizophyllum commune, a Basidiomycete, were studied. Lactobacillus casei ATCC No. 7469 was used as a test microorganism. B2-aldehyde exhibited a good response curve in the growth of L. casei. B2-acid had neither a stimulatory nor an inhibitory effect on the growth. When B2-aldehyde was incubated with the homogenate of L. casei, it was converted to riboflavin. The flavin formed from B2-aldehyde by the homogenate not only exhibited an equivalent response curve to authentic riboflavin in the growth of L. casei, but also showed the same Rf value as authentic riboflavin in any paper chromatogram, as far as tested. Hence, the microbial activity of B2-aldehyde for L. casei seems to be ascribable to riboflavin which is a reduction product of B2-aldehyde.