Association of hyperparathyroidism and benign fibro-osseous jaw tumors: a 25-year retrospective study at Mayo Clinic

PURPOSE

The purpose of this study is to evaluate the association between hyperparathyroidism (PHPT), parathyroid hormone levels, and calcium levels in patients diagnosed with benign fibro-osseous lesions such as fibrous dysplasia (FD), ossifying fibroma (OF), central giant cell granulomas (GCG).

METHODS

This is a retrospective, single-center study from a sample of patients who underwent surgical treatment of FD, OF, and GCG at Mayo Clinic between 1996 and 2021. Patient demographics, history of PHPT, histopathological diagnosis, and relevant laboratory values such as parathyroid hormone (PTH), serum calcium, vitamin D, and alkaline phosphatase were collected.

RESULTS

Of the patients diagnosed with FD (n = 64), OF (n = 24), and GCG (n = 5), a diagnosis of PHPT was found in 2 patients (3.1%), 1 patient (4.2%), and 0 patients (0%), respectively. Elevated PTH levels (>65 pg/mL) were observed in 3 patients (4.7%) with FD, 1 patient (4.2%) with OF, and 1 patient (20%) with GCG. Mean (standard deviation) calcium levels were 9.3 (0.6) mg/dL in the FD group, 9.4 (0.5) mg/dL in the OF group, and 9.3 (0.6) mg/dL in the GCG group. Patients with fibro-osseous jaw tumors including FD, OF, and GCG may have increased risk of PHPT compared to the general population.

CONCLUSION

Patients with benign jaw tumors including FD, OF, and GCG may have increased risk of PHPT compared to the general population. Surgeons treating these benign tumors need to be cognizant of these findings, obtain appropriate laboratory studies, and incorporate multidisciplinary care including endocrinologists, endocrine surgeons, and maxillofacial surgeons.

Clinical, imaging and biochemical presentation of cystic pheochromocytomas

OBJECTIVE

Cystic adrenal mass is a rare imaging presentation of pheochromocytoma. We aimed to describe the clinical, biochemical and imaging characteristics of patients with cystic pheochromocytoma.

DESIGN

Single-centre, retrospective study, 2000-2020.

PATIENTS

Consecutive patients with cystic pheochromocytoma were identified from our institutional pathology and adrenal tumour database.

RESULTS

Of the 638 patients with pheochromocytomas, 21 (3.2%) had cystic pheochromocytomas (median age: 57 years, 57% women). Most pheochromocytomas were discovered incidentally (57%) or due to symptoms of catecholamine excess (24%). The median tumour size was 6.4 cm. On imaging, cystic pheochromocytomas were round or oval (90%), heterogeneous lesions (86%) with a thick solid rim (median rim thickness 13.9 mm, unenhanced computed tomography (CT) attenuation 40 Hounsfield units (HU), venous-phase CT attenuation 83 HU), and a median cystic component of 40% (unenhanced CT attenuation 17.6 HU, venous-phase CT attenuation 20.4 HU), and rarely with calcifications (15%). All 20 patients with biochemical testing had functioning tumours (adrenergic in 80%, noradrenergic in 20%). Total urinary metanephrine excretion correlated with the volume of the solid component (R2  = .75, p < .0001) but not the cystic component (R2  = .04, p = .4386). All patients underwent adrenalectomy (48% laparoscopic, 52% open), and the median duration of hospital stay was 4 days.

CONCLUSIONS

Cystic pheochromocytomas are rare, large tumours with a phenotypic appearance that can masquerade as other adrenal cystic lesions. The degree of biochemical abnormality in cystic pheochromocytomas is associated with the volume of the solid component. All patients with adrenal cysts that have a solid component or an unenhanced attenuation >10 HU should undergo biochemical testing for pheochromocytoma.

Differentiating between adrenocortical carcinoma and lipid-poor cortical adenoma: A novel cross-sectional imaging-based score

BACKGROUND

Discrimination between adrenocortical carcinoma and lipid-poor cortical adenoma preoperatively is frequently difficult as these two entities have overlapping imaging characteristics. Differentiation will allow for the selection of the most appropriate operative approach and may help prevent over-treatment. We aimed to identify imaging features that could preoperatively differentiate adrenocortical carcinoma from lipid-poor cortical adenoma and use them in a novel imaging-based score.

