Case report: 65-year-old man with metachronous left sided adrenal metastasis of hepatocellular carcinoma

INTRODUCTION AND IMPORTANCE

Due to therapeutic advances and improvements in follow-up care, the diagnosis and treatment of extrahepatic metastases of hepatocellular carcinoma [HCC] have gained clinical significance. However, adrenal gland metastases of HCC remain a rare clinical encounter. Several systemic and local treatment options are discussed in current literature. Adrenalectomy in cases of isolated adrenal metastases with well-controlled intrahepatic lesions has been shown to benefit patients in case series.

PRESENTATION OF THE CASE

This 65-year-old patient presented with suspected metachronous left sided adrenal metastasis seven years after bisegmentectomy for HCC and after undergoing trans-arterial chemoembolization [TACE] for multifocal intrahepatic recurrences while being listed for liver transplantation "beyond Milan criteria". Adrenalectomy was suggested for histopathological confirmation of the suspected metastasis and re-consideration for liver transplant. The resection was performed laparoscopically and metastasis of HCC was confirmed in histopathological analysis. Postoperatively, the patient recovered quickly. However, the patient decided against re-listing for liver transplantation.

CLINICAL DISCUSSION

Current literature suggests, that minimally-invasive adrenalectomy should be considered in patients with no more than two extrahepatic lesions, a Child-Pugh-Score of less than A5, low alpha-fetoprotein [AFP] levels <100 ng/ml and size <3 cm. The oncological goal should be to achieve a tumor free extrahepatic situation with a potential oncological benefit.

CONCLUSION

Our patient presented as an ideal candidate for resection of the adrenal gland metastasis and could have been re-assessed postoperatively for liver transplantation. Still, more research is needed to improve patient-selection for metastasectomy in HCC.

[Loss of domain and reduction in median suture tension]

BACKGROUND

Abdominal wall reconstruction in large incisional hernia/laparostoma poses a particular challenge. A loss of domain is the extreme form of intestinal volume displacement. The challenge lies in overcoming retraction of the lateral abdominal muscles.

OBJECTIVE

Experienced surgeons have access to a variety of techniques aimed at gaining lateral length along the abdominal wall or reducing suture tension at the midline. These techniques are intended to facilitate reconstruction even in complex cases and are outlined in this article from a practical perspective.

MATERIAL AND METHODS

The application of botulinum toxin A (BTA) and progressive pneumoperitoneum (PPP) are described as preoperative methods to gain abdominal wall length. Peritoneal flaps, intraoperative fascial traction (IFT) and component separation including transversus abdominis muscle release (TAR) are available for the surgical reconstruction of the abdominal wall. Bridging and the intraperitoneal onlay mesh approach are fallback techniques. All these techniques were integrated into a practical algorithm for complex abdominal wall reconstruction including preoperative and postoperative care and assessed by the authors with respect to effort, effectiveness and complexity.

RESULTS AND CONCLUSION

In the opinion of the authors, the status of complex abdominal wall reconstruction is currently best described by a combination of the most effective and proven techniques in terms of a "categorical algorithm". The combination of BTA, IFT and TAR presently appears to be the most effective method; however, experience and expertise are a prerequisite.

The nucleation of C-S-H via prenucleation clusters

The nucleation and growth of calcium-silicate-hydrate (C-S-H) is of fundamental importance for the strength development and durability of the concrete. However, the nucleation process of C-S-H is still not fully understood. The present work investigates how C-S-H nucleates by analyzing the aqueous phase of hydrating tricalcium silicate (C₃S) by applying inductively coupled plasma-optical emission spectroscopy as well as analytical ultracentrifugation. The results show that the C-S-H formation follows non-classical nucleation pathways associated with the formation of prenucleation clusters (PNCs) of two types. Those PNCs are detected with high accuracy and reproducibility and are two species of the 10 in total, from which the ions (with associated water molecules) are the majority of the species. The evaluation of the density and molar mass of the species shows that the PNCs are much larger than ions, but the nucleation of C-S-H starts with the formation of liquid precursor C-S-H (droplets) with low density and high water content. The growth of these C-S-H droplets is associated with a release of water molecules and a reduction in size. The study gives experimental data on the size, density, molecular mass, and shape and outlines possible aggregation processes of the detected species.

Comparison of right hemicolectomies with and without complete mesocolic excision (CME)

Objective

Since the concept of complete mesocolic excision (CME) in right hemicolectomies was introduced, it is still under debate if all patients require this radical technique.

