P2-17-08: rospective Study of Aromatase Inhibitor Induced Bone Loss and Lipid Levels in Early Postmenopausal (PM) Hormone Receptor Positive (HR+) Breast Cancer (BC) Patients Treated with Adjuvant Letrozole Extended beyond 5 Years (yrs)

Introduction/Aim: Adjuvant treatment with aromatase inhibitors (AI) is associated with accelerated bone loss and increase in lipid levels. The effectiveness and tolerance of extended treatment with AI beyond 5 years is currently under investigation. In the SOLE study, five years of continuous (C) extended letrozole is compared to interrupted therapy (9 months on, 3 months off letrozole) after 5 yrs of tamoxifen, AI or sequential hormonal therapy. We have evaluated the bone mineral density and lipid levels during the extended use of letrozole beyond 5 yrs in a cohort of patients included in the SOLE study.

Patients and methods: Postmenopauzal women with HR+ BC, receiving extended continuous (C) or intermittent (I) letrozole for 5 yrs after 5 yrs of tamoxifen, 5 yrs of an AI, or switch therapy within the first 5 years, were included. Bone mineral density was measured at the lumbar spine (L2-4) and total hip BMD (g/cm2), by dual energy X-ray absorptiometry (DXA). The mean percentage change in BMD at 12, 36 and 60 months (mths) was compared between the C and I treatment with letrozole and with baseline values. Differences between the treatment groups were assessed by the independent samples T test. We also compared the evolution ofthe serum lipid levels in both arms. Results: Thirty two patients (pts) were included with a mean age of 62 yrs (+/− 8.7 yrs). Thirty pts were valuable because of missing baseline DXA values in 2. In their first 5 years of adjuvant letrozole, prior to inclusion in the current study, twenty three pts had a mean percentage decrease of −0,76 (13,25 SD) and 7 pts who had received preventive zoledronate in the ZOFAST study, had a mean percentage increase in BMD of 4,4 (6,08 SD).

Currently 12 pts receiving the continuous letrozole are evaluable after a first one year extension of adjuvant letrozole. They had a mean percentage increase in BMD for the lumbar spine of 1.8 (3.3 SD), and a mean percentage increase in BMD for the hip of 0.85 (SD 1.93). Eight pts included in the intermittent arm are evaluable. They experience a mean percentage decrease in BMD for the lumbar spine of −0.32(2.7 SD) and a mean decrease in BMD for the hip of −2.9(SD 3.6) The difference between the two treatment groups was not significant for the lumbar spine measurements (p=0.14), but it was significant for the hip (p=0.02). The mean fasting cholesterol levels at 12 months in the C arm (12pts) was 228mg/dl (24.4 SD) and in the I arm (11pts) was 225,5mg/dl(32,3 SD) (p=0.37).

Conclusion: This is the first prospective BMD and lipid follow-up study during adjuvant letrozole extended beyond 5 yrs in PM early breast cancer pts. After the first year of extended intake of continuous or intermittent letrozole a possible difference in bone mineral density between the two arms is emerging, but the two groups are too small to make final conclusions. An updated longer follow-up on more patients will be presented. After one year no differential effect on cholesterol levels has been observed.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-17-08.

Tolerance of adjuvant letrozole outside of clinical trials

Recently aromatase inhibitors have become a standard care as an adjuvant treatment for many postmenopausal patients with hormone receptor positive early breast cancer. Adjuvant letrozole was made available either immediately postoperative, after 2-3 years of tamoxifen, or as an extended treatment after 5 years of tamoxifen. Between October 2003 and October 2005, we analyzed the subjective tolerance in 185 postoperative early breast cancer patients receiving letrozole outside of a clinical trial. The most prominent toxicity was musculoskeletal pain. In addition hot flushes, increased fatigue, nausea, vomiting, anorexia, mood disturbances, vaginal dryness, hair loss and rash were also recorded. In contrast to the prospective randomized clinical trials, a high drop-out rate of 20% was documented, mainly due to aromatase inhibitor-associated arthralgia syndrome interfering significantly with the daily life of our patients. Although adjuvant aromatase inhibitors have proven to be generally superior to tamoxifen in the adjuvant setting, it is important to focus attention on the tolerance during the adjuvant therapy and to balance this against the potential benefit in individual patients. Alternative options including switching to tamoxifen remain available.