METHODS

We conducted a retrospective analysis of patients with pathologically proven adrenocortical carcinoma and lipid-poor cortical adenoma who underwent resection in a single tertiary referral center between March 1998 and August 2020. The inclusion criteria were diameter >1 cm, attenuation >10 Hounsfield units on nonenhanced computed tomography, and histopathologic diagnosis. Patients with metastatic or locally advanced adrenocortical carcinoma adenoma (stages 3-4) were excluded. We developed a score using binary logistic multivariate regression model in 5-fold derivation (∼70%) cohorts with stepwise backward conditional regression as feature selection. Standardized mean regression weight was used as variable score points.

RESULTS

We identified 232 adrenals resected across 211 patients. By comparing the imaging characteristics of adrenocortical carcinoma (n = 56) and lipid-poor cortical adenoma (n = 156), we revealed statistically significant differences between the groups in 9 parameters: size, attenuation, thin and thick rim enhancement patterns, heterogeneity, calcification, necrosis, fat infiltration, and lymph node prominence. The score mean performance was 100% sensitivity for the exclusion of adrenocortical carcinoma, 80% specificity (95% confidence interval, 68.3-91.5), 66% positive predictive value (95% confidence interval, 52.3-78.7), and 100% negative predictive value with area under the curve of 0.974.

CONCLUSION

We defined and evaluated a novel 9-variable, imaging-based score. This score outperformed any single variable and could facilitate safe preoperative discrimination of adrenocortical carcinoma and lipid-poor cortical adenoma.

C11 choline PET/CT succeeds when conventional imaging for primary hyperparathyroidism fails

BACKGROUND

Focused parathyroidectomy in primary hyperparathyroidism is possible with accurate preoperative localization. A growing body of data exists regarding the role of radio-labeled C¹¹ choline positron emission tomography/computed tomography. In cases of nonlocalized disease, it may be a useful adjunct to ultrasound, (123)I/(99)Tc-sestamibi (I-123 sestamibi), or 4-dimensional computed tomography imaging.

METHODS

Patients who received a neck and chest limited coverage C¹¹ choline positron emission tomography/computed tomography for evaluation of primary hyperparathyroidism from 2017 to 2021 at a single institution were retrospectively reviewed. We assessed the sensitivity, positive predictive value, and false negative rate. We also compared these rates to the standard modalities of ultrasound, I-123 sestamibi, 4-dimensional computed tomography, and examined concordance rates.

RESULTS

We identified 43 patients, of whom 33 had a positive C¹¹ choline positron emission tomography/computed tomography finding. This cohort of patients had failed to localize on multiple standard imaging modalities. Twenty-five patients proceeded to surgery, 72% of whom were reoperative cases. Twenty (80%) achieved an intraoperative cure. Analysis showed that C¹¹ choline positron emission tomography/computed tomography achieved a sensitivity of 64% (95% confidence interval 47%-82%) and positive predictive value of 72% (95% confidence interval 54%-90%). There were 5/25 (20%) false positive positron emission tomography C¹¹ choline results found to be lymph nodes, normal parathyroid, and 1 recurrent laryngeal nerve neuroma.

CONCLUSION

C¹¹ choline positron emission tomography/computed tomography is a useful adjunct for parathyroid localization in a complex population of patients who have failed standard localization techniques including ultrasound, I-123 sestamibi, or 4-dimensional computed tomography and/or prior operations. Although routine inclusion of C¹¹ choline positron emission tomography/computed tomography imaging may not be necessary, it may aid in preoperative localization in the reoperative setting.

RF33 | PSUN01 Clinical Course of Benign Adrenal Cysts: A Single-Center Experience of 90 Patients

Introduction

Benign adrenal cysts (BACs) comprise 1% of adrenal incidentalomas. Scarce data are available to guide hormonal evaluation and management. We aimed to describe the clinical presentation, imaging characteristics and outcomes of patients with BACs.

Methods

This was a single center retrospective study of patients with histologically or radiologically confirmed BACs evaluated between 1995-2021. Other cystic adrenal lesions (such as cystic pheochromocytoma and adrenocortical cancer) were excluded. Medical records were reviewed for clinical, biochemical, radiological, and surgical information. Subgroup analyses based on surgical versus nonsurgical management was performed.