Methods

Patients with adenocarcinoma of the colon undergoing right hemicolectomies at our hospital were retrospectively analyzed and stratified in a non-CME group (08/2014-04/2018) and a CME group (05/2018-11/2021). Patients were compared in regard to clinical, histopathological and prognostic parameters. CME were classified according to Benz et al.

Results

A total of 130 right hemicolectomies were performed, 33 (25.4%) patients were excluded due to other pathologies or emergency patients. Finally, 97 patients were included (53 in the CME group, 39 in the non-CME group). No difference in patient's characteristics were found except more male patients in the CME group (20 vs. 6; p=0.02). Tumors in the CME group were mainly located in the colon ascendens (66.0%), in the non-CME group in the coecum (48.7%; n.s.). In the CME group, 26 of 53 (49.1%) patients were operated laparoscopically compared to 10 of 39 (25.6%) patients in the non-CME group. Da Vinci system were used exclusively in the CME group (5 of 53 (9.4%); p=0.003). TNM classification, histology and UICC stadium showed no significant difference. In total, 50 (94.3%) surgical specimen were classification either as CME 0 or 1. In average, 35.2 lymph nodes (8.2% positive) were found in the CME group compared to 32.7 (16.2% positive) lymph nodes in the non-CME group (p=0.9). No relevant intraoperative complications occurred in both groups. Distance of the mesocolon were available in 39 (73.6%) patients in the CME group and 34 (37.1%) in the non-CME group; the distance tended to be longer in the CME group (mean 116.0 mm in CME group vs. 96.6 mm in non-CME group; p=0.09). Follow-up were 336.4 days in CME-group and 1210.4 days in the non-CME group. In the follow-up, 2 (5.1%) patients in the non-CME group developed a local recurrence in the smaller pelvis. No local recurrence occurred in the CME group (p=0.18). Distant metastasis occurred in 5 of 53 (9.4%) patients in the CME group and in 2 of 39 (5.4%) patients in the non-CME group (p=0.7).

Conclusion

This study shows that the benefit for CME in all performed right hemicolectomies is marginal and that the surgical standards was already high in the pre-CME era.

A multifactorial intervention to reduce use of antibiotics in acute uncomplicated diverticulitis – a single centre feasibility study

Objective

Standard treatment for uncomplicated diverticulitis in our institution consists of antibiotics. However, current evidence suggests that bacterial infection has a less predominant role than previously thought, and that uncomplicated acute diverticulitis may be a self-limiting condition in which inflammation can be managed without antibiotics. With the support of a multidisciplinary team we developed an intervention in order to reduce the use of antibiotics for patients with uncomplicated diverticular disease.

Methods

Standard practice and knowledge of current evidence were investigated with a structured survey sent to general practitioners and gastroenterologists with private practice in the area. A clinical process model for treatment of uncomplicated left-sided diverticulitis was created and exclusion criteria were selected in order to define patients with a high risk of developing complications. An educational intervention based on current evidence and the new treatment pathway was conducted on hospital staff as well as primary care physicians in the area in order to raise awareness about the possibility of avoiding antibiotics in uncomplicated diverticulitis. Patients were also involved and received an informative sheet about the rationale of the new treatment, the planned follow up and warning signs warranting further investigations and referral in case of outpatient treatment. All patients from May 2021 to December 2021 with a computed tomography-verified left-sided acute uncomplicated diverticulitis were included in the study and evaluated prospectively.

Results

Of 60 patients with acute uncomplicated diverticulitis, 23 (38%) were eligible for treatment without antibiotics. High inflammatory markers on presentation were the main reason (84%) for giving antibiotics. Adherence to the new policy was 74%. None of the 17 patients initially managed without antibiotics failed conservative treatment.

Conclusion

This project confirmed that treatment of uncomplicated diverticulitis without antibiotics can successfully be offered to a selected group of patients without altering the course of the disease. Further efforts are needed in order to overcome existing barriers to rational antimicrobial use such as lack of trust in new guidelines, general uncertainty and risk avoidance, patients’ expectations for antibiotic treatment, and fear of legal consequences.

0481 Impact of Lemborexant on Fatigue Severity in Subjects with Clinically Significant Levels of Fatigue at Baseline

Introduction

In Phase 3 SUNRISE-1 (NCT02783729; E2006-G000-304) and SUNRISE-2 (NCT02952820; E2006-G000-303), lemborexant (LEM) provided significant benefit versus placebo on sleep diary-based sleep onset/maintenance outcomes over 1mo and 6mo, respectively, in subjects with insomnia disorder. The impact of LEM on patient-reported fatigue, assessed using the Fatigue Severity Scale (FSS), in subjects with clinically significant fatigue (CSF) at baseline was examined for each study.

