Association between metformin use and the risk of developing open-angle glaucoma among patients with diabetes: a retrospective cohort study and meta-analysis

PURPOSE

Recent studies examining the neuroprotective effects of metformin on open-angle glaucoma (OAG) have failed to provide consistent results. In this study, we investigated the association between metformin use and OAG.

METHODS

Data were obtained from a sample cohort of the Korean National Health Insurance database. Patients diagnosed with type-2 diabetes (T2DM) between 2004 and 2013 were included. We performed propensity score-matched analysis in a matched cohort (N = 20,646). The risk of the newly developed OAG was estimated using a Cox proportional hazards model. Including the present study, the meta-analysis included five studies to calculate the pooled risk for OAG based on metformin use.

RESULTS

In the adjusted model, the analysis revealed no statistical association between metformin use and OAG incidence (hazard ratio [HR] 1.05; 95% confidence interval [CI] 0.79-1.40; P = 0.738). The highest tercile of metformin use demonstrated no statistical significance (HR 0.93 [95% CI 0.63-1.37]; P = 0.703). No significant dose-dependent association was observed between the cumulative dose and incidence of OAG (P-value for trend = 0.336). In a meta-analysis of four published articles and the present study, the common-effects and random-effects models indicated conflicting results in terms of significance. The random effects model demonstrated no significant association (pooled risk ratio 0.53; 95% CI 0.24-1.19; P = 0.123).

CONCLUSION

We found no significant association between metformin use and OAG incidence in patients with T2DM in this population-based cohort study and meta-analysis. Further studies are needed to investigate the association between metformin use and the risk of OAG among patients with T2DM.

Refining dietary metabolisable energy and crude protein levels in relation to duck performance and behaviour

1. The study evaluated the effect of dietary metabolisable energy (ME) content and crude protein (CP) level on the growth performance and behaviour of ducks.2. A total of 720, Cherry Valley ducks were allocated to 36 pens in groups of 20 birds. For the initial period, from 1 to 21 d age, six diets, containing a standard (SME), low (LME) and high (HME) ME of 12.14, 11.93 and 12.35 MJ/kg, and standard (SCP) or high (HCP) CP contents of 210 or 220 g/kg diet, respectively, were mixed. For the period from 22 to 42 d age, the diets contained ME of 12.98 (SME), 12.77 (LME), 13.19 (HME) MJ/kg and the levels of CP were 170 (SCP) or 180 (HCP) g/kg, respectively.3. An ME by CP interaction was seen from 1 to 21 d age in ducks fed HME + HCP diet, which had greater weight gain than those fed LME + SCP (P < 0.05). Compared to LME + SCP, dietary HME decrease feeding but increased walking behaviour compared to LME + SCP and SME + SCP (P < 0.05). High CP in LME and SME diets increased drinking behaviour (P < 0.05), but there was no change in HME diet. Compared to LME, feeding HME reduced ground pecking (P < 0.05). Feeding HME reduced feeding behaviour (P < 0.05) from 22 to 42 d age. During the same period, standing behaviour was reduced in HCP + LME (P < 0.05). Drinking was reduced in LME + SCP compared to SME + HCP and HME + HCP (P < 0.05).4. A diet formulated with HME and HCP is effective for enhancing growth performance of ducks aged 1-21 d and saving time for feeding or ground pecking, which may induce spending more time on other activities.

A Survey of Practice Patterns for Clinical Nodal Staging Prior to Neoadjuvant Chemotherapy in Breast Cancer

BACKGROUND

The importance of clinical staging in breast cancer has increased owing to the wide use of neoadjuvant systemic therapy (NST). This study aimed to investigate the current practice patterns regarding clinical nodal staging in breast cancer in real-world settings.

MATERIALS AND METHODS

A web-based survey was administered to board-certified oncologists in Korea, including breast surgical, medical, and radiation oncologists, from January to April 2022. The survey included 19 general questions and 4 case-based questions.

RESULTS

In total, 122 oncologists (45 radiation, 44 surgical, and 33 medical oncologists) completed the survey. Among them, 108 (88%) responded that clinical staging before NST was primarily performed by breast surgeons. All the respondents referred to imaging studies during nodal staging. Overall, 64 (52.5%) responders determined the stage strictly based on the radiology reports, whereas 58 (47.5%) made their own decision while noting radiology reports. Of those who made their own decisions, 88% referred to the number or size of the suspicious node. Of the 75 respondents involved in prescribing regimens for neoadjuvant chemotherapy, 58 (77.3%) responded that the reimbursement regulations in the selection of NST regimens affected nodal staging in clinical practice. In the case-based questions, high variability was observed among the clinicians in the same cases.

CONCLUSIONS

Diverse assessments by specialists owing to the lack of a clear, harmonized staging system for the clinical nodal staging of breast cancer can lead to diverse practice patterns. Thus, practical, harmonized, and objective methods for clinical nodal staging and for the outcomes of post-NST response are warranted for appropriate treatment decisions and accurate outcome evaluation.

Abstract 6654: Association PD-L1 overexpression with immune checkpoint inhibitor effect in triple-negative breast cancer

Background: Recently, studies on the antitumor effects of PD-L1 inhibitors have gained importance in difficult to treat solid tumors. In particular, the expression of PD-L1 could be an important factor in evaluating the possibility of immunotherapy in triple-negative breast cancer where targeted therapy is not possible and the prognosis is poor. Accordingly, this study investigated the effect of PD-L1 overexpression on the immune checkpoint inhibitor effect in triple-negative breast cancer.

Method: The relationship between T stage and N stage according to PD-L1 mRNA expression was analyzed in the TCGA and METABRIC datasets of breast cancer. To evaluate the role of PD-L1, PD-L1-overexpressing breast cancer cell lines for in vitro and in vivo experiments were established.

Result: Using TCGA and METABRIC datasets, we found that PD-L1 showed the highest expression in breast cancer of the basal subtype, but the correlation between T stage and N stage according to PD-L1 expression was not statistically significant. To determine the functional importance of PD-L1 in breast cancer, we established 4T1-PD-L1-overexpressing breast cancer cell lines. We observed that the overexpression of PD-L1 promoted cell proliferation, migration, and invasion. In the orthotopic tumor mouse model, PD-L1 showed no significant difference in tumor growth compared to the control group, but anti-PD-L1 treatment showed a significant antitumor effect.

Conclusion: We confirmed that overexpression of PD-L1 in an orthotopic breast cancer model did not induce increased tumor growth. Above all, it was confirmed that a high PD-L1 level enhances the antitumor effect of immune checkpoint inhibitors. Our findings show that the expression level of PD-L1 in breast cancer has a significant effect on the immune checkpoint inhibitor effect. We need to further investigate the role of PD-L1 in breast cancer.

Citation Format: A Young Park, Ju Hee Kim, Sangen Lee, Hong Kyu Kim, Han-Byoel Lee, Wonshick Han. Association PD-L1 overexpression with immune checkpoint inhibitor effect in triple-negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6654.

Risk Factors Associated With a Large Vertical Cup-to-Disc Ratio: Korean National Health and Nutritional Examination Survey

PRCIS

Higher intraocular pressure, higher systolic blood pressure, and higher serum aspartate transaminase to alanine aminotransaminase level were risk factors associated with a large vertical cup-to-disk ratio (vCDR).

PURPOSE

To identify risk factors for a large vCDR using data from the Korea National Health and Nutritional Examination Survey (2008-2012).

MATERIALS AND METHODS

Out of the total 29,322 participants aged 20 or older who participated in Korea National Health and Nutrition Survey (KHANES) from the year 2008 to 2012, this study was conducted on 21,780 participants, excluding 1449 of them without fundus photographs and 6093 of them with missing values. To identify the risk factors associated with a large vCDR, the participants were divided into 2 groups: ≥0.6 and <0.6.

RESULTS

Of the 21,780 subjects, 2357 of them had a vCDR ≥0.6 and 19,423 had a vCDR <0.6. There were significant differences in age, sex, and educational levels between the 2 groups. After adjusting age, sex, education level, and survey year by propensity score matching, in the group having vCDR ≥0.6, intraocular pressure (IOP) was high, systolic blood pressure (SBP) was high, and serum aspartate transaminase to alanine aminotransaminase level (AST/ALT ratio) was high ( P <0.001, P <0.001, and P <0.001). The results of multiple logistic regression analyses revealed that high IOP, high SBP, high myopia, and high AST/ALT ratio were risk factors for vCDR ≥0.6 ( P <0.001, P =0.006, P =0.005, P <0.001).

CONCLUSIONS

In this study, risk factors associated with large vCDR were analyzed. Higher IOP, higher SBP, and higher AST/ALT ratio were related to vCDR ≥0.6.

Predicting Postoperative Anterior Chamber Angle for Phakic Intraocular Lens Implantation Using Preoperative Anterior Segment Metrics

Purpose

The anterior chamber angle (ACA) is a critical factor in posterior chamber phakic intraocular lens (EVO Implantable Collamer Lens [ICL]) implantation. Herein, we predicted postoperative ACAs to select the optimal ICL size to reduce narrow ACA-related complications.

Methods

Regression models were constructed using pre-operative anterior segment optical coherence tomography metrics to predict postoperative ACAs, including trabecular-iris angles (TIAs) and scleral-spur angles (SSAs) at 500 µm and 750 µm from the scleral spur (TIA500, TIA750, SSA500, and SSA750). Data from three expert surgeons were assigned to the development (N = 430 eyes) and internal validation (N = 108 eyes) datasets. Additionally, data from a novice surgeon (N = 42 eyes) were used for external validation.

