Self-expanding versus balloon expandable stent for intracranial arterial stenosis: A systematic review and meta-analysis

BACKGROUND AND PURPOSE

There are limited data regarding the comparison of balloon expandable stents (BES) and self-expanding stents (SES) for the treatment of intracranial arterial stenosis.

METHODS

We conducted a systematic review to identify studies that compared SES and BES in patients with symptomatic intracranial arterial stenosis. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until from January 1, 2010 to September 28, 2023. Statistical pooling with random-effects meta-analysis was undertaken to compare the rates/severity of postprocedure stenosis, technical success, 30-day stroke and/or death, cumulative clinical endpoints, and restenosis rates.

RESULTS

A total of 20 studies were included. The standardized mean difference (SMD) for postprocedure stenosis (%) was significantly lower (SMD: -0.52, 95% confidence interval [CI]: -0.79 to -0.24, p < .001, 10 studies involving 1515 patients) with BES. The odds for 30-day stroke and/or death were significantly lower (odds ratio [OR] 0.68, 95% CI: 0.50-0.94, p = .019, 15 studies involving 2431 patients), and cumulative clinical endpoints on follow-up were nonsignificantly lower (OR 0.64, 95% CI: 0.30-1.37, p = .250, 10 studies involving 947 patients) with BES. The odds for restenosis during follow-up were significantly lower (OR 0.50, 95% CI: 0.31-0.80, p = .004, 13 studies involving 1115 patients) with BES.

CONCLUSIONS

Compared with SES, BES were associated with lower rates of postprocedure 30-day stroke and/or death with lower rates of restenosis during follow up and the treatment of symptomatic intracranial arterial stenosis.

Assessment of Blood Pressure and Heart Rate Related Variables in Acute Stroke Patients Receiving Intravenous Antihypertensive Medication Infusions

BACKGROUND

We performed an analysis of a large intensive care unit electronic database to provide preliminary estimates of various blood pressure parameters in patients with acute stroke receiving intravenous (IV) antihypertensive medication and determine the relationship with in-hospital outcomes.

METHODS

We identified the relationship between pre-treatment and post-treatment systolic blood pressure (SBP) and heart rate (HR)-related variables and in-hospital mortality and acute kidney injury in patients with acute stroke receiving IV clevidipine, nicardipine, or nitroprusside using data provided in the Medical Information Mart for Intensive Care (MIMIC) IV database.

RESULTS

A total of 1830 patients were treated with IV clevidipine (n = 64), nicardipine (n = 1623), or nitroprusside (n = 143). The standard deviations [SDs] of pre-treatment SBP (16.3 vs. 13.7, p ≤ 0.001) and post-treatment SBP (15.4 vs. 14.4, p = 0.004) were higher in patients who died compared with those who survived, particularly in patients with intracerebral hemorrhage (ICH). The mean SBP was significantly lower post treatment compared with pre-treatment values for clevidipine (130.7 mm Hg vs. 142.5 mm Hg, p = 0.006), nicardipine (132.8 mm Hg vs. 141.6 mm Hg, p ≤ 0.001), and nitroprusside (126.2 mm Hg vs. 139.6 mm Hg, p ≤ 0.001). There were no differences in mean SDs post treatment compared with pre-treatment values for clevidipine (14.5 vs. 13.5, p = 0.407), nicardipine (14.2 vs. 14.6, p = 0.142), and nitroprusside (14.8 vs. 14.8, p = 0.997). The SDs of pre-treatment and post-treatment SBP were not significantly different in patients with ischemic stroke treated with IV clevidipine, nicardipine, or nitroprusside or for patients with ICH treated with IV clevidipine or nitroprusside. However, patients with ICH treated with IV nicardipine had a significantly higher SD of post-treatment SBP (13.1 vs. 14.2, p = 0.0032).

CONCLUSIONS

We found that SBP fluctuations were associated with in-hospital mortality in patients with acute stroke. IV antihypertensive medication reduced SBP but did not reduce SBP fluctuations in this observational study. Our results highlight the need for optimizing therapeutic interventions to reduce SBP fluctuations in patients with acute stroke.

