Birmingham hip resurfacing: a systematic review of outcomes at minimum 10-years follow-up

Although controversy surrounding the use of metal-on-metal (MoM) arthroplasty implants continues to exist, satisfactory clinical and radiological outcomes have been reported following Birmingham Hip Resurfacing (BHR) at long-term follow-up, leading to an Orthopaedic Data Evaluation Panel (ODEP) rating of 13A. The purpose of this study was to systematically review the literature to evaluate the functional outcomes, radiological outcomes and revision rates following BHR at a minimum of 10 years follow-up. Using the PRISMA guidelines, two independent reviewers performed a literature search using Pubmed, Embase and Scopus databases. Only studies reporting on outcomes of BHR with a minimum of 10 years' follow-up were considered for inclusion. A total of 12 studies including 7132 hips (64.8% males), with mean follow-up of 11.5 years (10-15.3), met our inclusion criteria. Of included patients, 94.3% of patient underwent BHR for osteoarthritis at a mean age was 52.0 years (48-52). At final follow-up, 96% of patients reported being satisfied with their BHR, with mean Harris Hip Scores of 93.6 and Oxford Hip Scores of 16.5. Rates of radiological femoral neck narrowing of greater than 10% and non-progressive radiological loosening were reported as 2.0% and 3.8% respectively. At final follow-up, the overall revision rate was 4.9% (334/7132), deep infection rate was 0.4%, metal allergy/insensitivity rate was 1.6%, metal reaction rate was 0.3%, rate of peri-prosthetic fracture was 0.9% and aseptic loosening rates were 1.6%. This systematic review demonstrates that BHR results in satisfactory clinical outcomes, acceptable implant survivorship, low complication rates and modest surgical revision rates in the long-term at minimum 10-year follow-up.

Efficacy and Safety of Mirvetuximab Soravtansine in Patients With Platinum-Resistant Ovarian Cancer With High Folate Receptor Alpha Expression: Results From the SORAYA Study

PURPOSE

Single-agent chemotherapies have limited activity and considerable toxicity in patients with platinum-resistant epithelial ovarian cancer (PROC). Mirvetuximab soravtansine (MIRV) is an antibody-drug conjugate targeting folate receptor α (FRα). SORAYA is a single-arm, phase II study evaluating efficacy and safety of MIRV in patients with PROC.

METHODS

SORAYA enrolled FRα-high patients with PROC who had received one to three prior therapies, including required bevacizumab. The primary end point was confirmed objective response rate (ORR) by investigator; duration of response was the key secondary end point.

RESULTS

One hundred six patients were enrolled; 105 were evaluable for efficacy. All patients had received prior bevacizumab, 51% had three prior lines of therapy, and 48% received a prior poly ADP-ribose polymerase inhibitor. Median follow-up was 13.4 months. ORR was 32.4% (95% CI, 23.6 to 42.2), including five complete and 29 partial responses. The median duration of response was 6.9 months (95% CI, 5.6 to 9.7). In patients with one to two priors, the ORR by investigator was 35.3% (95% CI, 22.4 to 49.9) and in patients with three priors was 30.2% (95% CI, 18.3 to 44.3). The ORR by investigator was 38.0% (95% CI, 24.7 to 52.8) in patients with prior poly ADP-ribose polymerase inhibitor exposure and 27.5% (95% CI, 15.9 to 41.7) in those without. The most common treatment-related adverse events (all grade and grade 3-4) were blurred vision (41% and 6%), keratopathy (29% and 9%), and nausea (29% and 0%). Treatment-related adverse events led to dose delays, reductions, and discontinuations in 33%, 20%, and 9% of patients, respectively.

CONCLUSION

MIRV demonstrated consistent clinically meaningful antitumor activity and favorable tolerability and safety in patients with FRα-high PROC who had received up to three prior therapies, including bevacizumab, representing an important advance for this biomarker-selected population.

The impact of COVID-19 lockdown measures on rates of febrile neutropenia in a cohort of Irish patients receiving chemotherapy

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Background: Febrile neutropenia in patients receiving chemotherapy is a life-threatening condition requiring prompt attention. This condition may also result in dose reductions, delays, or discontinuations of chemotherapy which compromise patient outcomes. This study seeks to evaluate the impact of COVID19 “lockdown” public health measures in Ireland on the incidence of febrile neutropenia in patients who were receiving cytotoxic chemotherapy regimens. Methods: All patients receiving chemotherapy at the Bon Secours Hospital Cork who were admitted with neutropenia and fever during two separate time periods were included in the study: 1st April 2018 to 31st March 2019 (“pre-pandemic year”) and 1st April 2020 to 31st March 2021 (“pandemic year”). The pandemic year selected equates to a period of heightened infection control measures in Irish society, featuring public health advice re social distancing, routine mask wearing in public and successive lockdown waves. Retrospective chart review was performed on all patients admitted to the oncology inpatient ward who had blood cultures on admission to determine the number of these patients who were neutropenic at the time of blood culture draw. Similarly, pharmacy records were accessed to determine the number of unique chemotherapy items dispensed in each year in order to establish a rate of febrile neutropenia episodes per 100 chemotherapy items dispensed for each period. The incident rate ratio was calculated using the Exact Poisson Test. Results: During the pre-pandemic year there were 57 individual admissions with febrile neutropenia compared with 32 admissions during the pandemic year. There were 4581 chemotherapy units dispensed during the pre-pandemic year compared to 4628 during the pandemic year. The rate of febrile neutropenia episodes per 100 chemotherapy units dispensed was 1.24 (95% CI 0.94, 1.61) in the pre-pandemic year and 0.69 (95% CI 0.47, 0.98) in the pandemic year. The incident rate ratio is 1.80 (95% CI 1.14, 2.87, two-sided P = 0.007). 9 of 57 (16%) admissions in the pre-pandemic year were associated with positive blood cultures compared with 4 of 32 (13%) in the pandemic year (not significant by Fisher's exact test). Conclusions: Increased precautionary infection control measures during the COVID19 pandemic public health restrictions correlated with a significant reduction in the rate of febrile neutropenia amongst patients receiving cytotoxic chemotherapy. This suggests that there may be a role for similar measures for this patient cohort in the post-pandemic period. Options which patients may consider to employ include social distancing, wearing face-coverings and restricting social contacts while at risk of neutropenia from cytotoxic chemotherapy regimens.