Methods

SUNRISE-1 was a 1mo, randomized, double-blind, placebo- and active-controlled, parallel-group study in female (≥55y) and male (≥65y) subjects (n=1006); subjects received placebo, LEM 5mg (LEM5), LEM 10mg (LEM10) or zolpidem tartrate extended-release (not reported here). SUNRISE-2 was a 12mo, randomized, double-blind study in subjects age ≥18y (n=949). Subjects received placebo, LEM5, or LEM10 for 6mo. Placebo subjects were rerandomized to LEM5 or LEM10 for another 6mo; LEM subjects continued assigned treatment. CSF was defined as FSS total score (FSSts) ≥36.

Results

In subjects with baseline CSF, in SUNRISE-1, baseline FSSts was 46.8, 46.5, and 46.6 in placebo (n=117), LEM5 (n=157), and LEM10 (n=153) groups, respectively, and, in SUNRISE-2, was 45.7, 46.4, and 45.8 in placebo (n=169), LEM5 (n=181), and LEM10 (n=173) groups, respectively. At 1mo, mean changes from baseline in FSSts were not significantly different vs placebo for LEM5 in both studies, and for LEM10 in SUNRISE-1. In SUNRISE-2, LEM10 significantly decreased mean [SD] FSSts from baseline vs placebo at 1mo (LEM10, −11.2[13.9] vs placebo, −8.7[10.5]; P=0.03). By 6mo in SUNRISE-2, both LEM5 and LEM10 significantly decreased mean [SD] FSSts from baseline versus placebo (LEM5, −15.4[13.8]; LEM10, −15.0[14.2] vs placebo, −11.2[11.6]; both P&lt;0.05). At 12mo, mean [SD] FSSts improvements were sustained for LEM5 (−20.4[12.8]) and LEM10 (−18.1[14.7]).

Conclusion

In subjects with CSF, longer treatments (&gt;1mo) may be needed to observe significant FSSts improvements, which were evident at 6mo and sustained at 12mo with continuous LEM treatment.

Support

Eisai Inc.

0478 A Multicenter Pilot Study to Evaluate Next-Dose Transition from Zolpidem to Lemborexant for the Treatment of Insomnia

Introduction

Switching of medications for insomnia occurs often in clinical practice based on a variety of reasons. However, few clinical studies have examined methods for transitioning patients between different insomnia medications. This is especially important to consider when the classes of drugs are different (e.g., GABA-ergic agonism vs orexin receptor antagonism); thus, clinical guidance would be valuable. The safety and efficacy of the dual orexin receptor antagonist lemborexant (LEM) for the treatment of insomnia was confirmed in two Phase 3 studies, SUNRISE-1 (NCT02783729, E2006-G000-304) and SUNRISE-2 (NCT02952820, E2006-G000-303). This pilot study (NCT04009577, E2006-A001-312) was designed to assess pre-specified dosing approaches for directly transitioning from the sedative-hypnotic zolpidem (ZOL), a commonly prescribed sleep aid, to LEM.

Methods

This multicenter pilot study has enrolled subjects age ≥18 years with an insomnia diagnosis (DSM-5 criteria), who used ZOL (intermittently or frequently) as their only insomnia treatment. Following a 3-week Screening period, eligible subjects enter the Treatment Phase (2-week titration period: assigned to 1 of 3 treatment arms based on ZOL use during Screening), and then the Extension Phase (maintenance period up to 12 weeks). During both the Treatment and Extension Phases, the dose of LEM is flexible between 5 and 10 mg, depending on efficacy and tolerability. The primary endpoint is to evaluate the proportion of subjects taking ZOL who successfully transition to LEM (lemborexant 5 mg [LEM5] or lemborexant 10 mg [LEM10]) after 2 weeks of LEM treatment.

Results

Enrollment began July 15, 2019. It was initially projected that approximately 110 subjects would be screened to provide about 60 subjects for randomization across 3 treatment arms. Interim data will be presented (planned cutoff date Jan 08, 2020).

Conclusion

This pilot study will help inform on dosing guidance when transitioning a patient from a GABA-ergic drug to an orexin receptor antagonist.

Support

Eisai Inc.

0751 Epworth Sleepiness Scale Test-Retest Reliability Analysis In Solriamfetol Studies

Introduction

The Epworth Sleepiness Scale (ESS) measures excessive daytime sleepiness. This analysis examined test-retest reliability of ESS scores in participants with narcolepsy or obstructive sleep apnea (OSA) in solriamfetol studies.