Results

Postoperative ACAs were highly predictable using the machine-learning (ML) technique (extreme gradient boosting regression [XGBoost]), with mean absolute errors (MAEs) of 4.42 degrees, 3.77 degrees, 5.25 degrees, and 4.30 degrees for TIA500, TIA750, SSA500, and SSA750, respectively, in internal validation. External validation also showed MAEs of 3.93 degrees, 3.86 degrees, 5.02 degrees, and 4.74 degrees for TIA500, TIA750, SSA500, and SSA750, respectively. Linear regression using the pre-operative anterior chamber depth, anterior chamber width, crystalline lens rise, TIA, and ICL size also exhibited good performance, with no significant difference compared with XGBoost in the validation sets.

Conclusions

We developed linear regression and ML models to predict postoperative ACAs for ICL surgery anterior segment metrics. These will prevent surgeons from overlooking the risks associated with the narrowing of the ACA.

Translational Relevance

Using the proposed algorithms, surgeons can consider the postoperative ACAs to increase surgical accuracy and safety.

Systemic proinflammatory-profibrotic response in aortic stenosis patients with diabetes and its relationship with myocardial remodeling and clinical outcome

Background

It is unclear whether and how diabetes mellitus may aggravate myocardial fibrosis and remodeling in the pressure-overloaded heart. We investigated the impact of diabetes on the prognosis of aortic stenosis (AS) patients and its underlying mechanisms using comprehensive noninvasive imaging studies and plasma proteomics.

Methods

Severe AS patients undergoing both echocardiography and cardiovascular magnetic resonance (CMR) (n=253 of which 66 had diabetes) comprised the imaging cohort. The degree of replacement and diffuse interstitial fibrosis by late gadolinium enhancement (LGE) and extracellular volume fraction (ECV) was quantified using CMR. Plasma samples were analyzed with the multiplex proximity extension assay for 92 proteomic biomarkers in a separate biomarker cohort of severe AS patients (n=100 of which 27 had diabetes).

Results

In the imaging cohort, diabetic patients were older (70.4±6.8 vs. 66.7±10.1 years) and had a higher prevalence of ischemic heart disease (28.8% vs. 9.1%), with more advanced ventricular diastolic dysfunction. On CMR, diabetic patients had increased replacement and diffuse interstitial fibrosis (LGE% 0.3 [0.0–1.6] versus 0.0 [0.0–0.5], p=0.009; ECV% 27.9 [25.7–30.1] versus 26.7 [24.9–28.5], p=0.025) (Figure 1).

Plasma proteomics analysis of the biomarker cohort revealed that 9 proteins (E-selectin, interleukin-1 receptor type 1, interleukin-1 receptor type 2, galectin-4, intercellular adhesion molecule 2, integrin beta-2, galectin-3, growth differentiation factor 15, and cathepsin D) are significantly elevated in diabetic AS patients (Figure 2). Pathway over-representation analyses of the plasma proteomics with Gene Ontology terms indicated that pathways related to inflammatory response and extracellular matrix components were enriched, suggesting that diabetes is associated with systemic effects that evoke proinflammatory and profibrotic response to the pressure-overloaded myocardium.

During follow-up (median 6.3 years [IQR 5.2–7.2]) of the imaging cohort, 232 patients received aortic valve replacement (AVR) with 53 unexpected heart failure admissions or death. Diabetes was a significant predictor of heart failure and death, independent of clinical covariates and AVR (hazard ratio 1.88, 95% confidence interval 1.06–3.31, p=0.030).

Conclusion

Plasma proteomic analyses indicate that diabetes potentiates the systemic proinflammatory and profibrotic milieu in AS patients. These systemic biological changes underlie the increase of myocardial fibrosis, diastolic dysfunction, and worse clinical outcomes in severe AS patients with concomitant diabetes.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): National Research Foundation of Korea

Integrating wearables and modelling for monitoring rehabilitation following total knee joint replacement

BACKGROUND AND OBJECTIVE

Wearable inertial devices integrated with modelling and cloud computing have been widely adopted in the sports sector, however, their use in the health and medical field has yet to be fully realised. To date, there have been no reported studies concerning the use of wearables as a surrogate tool to monitor knee joint loading during recovery following a total knee joint replacement. The objective of this study is to firstly evaluate if peak tibial acceleration from wearables during gait is a good surrogate metric for computer modelling predicted functional knee loading; and secondly evaluate if traditional clinical patient related outcomes measures are consistent with wearable predictions.

METHODS

Following ethical approval, four healthy participants were used to establish the relationship between computer modelling predicted knee joint loading and wearable measured tibial acceleration. Following this, ten patients who had total knee joint replacements were then followed during their 6-week rehabilitation. Gait analysis, wearable acceleration, computer models of knee joint loading, and patient related outcomes measures including the Oxford knee score and range of motion were recorded.

RESULTS

A linear correlation (R² of 0.7-0.97) was observed between peak tibial acceleration (from wearables) and musculoskeletal model predicted knee joint loading during gait in healthy participants first. Whilst patient related outcome measures (Oxford knee score and patient range of motion) were observed to improve consistently during rehabilitation, this was not consistent with all patient's tibial acceleration. Only those patients that exhibited increasing peak tibial acceleration over 6-weeks rehabilitation were positively correlated with the Oxford knee score (R² of 0.51 to 0.97). Wearable predicted tibial acceleration revealed three patients with a consistent knee loading, five patients with improving knee loading, and two patients with declining knee loading during recovery. Hence, 20% of patients did not present with satisfactory joint loading following total knee joint replacement and this was not detected with current patient related outcome measures.

CONCLUSIONS

The use of inertial measurement units or wearables in this study provided additional insight into patients who were not exhibiting functional improvements in joint loading, and offers clinicians an 'off-site' early warning metric to identify potential complications during recovery and provide the opportunity for early intervention. This study has important implications for improving patient outcomes, equity, and for those who live in rural regions.

Oculomics for sarcopenia prediction: a machine learning approach toward predictive, preventive, and personalized medicine

Aims

Sarcopenia is characterized by a gradual loss of skeletal muscle mass and strength with increased adverse outcomes. Recently, large-scale epidemiological studies have demonstrated a relationship between several chronic disorders and ocular pathological conditions using an oculomics approach. We hypothesized that sarcopenia can be predicted through eye examinations, without invasive tests or radiologic evaluations in the context of predictive, preventive, and personalized medicine (PPPM/3PM).

Methods

We analyzed data from the Korean National Health and Nutrition Examination Survey (KNHANES). The training set (80%, randomly selected from 2008 to 2010) data were used to construct the machine learning models. Internal (20%, randomly selected from 2008 to 2010) and external (from the KNHANES 2011) validation sets were used to assess the ability to predict sarcopenia. We included 8092 participants in the final dataset. Machine learning models (XGBoost) were trained on ophthalmological examinations and demographic factors to detect sarcopenia.

Results

In the exploratory analysis, decreased levator function (odds ratio [OR], 1.41; P value <0.001), cataracts (OR, 1.31; P value = 0.013), and age-related macular degeneration (OR, 1.38; P value = 0.026) were associated with an increased risk of sarcopenia in men. In women, an increased risk of sarcopenia was associated with blepharoptosis (OR, 1.23; P value = 0.038) and cataracts (OR, 1.29; P value = 0.010). The XGBoost technique showed areas under the receiver operating characteristic curves (AUCs) of 0.746 and 0.762 in men and women, respectively. The external validation achieved AUCs of 0.751 and 0.785 for men and women, respectively. For practical and fast hands-on experience with the predictive model for practitioners who may be willing to test the whole idea of sarcopenia prediction based on oculomics data, we developed a simple web-based calculator application (https://knhanesoculomics.github.io/sarcopenia) to predict the risk of sarcopenia and facilitate screening, based on the model established in this study.

Conclusion

Sarcopenia is treatable before the vicious cycle of sarcopenia-related deterioration begins. Therefore, early identification of individuals at a high risk of sarcopenia is essential in the context of PPPM. Our oculomics-based approach provides an effective strategy for sarcopenia prediction. The proposed method shows promise in significantly increasing the number of patients diagnosed with sarcopenia, potentially facilitating earlier intervention. Through patient oculometric monitoring, various pathological factors related to sarcopenia can be simultaneously analyzed, and doctors can provide personalized medical services according to each cause. Further studies are needed to confirm whether such a prediction algorithm can be used in real-world clinical settings to improve the diagnosis of sarcopenia.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00292-3.

Machine learning predicting myopic regression after corneal refractive surgery using preoperative data and fundus photography

PURPOSE

Myopic regression after surgery is the most common long-term complication of refractive surgery, but it is difficult to identify myopic regression without long-term observation. This study aimed to develop machine learning models to identify high-risk patients for refractive regression based on preoperative data and fundus photography.

METHODS

This retrospective study assigned subjects to the training (n = 1606 eyes) and validation (n = 403 eyes) datasets with chronological data splitting. Machine learning models with ResNet50 (for image analysis) and XGBoost (for integration of all variables and fundus photography) were developed based on subjects who underwent corneal refractive surgery. The primary outcome was the predictive performance for the presence of myopic regression at 4 years of follow-up examination postoperatively.

RESULTS

By integrating all factors and fundus photography, the final combined machine learning model showed good performance to predict myopic regression of more than 0.5 D (area under the receiver operating characteristic curve [ROC-AUC], 0.753; 95% confidence interval [CI], 0.710-0.793). The performance of the final model was better than the single ResNet50 model only using fundus photography (ROC-AUC, 0.673; 95% CI, 0.627-0.716). The top-five most important input features were fundus photography, preoperative anterior chamber depth, planned ablation thickness, age, and preoperative central corneal thickness.