Impact of post-procedure stenosis on outcomes of patients with severe intracranial stenosis treated with intracranial stent placement

BACKGROUND

The optimal target post-procedure stenosis after percutaneous angioplasty and stent placement (PTAS) for intracranial stenosis is unknown. We determined the effect of post-procedure stenosis after intracranial PTAS on subsequent clinical events in patients with severe symptomatic intracranial stenosis.

METHODS

We categorized the severity of post-procedure stenosis as '<30%', '30-49%', and '≥50%' among 207 patients who underwent PTAS in a multicenter randomized clinical trial. Outcomes included stroke or death within 72 hours and within 30 days, ipsilateral stroke beyond 30 days of treatment, and stroke or death within 30 days or stroke in the qualifying artery beyond 30 days (primary endpoint of the trial). Cox proportional hazards analysis was performed with adjustments for age, initial severity of stenosis, location of stenosis, and qualifying event. Kaplan-Meier curves were generated for the primary endpoint stratified by post-procedure stenosis with log-rank analysis.

RESULTS

The severity of post-procedure stenosis was categorized as <30%, 30-49%, and ≥50% in 112, 73, and 22 patients, respectively. Compared with patients with post-procedure stenosis <30%, there was no difference in the risk of primary endpoint among patients with post-procedure stenoses of 30-49% (hazards ratio (HR) 0.85, 95% confidence interval (95% CI) 0.64 to 1.15) or those with ≥50% (HR 0.91, 95% CI 0.57 to 1.43). Log-rank analysis did not demonstrate a difference in rates of primary endpoint between groups stratified by post-procedure stenosis (P=0.70).

CONCLUSION

In the absence of any benefit on short- and long-term outcomes, strategies to achieve a low severity of post-procedure stenosis among patients with severe intracranial stenosis may not be warranted.

Mechanical thrombectomy with intra-arterial thrombolysis versus mechanical thrombectomy alone in patients with acute ischemic stroke: A systematic review and meta-analysis

BACKGROUND

There is conflicting evidence as to whether intra-arterial thrombolysis (IAT) adds benefit in patients with acute stroke who undergo mechanical thrombectomy (MT).

METHODS

We conducted a systematic review to identify studies that evaluate IAT in patients with acute stroke who undergo MT. Data were extracted from relevant studies found through a search of PubMed, Scopus, and Web of Science until February 2023. Statistical pooling with random effects meta-analysis was undertaken to evaluate odds of functional independence, mortality, and near-complete or complete angiographic recanalization with IAT compared to no IAT.

RESULTS

A total of 18 studies were included (3 matched, 14 unmatched, and 1 randomized). The odds ratio (OR) for functional independence (modified Rankin Scale: 0-2) at 90 days was 1.14 (95% confidence interval (CI): 0.95-1.37, p = 0.17, 16 studies involving 7572 patients) with IAT with moderate between-study heterogeneity (I2 = 38.1%). The OR for functional independence with IAT was 1.28 (95% CI: 0.92-1.78, p = 0.15) in studies that were either matched or randomized and 1.24 (95% CI: 0.97-1.58, p = 0.08) in studies with the highest quality score. IAT was associated with higher odds of near-complete or complete angiographic recanalization (OR: 1.65, 95% CI: 1.03-2.65, p = 0.04) in studies that were either matched or of randomized comparisons.

CONCLUSION

Although the odds of functional independence appeared to be higher with IAT and MT compared with MT alone, none of the results were statistically significant. A prominent effect of the design and quality of the studies was observed on the association between IAT and functional independence at 90 days.

Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients

INTRODUCTION

Several reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA.

METHODS

We analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis.

RESULTS

Five patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups.

CONCLUSION

Approximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.

Effect of Radiographic Contrast Media Shortage on Stroke Evaluation in the United States

BACKGROUND AND PURPOSE

We performed this study to identify the effect of the nationwide iodinated contrast media shortage due to reduction in GE Healthcare production, initiated on April 19, 2022, on the evaluation of patients with stroke.