Mirvetuximab soravtansine (MIRV) in patients with platinum-resistant ovarian cancer with high folate receptor alpha (FRα) expression: Characterization of antitumor activity in the SORAYA study

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Background: SORAYA is a global single arm phase 3 study evaluating MIRV in patients (pts) with FRα high platinum-resistant ovarian cancer (PROC). MIRV is an antibody drug conjugate comprising a FRα-binding antibody, cleavable linker, and maytansinoid DM4, a potent tubulin-targeting agent. In this study, MIRV demonstrated activity in a broad population of PROC, regardless of number of prior lines of therapy or prior PARPi (Matulonis, SGO 2022). Here we describe details of response to treatment important for clinical decision making. Methods: SORAYA enrolled PROC pts with high FRα expression by immunohistochemistry (Roche FOLR1 Assay ≥ 75% of cells with PS2+ staining intensity) who had received 1-3 prior therapies, including required prior bevacizumab. Pts received intravenous MIRV at 6 mg/kg, adjusted ideal body weight, on Day 1 of a 21-day cycle until disease progression or unacceptable toxicity. The primary endpoint was confirmed objective response rate (ORR) per RECIST v1.1 by investigator (INV) and the key secondary endpoint was duration of response (DOR); additional endpoints included time to response, CA-125 response, safety and tolerability. Results: 106 pts were enrolled; 51% had 3 prior lines; 48% had 1-2 prior lines of therapy; 48% received prior PARPi. ORR by INV was 32.4% (95% confidence interval [CI]: 23.6%, 42.2%), including five complete responses. Median time to response was 1.5 mos (range 1.0 to 5.6) and 71% of pts demonstrated tumor reduction. At the time of the protocol specified primary analysis (16 Nov 2021), the median DOR was 5.9 mos (95% CI: 5.6, 7.7). With 15 responders remaining on MIRV, the DOR continues to evolve. In the 86 response-evaluable patients for CA-125 (by Gynecologic Cancer Intergroup criteria), responses were observed in 46.5% (95% CI: 35.7, 57.6). Updated data will be presented including depth and duration of responses and impact of dose modifications. The most common treatment-related adverse events (TRAE; all grade, grade 3+) included blurred vision (41%, 6%), keratopathy (36%, 9%), and nausea (29%, 0%). TRAEs led to dose delays in 32%, dose reductions in 19%, and discontinuations in 7% of pts; one patient discontinued treatment due to an ocular event. The tolerability profile of MIRV consists of low-grade, reversible ocular and GI events, managed with dose modifications and supportive care. Conclusions: Treatment options for pts with PROC are limited. MIRV is the first biomarker-directed therapy demonstrating anti-tumor activity in pts with FRα high PROC. These results support the clinically meaningful impact MIRV has for pts with FRα high PROC, irrespective of prior therapies or dose modifications. Clinical trial information: NCT04209855.

Patient attitudes regarding the influence of diet on cancer development and treatment

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Background: Up to one third of cancers in high-income populations can be attributed to lifestyle factors (nutrition & physical activity). Data on dietary beliefs in Irish patients with cancer are lacking. This study aims to evaluate how patients with cancer conceptualize the effect of diet on their disease and treatment & determine if attitudes vary according to age, gender, education, disease type, treatment type & treatment intent. Methods: This is a questionnaire-based study, carried out in an Irish oncology unit over a 3-week period in April 2021. Patients with an active cancer diagnosis attending the oncology day ward were invited to participate. We adapted a previously used questionnaire following expert review. A combination of yes/no and Likert scale responses were used: Have you changed your diet since you received your diagnosis? (Yes/no). To what degree do you think that...(Likert): Diet may contribute to the condition that you are being treated for?. Your diet after diagnosis helps your sense of health and wellness?. Diet can help relieve side effects of treatment?. Diet helps in preventing cancer recurrence?. Demographic and treatment data were recorded from patient charts. Responses were compared across demographic variables including gender, age, highest education level, primary cancer location/type and treatment intent using Chi-squared/Fishers exact test. A P-value of < 0.05 was considered significant. Results: 130 patients were invited to take part & 113 responded (response rate 87%). 80% reported changing their diet since diagnosis, with no significant difference according to demographic variables. Most (68%) patients expressed a belief that diet played some role in their cancer development although only 15% believed that diet contributed ‘a lot’. Most patients (83%) believed that diet after a cancer diagnosis has an impact on their sense of health and well-being, and 32% expressed a strong belief in this regard (Likert scale 4, ‘a lot’). 75% believed that diet has some impact on managing treatment side effects. 81% believed that diet has some impact on cancer recurrence, and 30% believed it has a major impact (Likert scale 4). On multivariate analysis we found stronger beliefs in the impact of diet on cancer development (p = 0.049) and recurrence risk (p = 0.05) among men than women, and stronger belief in the impact of diet on recurrence risk among patients receiving treatment with curative versus palliative intent (p = 0.045). Conclusions: Most patients reported changing their diet following their cancer diagnosis, and most patients felt that diet had some impact on all of the areas studied including cancer development, health and well-being, managing side effects and cancer recurrence. Men expressed stronger beliefs than women in the impact of diet on cancer development and recurrence risk, and patients being treated with curative intent also expressed stronger beliefs in the impact of diet on cancer recurrence.