CONCLUSION

Our machine learning algorithm provides an efficient strategy to identify high-risk patients with myopic regression without additional labor, cost, and time. Surgeons might benefit from preoperative risk assessment of myopic regression, patient counseling before surgery, and surgical option decisions.

A deep learning approach for detection of shallow anterior chamber depth based on the hidden features of fundus photographs

BACKGROUND AND OBJECTIVES

Patients with angle-closure glaucoma (ACG) are asymptomatic until they experience a painful attack. Shallow anterior chamber depth (ACD) is considered a significant risk factor for ACG. We propose a deep learning approach to detect shallow ACD using fundus photographs and to identify the hidden features of shallow ACD.

METHODS

This retrospective study assigned healthy subjects to the training (n = 1188 eyes) and test (n = 594) datasets (prospective validation design). We used a deep learning approach to estimate ACD and build a classification model to identify eyes with a shallow ACD. The proposed method, including subtraction of the input and output images of CycleGAN and a thresholding algorithm, was adopted to visualize the characteristic features of fundus photographs with a shallow ACD.

RESULTS

The deep learning model integrating fundus photographs and clinical variables achieved areas under the receiver operating characteristic curve of 0.978 (95% confidence interval [CI], 0.963-0.988) for an ACD ≤ 2.60 mm and 0.895 (95% CI, 0.868-0.919) for an ACD ≤ 2.80 mm, and outperformed the regression model using only clinical variables. However, the difference between shallow and deep ACD classes on fundus photographs was difficult to be detected with the naked eye. We were unable to identify the features of shallow ACD using the Grad-CAM. The CycleGAN-based feature images showed that area around the macula and optic disk significantly contributed to the classification of fundus photographs with a shallow ACD.

CONCLUSIONS

We demonstrated the feasibility of a novel deep learning model to detect a shallow ACD as a screening tool for ACG using fundus photographs. The CycleGAN-based feature map showed the hidden characteristic features of shallow ACD that were previously undetectable by conventional techniques and ophthalmologists. This framework will facilitate the early detection of shallow ACD to prevent overlooking the risks associated with ACG.

Abstract P3-18-14: Assessment of quality of life and objective cosmetic outcome of breast conserving surgery with or without latissimus dorsi mini-flap in breast cancer

Introduction : Latissimus dorsi mini-flap (LDMF) with breast conserving surgery (BCS) was introduced as a useful volume replacement technique when the tumor is located in upper or outer portion of breast and the tumor size is large requiring extensive excision of breast tissue. However few studies have assessed quality of life (QoL) and objective cosmetic outcome of LDMF in breast cancer surgery. We tried to evaluate those in patients who underwent BCS with or without LDMF. Methods : This study was a prospective, single-center cohort study of patients who underwent LDMF and BCS between 2011 and 2018. As a control, patients who underwent BCS without any volume replacement and the tumor size equal to or greater than 2.5cm on the upper or upper outer of the breast on preoperative imaging. Breast Q questionnaire and body photo were taken at least 1 year after surgery. Two breast surgeons and one plastic surgeon who did not performed LDMF assessed the cosmetic outcome of the patients with photo. Results : 62 patients were in the BCS with LDMF group and 58 patients were in BCS-only group. Pathologic tumor size was significantly larger in LDMF group than BCS-only group (LDMF 3.89cm vs BCS-only 2.92cm, p= 0.001 ). Psychosocial well-being (P= 0.024), physical well-being (P= 0.000), and satisfaction with surgeon (p= 0.006) were significantly better in the BCS-only group than in the LDMF group respectively. But, there were no significant difference in neither sexual well-being (p= 0.286) nor satisfaction for breast (p=0.278) between BCS and LDMF group. In the physicians assessment, there was no significant difference in the cosmetic outcome score between the two groups (LDMF 2.56/4 vs. BCS-only 2.58/4, p= 0.884). Conclusion : In conclusion, physician assessed cosmetic outcome of LDMF was equivalent to that of BCS without LDMF although the tumor size was significantly larger in patients with LDMF. Some inferiority of QoL might be due to postoperative pain or arm movement discomfort. We are planning to evaluate objective cosmetic results using BCCT.core software.

Citation Format: Jang-il Kim, Yireh Han, Changjin Lim, Jong-Ho Cheun, Ji Gwang Jung, Hong Kyu Kim, Han-Byoel Lee, Hyeong-Gon Moon, Wonshik Han. Assessment of quality of life and objective cosmetic outcome of breast conserving surgery with or without latissimus dorsi mini-flap in breast cancer [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-14.

Abstract P4-07-07: Metaplastic carcinoma of the breast has comparable prognosis to non-metaplastic triple negative breast cancer despite poor response to chemotherapy

Introduction Metaplastic carcinoma (MC) of the breast is a rare pathologic entity accounting for &lt;1% of all invasive breast cancers and is generally negative for hormone receptors and HER2. They often show more aggressive characteristics and are resistant to treatment. Although triple negative breast cancers (TNBCs) have good response to neoadjuvant chemotherapy (NAC) and a pathologic complete response (pCR) rate of about 40%, benefit of NAC for MC is not clear. The aim of this study was to compare the Clinicopathologic characteristics and prognosis of MC with non-MC TNBC, and assess the usefulness of NAC for MC. Methods Retrospective chart review of TNBC patients who underwent breast surgery at Seoul National University Hospital between January 2000 and December 2018 were included for analysis. Clinicopathologic features including age, TNM stage, Ki-67 and histologic grade were collected. For patients who had received NAC, tumor size on ultrasound before NAC and pathologic size of residual tumor was used to assess responsiveness to NAC. We used 3:1 propensity score matching according to age, neoadjuvant chemotherapy, pT stage, pN stage. Kaplan-Meier analysis and log-rank test were performed. Results Among 1783 TNBC patients included for analysis, 82 (4.59%) were MC and 1701 (95.34%) were non-MC. MC had a worse DFS and OS. After propensity score matching, there was no difference in survival outcomes. The 5-year disease-free survival and overall survival between MC vs. non-MC TN was 61.9% vs. 73.0% (HR 1.379, 95% CI 0.594-3.202, p-value = 0.430) and 71.4% vs. 74.6% (HR 1.007, 95% CI 0.393-2.579, p-value = 0.480), respectively. The proportion of patients who received NAC among MC and propensity matched non-MC TNBC were 21/82 (25.6%) and 63/1701 (3.7%), respectively. The pathologic complete response rate for all and propensity score matched non-MC TNBC was 76/364 (20.9%) and 11/63 (17.5%), respectively, whereas no MC patients achieved a pathologic complete response (HR 1.404 95% CI 1.213-1.624, p-value = 0.058). Conclusions MC has comparable prognosis compared to non-MC TNBC in terms of disease-free survival and overall survival, while showing lower rate of pathologic complete response after NAC. Upfront surgery may be more beneficial for MC. A prospective study with larger number of patients evaluating the role of NAC in MC is warranted.

Citation Format: Changjin Lim, Jang-il Kim, Yireh Han, Jong-ho Cheun, Ji Gwang Jung, Hong Kyu Kim, Hyeong-Gon Moon, Wonshik Han, Han-Byoel Lee. Metaplastic carcinoma of the breast has comparable prognosis to non-metaplastic triple negative breast cancer despite poor response to chemotherapy [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-07-07.

Simple Code Implementation for Deep Learning-Based Segmentation to Evaluate Central Serous Chorioretinopathy in Fundus Photography

Purpose

Central serous chorioretinopathy (CSC) is a retinal disease that frequently shows resolution and recurrence with serous detachment of the neurosensory retina. Here, we present a deep learning analysis of subretinal fluid (SRF) lesion segmentation in fundus photographs to evaluate CSC.

Methods

We collected 194 fundus photographs of SRF lesions from the patients with CSC. Three graders manually annotated of the entire SRF area in the retinal images. The dataset was randomly separated into training (90%) and validation (10%) datasets. We used the U-Net segmentation model based on conditional generative adversarial networks (pix2pix) to detect the SRF lesions. The algorithms were trained and validated using Google Colaboratory. Researchers did not need prior knowledge of coding skills or computing resources to implement this code.

Results

The validation results showed that the Jaccard index and Dice coefficient scores were 0.619 and 0.763, respectively. In most cases, the segmentation results overlapped with most of the reference areas in the annotated images. However, cases with exceptional SRFs were not accurate in terms of prediction. Using Colaboratory, the proposed segmentation task ran easily in a web-based environment without setup or personal computing resources.

Conclusions

The results suggest that the deep learning model based on U-Net from the pix2pix algorithm is suitable for the automatic segmentation of SRF lesions to evaluate CSC.

Translational Relevance

Our code implementation has the potential to facilitate ophthalmology research; in particular, deep learning–based segmentation can assist in the development of pathological lesion detection solutions.

Interocular Difference of Axial Length, Anterior Chamber Depth, Keratometry, Corneal Astigmatism According to Axial Length

Purpose: To investigate the interocular difference of axial length (AL), mean keratometry (K), corneal astigmatism and anterior chamber depth (ACD) according to AL without history of ocular surgery.Methods: This study was performed on 16,411 patients (32,825 eyes) who were measured AL, K, corneal astigmatism and ACD by IOL Master® from April 2007 to September 2016, excluding patients with missing values and extreme values in AL. After, patients were divided into four groups based on AL; AL < 24 mm, 24 mm ≤ AL < 26 mm, 26 mm ≤ AL < 28 mm, AL ≥ 28 mm, we investigated which variables were associated according to AL. To compensate for age and sex, 1:1:1:1 random matching was performed for age and sex.Results: The longer the average AL of both eyes, the greater the difference between the AL, ACD and mean corneal K of both eyes. The longer AL group had the deeper ACD, the flatter mean corneal K, the higher corneal astigmatism. The older age group had the more shallow ACD, the steeper mean corneal K, lower corneal astigmatism.Conclusions: Ophthalmologists have to be careful in setting fellow eye as control in treating or studying patients with long AL or axial myopia. Because, the longer the average AL of both eyes, the greater the difference between the AL, the ACD and the mean corneal K of both eyes.