MATERIALS AND METHODS

We analyzed the data on 72,514 patients who underwent imaging processed with commercial software in a sample of 399 hospitals in United States from February 28, 2022, through July 10, 2022. We quantified the percentage change in the daily number of CTAs and CTPs performed before and after April 19, 2022.

RESULTS

The daily counts of individual patients who underwent CTAs decreased (a 9.6% reduction, P = .002) from 1.584 studies per day per hospital to 1.433 studies per day per hospital. The daily counts of individual patients who underwent CTPs decreased (a 25.9% reduction, P = .003) from 0.484 studies per day per hospital to 0.358 studies per day per hospital. A significant reduction in CTPs using GE Healthcare contrast media (43.06%, P < .001) was seen but not in CTPs using non-GE Healthcare contrast media (increase by 2.93%, P = .29). The daily counts of individual patients with large-vessel occlusion decreased (a 7.69% reduction) from 0.124 per day per hospital to 0.114 per day per hospital.

CONCLUSIONS

Our analysis reported changes in the use of CTA and CTP in patients with acute ischemic stroke during the contrast media shortage. Further research needs to identify effective strategies to reduce the reliance on contrast media-based studies such as CTA and CTP without compromising patient outcomes.

Intraarterial thrombolytics as an adjunct to mechanical thrombectomy in patients with basilar artery occlusion

BACKGROUND AND PURPOSE

There are limited data regarding safety and effectiveness of concurrent intraarterial thrombolytics as adjunct to mechanical thrombectomy in acute ischemic stroke patients with basilar artery occlusion.

METHODS

We analyzed data from a prospective multicenter registry to assess the independent effect of intraarterial thrombolysis on (1) favorable outcome (modified Rankin Scale 0-3) at 90 days; (2) symptomatic intracranial hemorrhage (sICH) within 72 hours; and (3) death within 90 days post-enrollment after adjustment for potential confounders.

RESULTS

There was no difference in the adjusted odds of achieving favorable outcome at 90 days (odds ratio [OR] = 1.1, 95% confidence interval [CI]: 0.73-1.68) in patients who received intraarterial thrombolysis (n = 126) compared with those who did not receive intraarterial thrombolysis (n = 1546) despite significantly higher use in patients with postprocedure modified Thrombolysis in Cerebral Infarction (mTICI) grade <3. There were no differences in adjusted odds of sICH within 72 hours (OR = 0.8, 95% CI: 0.31-2.08) or death within 90 days (OR = 0.91, 95% CI: 0.60-1.37). In subgroup analyses, intraarterial thrombolysis was associated with (nonsignificantly) higher odds of achieving a favorable outcome at 90 days among patients aged between 65 and 80 years, those with National Institutes of Health Stroke Scale score <10, and those with postprocedure mTICI grade 2b.

CONCLUSIONS

Our analysis supported the safety of intraarterial thrombolysis as adjunct to mechanical thrombectomy in acute ischemic stroke patients with basilar artery occlusion. Identification of patient subgroups in whom intraarterial thrombolytics appeared to be more beneficial may assist in future clinical trial designs.

The accuracy of ultrasonography for diagnosis of gallbladder polyps

INTRODUCTION

Gallbladder polyps (GBPs) are gallbladder lesions which can progress to gallbladder malignancy. The incidence has been estimated as high as 12.1% of all cholecystectomy patients. Gallbladder malignancy typically presents late, and therefore carries a poor prognosis. By identifying potential GBPs early, it would be possible to treat polyps before they undergo malignant change. The current gold standard for GBP identification is with histological examination which is performed after cholecystectomy. This study sought to assess whether radiological imaging could reliably identify GBPs and therefore guide management.

METHODS

1000 consecutive patients already undergoing cholecystectomy were sampled from two UK hospitals. Patients who underwent ultrasonography and had histological analysis of their gallbladders were selected. Overall 905 patients were included in the study.

RESULTS

There were 12 histologically confirmed GBPs in the cohort (1.33%). US correctly detected 1 GBP, with a sensitivity of 8.3% (95% CI 0.2-38.5%) and specificity of 96.0% (95% CI 94.5-97.2%). The overall accuracy was 94.8 (95% CI 93.2-96.2%).