Results

BACs were diagnosed in 92 patients (53, 57% women) at a median age of 45 years. Mode of discovery was incidental on imaging in 81 (88%), symptoms of mass effect in 9 (9.8%), and other in 2 (2.2%). Majority (89, 97%) of patients had unilateral cysts (45 right, 44 left) with a median size of 48 mm (range 4-200) at diagnosis. On imaging, most cysts were round/oval (85.4%), homogenous (83.2%) lesions with calcifications (64.0%) and no vascular enhancement (97.7%). During a median follow-up of 65 months (range 7-288), adrenal cysts demonstrated minimal enlargement (median size change 6 mm, median growth rate 2 mm/year).Age of diagnosis, sex, site and initial size of BAC were not associated with an increase in size during follow up. On hormonal evaluation, 10% (5/50 tested) had an abnormal overnight dexamethasone suppression test, and 9.5% (4/42 tested) had an abnormal case detection testing for primary aldosteronism. Adrenalectomy was performed in 46 (51%) patients. Patients treated with adrenalectomy (46, 50%) were younger (36.9 vs 50.8 years, P=0.0009) and had more rapidly enlarging cysts (median growth rate 5.5 vs 0.4 mm/year, P=0.0002).

Conclusions

BACs are usually incidentally discovered and nonfunctional lesions with excellent prognosis, irrespective of management. On imaging, benign adrenal cysts appear as large, homogenous lesions without vascular enhancement that demonstrate slow growth. Adrenalectomy should be reserved for the minority of patients with abnormal hormonal evaluation or imaging characteristics (heterogenous, vascular enhancement) concerning for an alternate etiology, or those who develop symptoms of mass effect.

Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:42 p.m. - 12:47 p.m.

RF09 | PSAT94 Challenging the Status Quo: Are Routine Post-Operative Day 1 Non-Endocrine Labs Necessary After Adrenalectomy?

Background

The Choosing Wisely campaign from the American Board of Internal Medicine (ABIM) Foundation has scrutinized the practice of routinely ordering tests that offer limited or no benefit to patients, and have the potential to cause harm. Although postoperative day 1 (POD1) hormonal testing is necessary for certain patients who undergo adrenalectomy (i.e. those with functional tumors), the clinical utility of routinely checking POD1 non-endocrine labs is unclear, particularly in patients with non-functional adenomas. We sought to investigate how often these non-endocrine labs were abnormal after adrenalectomy and whether they represent value-added care.

Methods

Patients who underwent open or laparoscopic adrenalectomy at our institution from 2011-2020 were identified, and those with non-endocrine serum labs (hemoglobin, potassium, creatinine, or glucose) obtained before 0800 on POD1 were analysed. The frequency of abnormal labs, and any associated intervention(s), was recorded. Exclusion criteria varied by lab type and included: preoperative hemoglobin <8 g/dL or intraoperative blood transfusion (hemoglobin analysis), presence of chronic kidney disease (potassium and creatinine analyses), diagnosis of primary aldosteronism (potassium analysis), and pheochromocytoma or diabetes mellitus (glucose analysis). Costs were calculated using the 2020 Medicare Clinical Laboratory Fee Schedule.

Results

Of 936 patients (56% female) who underwent adrenalectomy (92% laparoscopic), 91% (n=847) had ≥1 POD1 non-endocrine lab drawn. Only 0.4% (n=3) of 785 eligible patients had an abnormal POD1 hemoglobin (<8 g/dL), and 1 patient received a blood transfusion. Potassium abnormalities were present in 3.4% (n=21) of 624 eligible patients, including 9 with hypokalemia (<3.5 mmol/L) and 12 with mild hyperkalemia (5.5-5.9 mmol/L). Specific interventions for hypo/hyperkalemia were required in 5 patients (0.8% of all potassium values). AKI (creatinine increase of 0.3 g/dL or ≥1.5x baseline) was diagnosed in 4% of 759 eligible patients (n=28) and all were stage 1. Hyperglycemia (>180 mg/dL) was identified in 1% (n=6) of 577 eligible patients, and 1 patient received short-acting insulin. Of a total of 2,745 lab values, while only 2% were abnormal, the total aggregate cost of routine POD1 labs was ∼$17,000 during the study period.

Conclusions

Routine POD1 hemoglobin and creatinine testing are rarely abnormal after adrenalectomy and infrequently impact clinical management. Although patients with functional disease may require monitoring of electrolytes and/or glucose on POD1, in the current era of value-based healthcare, routine ordering of these labs may be unnecessary in selected patients with non-functioning tumors.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:18 p.m. - 1:23 p.m.

Favorable Early Outcomes With Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: The Mayo Clinic Experience

BACKGROUND

Until 2015, standard of care for low-risk papillary thyroid cancer (PTC) >1 cm was a total or near-total thyroidectomy. Despite changes in guidelines and surgical management of low-risk PTC since 2015, little data are available regarding the effect on the need for additional surgery or risk for development of lymph node metastases. Our aim was to determine outcomes in patients who underwent initial thyroid lobectomy for low-risk PTC at a high-volume tertiary care institution.