Calsequestrin 2 overexpression in breast cancer increases tumorigenesis and metastasis by modulating the tumor microenvironment

The spatial tumor shape is determined by the complex interactions between tumor cells and their microenvironment. Here, we investigated the role of a newly identified breast cancer-related gene, calsequestrin 2 (CASQ2), in tumor-microenvironment interactions during tumor growth and metastasis. We analyzed gene expression and three-dimensional tumor shape data from the breast cancer dataset of The Cancer Genome Atlas (TCGA) and identified CASQ2 as a potential regulator of tumor-microenvironment interaction. In TCGA breast cancer cases containing information of three-dimensional tumor shapes, CASQ2 mRNA showed the highest correlation with the spatial tumor shapes. Furthermore, we investigated the expression pattern of CASQ2 in human breast cancer tissues. CASQ2 was not detected in breast cancer cell lines in vitro but was induced in the xenograft tumors and human breast cancer tissues. To evaluate the role of CASQ2, we established CASQ2-overexpressing breast cancer cell lines for in vitro and in vivo experiments. CASQ2 overexpression in breast cancer cells resulted in a more aggressive phenotype and altered epithelial-mesenchymal transition (EMT) markers in vitro. CASQ2 overexpression induced cancer-associated fibroblast characteristics along with increased hypoxia-inducible factor 1α (HIF1α) expression in stromal fibroblasts. CASQ2 overexpression accelerated tumorigenesis, induced collagen structure remodeling, and increased distant metastasis in vivo. CASQ2 conferred more metaplastic features to triple-negative breast cancer cells. Our data suggest that CASQ2 is a key regulator of breast cancer tumorigenesis and metastasis by modulating diverse aspects of tumor-microenvironment interactions.

491 Comparison of Pandemic and Pre-pandemic Practices of Managing Acute Appendicitis

Aim

Acute appendicitis (AA) is a common indication for abdominal surgery, with more than 30,000 appendicectomies performed in England per year. However, SARS-CoV-2 (COVID-19) changed usual surgical practices following advice to minimise laparoscopic surgery, and instead favouring conservative management, or open surgery for AA.

Method

In this study, we compared the management of 50 patients with suspected/confirmed AA during the first wave of the COVID-19 pandemic at a district general hospital (DGH) with our usual practices, against 50 patients admitted with suspected/confirmed AA during a similar time period, one year prior to the pandemic.

Results

Demographics of patients in both groups were comparable with median age of 34 in the pandemic vs 32.5 in the pre-pandemic group. 74% of patients in the pandemic group (PG) underwent imaging to confirm appendicitis, compared to 58% of patients in the pre-pandemic group (PPG). 64% of PG patients were treated conservatively, compared to 8% in PPG patients. Outcomes demonstrated re-attendance events of 12% in the PG, as compared to 10% in the PPG, although the follow up period was longer in the PPG. Despite a significantly smaller number of patients managed surgically during the pandemic, 27% of patients undergoing appendicectomies had post-operative complications in the PG, as compared to 7% in the PPG.

Conclusions

During the pandemic, more patients at our DGH with AA were treated conservatively, more patients had re-attendance events and post-operative complications when compared to patients in the pre-pandemic group.

Factors associated with axial length elongation in high myopia in adults

AIM

To investigate the association of axial length (AL) and ocular factors on AL elongation.

METHODS

A retrospective chart review of patients who underwent two or more AL examinations for more than two years. Totally 4 groups were divided according to initial AL (<24 mm, 24-26 mm, 26-28 mm, ≥28 mm). Initial fundus photograph was used to find risk factors associated AL elongation.

RESULTS

The mean age of the patients was 47.21±7.79y. AL remained almost unchanged in the groups with AL<24 mm and 24≤AL<26 mm. On the contrary, AL increased by 0.011 mm/y in the group with 26≤AL<28 mm and 0.035 mm/y in the group with AL≥28 mm (P<0.001). In high myopia, AL elongation increased in eye with longer AL (r=0.003, P=0.024), female gender (r=0.014, P=0.019), eye with larger peripapillary chorioretinal atrophic area (r=0.002, P=0.019), and smaller vascular arcade angle (r=-0.004, P=0.006). The risk of elongation 0.03 mm/y in high myopia was increased in female gender (P=0.040), and gradually increased in eye with large peripapillary chorioretinal atrophy area (P<0.01).

CONCLUSION

AL elongate significantly in the eye with longer AL, female gender, and the eye with larger atrophic area and smaller arcade angle on fundus photography.

P–627 Optimal timing of day 6 blastocyst transfer in artificially prepared frozen-thawed embryo transfer cycles

Study question

When is the optimal timing of day 6 (D6) blastocyst transfer between the 6thday (P6)and the 7th(P7) day of progesterone administration in artificially prepared frozen-thawed embryo transfer(FET) cycle

Summary answer

When transferring D6 blastocysts in artificially prepared FET cycles, live birth rate tended to be higher in P6 group than in P7 group.

What is known already

Blastocyst transfer in FET cycles has increased due to several reasons including convenience for optimization of endometrial synchronization, improvement of laboratory techniques and preimplantation genetic testing. Meanwhile, D6 blastocyst which cryopreserved on day 6 after being developed to the full blastocyst stage, presented lower pregnancy outcomes in FET cycle than D5 blastocysts. However, there have been few studies on the optimal duration of progesterone administration when transferring D6 blastocysts.

Study design, size, duration

This was a retrospective cohort study including patients who underwent frozen-thawed blastocyst transfer in artificially prepared cycles from January 2000 to May 2020. Patients with D6 blastocyst transfer on the 6th day of progesterone administration were included in D6-P6 group, and patients with D6 blastocyst transfer on the 7th day of progesterone administration were included in D6-P7 group.

Participants/materials, setting, methods

Increasing dose of estradiol valerate was administered from the 3rd day of menstruation: 4 mg/day for the first four days, 6 mg/day for next four days, and then 8 mg/day until the confirmation of pregnancy. Progesterone was administered from the 14th day of menstruation if the endometrial thickness reached ≥7 mm. The independent t-test or Mann-Whitney test, chi-square test, and logistic regression analysis were performed.

Main results and the role of chance

A total of 50 patients were included, and 13 patients underwent FET on P6 and 37 patients underwent FET on P7. Live birth rate was comparable between the P6 group and the P7 group (18.9% vs. 15.4%, p = 0.775). Live birth rate was higher in the D6-P6 group than in the D6-P7 group after adjusting for age, AMH, endometrial thickness on the starting day of progesterone administration and good embryo rate transferred with statistical significance (OR: 6.716, p = 0.005).

Limitations, reasons for caution

Limitations of the present study is the retrospective design and the small sample size. Caution is needed in extrapolating results of this study because only intramural and vaginal progesterone supplementations were included in this study.

Wider implications of the findings: Even if the duration of blastocyst formation was delayed, frozen-thawed D6 blastocyst may need to be considered for on P6 rather than P7. The difference of live birth rate is not statistically significant. This study should be acknowledged for the underestimation of the difference because of the small sample size.

Trial registration number

Not applicable

Bilateral axillo-breast approach robotic thyroidectomy: review of a single surgeon's consecutive 317 cases

Background

Bilateral axillo-breast approach robotic thyroidectomy (BABA RT) is one of the most popular remote-access approaches for thyroid surgery. This study aimed to evaluate the surgical outcomes of BABA RT.

Methods

Medical records of patients who underwent BABA RT between July 2008 and July 2016 were retrospectively reviewed. Surgeries were performed by one surgeon at one institution. Clinicopathological features and postoperative surgical outcomes were evaluated.

Results

A total of 317 patients were enrolled. The mean age was 40.0±9.7 years, and 287 (90.5%) were female. The mean tumor size was 1.02 cm. Papillary thyroid carcinoma (PTC) was most commonly seen (n=282, 88.8%), followed by benign nodules (n=33, 10.5%) and follicular thyroid carcinoma (n=2, 0.6%). Total thyroidectomy was performed in 202 (63.7%) patients, while unilateral lobectomy was performed in 113 (35.6%). Two patients (0.6%) had transient vocal cord palsy, but none showed permanent vocal cord palsy. Thirty-four (16.8%) patients developed hypoparathyroidism, 33 (16.3%) were transient and 1 (0.5%) was permanent. The mean operation time for total thyroidectomy and lobectomy was 264.9±52.4 and 203.4±47.6 min, respectively. A decrease in operation time in total thyroidectomy was observed in 49-51 cases (P=0.015). Four patients (1.4%) had local recurrence during the median follow-up of 61±23 months.

Conclusions

BABA RT can be performed safely in selected patients with thyroid nodules. The learning curve duration for BABA RT was 49-51 cases of total thyroidectomy.

Adopting low-shot deep learning for the detection of conjunctival melanoma using ocular surface images

BACKGROUND AND OBJECTIVE

The purpose of the present study was to investigate low-shot deep learning models applied to conjunctival melanoma detection using a small dataset with ocular surface images.