Methods

Intraclass correlation coefficient (ICC) estimates and 95% confidence intervals (CIs) for ESS scores from two 12-week, placebo-controlled trials (1 narcolepsy; 1 OSA), and one long-term open-label extension (OLE) trial (narcolepsy or OSA) were calculated separately for each trial, based on assessments (at time-point pairs) when scores were expected to be stable (at weeks 4 and 8, 8 and 12, and 4 and 12 in the 12-week trials, and weeks 14 and 26/27, 26/27 and 39/40, and 14 and 39/40 in the OLE). ICCs were analyzed for the overall population in each trial and by treatment and adherence to primary OSA therapy. An ICC &gt;0.7 has been recommended as a quality criterion for acceptable test-retest reliability.

Results

In the 12-week narcolepsy trial, ICCs (95% CI) were 0.83 (0.79, 0.87) for weeks 4 and 8 (n=199), 0.87 (0.83, 0.90) for weeks 8 and 12 (n=196), and 0.81 (0.76, 0.85) for weeks 4 and 12 (n=196). In the 12-week OSA trial, ICCs (95% CI) were 0.74 (0.69, 0.78) for weeks 4 and 8 (n=416), 0.80 (0.76, 0.83) for weeks 8 and 12 (n=405), and 0.74 (0.69, 0.78) for weeks 4 and 12 (n=405). In the OLE trial, ICCs (95% CI) were 0.82 (0.79, 0.85) for weeks 14 and 27/26 (n=495), 0.85 (0.82, 0.87) for weeks 27/26 and 40/39 (n=463), and 0.78 (0.74, 0.81) for weeks 14 and 40/39 (n=463). Treatment (solriamfetol combined/placebo) or adherence to primary OSA therapy did not impact reliability.

Conclusion

In 3 large clinical trials of participants with narcolepsy or OSA, the ESS demonstrated an acceptable level of test-retest reliability.

Support

Jazz Pharmaceuticals

Cortical thickness following electroconvulsive therapy in patients with depression: a longitudinal MRI study

OBJECTIVE

Several studies have found an increase in hippocampal volume following electroconvulsive therapy (ECT), but the effect on cortical thickness has been less investigated. We aimed to examine the effects of ECT on cortical thickness and their associations with clinical outcome.

METHOD

Using 3 Tesla MRI scanner, we obtained T1-weighted brain images of 18 severely depressed patients at three time points: before, right after and 6 months after a series of ECT. The thickness of 68 cortical regions was extracted using Free Surfer, and Linear Mixed Model was used to analyze the longitudinal changes.

RESULTS

We found significant increases in cortical thickness of 26 regions right after a series of ECT, mainly within the frontal, temporal and insular cortex. The thickness returned to the baseline values at 6-month follow-up. We detected no significant decreases in cortical thickness. The increase in the thickness of the right lateral orbitofrontal cortex was associated with a greater antidepressant effect, r = 0.75, P = 0.0005. None of the cortical regions showed any associations with cognitive side effects.

CONCLUSION

The increases in cortical thickness induced by ECT are transient. Further multimodal MRI studies should examine the neural correlates of these increases and their relationship with the antidepressant effect.

Problems and Complications of Cochlear Implant Surgery

As with any operation, problems and complications may arise with cochlear implant surgery. These may be associated with the scalp flap, mastoid, facial recess, middle ear, or scala tympani. We describe a number of these potential problems and suggest means of avoiding or dealing with them. With careful planning and meticulous attention to detail, complications associated with cochlear implant surgery can be minimized.

[Evaluation of the new Canon HS-100 SD-OCT: Reproducibility of macular ganglion cell complex (GCC) thickness measurement in normal, hypertensive and glaucomatous eyes]

PURPOSE

To evaluate intra- and interobserver reproducibility of macular GCC thickness measurement by automated segmentation on the Canon HS-100 SD-OCT (Tokyo, Japan) in normal (N), hypertensive (OHT) and glaucomatous eyes.

METHODS

A total of 179 eyes of 93 patients were included: 90 N, 28 OHT and 36 early glaucoma and 25 advanced glaucoma. All patients underwent a complete ophthalmologic exam, central corneal thickness and 24-2 standard automated perimetry (HFA SITA standard). Each of two observers performed three macular acquisitions with the Canon OCT HS-100. Acquisitions were analyzed with the Glaucoma 3D mode, which estimated the macular GCC thickness in global, superior and inferior hemisectors, and in eight separate macular areas. Reproducibility was assessed by intraclass correlation coefficient (ICC), coefficient of variation (CV) and test-retest variability (TRTV) calculated as 1.96 times the standard deviation.