CONCLUSION

These data show that US is an ineffective tool for GBP identification. The lack of prior operator exposure, imprecise nature of US and possible obstruction of images from underlying gallstone disease delivered a high rate of false positives.

IMPLICATIONS FOR PRACTICE

Surgical or oncological decisions regarding GBPs should not be based upon US findings alone as this would lead to unnecessary interventions. MRI should be investigated as an alternative imaging modality for GBP identification, as its differentiation of soft tissues could guide surgical management.

An Artificial Intelligence Platform for Asset Management Contributes to Better Decision-making Tools for Operations, Maintenance, and Utility Management

  An Artificial Intelligence system was developed and implemented for water, wastewater, and reuse plants to improve management of sensors, short and long-term maintenance plans, asset and investment management plans. It is based on an integrated approach to capture data from different computer systems and files. It adds a layer of intelligence to the data. It serves as a repository of key current and future operations and maintenance conditions that a plant needs have knowledge of. With this information, it can simulate the configuration of processes and assets for those conditions to improve or optimize operations, maintenance and asset management, using the IViewOps (Intelligent View of Operations) model. Based on the optimization through model runs, it is able to create output files that can feed data to other systems and inform the staff regarding optimal solutions to the conditions experienced or anticipated in the future.

P4-07-11: Circulating Tumor Cells after Neoadjuvant Therapy Predict Outcome in Stage I to III Breast Cancer

Introduction: Circulating tumor cells (CTCs) predict outcome in metastatic breast cancer, but their significance is unclear in non-metastatic patients. Furthermore, it is unclear if the presence of CTCs after completion of neoadjuvant chemotherapy (NACT) predicts worse outcome. The purpose of this study was to determine if CTCs after NACT predicts worse outcome.

Methods: Clinical stage I-III breast cancer patients seen at a single tertiary cancer center provided informed consent to participate in an IRB-approved study involving collection of blood (7.5 ml x 2 tubes) at the time of surgery for their primary breast cancer. CTCs were detected using the Cell SearchTM system. A positive result was defined as the presence of one or more cells per 7.5 ml blood since the threshold for positivity has not been established in non-metastatic breast cancer. Statistical analyses used chi-square and Fischer's exact test.

Results: One hundred and twenty patients were prospectively enrolled. Median age was 50 years and median follow-up was 33 months. Eight percent of patients had T1 disease, 35% T2, 18% T3, and 39% T4. Fifty-three percent of patients (63/120) had hormone receptor positive disease. Thirty-two percent of patients (38/120) were HER-2 positive. Thirty percent (36/120) were triple negative. Seventy-eight percent (91/120) had lymph node positive disease. Two or more CTCs were present in 9% of patients (11/120). Of the 11 patients who died, 3 had 2 or more CTCs (P=0.08). Of the 20 who relapsed, 6 had 2 or more CTCs (P=0.0019).

Conclusions: Presence of two or more CTCs after NACT predicted worse relapse free survival in patients with stage I-III breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-11.

P4-07-07: Circulating Tumor Cells Predict Survival in Non-Metastatic Breast Cancer

Background: Circulating tumor cells (CTCs) predict outcome in metastatic breast cancer (BC), but their prognostic significance in non-metastatic BC is unclear. This study determined whether CTCs could be identified in non-metastatic BC patients and 2) if CTCs predict relapse-free and overall survival.

Methods: Clinical stage I-III BC patients seen at a single tertiary cancer center provided informed consent to participate in an IRB-approved study involving collection of blood (7.5 ml x 2 tubes) before systemic therapy and at the time of surgery for their primary BC. CTCs were detected using the Cell SearchTM system. A positive result was defined as the presence of two or more cells per 7.5 ml blood since a threshold for positivity has not been established in primary BC. Statistical analyses were done using STATA-IC 11 software.