METHODS

A dataset was composed of anonymized images of four classes; conjunctival melanoma (136), nevus or melanosis (93), pterygium (75), and normal conjunctiva (94). Before training involving conventional deep learning models, two generative adversarial networks (GANs) were constructed to augment the training dataset for low-shot learning. The collected data were randomly divided into training (70%), validation (10%), and test (20%) datasets. Moreover, 3D melanoma phantoms were designed to build an external validation set using a smartphone. The GoogleNet, InceptionV3, NASNet, ResNet50, and MobileNetV2 architectures were trained through transfer learning and validated using the test and external validation datasets.

RESULTS

The deep learning model demonstrated a significant improvement in the classification accuracy of conjunctival lesions using synthetic images generated by the GAN models. MobileNetV2 with GAN-based augmentation displayed the highest accuracy of 87.5% in the four-class classification and 97.2% in the binary classification for the detection of conjunctival melanoma. It showed an accuracy of 94.0% using 3D melanoma phantom images captured using a smartphone camera.

CONCLUSIONS

The present study described a low-shot deep learning model that can detect conjunctival melanomas using ocular surface images. To the best of our knowledge, this study is the first to develop a deep learning model to detect conjunctival melanoma using a digital imaging device such as smartphone camera.

Feasibility study to improve deep learning in OCT diagnosis of rare retinal diseases with few-shot classification

Deep learning (DL) has been successfully applied to the diagnosis of ophthalmic diseases. However, rare diseases are commonly neglected due to insufficient data. Here, we demonstrate that few-shot learning (FSL) using a generative adversarial network (GAN) can improve the applicability of DL in the optical coherence tomography (OCT) diagnosis of rare diseases. Four major classes with a large number of datasets and five rare disease classes with a few-shot dataset are included in this study. Before training the classifier, we constructed GAN models to generate pathological OCT images of each rare disease from normal OCT images. The Inception-v3 architecture was trained using an augmented training dataset, and the final model was validated using an independent test dataset. The synthetic images helped in the extraction of the characteristic features of each rare disease. The proposed DL model demonstrated a significant improvement in the accuracy of the OCT diagnosis of rare retinal diseases and outperformed the traditional DL models, Siamese network, and prototypical network. By increasing the accuracy of diagnosing rare retinal diseases through FSL, clinicians can avoid neglecting rare diseases with DL assistance, thereby reducing diagnosis delay and patient burden.

Reliability of Skeletal Muscle Area Measurement on CT with Different Parameters: A Phantom Study

Objective

To evaluate the reliability of CT measurements of muscle quantity and quality using variable CT parameters.

Materials and Methods

A phantom, simulating the L2–4 vertebral levels, was used for this study. CT images were repeatedly acquired with modulation of tube voltage, tube current, slice thickness, and the image reconstruction algorithm. Reference standard muscle compartments were obtained from the reference maps of the phantom. Cross-sectional area based on the Hounsfield unit (HU) thresholds of muscle and its components, and the mean density of the reference standard muscle compartment, were used to measure the muscle quantity and quality using different CT protocols. Signal-to-noise ratios (SNRs) were calculated in the images acquired with different settings.

Results

The skeletal muscle area (threshold, −29 to 150 HU) was constant, regardless of the protocol, occupying at least 91.7% of the reference standard muscle compartment. Conversely, normal attenuation muscle area (30–150 HU) was not constant in the different protocols, varying between 59.7% and 81.7% of the reference standard muscle compartment. The mean density was lower than the target density stated by the manufacturer (45 HU) in all cases (range, 39.0–44.9 HU). The SNR decreased with low tube voltage, low tube current, and in sections with thin slices, whereas it increased when the iterative reconstruction algorithm was used.

Conclusion

Measurement of muscle quantity using HU threshold was reliable, regardless of the CT protocol used. Conversely, the measurement of muscle quality using the mean density and narrow HU thresholds were inconsistent and inaccurate across different CT protocols. Therefore, further studies are warranted in future to determine the optimal CT protocols for reliable measurements of muscle quality.

Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema

PURPOSE

Sentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm.

METHODS

Prospectively collected medical records of 910 patients were reviewed. Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic.

RESULTS

Together with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs. breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p =0.111).

CONCLUSION

The risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.

Impact of Trastuzumab on Ipsilateral Breast Tumor Recurrence for Human Epidermal Growth Factor Receptor 2-Positive Breast Cancer after Breast-Conserving Surgery

Purpose

Trastuzumab is effective in early and advanced human epidermal growth factor receptor 2 (HER2)-positive breast cancer. However, few studies have reported the effect of trastuzumab on ipsilateral breast tumor recurrence (IBTR), whose incidence is higher in the HER2-positive subtype than in other subtypes.

Methods

We retrospectively investigated 959 patients who underwent breast-conserving surgery (BCS), chemotherapy, and radiotherapy for HER2-positive breast cancer between 2000 and 2017. IBTR was compared between the patients who received neoadjuvant or adjuvant trastuzumab (Tmab group) for a total duration of 1 year and those who received no trastuzumab (N-Tmab group).

Results

Propensity score matching designated 426 and 142 patients in the Tmab and N-Tmab groups, respectively. The median follow-up period for all patients after matching was 73.79 months. The IBTR-free survival rate was significantly higher in the Tmab group than in the N-Tmab group (10-year IBTR-free survival rate, 92.9% vs. 87.3%; p = 0.002). The multivariate analysis showed a significant association between the N-Tmab and Tmab group (hazard ratio, 3.03; 95% confidence interval, 1.07–8.59) and IBTR in addition to close or positive resection margin and hormone receptor (HR) positivity. The subgroup analysis showed that adjuvant treatment with trastuzumab significantly reduced IBTR among the patients with HR-negative or lymph node-negative breast cancer.

Conclusion

Significantly reduced IBTR after BCS was observed in the patients who received 1 year of adjuvant/neoadjuvant trastuzumab treatment for HER2-positive breast cancer.

Deep learning can generate traditional retinal fundus photographs using ultra-widefield images via generative adversarial networks

BACKGROUND AND OBJECTIVE

Retinal imaging has two major modalities, traditional fundus photography (TFP) and ultra-widefield fundus photography (UWFP). This study demonstrates the feasibility of a state-of-the-art deep learning-based domain transfer from UWFP to TFP.

METHODS

A cycle-consistent generative adversarial network (CycleGAN) was used to automatically translate the UWFP to the TFP domain. The model was based on an unpaired dataset including anonymized 451 UWFP and 745 TFP images. To apply CycleGAN to an independent dataset, we randomly divided the data into training (90%) and test (10%) datasets. After automated image registration and masking dark frames, the generator and discriminator networks were trained. Additional twelve publicly available paired TFP and UWFP images were used to calculate the intensity histograms and structural similarity (SSIM) indices.

RESULTS

We observed that all UWFP images were successfully translated into TFP-style images by CycleGAN, and the main structural information of the retina and optic nerve was retained. The model did not generate fake features in the output images. Average histograms demonstrated that the intensity distribution of the generated output images provided a good match to the ground truth images, with an average SSIM level of 0.802.

CONCLUSIONS

Our approach enables automated synthesis of TFP images directly from UWFP without a manual pre-conditioning process. The generated TFP images might be useful for clinicians in investigating posterior pole and for researchers in integrating TFP and UWFP databases. This is also likely to save scan time and will be more cost-effective for patients by avoiding additional examinations for an accurate diagnosis.

Comparison of postoperative outcomes between bilateral axillo-breast approach-robotic thyroidectomy and transoral robotic thyroidectomy

Background

The use of robotic systems for thyroidectomy has increased as it enables more diverse approaches than the conventional open method. The aim of this study was to compare the clinical outcomes of Transoral Robotic Thyroidectomy (TORT) and Bilateral Axillo-Breast Approach-Robotic Thyroidectomy (BABA-RT).

Methods

This study was designed as a retrospective study. The included patients who underwent surgery by BABA-RT or TORT approach in our facility between 2008 and 2018. All surgeries were performed by one surgeon. Total thyroidectomy with central node dissection (CND) was performed only if tumors were >4 cm and had extrathyroidal extension, clinically apparent lymph node or distant metastases. In all other cases, lobectomy ± CND was performed.

Results

The group treated with TORT comprised 248 patients and the group that underwent BABA-RT had 316 patients. The number of retrieved lymph node (LN) was higher in the TORT group (4.9±4.4 vs. 4.2±4.9; P=0.01). There were no significant differences between the TORT and BABA-RT groups in concerns to the location of the tumor. Postoperative hospital stay was also shorter in the TORT group when compared with the BABA-RT group (2.8±0.90 vs. 3.4±0.97 days, P=0.012). Operative time was significantly shorter in the TORT group (204.11±40.19 vs. 243.78±57.16 min, P<0.01).

Conclusions

When comparing a total of 248 patients treated with TORT versus 316 with BABA-RT. TORT not only has advantages in better cosmetic outcomes with minimized postoperative scars, but also shows comparable, or even superior, surgical outcomes with shorter operation time than the BABA-RT procedure.

An international collaborative evaluation of central serous chorioretinopathy: different therapeutic approaches and review of literature. The European Vitreoretinal Society central serous chorioretinopathy study

PURPOSE

To study and compare the efficacy of different therapeutic options for the treatment of central serous chorioretinopathy (CSCR).

METHODS

This is a nonrandomized, international multicentre study on 1719 patients (1861 eyes) diagnosed with CSCR, from 63 centres (24 countries). Reported data included different methods of treatment and both results of diagnostic examinations [fluorescein angiography and/or optical coherent tomography (OCT)] and best-corrected visual acuity (BCVA) before and after therapy. The duration of observation had a mean of 11 months but was extended in a minority of cases up to 7 years. The aim of this study is to evaluate the efficacy of the different therapeutic options of CSCR in terms of both visual (BCVA) and anatomic (OCT) improvement.