RESULTS

Mean GCC thickness was respectively 92.4 μm, 89.0 μm, 80.7 μm and 71.2 μm in N, OHT, early and advanced glaucomatous eyes. In all groups, intra- and interobserver reproducibility ranged respectively for ICC from 89.8 to 99.8% and from 90.2 to 99.4%, for CV from 0.43 to 1.95% and from 0.58 to 2.16% and for TRTV from 0.8 to 3.22 μm and from 1.04 to 3.53 μm. GCC thickness measurements using the new HS-100 SD-OCT were highly reproducible. However, in the advanced glaucoma group, while the reproducibility of GCC thickness measurement is good in the average, superior and inferior hemisectors of the macula, it was slightly less for the paracentral sectors, especially inferior. These sectors correspond generally to the areas most affected by glaucoma.

CONCLUSION

The reproducibility of GCC thickness measurements using the new Canon HS-100 SD-OCT is high for normal, OHT, and glaucomatous eyes. It is thus a reliable and reproducible ancillary test available to the clinician for the examination of glaucomatous optic neuropathies.

Development and validation of a clinical prediction score (the SCOPE score) to predict sedation outcomes in patients undergoing endoscopic procedures

BACKGROUND

Use of anaesthesia services during endoscopy has increased, increasing cost of endoscopy.

AIM

To identify risk factors for and develop a clinical prediction score to predict difficult conscious sedation.

METHODS

We performed a retrospective cross-sectional study of all patients who underwent oesophagogastroduodenoscopy (OGD) and colonoscopy with endoscopist-administered conscious sedation. The endpoint of difficult sedation was a composite of receipt of high doses (top quintile) of benzodiazepines and opioids, or the documentation of agitation or discomfort. Univariate and multivariate analyses were performed to measure association of the outcome with: age, sex, body mass index (BMI), procedure indication, tobacco use, self-reported psychiatric history, chronic use of benzodiazepines, opioids or other psychoactive medications, admission status and participation of a trainee. A clinical prediction score was constructed using statistically significant variables.

RESULTS

We identified 13,711 OGDs and 21,763 colonoscopies, 1704 (12.4%) and 2299 (10.6%) of which met the primary endpoint, respectively. On multivariate analysis, factors associated with difficulty during OGD were younger age, procedure indication, male sex, presence of a trainee, psychiatric history and benzodiazepine and opioid use. Factors associated with difficulty during colonoscopy were younger age, female sex, BMI <25, procedure indication, tobacco, benzodiazepine, opioid and other psychoactive medication use. A clinical prediction score was developed and validated that may be used to risk-stratify patients undergoing OGD and colonoscopy across five risk classes.

CONCLUSIONS

Using the Stratifying Clinical Outcomes Prior to Endoscopy (SCOPE) score, patients may be risk stratified for difficult sedation/high sedation requirement during OGD and colonoscopy.

Perforated sigmoid diverticulitis in the presence of toxic epidermal necrolysis

Even though the incidence of toxic epidermal necrolysis (TEN) is low, it is also associated with a high mortality rate. The condition predominantly affects the skin, but may also affect the gastrointestinal tract, dramatically increasing mortality. We present a case of perforated sigmoid diverticulitis in the presence of TEN. The patient was taking medication, known to be a risk factor, and presented an affected total body surface area and temporal development similar to previously reported cases of TEN. Characteristic abdominal symptoms, however, were missing. Gastrointestinal involvement in TEN appears to be a poor prognostic factor; medical staff must therefore be alert to patients with TEN who complain of abdominal discomfort. The exact pathogenesis, however, remains unclear.

Plasma brain-derived neurotrophic factor and prefrontal white matter integrity in late-onset depression and normal aging

OBJECTIVE

To explore the relationship between brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF), cerebral deep white matter lesions (DWMLs), and measures of white matter integrity in patients with late-onset depression, with respect to vascular risk factors.

METHOD

We examined 22 patients with late-onset depression and 22 matched controls. Quantification of plasma BDNF and VEGF levels were performed with enzyme-linked immunosorbent assay (ELISA) kits. Measures of white matter integrity comprised apparent diffusion coefficient (ADC) and fractional anisotropy (FA), obtained by diffusion tensor imaging (DTI). Effects of DWMLs, FA, ADC, and vascular risk factors on BDNF and VEGF were assessed using multiple linear regression.