Results: We prospectively evaluated 291 patients. Mean age was 54 years, and median follow-up was 30 months. 54% (157) had T1 tumors, 36%(104) T2, 6% (18) T3, and 4%(12) had T4 disease; 37% (107/289) were clinically node-positive (LNs) by axillary ultrasound and FNA. Two or more CTCs were identified in 10% (29) patients. Seventy-seven percent (225) patients were hormone receptor positive, 11% (32) were HER2 positive while 16% (48) expressed no receptors. Sixteen percent (48) were tumor grade 1, 50% (143) were grade 2 and 34% (98) were grade 3. Systemic chemotherapy and/or endocrine therapy were administered in 80% (233/289) of patients. Sixty-eight percent (167/244) of patients were post-menopausal. Additionally, there was no significant correlation between CTCs with primary tumor size, lymph node status, estrogen or progesterone receptor status, HER2 amplification or tumor grade. Thirty-eight percent (6/16) of all relapses occurred in patients with 2 or more CTCs (HR: 4.48 (95% C.I. 1.61−12.45), Logrank P 0.002) while 40% (4/10) of all deaths occurred in patients with 2 or more CTCs (HR: 4.54 (95% C.I. 1.27−16.25), Logrank P 0.011).

Conclusions: CTCs were a significant predictor of disease-free and overall survival in non-metastatic breast cancer.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-07-07.

P5-01-17: HER2 Amplification in Primary Tumor: A Potential Marker for Presence of Circulating Tumor Cells in Inflammatory Breast Cancer Patients?

Background: Inflammatory breast cancer (IBC) is a rare but aggressive form of invasive breast cancer accounting for 3–6% of all cases and have higher rates of distant recurrence. Circulating tumor cells (CTCs) are known to predict outcome in metastatic breast cancer (BC) patients, but little is known about their prognostic significance in non-metastatic BC. We hypothesized that CTCs can be identified in patients with IBCs and may correlate with primary tumor characteristics. Methods: All patients had blood samples collected at the time of primary surgery. CTCs (per 7.5 ml blood) were detected using the Cell Search™ system (Veridex) and were defined as nucleated cells lacking CD45 but expressing cytokeratins (CK) 8, 18, or 19. The presence of ≥ 1 epithelial cells meeting morphologic criteria for malignancy was considered a positive result. Statistical analyses employed Chi square and Fisher's exact tests using STATA IC 11. Results: We prospectively evaluated 41 IBC patients enrolled in an IRB approved protocol undergoing surgery for stage I-III breast cancer. Median follow-up was 30 months. Mean age was 52 years. Thirty five patients (94%) had positive lymph nodes (LNs) at presentation, 30 (75%) had high-grade tumors and 20 (53%) had lymphovascular invasion. Eleven patients (28%) were ER positive, 11 (27%) were PR positive and 18 (44%) were HER2 positive. IBCs were more likely to be high grade (P&lt;0.0001), ER negative (P&lt;0.0001), PR negative (P&lt;0.0001), HER2 positive (P&lt;0.0001), High Ki-67 (P= 0.005) and had a BMI of more than 25kg/m2 (P=0.04). Eleven (27%) patients were CTC positive. CTCs were more likely be found in HER2 positive (8/18; 44%) vs. HER2 negative primary tumors (3/20; 15%) [OR= 4.53; 95% C.I. = 1.02−19.52; P= 0.04]. We found no statistically significant correlations between primary tumor characteristics (ER, PR, LNs, high grade) and presence of CTCs. Conclusions: About a quarter of IBC patients had CTCs at the time of primary surgery. In these patients HER2 overexpression predicted the presence of CTCs. Studies with longer follow-ups is needed to determine if CTCs predicted survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-01-17.

P4-06-02: Microscopic Disease in Blood and Bone Marrow Predicts Survival in Early Stage Breast Cancer

Background

Disseminated tumor cells (DTCs) in the bone marrow have been identified in 30% of stage I - III breast cancer (BC) patients and predict survival. Circulating tumor cells (CTCs) in the blood predict outcome in metastatic BC, but their prognostic significance in primary BC is unclear. This study determined whether: 1) DTCs and CTCs could be identified in significant numbers of non-metastatic BC patients and 2) if these cells predict relapse-free (RFS) and overall survival (OS).