RESULTS

One thousand seven hundred nineteen patients (1861 eyes) diagnosed with CSCR were included. Treatments performed were nonsteroidal anti-inflammatory eye drops, laser photocoagulation, micropulse diode laser photocoagulation, photodynamic therapy (PDT; Standard PDT, Reduced-dose PDT, Reduced-fluence PDT), intravitreal (IVT) antivascular endothelial growth factor injection (VEGF), observation and other treatments. The list of the OTHERS included both combinations of the main proposed treatments or a variety of other treatments such as eplerenone, spironolactone, acetazolamide, beta-blockers, anti-anxiety drugs, aspirin, folic acid, methotrexate, statins, vitis vinifera extract medication and pars plana vitrectomy. The majority of the patients were men with a prevalence of 77%. The odds ratio (OR) showed a partial or complete resolution of fluid on OCT with any treatment as compared with observation. In univariate analysis, the anatomical result (improvement in subretinal fluid using OCT at 1 month) was favoured by age <60 years (p < 0.005), no previous observation (p < 0.0002), duration less than 3 months (p < 0.0001), absence of CSCR in the fellow eye (p = 0.04), leakage outside of the arcade (p = 0.05) and fluid height >500 μm (p = 0.03). The OR for obtaining partial or complete resolution showed that anti-VEGF and eyedrops were not statistically significant; whereas PDT (8.5), thermal laser (11.3) and micropulse laser (8.9) lead to better anatomical results with less variability. In univariate analysis, the functional result at 1 month was favoured by first episode (p = 0.04), height of subretinal fluid >500 μm (p < 0.0001) and short duration of observation (p = 0.02). Finally, there was no statistically significant difference among the treatments at 12 months.

CONCLUSION

Spontaneous resolution has been described in a high percentage of patients. Laser (micropulse and thermal) and PDT seem to lead to significant early anatomical improvement; however, there is little change beyond the first month of treatment. The real visual benefit needs further clarification.

Impact of Diabetes Control on Subclinical Atherosclerosis: Analysis from Coronary Computed Tomographic Angiography Registry

BACKGROUND

There are limited data on the impact of diabetes control on the risk of subclinical coronary atherosclerosis.

METHODS

We analyzed 6,434 consecutive asymptomatic individuals without previous history of coronary artery disease who underwent coronary computed tomographic angiography (CCTA) (mean age, 53.7±7.6 years and 4,694 men [73.0%]). The degree and extent of subclinical coronary atherosclerosis were assessed by CCTA, and ≥50% diameter stenosis was defined as significant. A cardiac event was defined as a composite of all-cause death, myocardial infarction, unstable angina, or coronary revascularization. Study participants were categorized as normal (n=5,319), controlled diabetes (glycosylated hemoglobin [HbA1c] <7%, n=747), or uncontrolled diabetes (HbA1c ≥7%, n=368), respectively.

RESULTS

Compared with normal individuals, there were no statistically significant differences in the risk of for any atherosclerotic plaque (odds ratio [OR], 1.16; 95% confidence interval [CI], 0.98 to 1.38; P=0.086) and significant coronary artery stenosis (OR, 1.08; 95% CI, 0.82 to 1.42; P=0.583) in controlled diabetic individuals. In contrast, uncontrolled diabetic individuals had consistently higher risks of any atherosclerotic plaque (OR, 2.16; 95% CI, 1.70 to 2.75; P<0.001) and significant coronary artery stenosis (OR, 3.34; 95% CI, 2.52 to 4.43; P<0.001) than normal individuals. During a follow-up of median 5.4 years, there was no significant difference in cardiac events between normal and controlled diabetic individuals (P=0.365). However, uncontrolled diabetes was associated with an increased risk of cardiac events compared with normal individuals (P<0.001) and controlled diabetic individuals (P=0.023).

CONCLUSION

Asymptomatic uncontrolled diabetes was associated with significant subclinical coronary atherosclerosis with subsequent high risk for cardiac events.

Personalized neoadjuvant strategy in luminal A breast cancer to increase breast conserving surgery (BCS) rate [PLATO study]

TPS603

Background: The most important and well established benefit of neoadjuvant therapy for breast cancer patients is increased breast conservation rate. However, in ER-positive and HER-2 negative breast cancer, the response to neoadjuvant chemotherapy (NCT) is not as good as other subtype of breast cancer, such as HER-2 or triple-negative breast cancer. In addition, with the advancement of multi-gene assay tools for this subtype, adjuvant chemotherapy is not needed at all in significant proportion of this subtype. Through a selective neoadjuvant therapy, either chemotherapy or endocrine therapy using histopathologic markers and 70-gene assay (Mammaprint. Agendia inc.), we hypothesize that we could increase the breast conservation rate in ER-positive and HER-2 negative breast cancer. Methods: This study is a non-randomized, phase II, prospective study. The main inclusion criteria is women with stage I-IIIA, ER-positive and HER-2 negative breast cancer that tumor size is measurable. BCS is not feasible considering the tumor size, location, and patient's breast size. Two surgeons in each institution will judge the feasibility of BCS. Main exclusion criteria is diffuse malignant microcalcification or multicentric breast cancer. The conversion rate from BCS-ineligible to BCS-eligible with NCT was 35.8% in ER-positive and HER-2 negative breast cancer in our previous study. We assumed that with the study regimen, the rate will be increased to 50.8% (15% increase). Given these estimates, under 10% type II error rate and 90% power, 122 patients in total will be enrolled from nine tertiary hospitals in Korea. All the patients initially will be tested with Mammaprint assay. When the Mammaprint result is high risk, the patients will receive NCT. When the Mammaprint result is low risk, the patients will receive neoadjuvant endocrine therapy. Postmenopausal women receive letrozole 2.5mg per day for 16 weeks. Premenopausal women receive leuprorelin every 4 weeks with letrozole for 16 weeks. Period of neoadjuvant endocrine therapy can be prolonged maximum 24 weeks by physician’s decision. The primary endpoint is conversion rate from BCS-ineligible to BCS-eligible of more than 50%. The secondary endpoint is actual breast conservation rate, pathologic complete response, clinical response rate, and disease-free survival. Clinical trial information: NCT03900637 .

Deep learning-based smart speaker to confirm surgical sites for cataract surgeries: A pilot study

Wrong-site surgeries can occur due to the absence of an appropriate surgical time-out. However, during a time-out, surgical participants are unable to review the patient's charts due to their aseptic hands. To improve the conditions in surgical time-outs, we introduce a deep learning-based smart speaker to confirm the surgical information prior to cataract surgeries. This pilot study utilized the publicly available audio vocabulary dataset and recorded audio data published by the authors. The audio clips of the target words, such as left, right, cataract, phacoemulsification, and intraocular lens, were selected to determine and confirm surgical information in the time-out speech. A deep convolutional neural network model was trained and implemented in the smart speaker that was developed using a mini development board and commercial speakerphone. To validate our model in the consecutive speeches during time-outs, we generated 200 time-out speeches for cataract surgeries by randomly selecting the surgical statuses of the surgical participants. After the training process, the deep learning model achieved an accuracy of 96.3% for the validation dataset of short-word audio clips. Our deep learning-based smart speaker achieved an accuracy of 93.5% for the 200 time-out speeches. The surgical and procedural accuracy was 100%. Additionally, on validating the deep learning model by using web-generated time-out speeches and video clips for general surgery, the model exhibited a robust and good performance. In this pilot study, the proposed deep learning-based smart speaker was able to successfully confirm the surgical information during the time-out speech. Future studies should focus on collecting real-world time-out data and automatically connecting the device to electronic health records. Adopting smart speaker-assisted time-out phases will improve the patients' safety during cataract surgeries, particularly in relation to wrong-site surgeries.

Institutional experience of 200 consecutive papillary thyroid carcinoma patients in transoral robotic thyroidectomy surgeries

BACKGROUND

We evaluated the outcomes of patients with papillary thyroid carcinoma (PTC) who underwent transoral robotic thyroidectomy (TORT).

METHODS

We retrospectively analyzed the perioperative outcomes of 200 patients (170 women and 30 men) with PTC who underwent TORT at a single center between March 2016 and February 2018.

RESULTS

There were 182 and 13 cases of lobectomy and total thyroidectomy, respectively, with corresponding mean operative times of 200.6 ± 31.2 and 265.7 ± 63.0 minutes. On average, 5.6 ± 3.45 lymph nodes were retrieved per patient. There were 12 cases of perioperative morbidity. No conversion to endoscopic or conventional open surgery was noted. In a subgroup analysis for predictors of difficult TORT, patient sex was the only factor showing a significant operative time difference between a difficult and a nondifficult thyroidectomy.

CONCLUSION

TORT can be performed safely in patients with PTC without serious complications.

Hepatitis C Virus p7 Induces Membrane Permeabilization by Interacting with Phosphatidylserine

Hepatitis C virus (HCV) p7 is known to be a nonselective cation channel for HCV maturation. Because the interaction of HCV proteins with host lipids in the endoplasmic reticulum membrane is crucial for the budding process, the identification of p7–lipid interactions could be important for understanding the HCV life cycle. Here, we report that p7 interacts with phosphatidylserine (PS) to induce membrane permeabilization. The interaction of p7 with PS was not inhibited by Gd³⁺ ions, which have been known to interact with negatively charged lipids, but channel activity and p7-induced mitochondrial depolarization were inhibited by Gd³⁺ ions. From the present results, we suggest that the p7–PS interaction plays an essential role in regulating its ion channel function and could be a potential molecular target for anti-HCV therapy.