Integrated safety summary of single-agent mirvetuximab soravtansine in patients with folate receptor α (FRα)-positive recurrent ovarian cancer: Phase 1 and 3 clinical trials

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Background: Available chemotherapies for platinum-resistant ovarian cancer (PROC) have limited clinical activity and considerable toxicity. Mirvetuximab soravtansine (MIRV) is a first-in-class antibody drug conjugate (ADC) comprising a folate receptor alpha (FRα)-binding antibody, cleavable linker, and the maytansinoid payload DM4, a potent tubulin-targeting agent that has demonstrated significant anti-tumor activity in this difficult to treat population. The objective is to characterize the tolerability profile of MIRV in a pooled analysis of experience when administered as monotherapy in patients (pts) with FRα positive recurrent ovarian cancer. Methods: Retrospective pooled analysis included pts enrolled across three studies: phase 1 first-in-human, phase 3 FORWARD I, and phase 3 SORAYA. Analysis included pts with FRα positive recurrent ovarian cancer and those pts with low, medium, and high FRα expression by immunohistochemistry (Roche FOLR1 Assay ≥ 25% of cells with PS2+ staining intensity). All pts received intravenous MIRV at 6 mg/kg, adjusted ideal body weight, on Day 1 of a 21-day cycle until disease progression or unacceptable toxicity. Results: 464 pts were included from 15 countries, with key characteristics: median age 63 yrs, 87% 1-3 prior therapies, 91% platinum free interval ≤6 months, 65% prior bevacizumab, and 25% prior PARPi. The most common treatment-related adverse events (TRAE) (all grade, grade 3+) included blurred vision (42%, 3%), nausea (40%, 2%), diarrhea (33%, 2%), fatigue (31%, 2%), keratopathy (26%, 3%), and dry eye (22%, 1%). TRAEs leading to a dose delay or reduction occurred in 33% and 21% of pts, respectively. Seven % discontinued due to a TRAE. Four pts ( < 1%) discontinued MIRV due to an ocular event. Ninety % of pts with a grade 2+ blurred vision resolved to grade 0 or 1, 93% of pts with grade 2+ keratopathy resolved to grade 0 or 1. No corneal ulcers or perforation have been reported and no patient with a serious ocular event has been reported to have permanent sequelae. Conclusions: In a pooled analysis of 464 patients, MIRV monotherapy has a differentiated and predictable safety profile consisting primarily of low grade and reversible gastrointestinal and ocular events. These events were managed with supportive care and dose modifications if needed, with a low rate of treatment-related discontinuation. The safety profile of MIRV in recurrent ovarian cancer along with the anti-tumor activity in PROC (32.4% ORR Matulonis SGO 2022) support a favorable benefit/risk in this population. Clinical trial information: NCT01609556, NCT04296890, NCT02631876.

Breast cancer outcomes in a private hospital appear better than national outcomes in a country with a mixed public/private healthcare model

BACKGROUND

Ireland has a mixed model of healthcare delivery with a public healthcare system funded by general taxation and a large private healthcare insurance system, covering 43% of the population in 2012 and 2016. We set out to examine disparities in outcomes among patients with breast cancer treated in a private hospital compared to national outcomes over a comparable period.

METHODS

Medical records of patients diagnosed with early (Stage 1-3 as per AJCC version 5) breast cancer between 2010 and 2015 at Bon Secours Hospital, Cork, Ireland were reviewed. Staging was confirmed and 5-year disease specific survival (DSS) and overall survival (OS) were calculated. DSS was compared to 5-year net survival (NS) figures from the National Cancer Registry of Ireland (NCRI) for a comparable period (2010-2014).

RESULTS

DSS (Bon Secours) and NS (NCRI) are summarized in Table 5 and Fig. 2. 5-year survival figures are numerically higher in the private hospital compared with national data for individual stage. Taking stages 1 to 3 combined, the 95% confidence intervals do not cross, indicating statistical significance.

CONCLUSIONS

We found evidence of superior outcomes in patients with early breast cancer treated at a private hospital compared with national outcome figures. This was demonstrated in 'all comers' (stages 1-3 combined), and particularly in patients with stage 3 breast cancer. Potential reasons for this disparity include differences in socioeconomic status, health-seeking behaviours and/or underlying health status between the two populations included. Differences in extent or timeliness of access to therapies may also contribute.

Fat Embolism Syndrome - A Qualitative Review of its Incidence, Presentation, Pathogenesis and Management

Fat Embolism Syndrome (FES) is a poorly defined clinical phenomenon which has been attributed to fat emboli entering the circulation. It is common, and its clinical presentation may be either subtle or dramatic and life threatening. This is a review of the history, causes, pathophysiology, presentation, diagnosis and management of FES. FES mostly occurs secondary to orthopaedic trauma; it is less frequently associated with other traumatic and atraumatic conditions. There is no single test for diagnosing FES. Diagnosis of FES is often missed due to its subclinical presentation and/or confounding injuries in more severely injured patients. FES is most frequently diagnosed using the Gurd and Wilson criteria, like its rivals it is not clinically validated. Although FES is a multi-system condition, its effects in the lung, brain, cardiovascular system and skin cause most morbidity. FES is mostly a self-limiting condition and treatment is supportive in nature. Many treatments have been trialled, most notably corticosteroids and heparin, however no validated treatment has been established.

Key Service Improvements After the Introduction of an Integrated Orthogeriatric Service

Introduction:

Models of orthogeriatric care have been shown to improve functional outcomes for patients after hip fractures and can improve compliance with best practice guidelines for hip fracture care.