METHODS

Retrospective review of patients ≥18 years old with biopsy proven low-risk PTC 1-4 cm who underwent partial thyroidectomy (eg, lobectomy/isthmusectomy) at Mayo Clinic, Rochester, MN, between March 2016 and June 30, 2019.

RESULTS

From 1481 thyroidectomies performed during study period, 940 contained PTC on final pathology. Of these, 87 (of 123) patients who had an initial thyroid lobectomy met inclusion criteria. Five (6%) of these patients proceeded to completion thyroidectomy (CT), with 3 requiring CT and radioactive iodine in the first postoperative year and 2 undergoing only CT in the second postoperative year. No postoperative complications were reported. No patient in this cohort required additional surgery or treatment for newly discovered lymph node metastases during the follow-up period. 43 (of 72, 60%) patients not on thyroxine therapy preoperatively were started on thyroxine therapy postoperatively.

CONCLUSIONS

Early outcomes for those undergoing thyroid lobectomy for low-risk PTC at our institution have been favorable. These results support the 2015 American Thyroid Association guidelines to offer lobectomy for those with low-risk PTC 1-4 cm.

Presentation and outcomes of adrenal ganglioneuromas: A cohort study and a systematic review of literature

OBJECTIVE

To describe the presentation and outcomes of patients with adrenal ganglioneuromas (AGNs).

DESIGN

Single-centre retrospective cohort study (1 January 1995 to 31 December 2019) and systematic review of literature (1 January 1980 to 19 November 2019).

PATIENTS

Diagnosed with histologically confirmed AGN.

MEASUREMENTS

Baseline clinical, imaging and biochemical characteristics, recurrence rates and mortality. Subgroup analysis was performed on tumours with histologic elements of ganglioneuroma and pheochromocytoma (ie composite tumours).

RESULTS

The cohort study included 45 patients with AGN, 20 (44%) of which had composite tumours. Compared to pure AGN, patients with composite tumour were older (median age, 62.5 vs. 35 years, p < .001), had smaller tumours (median size, 3.9 vs. 5.7 cm, p = .016) and were discovered incidentally less frequently (65% vs. 84%, p = .009). No recurrences or ganglioneuroma-specific mortality occurred during follow-up (range, 0-266 months). The systematic review included 14 additional studies and 421 patients. The mean age of diagnosis was 39 years, and 47% were women. AGNs were discovered incidentally in 72% of patients, were predominantly unilateral (99%) and had a mean diameter of 5.8 cm and an unenhanced computed tomography (CT) attenuation of -118 to 49 Hounsfield units (HU). On imaging, 69% of AGNs were homogenous, 41% demonstrated calcifications, and 40% were lobulated.

CONCLUSIONS

AGNs are rare benign tumours that present with variable imaging features including large size, unenhanced CT attenuation >20 HU, calcifications and lobulated shape. Imaging characteristics can assist in establishing a diagnosis and avoiding an unnecessary adrenalectomy. The association of pheochromocytomas with AGNs is frequent. Diagnosis should include biochemical testing.

Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization

BACKGROUND

In Jan 2018, we began routinely obtaining neck ultrasound (US) with 123I/99Tc-sestamibi (MIBI) for parathyroid gland localization and to identify thyroid pathology in the setting of primary hyperparathyroidism (1HPT). The aim of this study is to assess if routine neck US is a useful adjunct to 123I/99Tc-MIBI in 1HPT.

METHODS

Patients undergoing surgery for 1HPT with both 123I/99Tc-MIBI and US at our institution after implementation of routine US were reviewed. Biopsy and surgical management of thyroid pathology was evaluated. 123I/99Tc-MIBI and US results were compared to intraoperative findings to determine sensitivity and positive predictive value (PPV) for parathyroid localization.

RESULTS

From January 2018 to September 2019, there were 423 patients (mean, 61 years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8 cm. Fine needle aspiration (FNA) was performed in 87 patients with nodules (36%). 35 patients (8.5%) required total or partial thyroidectomy for diagnoses/treatment. Papillary thyroid cancer (PTC) was found in 3.5% of the cohort with micro-PTC 53% and PTC 1-2 cm 40%. A successful parathyroid operation for 1HPT was achieved in 98.6% of patients. Positive predictive value for localization of abnormal parathyroid glands was 97% when US and 123I/99Tc-MIBI had concordant findings.