Methods: Clinical stage I-III BC patients seen at a single tertiary cancer center provided informed consent to participate in an IRB-approved study involving collection of blood (7.5 ml x 2 tubes) and bone marrow (10 ml from bilateral iliac crests), and at the time of surgery for their primary BC. DTCs were assessed using an anti-cytokeratin antibody cocktail (MNF 116, CK 8,18, and 19, CAM 5.2, and AE1/AE3) following ficoll enrichment and cytospin. A positive result for DTCs was defined by presence of one or more CK-positive cells meeting morphologic criteria for malignancy. CTCs were detected using the Cell SearchTM system. A positive result was defined as the presence of one or more cells per 7.5 ml blood since a threshold for positivity has not been established in non-metastatic BC. Statistical analyses used chi-square and Fischer's exact test.

Results: We prospectively evaluated 313 patients. Mean age was 53 years, and median follow-up was 32 months. Forty-two percent of patients (131) had T1 tumors, 36% (112) T2, 10% (30) T3, and 13% (40) had T4 disease. Forty-five percent of patients (141/312) had positive lymph nodes. DTCs were identified in 29% (91/313) and CTCs in 25% (79/313) of all patients. Seven percent (21/313) of patients had both DTCs and CTCs. In the overall cohort, 26 (8%) patients relapsed and 15 (5%) died. Ten percent (9/91) of DTC positive patients died compared to 3% (6/222) of those who did not have DTCs (p=0.01). Similarly, 6% (7/79) of those who had CTCs died compared to 3% (8/234) of those who did not (p=0.03). Fifteen percent (12/79) of CTC positive patents relapsed compared to 6% (14/234, P=0.01) of those who were CTC negative. Simultaneous presence of DTCs and CTCs was a strong predictor of RFS (log rank p=0.030, HR= 2.8, 95% C.I. 1.20- 8.10) as well as OS (log rank p=0.026, HR= 3.66, 95% C.I. 1.03- 13.00) at 2 years. Combined presence of DTCs and CTCs was a predictor of outcome and these findings persisted after adjusting for variables including hormone receptor status, HER2 status, primary tumor size, grade, and preoperative lymph node status. There was no significant correlation between DTCs and/or CTCs with other primary tumor characteristics.

Conclusions: Circulating and disseminated tumor cells can be identified in a significant number of non-metastatic breast cancer patients. Both CTCs and DTCs predicted outcome, and their combined presence was an independent predictor of survival.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-06-02.

Predictors of Persistent Micrometastatic Disease after Neoadjuvant Chemotherapy

Introduction: Patients who receive neoadjuvant chemotherapy (NAC) for breast cancer typically do not receive further cytotoxic chemotherapy after surgery. We hypothesized that some patients would have micrometastatic disease in the bone marrow (disseminated tumor cells, DTCs) or peripheral blood (circulating tumor cells, CTCs) after NAC. This study documented rates and factors predicting DTCs and CTCs after NAC.Methods: We prospectively evaluated patients undergoing surgery for stage I-III breast cancer. All patients had blood and bone marrow samples taken after completing systemic NAC. CTCs (per 7.5ml blood) were detected using the CellSearchTM system (Veridex). CTCs were defined as nucleated cells lacking CD45 but expressing cytokeratins (CK) 8, 18, or 19. DTCs were assessed using anti-CK antibody cocktail (AE1/AE3, CAM5.2, MNF116, CK8 and 18) following cytospin. The presence of ≥1 CK positive cells and ≥1 epithelial cells meeting morphologic criteria for malignancy was considered a positive result for DTCs and CTCs, respectively. Clinicopathologic factors correlated with DTCs and CTCs and response after NAC included: Her2/neu, estrogen receptor (ER), progesterone receptor (PR) and COX2 status as well as tumor size and grade. Complete pathologic response (pCR) was defined as lack of any residual invasive disease in primary tumor and regional lymph nodes after NAC. Statistical analyses used chi-square and Fischer's exact test.Results: Results were available for 53 patients who had bone marrow and blood collected after NAC. Median follow-up was 26 months. Mean age was 52 years. NAC included anthracyclines and taxanes +/- trastuzumab. Forty percent of patients had either DTCs or CTCs after NAC. Six patients had DTCs amongst 11 patients (55%) who received trastuzumab as compared to those who did not 6/33 (18%), P=0.019. DTCs and CTCs were found in 10/43 patients (23%) and 11/43 patients (27%), respectively. Factors predicting the presence of DTCs after NAC were Her2/neu positivity (P=0.001) and COX2 positivity determined in the primary tumor at diagnosis (P=0.04). No statistically significant correlations were found between CTCs after NAC and primary tumor characteristics. Thirty percent of patients with evidence of DTCs and 10% with CTCs had a pCR. Among the 7 patients with pCR after NAC, 2 (28%) had DTCs and 2 (28%) had CTCs. Factors predicting pCR following NAC were Her2/neu positivity (P=0.0003) and ER negativity (P=0.044). In our analysis, the best predictor of the presence of DTCs and the most likely reason for pCR following NAC was Her2/neu positivity.Conclusions: A significant number of patients have persistent DTCs and/or CTCs after NAC. Interestingly, HER2 positive patients were more likely to have pCR but were also more likely to show persistence of DTCs following NAC. Follow-up is needed to determine if these patients comprise groups at higher risk for recurrence, and therefore benefit from additional chemotherapy or targeted therapies.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3020.