Methods:

We evaluated improvements to key performance indicators in hip fracture care after implementation of a formal orthogeriatric service. Compliance with Irish Hip Fracture standards of care was reviewed, and additional outcomes such as length of stay, access to rehabilitation, and discharge destination were evaluated.

Results:

Improvements were observed in all of the hip fracture standards of care. Mean length of stay decreased from 19 to 15.5 days (mean difference 3.5 days; P < .05). A higher proportion of patients were admitted to rehabilitation (16.7% vs 7.9%, P < .05), and this happened in a timelier fashion (17.8 vs 24.8 days, P < .05). We found that less patients required convalescence post-hip fracture.

Discussion:

A standardized approach to integrated post-hip fracture care with orthogeriatrics has improved standards of care for patients.

Conclusion:

Introduction of orthogeriatric services has resulted in meaningful improvements in clinical outcomes for older people with hip fractures.

A growing challenge: The rise of femoral periprosthetic fractures - An 11-year observational study

INTRODUCTION

The demand for joint arthroplasty has risen as our elderly population increases and ages. With this so to has the number of patients suffering periprosthetic fractures (PPF). The aim of our study was to quantify the burden of PPF and provide an up to date reference of the epidemiology of PPF in Ireland. We also sought to assess length of stay (LOS), resource utilisation and mortality associated with this cohort of patients.

METHODS

An eleven-year retrospective observational study was conducted of a consecutive series of patients treated for a femoral PPF. Costs were obtained from activity based tariffs provided by the hospital inpatient enquiry system and mortality was confirmed using the national death events publication system.

RESULTS

Over the 11-year study period 174 procedures for a femoral PPF were performed. Mean age of patients was 77.6 years (SD 11.1 years) with 44.7% male. Median ASA grade was 3 (range 1-4) and mean LOS was 19 days. There was a 700% increase in patients undergoing surgery for a PPF over the study period. The mean cost of care was €24,413 in 2017. Thirty-day mortality was 2.9% while one-year mortality was 12.4%.

CONCLUSIONS

PPF occur in an elderly comorbid cohort of patients. Care of these patients now makes up a considerable part of the orthopaedic workload and consumes a significant portion of healthcare resources. Patients should be treated in tertiary referral centres with surgeons skilled in their management. Better access to rehabilitation is needed.

Utility of somatic mutation panel testing in patients with advanced cancer receiving treatment in an Irish teaching hospital

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Background: Tumor testing for potentially actionable somatic mutations via commercially available panel tests has entered routine clinical practice in many countries. In Ireland the cost of these tests is not covered by insurance companies and must be paid for by patients. Use of these tests is sporadic and depends on patient and clinician factors (including ability to pay). Existing data suggest that such testing results in a direct impact on patient therapy in a minority of patients only. We reviewed the impact of somatic mutation testing on treatment selection and outcomes in patients attending a medical oncology service in a teaching hospital in Ireland. Methods: We performed a retrospective study of patients who had commercial panel testing performed as part of routine oncology care. All patients opportunistically tested between 2013 and 2018 were included. Patients having focused molecular tests for approved therapies (e.g. RAS mutations in colon cancer, EGFR and ALK mutations in non-small cell lung cancer) were excluded.We reviewed medical records to assess the frequency and utility of mutations detected, the impact of testing on next and subsequent lines of therapy, and the effectiveness of therapy. Results: 74 panel tests were performed in 71 patients. 39 tests (53%) detected mutations, of which 21 (28%) were potentially actionable. 36 patients (51%) had further treatment after testing was performed. 9 tests (12%) led to test-based treatment. The mean duration of test-based treatment was 34 days (range 1-90 days). No patients had benefit from test based treatment, defined as tumour response or disease stabilisation on restaging scans. 23 patients died within 90 days of panel tests being requested. Among patients starting and completing a subsequent line of therapy after testing, the mean duration of therapy with test-based treatment was 39 days (range 6-90) and for standard of care treatment was 56 days (range 1-262 days). Conclusions: While testing for tumor-specific somatic mutations with proven predictive benefit is very useful, somatic mutation panel testing for non standard of care genetic alterations is not of utility in this real world setting. Its role in Ireland should be limited to identification of suitable early phase clinical trials. Discussions of panel testing should include frank discussion of expected benefits, and should also address factors such as patient ability to travel for clinical trials. [Table: see text]

The Role of CDK4/6 Inhibitors in Breast Cancer

OPINION STATEMENT

Oral inhibitors of CDK4/6 have been shown to increase response rates and prolong disease control when combined with endocrine therapy in hormone-responsive (HR+) HER2-negative advanced breast cancer. Palbociclib, ribociclib and abemaciclib are all approved in combination with non-steroidal aromatase inhibitors in first-line therapy for post-menopausal women, with a 40-45% improvement in progression-free survival seen with the addition of any of these CDK4/6 inhibitors. Additional approved indications, including first- and second-line combination therapy for pre-menopausal women, combination with fulvestrant and use as monotherapy, vary with each agent and are reviewed fully in the subsequent texts. These agents also differ in their toxicity profiles and monitoring requirements, and prescribers should be aware of the individual requirements for each agent. Current clinical trials are investigating the expanded use of these agents in other breast cancer subtypes, such as HER2-positive and triple-negative breast cancer, as well as in the adjuvant and neoadjuvant treatments of early breast cancer. Resistance to CDK4/6 inhibition can occur through multiple mechanisms. Rational combinations with other therapies, such as PI3K inhibitors, HER2-directed therapies and immunotherapy, are being explored.