DISCUSSION

Routine use of US in 1HPT commonly identifies nodules that are benign or low-risk PTC. Ultrasound is less sensitive for parathyroid localization but when used with 123I/99Tc-MIBI, concordant imaging has a high PPV.

Early assessment of postoperative adrenal function is necessary after adrenalectomy for mild autonomous cortisol secretion

BACKGROUND

The diagnostic threshold for mild autonomous cortisol secretion using low dose, overnight, dexamethasone suppression testing is recognized widely as a serum cortisol ≥1.8 mcg/dL. The degree to which these patients require postoperative glucocorticoid replacement is unknown.

METHODS

We reviewed adult patients with corticotropin (ACTH)-independent hypercortisolism who underwent unilateral laparoscopic adrenalectomy for benign disease with a dexamethasone suppression testing ≥1.8 mcg/dL at our institution from 1996 to 2018. Patients with a dexamethasone suppression testing of 1.8 to 5 mcg/dL were compared with those with a dexamethasone suppression testing >5 mcg/dL.

RESULTS

We compared 68 patients with a preoperative dexamethasone suppression testing of 1.8 to 5 mcg/dL to 53 patients with a preoperative dexamethasone suppression testing >5 mcg/dL. Preoperative serum ACTH (mean 10.0 vs 9.2 pg/mL), adenoma size (mean 3.4 vs 3.5 cm), and side of adrenalectomy (37 and 47% right) were similar between groups (P > .05 each). Patients with a dexamethasone suppression testing 1.8 to 5 mcg/dL were older (mean values 58 ± 11 vs 52 ± 16 years ; P = .01), less likely to be female (63 vs 81%; P = .03), had greater body mass indexes (33.1 ± 8.4 vs 29.1 ± 5.6; P = .01), and had lesser 24 hour preoperative urine cortisol excretions (32.6 ± 26.7 vs 76.1 ± 129.4 mcg; P = .03). Postoperative serum cortisol levels were compared in 22 patients with a dexamethasone suppression testing of 1.8 to 5 mcg/dL to 14 patients with a dexamethasone suppression testing >5 mcg/dL. Those with dexamethasone suppression testing 1.8 to 5 mcg/dL had greater postoperative serum cortisol levels (8.0 ± 5.7 vs 5.0 ± 2.6 mcg/dL; P = .03), were less likely to be discharged on glucocorticoid replacement (59% vs 89%; P = .003), and had a decreased duration of treatment (4.4 ± 3.8 vs 10.7 ± 18.0 months; P = .04).

CONCLUSION

Assessment of early postoperative adrenal function with mild autonomous cortisol secretion is necessary to minimize unnecessary glucocorticoid replacement.

Thyroidectomy for Amiodarone-Induced Thyrotoxicosis: Mayo Clinic Experience

Context

Amiodarone-induced thyrotoxicosis (AIT) is a difficult diagnostic and management challenge, especially during severe thyrotoxicosis accompanied by cardiovascular compromise.

Objective

To evaluate thyroidectomy for the management of AIT.

Design

Retrospective cohort study of adults with noncongenital heart disease with AIT after >3 months of amiodarone who underwent thyroidectomy from 1 November 2002 to 31 December 2016.

Setting

Referral center.

Patients

The group was comprised of 17 patients.

Main Outcome Measures

Thyroid function, left ventricular ejection fraction (LVEF), and surgical complications were the main outcome measures.

Results

Patients had median age of 60 years, 82.4% were male, and 47% had systolic heart failure. At diagnosis, median TSH was 0.005 mIU/L, median free T4 was 3.25 ng/dL, and total T3 was 198.5 ng/dL. We classified five patients as type 1 and type 2 and two patients as mixed; five patients remained undefined. The most common surgical indications were medically refractory disease, worsening cardiac status, and severe thyrotoxicosis requiring prompt resolution. Within 1 week post-thyroidectomy, median TSH was 0.565 mIU/L, and free T4 was 1.8 ng/dL. Median LVEF improved by 8% in patients with systolic heart failure. Seven patients had a complication within 30 days postsurgery (rehospitalization, n = 4; cervical hematoma, n = 2; recurrent arrhythmia, n = 2; symptomatic hypocalcemia, n = 1; death, n = 1). A larger thyroid gland was a risk factor for complications.

Conclusions

Thyroidectomy resulted in rapid resolution of thyrotoxicosis. Its complication rate was higher than for non-AIT indications but lower than previously reported in a similar population of high-risk surgical patients.