Pleomorphic Calcifications, Tumor Markers, and Response to Therapy

IntroductionMany breast cancers are initially identified by pleomorphic calcifications (PC) on mammography (MG). We hypothesized that presence of PC correlates with primary tumor markers and with response to systemic therapy.MethodsMammograms of women with Stage I-III breast cancer were evaluated for the presence of PC. Only patients with biopsy proven invasive carcinoma in association with PC were included. Primary tumor markers (ER, PgR, and HER2) were determined in the standard manner at the time of core biopsy and correlated with presence or absence of PC on MG. We also evaluated cyclooxygenase-2 (COX2), based on data showing a role in tumor progression and possible interaction with HER2 and/or ER. Primary tumors were immunostained with an anti-COX2 monoclonal antibody, and staining of ≥ 5% or more of tumor cells was considered as positive. For response to therapy analyses, complete pathologic response (pCR) was defined as lack of any residual invasive disease in primary tumor and regional lymph nodes. We used chi-square and Fischer's exact test for the statistical analysis.ResultsWe prospectively enrolled 239 patients. Median age was 51.2 years and the median follow up was 26 months. Pleomorphic calcifications were more often found in HER2 positive patients (22/37) vs. HER2 negative (71/202), P = 0.005, as well as in COX2 positive patients (28/57), P = 0.044. There were no significant associations between PC and ER or PgR. PC were less prevalent in triple receptor negative patients (11/55)[20%] as compared to receptor positive patients (84/188), P = 0.001. We found PC predicted DCIS to be associated with invasive cancers (27/51)[53%] compared to those who showed no DCIS associated with their invasive breast cancer (57/157) [36%] (P=0.035).When evaluating response to therapy, patients with PC on MG were more likely to have a pCR (6/18) [33%] as compared to those who showed absence of pleomorphic calcifications (2/34)[ 6%], following neoadjuvant chemotherapy, P= 0.015.ConclusionsPleomorphic calcifications were significantly associated with HER2 and COX2 positive primary tumors. Patients with PC were also more likely to have a pCR after systemic therapy. Information regarding PC on MG may be helpful in predicting tumor marker status and response to therapy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2027.

Lip injury prevention during tonsillectomy

Patients commonly complain of discomfort at the angle of the mouth following tonsillectomy. This can be attributed to trauma sustained during the procedure. A prospective, patient-blinded, controlled trial of 34 tonsillectomies was performed using a protective, plastic oral guard. A blinded observer recorded postoperative pain and clinically evident trauma to the angle of the mouth. The patient group in whom the guard was used had a significantly lower incidence of labial trauma (p<0.002) and complained of pain less frequently (p<0.002) when compared with a control group in whom no guard was used. The use of a protective lip guard during tonsillectomy is recommended.