Abstract P4-16-08: A regional audit of 6-hour monitoring for administration related reactions during the first administration of subcutaneous trastuzumab

Introduction

In 2012, Subcutaneous Trastuzumab (TSC) was introduced as an alternative to Intravenous Trastuzumab (TIV) for HER2+ breast cancer. The pivotal HannaH study demonstrated that TSC was non-inferior to TIV, was preferred by patients, and serious administration related reactions (ARRs) were not reported. However, the Summary of Product Characteristics (SPC) advises that patients be observed for ARRs for 6 hours post-first administration (and 2 hours post-subsequent administrations), similar to TIV.

Aim

To assess the frequency and tolerability of ARRs during the 6-hour observation period post first administration of TSC in patients with HER2+ breast cancer.

Method:

A retrospective audit of TSC was conducted in Southwest Ireland across five centers from 2014-2016. Patient charts were reviewed to record ARRs reported on the first-administration or at subsequent visit. In addition a subset of patients were interviewed regarding their recollection of ARRs with first or subsequent injections.

Results:

The study is ongoing having identified 192 patients. These centers have administered 2111 TSC injections in total, associated with 4998 hours of observation as per SPC. From the 385 injections given over the first two TSC administrations, 13 injections (3.4%) were associated with ARRs within 24 hours. Nine patients (2.3%) experienced injection site reactions immediately post injection, one injection site pain (0.3%), and one experienced petechiae on subsequent exposure (0.3%). Three patients experienced pyrexia and dry cough 24 hours post-injection and were hospitalized for respiratory tract infection. There were no reactions experienced between 2 and 6 hours post-first injection. There were no serious ARRs. Telephone interviews are ongoing and these results will be reported.

Conclusion:

ARRs related to TSC are usually immediate, mild and self-limiting. Observing patients for 6 hours post-first injection and 2 hours post-subsequent injections represents an inefficient use of healthcare resources.

Citation Format: Karmali S, Hughes N, Kinneally A, Kroes J, Cook J, Killian M, Shafiq T, O'Mahony D, Bird B, O'Connor M, O'Reilly S, Galiauskas R, Murphy CG. A regional audit of 6-hour monitoring for administration related reactions during the first administration of subcutaneous trastuzumab [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-08.

Abstract P5-14-05: Use of complementary and alternative medicine in cancer patients receiving chemotherapy in Ireland

Introduction:

The use of complementary and alternative medicine (CAM) in cancer patients has been documented in major cities across USA, Canada, Europe, Nigeria, and Saudi Arabia. These studies suggest that cancer patients on chemotherapy simultaneously use CAMs. In Ireland, there have been two studies in pediatric cancer centers that have documented the use of CAM. To our knowledge, no study has examined the use of CAM in the adult population in Ireland.

Method:

A cross-sectional survey was conducted at a single adult cancer center over a three-week period. The survey was offered to all oncology and hematology patients attending the medical day unit.

Results:

The survey was completed by 81 patients, 51 of them were females (63%). The majority (93.8%) of the patients in our sample were in the age range of 41-80.

47 (58%) of the patients reported using CAM concurrently with conventional chemotherapy. The average cost of CAM was under €20 per month, but five patients (6.2%) spent over €100 per month. The major reasons for taking CAM were to enhance quality of life (23.5%), improve psychological/emotional wellbeing (17.3%), improve immunity (16%), relieve side effects of cancer (9.9%), relieve side effects of treatment (8.6%), and to directly treat/cure cancer (2.5%). Patients using CAM reported their source of information as healthcare professionals (30.9%), family/friends (19.8%), media (13.6%), and CAM practitioners (2.5%). Out of 81 patients, only 27 (33.3%) discussed the use of CAM with a healthcare professional involved in their care, of which 18.2% asked regarding interactions with the conventional therapy, 18.2% asked regarding CAM effectiveness and the type to use, 16.7% asked advice whether to pursue it, and 15.2% asked regarding safety of CAM. From the 26 patients using CAM who did not discuss with HCP the reasons cited were that they were never asked by the HCP (25.9%), did not think it was important to discuss with the HCP (13.0%), and 61.1% did not specify their reason.

Of the 81 patients, 18 consumed herbal products (13.6% green tea, 8.6% flax seed, 3.7% evening primrose, 2.5% soy supplements), 34 used dietary supplements (28.4% vitamins, 12.3% minerals, 3.7% fish oils), and 21 used other CAMs (8.6% massage, 7.4% meditation/mind-body technique, 7.4% acupuncture, 6.2% reflexology, 2.5% reiki).

Conclusion:

The use of CAM in adult cancer patients has not been well documented in Ireland. As demonstrated from the pilot study, adult cancer patients in Ireland do seek out CAMs when simultaneously receiving chemotherapy, highlighting the importance for physicians to explicitly ask all patients regarding their intentions of CAM in order to provide safe and evidence-based options. This cancer center appeared to not have patients pursuing ayurvedic or Chinese medicine. However, similar conclusions cannot be made for other urban centers with more diverse population mixes with differing cultural experiences and attitudes to CAM.

Citation Format: Karmali S, Markey G, Killian M, Ahmed G, Bird BR, Murphy CG. Use of complementary and alternative medicine in cancer patients receiving chemotherapy in Ireland [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-14-05.