Abstract P5-14-06: Outcomes in 500 patients from a large, retrospective study of APBI with a strut-based breast brachytherapy applicator

Purpose/Objectives:

The SAVI Collaborative Research Group (SCRG) is a coalition of 14 institutions who have retrospectively compiled a large database of APBI patients treated with a strut-based brachytherapy device (SAVI). This report details the findings of statistical correlations between numerous dosimetric variables and cosmetic outcome.

Materials/Methods:

The SCRG study enrolled 1005 patients. A subset of patients with complete dosimetry and more than 1 year of follow-up by a radiation oncologist were analyzed for toxicity, cosmesis and recurrence/survival. Dosimetric parameters were tabulated for patients, including: V90, V95, V100, V150, V200, skin spacing (skin-bridge), maximum skin dose, tumor size, PTV-Eval volume and applicator size (model). Toxicity (e.g., telangiectasia, fibrosis, fat necrosis, seroma) were graded by physicians for patients with at least 1 year of follow-up (up to 6 years) using the CTCAE v3 Scale and fat necrosis using a simplified CTCAE scale (Grade 1 asymptomatic but seen on imaging, grade 2 symptomatic without intervention, & grade 3 required intervention).

Results:

Median follow up in this cohort was 29.2 months (range 2.4 to 72.2 months). Follow up was &gt;2 yr and &gt;3 yr for 323 and 191 subjects, respectively. Overall, in 500 subjects the late toxicity (grade ≥2) rates were less than 5% during follow up: telangiectasia 1.0%, fibrosis 4.1%, seroma 2.9% and fat necrosis 0.6%. Cosmesis was reported at various post-APBI follow-up visits following treatment completion (6, 12, 24, 36, 48 & 60+ months). For the 6 and 12 month intervals, 98% (n = 122) and 97% (n = 262) were reported excellent or good (E/G), respectively. At 24, 36, 48 and 60 month intervals, the E/G rates were 93% (n = 184), 90% (n = 98), 100% (n = 41) and 94% (n = 15), respectively. The raw rates of ipsilateral breast tumor recurrence (IBTR) and TR/MM were 1.6% (n = 8) and 1.2% (n = 6), respectively, in 500 patients with &gt;1 year of follow up. The 1- and 2-year actuarial rates of overall survival and disease-free survival were: 1-year, 99.6% & 99.4%, resp. and 2-year, 99.2% & 96.7%.

Conclusions:

APBI treatment with the strut-based applicators was well-tolerated, demonstrated low toxicity rates, favorable cosmetic outcomes and excellent local control over the follow-up to date. Patients with challenging breast anatomy were successfully treated with strut-based devices.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-06.

The use of bioimpedance spectroscopy to monitor therapeutic intervention in patients treated for breast cancer related lymphedema

We performed a multi-institutional analysis to evaluate the ability of bioimpedance spectroscopy (BIS) to capture the impact of lymphedema treatment compared with observation alone in the management of breast cancer related lymphedema (BCRL). We utilized a retrospective review of 50 patients with breast cancer who were evaluated with BIS at baseline and following loco-regional treatment. An analysis was performed comparing changes in L-Dex scores for those patients undergoing treatment for BCRL (n=13) versus those not undergoing intervention (n=37). A second (subset) analysis was also performed on all patients with elevated L-Dex scores compared to baseline prior to undergoing loco-regional treatment (n=32). When comparing the cohort treated for BCRL to those not treated, L-Dex scores were significantly reduced (-4.3 v. 0.1, p=0.005) in the period following intervention (for treated patients). For the subset of patients with elevated L-Dex scores postoperation, the change in L-Dex score following BCRL treatment was significantly reduced (-5.8 v. 0.1, p=0.001) compared with the group observed that had elevated postsurgical L-Dex scores. In this analysis, BIS was able to detect early onset lymphedema and subsequently significant changes (reductions) in L-Dex scores directly related to intervention for BCRL compared with observation alone.

Low Risk Ductal Carcinoma In Situ (DCIS) Treated with Breast Conserving Surgery & Accelerated Partial Breast Irradation (APBI): Comparison of the Mammosite Registry Trial with Intergroup Study E5194