A generative adversarial network approach to predicting postoperative appearance after orbital decompression surgery for thyroid eye disease

PURPOSE

Orbital decompression for thyroid-associated ophthalmopathy (TAO) is an ophthalmic plastic surgery technique to prevent optic neuropathy and reduce exophthalmos. Because the postoperative appearance can significantly change, sometimes it is difficult to make decisions regarding decompression surgery. Herein, we present a deep learning technique to synthesize the realistic postoperative appearance for orbital decompression surgery.

METHODS

This data-driven approach is based on a conditional generative adversarial network (GAN) to transform preoperative facial input images into predicted postoperative images. The conditional GAN model was trained on 109 pairs of matched pre- and postoperative facial images through data augmentation.

RESULTS

When the conditional variable was changed, the synthesized facial image was transferred from a preoperative image to a postoperative image. The predicted postoperative images were similar to the ground truth postoperative images. We also found that GAN-based synthesized images can improve the deep learning classification performance between the pre- and postoperative status using a small training dataset. However, a relatively low quality of synthesized images was noted after a readout by clinicians.

CONCLUSIONS

Using this framework, we synthesized TAO facial images that can be queried using conditioning on the orbital decompression status. The synthesized postoperative images may be helpful for patients in determining the impact of decompression surgery. However, the quality of the generated image should be further improved. The proposed deep learning technique based on a GAN can rapidly synthesize such realistic images of the postoperative appearance, suggesting that a GAN can function as a decision support tool for plastic and cosmetic surgery techniques.

P1274 Early surgery versus watchful waiting in patients with moderate aortic stenosis and left ventricular systolic dysfunction

Background

Aortic stenosis (AS) induces significant pressure overload to the left ventricle (LV) and its burden may increase if there is concomitant LV systolic dysfunction. Severe AS with LV systolic dysfunction is a class I indication for aortic valve replacement (AVR) irrespective of symptoms, however, this recommendation is not well established in those with moderate AS and LV systolic dysfunction. In this study, we sought to investigate the clinical impact of surgical AVR among patients with moderate AS and LV systolic dysfunction.

Methods

From 2001 to 2017, we retrospectively but consecutively identified patients with moderate AS and LV systolic dysfunction from a single tertiary hospital. Moderate AS was defined as aortic valve area between 1.0 and 1.5cm2 and LV systolic dysfunction as LV ejection fraction less than 50%. The primary outcome was all-cause death and we additionally analyzed cardiac death as a secondary endpoint. The outcomes were compared between those who underwent early surgical AVR at the stage of moderate AS versus those who were followed without AVR at the outpatient clinic.

Results

Among a total of 257 patients with moderate AS and concomitant LV systolic dysfunction (70.0 ± 11.3 years, 63.4% of male), 34 patients received early AVR. Patients in the AVR group was younger than the observation group (64.2 ± 8.1 vs. 70.9 ± 11.5, respectively), and had a lower prevalence of hypertension and chronic kidney disease. During a mean of 3-year follow up, 112 patients (47.5%) died and the overall death rate was 15.367 per 100 person-year (PY). The AVR group showed a significantly lower rate of all-cause death than the observation group (5.241PY vs. 18.160PY, p-value = 0.002). After multivariable Cox proportional hazard regression adjusting for age, sex, comorbidities and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of all-cause death (hazard ratio [HR] 0.340, 95% confidence interval [CI] 0.117 - 0.985, p-value = 0.047). However, there was no risk reduction of cardiac death (HR 0.578 95% CI 0.150 - 2.231, p-value = 0.426).

Conclusions

In patients with moderate AS and LV systolic dysfunction, AVR reduces the risk of all-cause death. A prospective design study is warranted to confirm our findings in the near future.

Abstract P1274 Figure. Kaplan-Meier curves for deaths

P1603 Changes of cardiac function in cirrhotic patients after liver transplantation

Funding Acknowledgements

This study was supported by the grant of CJ healthcare 2016 research fund.

Background

Liver cirrhosis (LC) has been known to affect cardiovascular performance. Limited study have evaluated the alteration of myocardial function in patients with LC after liver transplantation (LT).

Purpose

The aim of study was to evaluate changes of cardiac function in patients with cirrhosis following LT using conventional and speckle-tracking echocardiography and late gadolinium enhancement (LGE) of cardiac magnetic resonance (MR).

Methods

Thirty-five patients with cirrhosis (mean age, 57.1 ± 9.0; male, 75%) who were listed for LT were prospectively enrolled. Patients underwent conventional, speckle-tracking echocardiography, and cardiac MR imaging with LGE. Echocardiography and cardiac MR were performed at pre and 1 year after LT. Cirrhotic patients were compared with normal control (n = 20, mean age, 65.0 ± 14.8; men, 11(55%)) and echocardiographic and cardiac MR data were compared pre and post LT.

Results

Conventional and speckle-tracking echocardiography and Cardiac MR imaging demonstrated hyperdynamic left ventricular (LV) function in patients with cirrhosis (LV ejection fraction (EF) with cardiac MR 67.8 ± 7.0% in LC vs. 63.4 ± 6.4% in control, P = 0.028; global longitudinal strain (GLS) -24.3 ± 2.6% in LC vs. -18.6 ± 2.2% in control, P &lt; 0.001). There were no LGE in patients with cirrhosis and no significant differences in LV size, LV wall thickness, LV mass index, and diastolic function between cirrhotic patients and control group (all P &gt; 0.1). Corrected QT interval (QTc) in electrocardiogram was prolonged in LC patients (P &lt; 0.001). One-year after LT, LV end-diastolic diameter and LV end-diastolic volume significantly decreased (P = 0.016 and 0.022, respectively). Although LVEF showed no significant changes 1 year post-LT (P = 0.362), LV-GLS (from -24.7 ± 1.8% to -20.8 ± 3.4%, P &lt; 0.001) significantly decreased. QTc interval also decreased 1 year after LT (from 470.4 ± 29.6msec to 428.2 ± 31.6msec, P = 0.001).

Conclusions

The present study demonstrated that cirrhotic patients showed hyperdynamic circulation and prolonged QTc interval compared with normal controls. After 1 year LT, LV size reduced and augmented LV function was normalized. Given that no LGE in cardiac MR and normalized GLS and QTc after LT, cardiac dysfunction in LC patients could be reversed by LT.

P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.

Mitochondrial DNA content and oxidation in bipolar disorder and its role across brain regions

The underlying pathology of bipolar disorder remains unknown, though evidence is accumulating to support a role of mitochondrial dysfunction. In this study, we aim to investigate electron transport chain complex I subunit NDUFS7 protein expression; mtDNA content; common deletion; and oxidation in the Broadmann area 24 (BA24), cerebellum, hippocampus, and prefrontal cortex from patients with bipolar disorder, schizophrenia, and non-psychiatric controls. Here, we demonstrate no changes in NDUFS7 in BA24, cerebellum or hippocampus, increases in mtDNA content in hippocampus of patients with bipolar disorder, and decreases in mtDNA oxidation in patients with bipolar disorder and schizophrenia, respectively. Paired analysis between BA24 and cerebellum reveal increases within NDUFS7 levels and mtDNA content in cerebellum of patients with bipolar disorder or schizophrenia. We found a positive correlation between NDUFS7 and mtDNA content (ND4 and ND5) when combining brain regions. Our study supports the involvement of mitochondrial dysfunction in bipolar disorder and schizophrenia.

Longitudinal Changes of Body Composition Phenotypes and Their Association with Incident Type 2 Diabetes Mellitus during a 5-Year Follow-up in Koreans

BACKGROUND

To elucidate longitudinal changes of complex body composition phenotypes and their association with incident type 2 diabetes mellitus.

METHODS

A total of 17,280 (mean age, 48.1±8.2 years) Korean adults who underwent medical check-ups were included. The mean follow-up duration was 5.5±0.5 years. Body compositions were assessed using a bioelectrical impedance analysis. Four body composition phenotypes were defined using the median of appendicular skeletal muscle mass (ASM) index and fat mass index: low muscle/low fat (LM/LF); high muscle (HM)/LF; LM/high fat (HF); and HM/HF groups.

RESULTS

Of the individuals in the LM/LF or HM/HF groups, over 60% remained in the same group, and over 30% were moved to the LM/HF group. Most of the LM/HF group remained in this group. In the baseline HM/LF group, approximately 30% stayed in the group, and the remaining individuals transitioned to the three other groups in similar proportions. Incident diabetes was significantly lower in participants who remained in the HM/LF group than those who transitioned to the LM/LF or LM/HF group from the baseline HM/LF group in men. ASM index was significantly associated with a decreased risk for incident diabetes in men regardless of obesity status (adjusted odds ratio [OR], 0.71 per kg/m²; 95% confidence interval [CI], 0.52 to 0.97 in non-obese) (adjusted OR, 0.87; 95% CI, 0.77 to 0.98 in obese) after adjusting for other strong risk factors (e.g., baseline glycosylated hemoglobin and homeostasis model assessment of insulin resistance).

CONCLUSION

Maintenance of ASM may be protective against the development of type 2 diabetes mellitus in men, regardless of obesity status.

A Nationwide Cohort Study on the Association Between Past Physical Activity and Neovascular Age-Related Macular Degeneration in an East Asian Population

Importance

It has been suggested that physical activity (PA) is associated with reduced risk for early age-related macular degeneration (AMD). Systematic evaluation has been examining the association between lifestyle and neovascular AMD in an East Asian population, with a particular focus on past vigorous PA.