Prevalence of overweight and prediabetes in men receiving systemic therapies for metastatic prostate cancer

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Background: Patients with metastatic prostate cancer receive several therapies which may be associated with a tendency to overweight and impaired glucose tolerance. These include androgen deprivation therapy and long term steroid therapy. We set out to assess the prevalence of overweight and diabetes/prediabetes in a cohort of patients attending an oncology day ward for a variety of systemic therapies. Methods: We performed a retrospective review of the medical records of men attending an oncology day ward for prostate cancer treatment. As part of their usual care, these men had regular height and weight checks and also had periodic hemoglobin A1C (HbA1C) measurements performed. The prevalence of prediabetes and diabetes in this patient population was assessed from the HbA1C results using the American Diabetes Association 2016 definitions. Information on patient steroid use (and type), and treatment type were also recorded. Results: Among 34 men with metastatic prostate cancer, the mean age was 74 (range 57-88). Therapies received included androgen deprivation therapy in all cases, with chemotherapy or novel androgen receptor pathway inhibitors such as abiraterone and enzalutamide. Only 12% had a pre-existing diagnosis of diabetes mellitus (all type 2). The majority (79%) are overweight or obese. 59% have pre-diabetes as per the American Diabetes Association 2016 Guidelines, while a further 24% meet criteria for diabetes. Only 18% have HbA1c in the normal range. 56% are on continuous long term steroid therapy, usually as part of their prostate cancer therapy. A further 23% receive intermittent steroids. Only 21% had received no steroids in the 6 months prior to first HbA1C check. 18% had castrate-sensitive disease and 82% had castrate resistant disease. Even among patients with castrate sensitive disease, 2/3 had abnormal HbA1c values. Conclusions: Overweight and prediabetes are very prevalent in men receiving systemic therapies for metastatic prostate cancer. A large percentage of men are on long-term steroid therapy which may be contributing to their risk of these conditions. Intervention is required for this group of patients to reduce the impact of therapy on cardiovascular and overall health.

The Selfie Wrist - Selfie induced trauma

The selfie phenomenon has exploded worldwide over the past two years. Selfies have been linked to a large number of mortalities and significant morbidity worldwide. However, trauma associated with selfies including fractures, is rarely publicised. Here we present a case series of upper extremity trauma secondary to selfies across all age groups during the summer period. Four cases of distal radius and ulna trauma in all age groups were reported. This case series highlights the dangers associated with taking selfies and the trauma that can result.

Medium term review of the ASR implant system: A single surgeon series

INTRODUCTION

Both ASR hip resurfacings and stemmed ASR XL arthroplasties have failed at high rates in several published series. We assessed a single surgeon series of these arthroplasties looking to identify factors associated with their failure.

METHODS

All surgeries were performed by one surgeon. Patients were evaluated clinically, radiologically and with serial cobalt and chromium ion analysis.

RESULTS

274 implants were analysed - 152 ASR resurfacings and 122 ASR XL implants. Thirty revisions were performed.

CONCLUSION

The failure rate of the ASR implant in our series is unacceptably high - its use in routine hip arthroplasty cannot be supported.

Abstract P3-12-04: Is 6 hour monitoring for administration related reactions after first administration of subcutaneous trastuzumab necessary? A single institution audit

Background: Subcutaneous (sc) trastuzumab has demonstrated non-inferiority to intravenous (iv) trastuzumab and is preferred by patients and providers. Serious administration related reactions (ARRs) such as hypotension, respiratory distress etc. were not reported in the pivotal HannaH study. However, the summary of product characteristics (SPC) advises that patients should be observed for ARRs for 6 hours post the first injection (and 2 hours post subsequent injections), similar to the iv formulation.

Methods: We conducted an audit of patients commencing sc trastuzumab at our institution. Medical notes of each patient were reviewed to record adverse events reported on the day of first administration or at the subsequent visit. In addition all patients were interviewed by telephone and questioned regarding adverse events with first or subsequent injections.

Results: 39 patients were identified, 32 had received prior iv trastuzumab. Patients received a mean of 12 injections. In total patients received 470 sc trastuzumab injections, associated with a recommended 1,096 hours of observation as per SPC. 3 injections (0.6%) were associated with ARRs within 24 hours, all on the first cycle. 2 patients (5%) experienced injection site reactions immediately post injection and 1 patient had injection site pain during the injection. 1 patient experienced pyrexia and dry cough 24 hours post injection and was hospitalized for respiratory tract infection. No patient experienced a reaction between 2 and 6 hours post first injection. There were no serious ARRs.

Conclusions: ARRs related to sc trastuzumab are usually immediate, mild and self-limiting. Observing patients for 6 hours post first injection and 2 hours post subsequent injections represents an inefficient use of healthcare resources.

Citation Format: Karmali S, Hughes N, Galiauskas R, Cook J, Murphy K, Bird BR, Murphy CG. Is 6 hour monitoring for administration related reactions after first administration of subcutaneous trastuzumab necessary? A single institution audit [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-12-04.

Endocrine resistance in hormone-responsive breast cancer: mechanisms and therapeutic strategies

The majority of breast cancers may be considered hormone responsive due to expression of hormone receptors (HR+). Although endocrine therapy is always considered for advanced HR+ breast cancer, the emergence of resistance is inevitable over time and is present from the start in a proportion of patients. In this review, we explore the mechanisms underlying de novo and acquired resistance to endocrine therapy. We comprehensively review newly approved and emerging therapies that have been developed to counteract specific mechanisms of resistance. We discuss the challenges pertinent to this therapeutic arena including the potential relief of negative regulatory feedback inhibition with compensatory pathway activation and the evolution of molecular changes in HR+ breast cancers during treatment. We discuss strategies to address these challenges in order to develop rational therapy approaches for patients with advanced HR+ breast cancer.