Purpose/Objective(s): Recent data from Intergroup Study E5194 prospectively defined a low risk subset of ductal carcinoma in situ (DCIS) patients where radiation therapy was omitted after local excision alone. At 5 years, they found a 6.8% ipsilateral breast event rate (IBTR) in selected low/intermediate grade (LIG) patients and a 13.7% IBTR in selected high grade (HG) patients. The purpose of our study was to determine the IBTR in DCIS patients treated on the American Society of Breast Surgeons (ASBrS) MammoSite® Breast Brachytherapy registry trial who met the criteria of E5194 treated with local excision and adjuvant APBI.Material/Methods: A total of 194 patients with DCIS were treated between 2002 and 2004 on the Mammosite registry trial; of these, 69 patients met the enrollment criteria for E5194: 1. LIG: low to intermediate grade with a pathological size &gt; 0.3cm but &lt; 2.5cm and margins &gt;3mm (n=40) or 2. HG: high grade, pathological size &lt;1cm and margins &gt;3mm (n=29). All patients were treated with lumpectomy followed by adjuvant APBI (34 Gy in 3.4 Gy fractions). Median follow-up for surviving patients was 50.7 months (range, 0-73.4). Hormonal therapy was given to 51% of these patients (compared to 30% of patients on E5194). The clinical-pathologic data and long term outcomes for each patient were entered into a database for statistical analysis using SAS (v 8.2).Results: The median age of the entire cohort was 62.5 years. In the LIG cohort, the median size was 0.8cm. In the HG cohort, the median size was 0.6cm. In the LIG cohort, the 5-year IBTR was 0%, compared to 6.8% at 5 years in E5194. In the HG cohort, the 5-year IBTR was 5.3% compared to 13.7% at 5years in E5194. The overall the 5-year IBRT was 2% and there were no cases of elsewhere or regional failures in the entire cohort. The 5-year contralateral breast event rate was 0% and 5.6% in LIG and HG patients, respectively (compared to 3.5% and 4.2%, respectively, in E5194). The 5-year disease free survival and overall survival rate was 92.4% and 96.5%, respectively. In all patients with DCIS (n=194) treated with Mammosite on the registry trial, the 5-year actuarial IBTR, DFS, and OS was 3.1%, 93.8% and 98.2%, respectively.Conclusion: Adjuvant accelerated partial breast irradiation using Mammosite is a relatively convenient form of radiotherapy which shortens treatment time to 1 week. This study found that patients who met the criteria of E5194 treated with APBI had extremely low rates of recurrence (0% vs. 6.8% in the low to intermediate grade and 5.3% vs. 13.7% in the high grade). We conclude that all patients with DCIS who were eligible for E5194 have appreciable benefit from adjuvant APBI.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 951.

Three year analysis of patient demographics, treatment efficacy, cosmesis, and toxicity by the American Society of Breast Surgeons MammoSite® registry in patients (age &lt;50 or ≥ 50) treated with accelerated partial breast irradiation (APBI)

Abstract #5126

Background: We present 3 year data on patient demographics, treatment efficacy, cosmesis, and early toxicity for patients enrolled on the American Society of Breast Surgeons MammoSite (Hologic Bedford, MA) Registry based upon patient age (&lt;50 versus ≥50).&#x2028; Material and Methods: From 5/02 to 7/04, 1449 breasts (1440 patients) with Stage 0-II breast cancer undergoing breast-conserving therapy were treated with the MammoSite device to deliver APBI (34 GY in 3.4 Gy fractions). Of these 1449 breasts, 1255 (86.6%) breasts had invasive breast cancer (IBC; median size 10mm) and 194 (13.3%) breasts had ductal carcinoma in situ (DCIS; median size 8mm). Of the 1255 IBC breasts/1249 patients, 109 (8.68%) breasts/patients were &lt;50 years of age (YOA) and 1140/1146 (91.3%) patients/breasts were ≥ 50. Of the 194 DCIS breasts/patients, 21 (10.8%) patients were &lt;50 YOA and 173 (89.2%) patients were ≥ 50. Prognostic factors, technique, cosmesis, recurrence rates, and toxicity were assessed for all patients. Median follow-up was 38 months.&#x2028; Results: Of the IBC cases, 3 (2.8%) breasts (age&lt;50) and 20 (1.7%) breasts (age≥50) developed an ipsilateral breast tumor recurrence (IBTR) for a 3 year actuarial rate (YAR) of 2.27% and 1.76%, respectively (p=0.4587). Of the DCIS patients, 1 (4.8%) breast (age&lt;50) and 1 (0.6%) breast (age≥50) developed an IBTR for a 3 YAR of 6.25% and 1.4%, respectively (p=0.2575). Of the IBC cases, patients &lt;50 YOA compared to age ≥ 50 more frequently had positive nodes (6.4% vs 2.7%, P = .04), higher grade (≥ II) (72.5% vs 58.9%, P=.0056), and were treated with chemotherapy (31.2% vs 11.5%, P&lt;.0001). No significant difference was found in margin status, tumor location and size, extensive intraductal component, and use of tamoxifen based on age. Of the DCIS cases, patients &lt;50 YOA compared to patients ≥ 50 more frequently had an open cavity MammoSite placement (81% vs 52%, P = .0184). No significance was found in margin and node status, tumor location or size, histology, and use of tamoxifen due to age. Patients &lt;50 compared to ≥ 50 with IBC or DCIS had excellent/good cosmetic 3 year outcome (YO) (90.3%) and (93.3%), respectively (p=0.2902). Patients &lt;50 compared to ≥ 50 with IBC or DCIS more frequently experienced a fair/poor cosmetic 2 YO (13.5% vs 5.6%, P=0.0197) and fat necrosis (4.6% vs 1.8%, P=.0456). This fair/poor cosmetic 2 YO finding for patients &lt;50 vs. &gt; 50 was not significant at 3 YO (9.7% vs 6.4%, p=0.2902). No difference due to age was found for seroma formation, breast infection, telengectasia, retraction, skin spacing, placement method, bra size and balloon volume.&#x2028; Discussion: Treatment efficacy, cosmesis, early toxicity and IBTR 3 years after treatment with APBI using the MammoSite device were similar for IBC and DCIS patients for age&lt;50 or ≥ 50 years at diagnosis.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5126.