RESULTS

The BDNF and VEGF levels did not differ significantly between groups. With pooled data for patients and controls, the BDNF level was positively associated with both number (t = 2.14, P = 0.039) and volume (t = 2.04, P = 0.048) of prefrontal DWMLs and negatively associated with FA in prefrontal normal-appearing white matter (t = -2.40, P = 0.02), adjusted for age and gender. Smoking and hypercholesterolemia was positively associated with the BDNF (t = 2.36, P = 0.023) and VEGF levels (t = 2.28, P = 0.028), respectively.

CONCLUSION

Our results suggest a role for BDNF in the complex pathophysiologic mechanisms underlying DWMLs in both normal aging and late-onset depression.

[Imaging and quantification of corneal neovascularization]

Corneal neovascularization is defined as the invasion of vessels into the normally avascular clear corneal stroma, secondary to acute or chronic tissue injury. In addition to decreasing visual acuity, vascularity introduces circulating immune cells, reducing corneal immune privilege and the graft survival of subsequent keratoplasty. Thus, reducing neovascularization has become a recent therapeutic target in order to increase the success of corneal transplantation. Comparing the effects of antiangiogenic drugs assumes that we are able to quantify corneal neovascularization before and after treatment. In the first part of this literature review, we present the various methods to document neovessels (color photos, fluorescein and indocyanine green anterior segment angiography, in vivo confocal microscopy). Next, we report methods to classify and quantify corneal neovascularization.

Optic Nerve Sheath Meningocele: A Case Report

Isolated optic nerve sheath meningocele is a rare affection defined as the cystic enlargement of the optic nerve sheath filled with cerebrospinal fluid. We report the case of a 39-year-old woman presenting with bilateral meningocele uncovered during a routine examination for headache complaints. A 5-year follow-up validated the lesion's clinical and imaging stability. Magnetic resonance imaging (MRI) is an essential tool in the diagnosis of this pathology, alongside characteristic symptoms indicating that the meningocele might have progressively expanded into the orbit. In this case we present a therapeutic approach based on pathophysiological hypotheses and review of the literature.

P2-10-04: 3D Mapping of Total Choline in Human Breast Cancer Using High-Speed MR Spectroscopic Imaging at 3T: A Feasibility Study

PURPOSE: To assess the feasibility of quantitative high-speed MR spectroscopic imaging (MRSI) of total Choline (tCho) as an adjunct to dynamic-contrast enhanced (DCE) MRI to improve lesion characterization and monitor treatment response in patients undergoing neoadjuvant chemotherapy.

METHOD AND MATERIALS: Seven patients with biopsy-confirmed, infiltrating ductal carcinoma were studied using a clinical 3T MR scanner (Siemens Medical Solutions, Erlangen, Germany) equipped with 8- and 16-channel breast array (Hologic Inc., Bedford, MA). Measurements were performed using PRESS prelocalized 3D Proton-Echo-Planar-Spectroscopic-Imaging (PEPSI) using TR/TE=2000ms/135ms, matrix size up to 32×16x8, voxel size=1cc, and total acquisition time of 10 minutes (including water reference scan). Additional data were collected at TE 60 ms to enhance sensitivity for detecting tCho and J-coupled resonances. TE-averaging (8 steps, ΔTE: 2.5 ms) was employed to minimize gradient sideband artifacts. Quantification of tCho in reference to tissue water was performed using spectral fitting and relaxation correction.

RESULTS: Strongly elevated tCho with maximum concentration ranging from 0.3 to 4.1 mmol/kg was measured in five patients with single and multi-centric enhancing lesions larger than 2 cc volume (Table 1). The measured tCho concentration in Grade 3 tumors was higher than in lower grade untreated and treated tumors. Strong decreases in tCho concentration were measured in 2 patients undergoing neoadjuvant therapy in a follow-up scan. At short TE an additional resonance was detected that was elevated in enhancing lesions and tentatively assigned to Taurine. Two patients had lesions smaller than 2 cc with surgical clips in which tCho was not detectable due to line broadening. MRSI data sets were preferentially collected before contrast injection, since it increased spectral line width by up to 50%.