PARP Inhibitors in Clinical Use Induce Genomic Instability in Normal Human Cells

Poly(ADP-ribose) polymerases (PARPs) are the first proteins involved in cellular DNA repair pathways to be targeted by specific inhibitors for clinical benefit. Tumors harboring genetic defects in homologous recombination (HR), a DNA double-strand break (DSB) repair pathway, are hypersensitive to PARP inhibitors (PARPi). Early phase clinical trials with PARPi have been promising in patients with advanced BRCA1 or BRCA2-associated breast, ovary and prostate cancer and have led to limited approval for treatment of BRCA-deficient ovary cancer. Unlike HR-defective cells, HR-proficient cells manifest very low cytotoxicity when exposed to PARPi, although they mount a DNA damage response. However, the genotoxic effects on normal human cells when agents including PARPi disturb proficient cellular repair processes have not been substantially investigated. We quantified cytogenetic alterations of human cells, including primary lymphoid cells and non-tumorigenic and tumorigenic epithelial cell lines, exposed to PARPi at clinically relevant doses by both sister chromatid exchange (SCE) assays and chromosome spreading. As expected, both olaparib and veliparib effectively inhibited poly-ADP-ribosylation (PAR), and caused marked hypersensitivity in HR-deficient cells. Significant dose-dependent increases in SCEs were observed in normal and non-tumorigenic cells with minimal residual PAR activity. Clinically relevant doses of the FDA-approved olaparib led to a marked increase of SCEs (5-10-fold) and chromatid aberrations (2-6-fold). Furthermore, olaparib potentiated SCE induction by cisplatin in normal human cells. Our data have important implications for therapies with regard to sustained genotoxicity to normal cells. Genomic instability arising from PARPi warrants consideration, especially if these agents will be used in people with early stage cancers, in prevention strategies or for non-oncologic indications.

Assessing the quality of life of non–Hodgkin lymphoma survivors: A population-based study

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Background: Non-Hodgkin Lymphoma survival in Ireland has improved significantly over recent years. However, little survivorship research has been conducted in this country. The aim of this study is to assess the quality of life (QOL) in an Irish population of Non-Hodgkin Lymphoma (NHL) survivors. Methods: High–grade NHL survivors treated in 2 University Hospitals participated in this cross–sectional study by completing the validated Lymphoma specific Functional Assessment of Cancer Therapy (FACT–Lym) questionnaire and Symptom Index–18. Scales were measured using a score from 1 (not at all) to 4 (very much). Raw data was transformed to linear scores, with high scores indicating a higher level of functioning. Linear regression analysis was used to compare scores according to time since diagnosis. Results: Of 87 questionnaires, 47 were completed and returned by NHL survivors (54% response rate). QOL scores improved from time of diagnosis, with the exception of 4–5 years where scores decreased before again improving in the following years. After adjusting for age and sex, statistically significant differences were identified 5+ years after diagnosis in emotional, functional wellbeing and global FACT-Lym scores when compared to 1-2 years after diagnosis. Conclusions: QOL improves post diagnosis with a transient decrease at year 4-5 which may represent anxiety prior to being declared ‘cured’ or being discharged from follow–up. Our small, mostly private patient population reported higher QOL than larger government insured American groups (Smith et. al. Health status and quality of life among Non-Hodgkin lymphoma survivors. Cancer. 2009.). Patients reported on–going symptoms after treatment ended. These findings may help to develop a focused cancer survivorship programme in the future. [Table: see text]

Definitive use of external fixation for pelvic ring injuries (open book/APC2) in pregnancy

Pelvic fractures in pregnancy are rare, resulting in a paucity of evidence-based management. We describe a case of open book pelvic injury in a 32-year-old woman in her third trimester of pregnancy. She was successfully managed with a supra-acetabular external fixator, which allowed the safe delivery of a healthy baby boy at 34 weeks, via caesarean section. The external fixator was removed postpartum, when the pelvis was deemed stable, and mother and baby both continue to do well. This is the only case in the literature that demonstrates the successful use of external fixation for pelvic injuries in pregnancy.

Impact of dosing schedule of doxorubicin and cyclophosphamide (AC) chemotherapy on rates of hospitalization and resource utilization

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Background: 4 cycles ofAC chemotherapy are given as a component of several important and widely used chemotherapy regimens in the adjuvant treatment of breast cancer. We queried whether the use of dose-dense (every 2 week) AC chemotherapy is associated with a lower rate of hospitalization and resource utilization in clinical practice. Methods: We identified patients with early stage breast cancer treated with 3-weekly AC chemotherapy in a single institution. Cases were matched to controls by year of diagnosis and age. Rates of hospitalization during AC chemotherapy as well as duration of hospitalization, associated costs and use of pegfilgrastim were compared between the two groups. Fisher's exact test was used to compare categorical variables, and paired t-test was used to compare continuous variables. Results: 26 patients were included in the analysis. The mean age was 56 in both groups. As expected, rates of growth factor support with pegfilgrastim were higher in the dose dense versus 3-weekly group (52 versus 23 cycles, 2-tailed p = 0.0003). There was no difference in the likelihood of hospitalization among patients treated with dose dense versus 3-weekly AC (Fisher's exact test, p-value = 1.00). There was no difference in the mean duration of hospitalization between groups (mean 2.31 versus 1.23 days, 2-tailed p = 0.3352).Costs pertaining to pegfilgrastim use and hospitalization will be compared. Conclusions: In this clinical setting, dose dense administration of AC was not associated with lower rates or mean duration of hospitalization.

Increased incidence of femoral fractures in small femurs and women undergoing uncemented total hip arthroplasty - why?

The aim of this study was to investigate the relationship between the geometry of the proximal femur and the incidence of intra-operative fracture during uncemented total hip arthroplasty (THA). We studied the pre-operative CT scans of 100 patients undergoing THA with an uncemented femoral component. We measured the anteroposterior and mediolateral dimensions at the level of division of the femoral neck to calculate the aspect ratio of the femur. Wide variations in the shape of the femur were observed, from round, to very narrow elliptic. The femurs of women were narrower than those of men (p < 0.0001) and small femurs were also narrower than large ones. Patients with an intra-operative fracture of the calcar had smaller and narrower femurs than those without a fracture (p < 0.05) and the implanted Corail stems were smaller in those with a fracture (mean size 9 vs 12, p < 0.0001). The variability of the shape of the femoral neck at the level of division contributes to the understanding of the causation of intra-operative fractures in uncemented THA.