Granulomatous lobular mastitis: a rare chronic inflammatory disease of the breast which can mimic breast carcinoma

Granulomatous lobular mastitis is a rare chronic inflammatory disease of the breast. The differential diagnosis with malign breast disease is often not easy. In most cases a surgical biopsy is needed for correct diagnosis. Idiopathic granulomatous mastitis is an exclusion diagnosis, based on the demonstration of a characteristic histological pattern, combined with the exclusion of other possible causes of granulomatous breast lesions. There is still no generally accepted optimal treatment. If surgery forms part of the treatment, a conservative approach seems to be adequate in most cases. Another option is a long-term steroid treatment. It is mandatory to exclude infectious causes of granulomatous mastitis before corticoid therapy is started.

Use of a Port-a-Cath system in the home setting for the treatment of symptomatic recurrent malignant pleural effusion

Symptomatic malignant pleural effusions represent a common problem in metastatic cancers and are associated with a significant morbidity. Pleurodesis still remains the primary therapy of choice. In a few cases, however, pleurodesis is unsuccessful because of a limited lung expansion and pleuroperitoneal shunts have been used. We describe two cases where an implantable PORT-A-CATH system is used for regular drainage of the pleural effusion. The main advantage of this technique is the fact that the procedure of drainage can be performed by a nurse in the home setting.

Lymphedema development following breast cancer surgery with full axillary resection

Several studies have investigated the influence of disease related, treatment related, and patient related risk factors on the development of postmastectomy edema (PME). The aim of the present study was to determine which factors present a higher risk of developing PME after breast surgery with full axillary resection (level I, II and III). To accomplish this aim, we investigated 245 women who underwent unilateral breast cancer surgery in the Academic Hospital of the Vrije Universiteit, Brussels. Information concerning treatment and disease related factors were collected from the patient's medical records and factors related to clinical condition were obtained by a personal interview. Arm circumference was taken at 15 cm proximal and 10 cm distal to the olecranon. PME was defined as 2.5 cm difference between the arms. Height and weight of the patient were also measured. Statistical analysis was performed by calculating the Odds Ratio and the 95% Confidence Interval. We found the following factors posed an increased risk of developing PME: axillary/supraclavicular radiotherapy, pathological status of the lymph nodes, overweight (BMI > 25 kg/m2), trauma to the arm, menopause and surgery on the dominant side.

A key to understanding postoperative lymphoedema: a study on the evolution and consistency of oedema of the arm using ultrasound imaging

Post-mastectomy oedema is a very serious complication that, in the course of time, will transform into fibrotic tissue. The aim of our study is to evaluate when and in which layer liquid oedema transforms into fibrotic tissue. To do so, ultrasonographic images were taken of 22 patients and 9 control women at the shoulder and 10 cm proximal and distal from the olecranon, with the images then being scanned and imported into a computer program to determine echogenicity of the dermis, subcutis, subcutis on dermal side and subcutis on fascial side. Statistical analyses were performed by means of the Wilcoxon test and a Student's t-test. No significant differences (P< or =0.05) were found for the different parameters in the control group. In the experimental group: significant differences in perimeter, skinfold, thickness of dermis and subcutis were found. Although not significant, subcutaneous tissue was more echogenic on the oedematous side, with significant hyperechogenicity at the fascial subcutaneous layer. This indicates that fibrotic tissue develops distally in the forearm.

Emergency treatment of life-threatening spontaneous haematopneumothorax

We report two cases of spontaneous life-threatening haemopneumothorax, successfully treated by early thoracotomy. In the first patient no source of bleeding could be identified. The second patient presented bleeding from a torn vascular adhesion at the apex of the lung. The first patient benefited from early clot evacuation and in the second patient the bleeding could be controlled by electrocautery and a single suture of the bleeding vessel. These cases stress the need for early recognition and management of a potentially life-threatening event.

Patterns of axillary lymph node metastasis in breast cancer

The pattern of axillary lymph node involvement was analyzed in a review of 377 cases of T1-4 breast cancers. Clinical judgment of the axillary status proved to be wrong in approximately one-third of the cases. In univariate analysis, a strong correlation (P < .01) between the number of involved nodes, tumor size, and blood vessel invasion was found. Other features of the primary tumor (lymphatic invasion, degree of differentiation, presence of necrotic areas) were related to a lesser degree (P < .05). While others (age, site) were not at all significant. However, the number of nodes resected proved to be the most important determinant of all (P = .003). Also, the simple distinction between node-negative and node-positive cases is strongly dependent on the extent of axillary dissection (P = .009). In multivariate analysis, only the number of resected nodes and T stage showed a good relationship with the number of positive nodes. Skip metastases above levels 1 and 2 were seen in only 2% of the cases. A clear influence of the number of invaded nodes on survival could be demonstrated. These findings are discussed, especially as concerns the technique, prognostic significance, and therapeutic usefulness of axillary dissection.