CONCLUSION: This study demonstrates feasibility of quantitatively mapping tCho in invasive breast carcinoma using high-speed MRSI. The long-term goals are to utilize high-speed MRSI as an early predictor of treatment failure in women undergoing neoadjuvant therapy (i.e. chemotherapy, endocrine therapy or biologic therapy) for breast cancer and to develop an improved screening protocol for high-risk patients. Grant support: 1RC1EB010617-01

Specific activity of cyclin-dependent kinase I is a new potential predictor of tumour recurrence in stage II colon cancer

Background:

There are no established biomarkers to identify tumour recurrence in stage II colon cancer. As shown previously, the enzymatic activity of the cyclin-dependent kinases 1 and 2 (CDK1 and CDK2) predicts outcome in breast cancer. Therefore, we investigated whether CDK activity identifies tumour recurrence in colon cancer.

Methods:

In all, 254 patients with completely resected (R0) UICC stage II colon cancer were analysed retrospectively from two independent cohorts from Munich (Germany) and Leiden (Netherlands). None of the patients received adjuvant treatment. Development of distant metastasis was observed in 27 patients (median follow-up: 86 months). Protein expression and activity of CDKs were measured on fresh-frozen tumour samples.

Results:

Specific activity (SA) of CDK1 (CDK1SA), but not CDK2, significantly predicted distant metastasis (concordance index=0.69, 95% confidence interval (CI): 0.55–0.79, P=0.036). Cutoff derivation by maximum log-rank statistics yielded a threshold of CDK1SA at 11 (SA units, P=0.029). Accordingly, 59% of patients were classified as high-risk (CDK1SA ⩾11). Cox proportional hazard analysis revealed CDK1SA as independent prognostic variable (hazard ratio=6.2, 95% CI: 1.44–26.9, P=0.012). Moreover, CKD1SA was significantly elevated in microsatellite-stable tumours.

Conclusion:

Specific activity of CDK1 is a promising biomarker for metastasis risk in stage II colon cancer.

Longitudinal MR study of brain structure and hippocampus volume in major depressive disorder

OBJECTIVE

To determine whether long-term course of treated major depression has an effect on the structure of the brain and the hippocampal volume.

METHOD

An 11-year follow-up procedure was used with data collection at baseline and again at follow-up. Tensor-based morphometry (TBM) and automatic hippocampal volume measure was performed on different datasets. The baseline dataset consisted of T1-weighted magnetic resonance images (MRIs) of 24 in-patients suffering from major depression and 33 healthy controls. The second dataset consisted of T1-weighted MRIs of 31 remitted depressive patients and 36 healthy controls. The longitudinal dataset consisted of 19 patients and 19 matched healthy controls present at both the first and the second dataset. Brain segmentation and hippocampal segmentation were fully automated and were based on a spatial normalization to the International Consortium of Brain Mapping (ICBM) non-linear model.

RESULTS

Depressed patients were found to have smaller temporal lobes bilaterally, medulla and right hippocampus at baseline. However, these changes were not found at follow-up 11 years later. Moreover, these changes did not significantly correlate with the illness outcome.

CONCLUSION

Brain structure changes seem to be state dependent in major depression, only occurring in acute episode of major depression and normalizing after remission.

Independent validation of a prognostic genomic profile (ColoPrint) for stage II colon cancer (CC) patients

358

Background: Adjuvant therapy is not routinely recommended for stage II CC patients but may be considered for high-risk patients. In this study we aim to independently validate a genomic profile that was developed to identify high-risk patients and can assist in treatment decisions.

Methods: An 18-gene profile had been developed using gene expression data from whole genome Agilent 44K oligonucleotide arrays and was validated in samples from an independent cohort of 206 CC patients and in in-silico datasets (Salazar et al. JCO 2010 in press). The profile was translated into a robust diagnostic test (ColoPrint) using customized 8-pack arrays. For this study, 233 patients who underwent curative resection (R0) for colon cancer stages II or III at the Klinikum rechts der Isar from 1987 to 2003 were selected. Fresh frozen tissues, clinical parameters and follow-up data for all patients were available. The samples were hybridized and the ColoPrint index was determined for all samples blinded from the clinical data.

Results: Patients in this study had a median age of 64 years and median follow-up of 97 months. The median number of resected lymph nodes was 21, giving an indirect measure of the quality of surgery. In the 135 stage II patients, ColoPrint identified most patients (73%) as low risk. The 5-year distant-metastasis free survival was 95% for low-risk patients and 80% for high-risk patients. In the univariate analysis, ColoPrint was the only significant parameter to predict the development of distant metastasis with a HR of 4.1 (95% CI 1.31-13.01, p=0.009). Using clinical parameters from the ASCO recommendation (T4, perforation, less than 12 LN assessed and/ or high grade) for the identification of high-risk patients was not significant (HR 2.3; 95% CI 0.68-7.53, p=0.18) and did not add power to the ColoPrint classification. These results are in good agreement with results from the first independent validation.