Objective

To investigate the association between neovascular AMD and past PA, particularly a history of vigorous exercise, in the overall study population and among 2 a priori-defined subgroups.

Design, Setting, and Participants

In this propensity score-matched cohort study, individuals between ages 45 and 79 years who were included in the South Korean National Health Insurance Service database from 2002 through 2013 were evaluated. Physical activity and incident neovascular AMD were recorded at baseline (2002-2003) and at follow-up (August 1, 2009, to December 31, 2013), respectively. Using a 1:1 propensity score-matched analysis, the incidence of neovascular AMD was compared using hazard ratios (HRs) for neovascular AMD between 105 980 participants who did and 105 980 who did not (no-PA) engage in vigorous PA. The data analysis was performed from April 19, 2017, to June 5, 2017.

Exposures

Physical activity.

Main Outcomes and Measures

Incident cases of neovascular AMD.

Results

Of the 211 960 participants (92 036 [43.4%] women; mean [SD] age, 55.1 [7.8] years), neovascular AMD was detected at follow-up in 250 (0.24%) individuals who engaged in past vigorous PA and in 198 (0.19%) of those who did not (HR, 1.23; 95% CI, 1.02-1.49). In subgroup analysis, vigorous PA was associated with a greater HR for neovascular AMD in participants aged 45 to 64 years (HR, 1.30; 95% CI, 1.04-1.63) and in men (HR, 1.36; 95% CI, 1.09-1.69). In the high-PA (≥5 times/wk: HR, 1.54; 95% CI, 1.15-2.06) and moderate-PA (1-4 times/wk: HR, 1.28; 95% CI, 1.01-1.63) groups, there was a greater incidence of neovascular AMD in the vigorous PA than in the no-PA group for men; no association was found for women.

Conclusions and Relevance

Self-reported past vigorous PA in men aged 45 to 64 years was associated with an increased risk for neovascular AMD. To our knowledge, no previous study has reported such an association; replication of the results would seem warranted to strengthen the likelihood of a cause and effect relationship.

Prevalence of fentanyl exposure and knowledge regarding the risk of its use among emergency department patients with active opioid use history at an urban medical center in Baltimore, Maryland

Background: Overdose deaths from fentanyl and its analogs have increased significantly since 2013. There are limited data regarding the prevalence of fentanyl exposure among emergency department (ED) patients with active opioid use.Methods: We conducted a cross-sectional study at an urban hospital from May 20 to July 30, 2018. A convenience sample of adult ED patients with active opioid use, defined as opioid use within seven days prior to ED visit, were enrolled. Rapid Response^® Single Drug Test Strip (BTNX Inc., Markham, Canada) was used to detect fentanyl in urine samples. Information on demographic, substance use history, and knowledge of fentanyl was obtained using a brief survey tool. Our primary outcome was the prevalence of fentanyl exposure; secondary outcomes included patients' knowledge regarding potency, risk of overdose death from fentanyl and intentional purchase of fentanyl.Results: During our study period, 451 patients reported active substance use. Of these, 208 reported active opioid use and 165 consented for the study. The median age was 49 years [interquartile range: 38, 57] and 77.0% (n = 127) were male; 42 participants (25.5%) presented to ED after an acute overdose event. Heroin was the preferred opioid of use in 90.8% of the participants, primarily via intranasal route (64.6%). Polysubstance use was reported in 98.8%, most commonly with cocaine (57.6%; n = 95). Fentanyl was detected in 104 out of 129 urine samples tested (80.6%). 84.2% (n = 139) identified fentanyl as highly potent and 85.5% (n = 141) recognized highest risk of death in fentanyl overdose. A larger proportion of non-overdose participants intentionally purchased fentanyl (34.1%; n = 42) compared to the overdose group (16.7%, n = 7; p = .04).Conclusions: The majority of ED patient with active opiate use were exposed to fentanyl while one in three participants intentionally purchased fentanyl despite their awareness of its potency and the high-risk of death from overdose.

Obesity May Not Affect Outcomes of Transoral Robotic Thyroidectomy: Subset Analysis of 304 Patients

OBJECTIVES/HYPOTHESIS

Obesity is an increasing health concern worldwide. It has been associated with perioperative complications that could affect patient outcomes. Our aim was to compare surgical outcomes in obese and nonobese patients after transoral robotic thyroid (TORT) surgery.

STUDY DESIGN

Retrospective cohort study.

METHODS

A total of 304 consecutive patients who underwent TORT between January 2012 to December 2017 were included in the study. Patients were divided into two groups according to their body mass index (BMI): BMI < 30 kg/m² and BMI ≥30 kg/m² . Patient demographics, operative extent, pathological data, surgical outcomes, and postoperative complications were included and analyzed. A χ² test was used to compare categorical variables, and a Student t test was used to compare changes of continuous variables between groups. Statistical significance was conferred by a two-tailed P value of ≤.05.

RESULTS

There were 290 patients in the non-obese group and 14 patients in the obese group. There was no statistically significant difference between the two groups in terms of patient demographics, operative procedure, or pathological characteristics. The only statistically significant difference was for lymph node dissection (P = .012); however, for both groups, unilateral central node dissection was the most common procedure. There was also no statistically significant difference found for operative time, length of stay, pain score, or postoperative complications including TORT-specific complications such as oral commissure tear and general complications such as recurrent nerve injury.

CONCLUSIONS

This initial experience shows that TORT appears to be a safe and feasible option for obese patients pursuing scarless thyroid surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1343-1348, 2020.

Clinical Analysis of Pediatric Thyroid Cancer: A Single Medical Institution Experience of 18 Years

OBJECTIVE

The incidence of pediatric thyroid cancer is relatively low compared to the disease in adults. This study aims to present the data in our institution on pediatric thyroid cancer patients, with particular emphasis on the risk factors of recurrence together with treatment outcomes.

SUBJECTS AND METHODS

Between January 2000 and July 2018, patients <20 years who were diagnosed with thyroid carcinoma and primarily treated with surgery at a major large-volume tertiary medical center specializing in thyroid cancer were enrolled. A total of 83 patients were eligible for this study.

RESULTS

The majority of the studied patients were girls and adolescents (age ≥13 years). Papillary thyroid carcinoma (PTC) was the most common pathology (n = 74). PTC tumors >1 cm showed higher rate of lymph node metastasis and extrathyroidal extension than tumors ≤1 cm. All patients survived with nine PTC patients who displayed treatment failure. Age, tumor size, multifocality, lateral lymph node metastasis, and postoperative thyroglobulin levels were significant prognosticators for disease recurrence.

CONCLUSION

Pediatric thyroid cancer is relatively rare and should be considered a specific disease entity with respect to the thyroid cancer in adults, since there are several distinctive characteristics.

Mastocheck: Notable plasma protein biomarker for diagnosis of breast cancer in the real clinical practice by using multiple reaction monitoring-based mass spectrometry

3044

Background: Breast cancer is the most frequently diagnosed cancer and the most leading cause of cancer-related deaths among women worldwide. Although screening mammography is available, there is an ongoing interest in improved early detection and prognosis. And also, serum tumor marker levels, such as CA 15-3 and others, may reflect disease progression and recurrence, they have not proven to be sensitive for early disease detection. Research investigating biomarkers for early detection, prognosis and the prediction of treatment responses in breast cancer is rapidly expanding. However, no validated biomarker currently exists for use in routine clinical practice, and breast cancer detection and management remains dependent on invasive procedures We aimed to develop biomarker for diagnosis of breast cancer in the real clinical practice by using proteomics technology. Methods: Based on our previous studies, we performed verification and validation of 124 candidate proteins by using proteomics approach. Among these 124 candidate proteins, the three proteins (neural cell adhesion molecule L1-like protein, apolipoprotein C-1, carbonic anhydrase-1) with highest statistical significance were selected. We created the performance algorithm of the 3-protein diagnostic model to predict of the breast cancer. We performed several experiments for establishment and validation of cut-off value. Furthermore we conducted test for acquisition of sample stability and more experiments to achieve the reproducibility and level of evidence, compared with other cancers (colon, thyroid, ovary, pancreas and lung cancer) and established effect of anesthesia. Results: Total 1226 samples (532 patients of breast cancer, 562 healthy women and 100 sample of other cancers) was analyzed. The sensitivity, specificity and accuracy from confirmation experiment was 71.58%, 85.25% and AUC 0.8323, respectively. The result of comparison with other cancers, there are no statistical significant difference and no relevance with effects of anesthesia. With these results, we recently got permission it to use for in vitro diagnostic use from Korea Food and Drug Administration. Conclusions: In this study, we developed a plasma protein biomarker that may help to diagnosis of breast cancer in the real clinical practice. By using MRM approach, the 3-protein biomarker was validated in an independent cohort with acceptable accuracy for early diagnosis of breast cancer.

Robotic transoral thyroidectomy for papillary thyroid carcinoma

Transoral robotic thyroidectomy (TORT) is well consistent with the primary goal of remote-access thyroid surgery, which is to avoid a visible cervical scar. Additionally, the extent of transoral thyroidectomy dissection is less than that of other remote-access surgical procedures. Owing to these merits of the transoral approach, several institutions around the world are now performing this procedure. Since transoral thyroidectomy is performed in a confined, narrow space, and is characterized by a close distance from the ports to the working space, more benefits can be derived from multiarticulation of robotic instruments. Especially when performing left lobectomy by TORT, the surgeon can use right-handed robotic instruments over the thyroid cartilage with the merits of multiarticulation. In this study, we present our unique procedure of left lobectomy by TORT in detail.