Effect of ophthalmic metipranolol and timolol on exerise-induced tachycardia

PURPOSE

We compared the systemic beta-adrenoceptor blockade elicited by metipranolol with timolol in a randomized, double-masked, multiple crossover study in 24 healthy volunteers.

METHODS

On each of 4 test days, subjects exercised on a treadmill for 10 min at 4 mi/h at a 5% gradient. After a 30-min rest, they received one drop OU of either 0.1 or 0.3% metipranolol HCI, 0.5% timolol maleate, or an artificial tear vehicle.

RESULTS

With 10 min of exercise, mean heart rate increased from +/-80 to 140 beats/min preinstillation. During the postinstillation exercise, mean heart rate increased to a maximum of 141.5 +/- 19.6, 141.8 +/- 17.2, 139.7 +/- 19.7, and 131.5 +/- 16.9 beats/min in the vehicle, 0.1% metipranolol, 0.3% metipranolol, and 0.5% timolol groups, respectively. Pairwise comparisons at this time revealed a significant difference between timolol and each of the other treatments.

CONCLUSIONS

Given the ocular hypotensive equivalency of various concentrations of metipranolol to timolol in other studies, it appears that metipranolol may have an improved therapeutic index relative to timolol.

Second primary cancers following treatment of Hodgkin's disease

A cohort study designed to evaluate the carcinogenicity of treatment for Hodgkin's disease (HD) was conducted. This report describes 2,591 patients with HD diagnosed in 1940-75 and presents an analysis of follow-up findings through 1978. Seventy-four second primary cancers (excluding basal cell and squamous cell cancers of the skin and in situ carcinomas of the cervix uteri) were observed 1 year or more after diagnosis of HD, including 21 leukemias. Twenty leukemias occurred after chemotherapy. The relative risk (RR) of leukemia after intensive chemotherapy with or without radiotherapy was 136 relative to general population incidence rates. In the subgroup with both intensive chemotherapy and intensive radiotherapy, the RR of leukemia was 125. Both RR estimates differed significantly from unity. The RR of cancers other than leukemia 10 years or more after intensive radiotherapy relative to no intensive therapy was 19.5 (95% confidence limits: 4.8-80).

The epidemic of acquired immunodeficiency syndrome (AIDS) and suggestions for its control in drug abusers

Intravenous (IV) users of illicit drugs have accounted for 17% of AIDS cases seen in the United States. Previous research has shown that more than half of IV drug abusers entering a drug detoxification program in New York City had serologic evidence of exposure to the virus believed to cause AIDS. Spread of AIDS among drug abusers presumably occurs by transmission of the virus via shared needles, works, or drug-containing solutions. Secondary spread of AIDS from IV drug abusers to others may occur by venereal transmission or by perinatal transmission to infants. In this article, relevant characteristics of the AIDS epidemic are presented to assist the staff of drug treatment programs in their work with IV drug abusers. Suggestions regarding the education of drug treatment personnel and the dissemination of information about AIDS to drug abusers and their families are offered. Fact sheets on AIDS for drug treatment and prison staff, and for drug abusers with and without the disease are presented. Finally, possible approaches to the prevention of AIDS in drug users are discussed.