Conclusions: ColoPrint is able to predict the development of distant metastasis of stage II colon cancer patients and facilitates the identification of patients who may be safely managed without chemotherapy.

[Table: see text]

The PARSC trial: A prospective study for the assessment of recurrence risk in stage II colon cancer (CC) patients using ColoPrint

602

Background: Clinical trials have not yet shown convincingly if adjuvant chemotherapy is justified for stage II CC patients of whom 25% are at risk of recurrence. An 18-gene expression profile, ColoPrint, has been developed for identifying CC cancer patients more likely to develop recurrent disease and who would be candidates for adjuvant chemotherapy. The gene signature has been validated in independent cohorts of 206 CC patients and in in-silico datasets (Salazar et al, JCO in press). The profile classified 63.2% of the stage II patients (n=134) as low risk. The HR for relapse free survival (RFS) was 3.34 (p=0.017) with a 5-year RFS rate of 90.9% (95%CI, 84.0 -97.8%) for low risk patients and 73.9% (95%CI, 59.2-88.6%) for high risk patients. Moreover, the profile stratified patients independent of ASCO clinical risk factors.

Methods: A prospective trial, PARSC (Prospective Study for the Assessment of Recurrence Risk in Stage II CC Patients Using ColoPrint) has been initiated. The main objectives are: (1) determine risk assessment by ColoPrint profile versus clinical parameters based on local protocol and ASCO high-risk recommendations in stage II patients; (2) establish proportion of ′good prognosis′ and ′poor prognosis profile′ in various countries; and (3) validate the power of risk assessment and compare performance of ColoPrint and clinical risk assessment in estimating 3 year relapse rate. Inclusion criteria: age ≥ 18 years, adenocarcinoma of the colon, stage II,no neoadjuvant systemic therapy, no synchronous tumors, fresh tumor sample, and written informed consent. The treatment of the patient is at the discretion of the physician.

Results: The trial started in Sept. 2008 with currently 26 participating sites in 11 countries. So far, 223 stage II patients have been enrolled of whom 183 are eligible. 11 patients were rejected because of prior malignancies; 24 patients were rejected based on low tumor content of the sample (< 30% tumor cells), 3 patients had rectal cancer and 2 synchronous tumor.

Conclusions: The aim is to enroll 600 stage II patients to differentiate between 3 year relapse- free survival predicted by ColoPrint versus clinical factors.

[Table: see text]

Specific activity of cyclin dependent kinase 1 as a novel predictor of recurrence risk in stage II colon cancer

402

Background: Altered cell cycle dynamics and check points are typical features of solid tumors, and cyclin dependent kinases (CDKs) play pivotal roles in these processes. Previously we have demonstrated that CDK-based analysis, composed of CDK1 and CDK2, is useful in the prediction of outcomes in early breast cancer patients (Ann Oncol. 19(1):68-72, 2008, Br J Cancer. 100(3):494-500, 2009). Clinically, there is a need for risk stratification in patients with stage II colon cancer who have a recurrence risk of 20 to 30%. Therefore we investigated the use of CDK-based analysis for recurrence prediction of stage II colon cancer patients.

Methods: Fresh frozen tissue samples of 254 patients with histologically confirmed adenocarcinoma of the colon, UICC stage II, who received primary tumor resection in Munich (217 cases), and Leiden (37 cases) were used. Protein expression and activity of CDK1 and CDK2 were determined by in vitro assays as previously described. Specific activity (SA) of CDKs was calculated as kinase activity in relation to its corresponding mass concentration.

Results: Development of distant metastasis was observed in 27 patients (10.6%) after a median follow up of 86 months. We found that predictive performance of CDK1SA, but not CDK2SA, for the metastasis was substantial and almost constant for long-term event prediction (average area under the curve (AUC) = 0.69). Tumor recurrence risk analysis in association with CDK1SA identified a low- (41% of population) and high- risk group (59%). Cox proportional hazard model analysis retained the CDK-based patient classification as an independent prognostic factor for distant metastases-free survival (low vs. high-risk group: Hazard ratio = 6.2, 95% CI: 1.45 to 26.9, p=0.0049). Clinical parameters such as grading, T-categories, age, and sex were excluded as confounding factors for CDK1SA-risk.

Conclusions: CDK1SA allows stratification of different risk subgroups of stage II colon cancer patients. CDK1SA-based analysis is useful for predicting patients with high risk of distant recurrence, who should be treated with chemotherapy.

No significant financial relationships to disclose.