Modern thoughts on lymph nodes in breast cancer

Axillary lymph node status remains the single most useful prognostic parameter in breast cancer patients. As clinical examination, imaging techniques, and lymph node sampling methods cannot accurately assess the axillary node involvement, a complete axillary dissection should always be performed. Moreover, this technique provides an excellent treatment modality for regional disease, abolishing the need for radiotherapy to the axilla. The status of the internal mammary lymph nodes is of less importance in the management of the breast cancer patient.

Immunocytochemical and ultrastructural findings in a mature retroperitoneal teratoma

Report is made of a mature retroperitoneal teratoma in a 32-year-old man. Investigation of the tumor revealed cells immunoreactive for ACTH, Met-enkephalin, beta-LPH, serotonin, FSH, BPP, S100, Neuron-specific-enolase. These cells were mainly present in the glandular epithelium, lining the cysts of the tumor. Ultrastructurally, neuro-secretory granules were demonstrated in the cytoplasm of the tumoral endocrine cells. At no time did the patient display endocrine symptoms.

[Adenocarcinoma of the thyroglossal duct]

Carcinoma of the thyroglossal duct is a rare entity. In most cases, papillary carcinomas are reported. Follicular or squamous cell carcinomas are seldom. Insofar no capsular refraction exists, the best treatment seems to be the Sistrunk operation with postoperative thyroid suppression medication.

[Breast-sparing surgery in T1 breast carcinoma]

31 female patients with a T1 No N1a Mo breast tumour (diameter smaller or equal to 2 cm) were treated by segmental resection with complete axillar dissection, followed by radiotherapy. Chemotherapy was given in any case of axillary lymph node involvement. The mean follow-up period was 44 months. Absolute survival is 100%. One patient (3%) developed distant metastasis, 2 patients (6%) had a loco-regional recurrence and 3 presented with a metachronous tumour in the contralateral breast. 97% of the patients are actually alive and free of disease.

Clonidine-suppression test in epinephrine secreting pheochromocytoma: report of a case

A patient is described in whom the diagnosis of pheochromocytoma was suspected on clinical grounds. He had normal urinary and plasma norepinephrine levels, with normal suppression of plasma norepinephrine by clonidine. However, plasma and urinary epinephrine levels were above normal, and plasma epinephrine was not suppressed but increased by clonidine. Selective venous sampling showed marked unilateral adrenal epinephrine excess. A large epinephrine secreting pheochromocytoma was surgically removed. This case suggests that, in pheochromocytomas releasing predominantly epinephrine, normal norepinephrine release from axon terminals of sympathetic postganglionic neurons is maintained and is suppressed by clonidine administration. It further reaffirms the value of plasma epinephrine estimations in the diagnosis of pheochromocytoma and indicates that normal suppression of plasma norepinephrine by clonidine does not preclude the presence of a predominantly epinephrine secreting tumor.

A new instrument: the goiter extractor

In order to simplify the extraction of large intrathoracic goiters and to avoid dramatic surgical problems, the author developed a simple instrument to extract goitric masses. The extractor was used 17 times (approximately 10% of the thyroidectomy procedures performed during 3 years). Its effectiveness was proven in 16 cases.

Ultrasound examination of the thyroid

Ultrasound examination of the thyroid offers an accurate morphological picture and the possibility of comparing objectively the size of lobes and lesions over long periods. Cysts and calcifications, mostly benign, are readily recognized. Neoplastic lesions in our series were all less reflective than normal thyroid tissue. But so were the majority of benign nodules. In hyperthyroidism, subacute thyroiditis and Hashimoto's thyroiditis, the thyroid tissue is much less echogenic than in the normal gland.

Pattern of metastases distribution in 173 state I or II melanoma patients

173 patients treated for melanoma (stage I or II) were followed up for 8 to 10 years. The distribution pattern of metastases discovered during the follow-up period was studied. The main localizations in order of decreasing frequency were: regional lymph nodes. local recurrences, skin metastases (including transit metastases), lung, liver, brain, bone, parotid, mediastinum, bowel. mesenterium, stomach, adrenals, larynx and ovary. The data strongly suggest that efficient follow-up of malignant melanoma patients should include regular X-rays, liver, bone and brain scans, and in some cases, laparoscopy.