Abstract P6-08-35: Pre-surgical neutrophil-to-lymphocyte ratio (NLR) is a prognostic indicator of recurrence free and overall survival in breast cancer patients undergoing primary surgery

Background

There is growing evidence that elevated neutrophil-to-lymphocyte ratio (NLR) is an independent prognostic indicator associated with poor survival in various cancers including colon cancer, ovarian cancer, esophageal cancer and gastric cancer. Several studies in early breast cancer suggest that NLR at diagnosis may be an independent negative prognostic marker in this population also. The aim of the current study is to evaluate the association between blood NLR immediately prior to surgery and recurrence free and overall survival in breast cancer patients.

Methods

We performed a single institution, retrospective cohort study including all patients treated for invasive breast cancer amenable to primary surgery at our institution between 1st January 2006 and 31st December 2010. Clinical and pathologic details were collected from the patient medical records. Exclusion criteria included prior malignancy, chemotherapy receipt prior to surgery, recent corticosteroid use, systemic autoimmune conditions, recent significant cardiovascular illness, infection or inflammatory condition. NLR was calculated on the most recent complete blood count performed on the day of surgery or at the pre-surgical assessment. Eligible patients were divided into high (≥4) and low (&lt;4) NLR groups.

Results

We identified 357 patients, of whom 223 met eligibility criteria for analysis. At a median follow-up of 55.8 months, 18 patients (8.1%) died and 32 (14.3%) experienced disease recurrence. Kaplan Meier survival curves revealed significantly inferior overall survival (log-rank p=0.003) and recurrence free survival (log-rank p=0.01) in the high NLR group. Univariate Cox proportional hazard regression demonstrated an increased risk of mortality and breast cancer recurrence with pre-treatment NLR≥4, with hazard ratios of 5.49 (p=0.008, 95% CI 1.56 to 19.37) and 3.68 (p=0.016, 95% CI 1.28 to 10.58) respectively.

Conclusion

This study confirms pre-treatment NLR as a prognostic factor for breast recurrence and death among patients receiving curative surgery for early breast cancer. Strict inclusion criteria reduced the likelihood of confounding due to comorbidities which might affect NLR and be independently associated with poor outcomes. Our study supports the usefulness of NLR as a component of the prognostic assessment of early breast cancer patients.

Citation Format: Derbrenn O Connor, Mark L Griffin, Jenna S O'Sullivan, Sean Millar, Jo O'Keeffe, Brian R Bird, Sandra Deady, Conleth G Murphy. Pre-surgical neutrophil-to-lymphocyte ratio (NLR) is a prognostic indicator of recurrence free and overall survival in breast cancer patients undergoing primary surgery [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-35.

Prognostic significance of prospectively detected bone marrow micrometastases in esophagogastric cancer: 10-year follow-up confirms prognostic significance

We have previously reported that most patients with esophagogastric cancer (EGC) undergoing potentially curative resections have bone marrow micrometastases (BMM). We present 10-year outcome data of patients with EGC whose rib marrow was examined for micrometastases and correlate the findings with treatment and conventional pathologic tumor staging. A total of 88 patients with localized esophagogastric tumors had radical en-bloc esophagectomy, with 47 patients receiving neoadjuvant (5-fluorouracil/cisplatin based) chemoradiotherapy (CRT) and the remainder being treated with surgery alone. Rib marrow was examined for cytokeratin-18-positive cells. Standard demographic and pathologic features were recorded and patients were followed for a mean 10.04 years. Disease recurrences and all deaths in the follow-up period were recorded. No patients were lost to follow-up. 46 EGC-related and 10 non-EGC-related deaths occurred. Multivariate Cox analysis of interaction of neoadjuvant chemotherapy, nodal status, and BMM positivity showed that the contribution of BMM to disease-specific and overall survival is significant (P = 0.014). There is significant interaction with neoadjvant CRT (P < 0.005), and lymph node positivity (P < 0.001) but BMM positivity contributes to increase in risk of cancer-related death in patients treated with either CRT or surgery alone. Bone marrow micrometastases detected at the time of surgery for EGC is a long-term prognostic marker. Detection is a readily available, technically noncomplex test which offers a window on the metastatic process and a refinement of pathologic staging and is worthy of routine consideration.

The Role of CDK4/6 Inhibition in Breast Cancer

Imbalance of the cyclin D and cyclin-dependent kinase (CDK) pathway in cancer cells may result in diversion away from a pathway to senescence and toward a more proliferative phenotype. Cancer cells may increase cyclin D-dependent activity through a variety of mechanisms. Therapeutic inhibition of CDKs in tumors to negate their evasion of growth suppressors has been identified as a key anticancer strategy. In this review, we outline the development of CDK inhibitory therapy in breast cancer, including the initial experience with the pan-CDK inhibitor flavopiridol and the next generation of oral highly selective CDK4 and CDK6 inhibitors PD0332991 (palbociclib), LEE011 (ribociclib), and LY2835219 (abemaciclib). Data from phase I and II studies in estrogen receptor-positive (ER+) breast cancer demonstrate promising efficacy with manageable toxic effects, chiefly neutropenia. We discuss these studies and the phase III studies that are accruing or nearing completion. We describe the application of such therapy to other breast cancer settings, including HER2-positive breast cancer and the adjuvant treatment of early breast cancer. We also discuss potential concerns surrounding the combination of CDK inhibitors with chemotherapy and their effects on repair of double-strand DNA breaks in cancer cells. Oral highly selective CDK inhibitors show great promise in improving the outcomes of patients with ER+ breast cancer, although caution must apply to their combination with other agents and in the early breast cancer setting.

A comparative analysis of the occupational energy expenditure of radiologists versus clinicians

BACKGROUND

Sedentary lifestyles have been associated with increased morbidity and mortality. Radiology as a profession may be sedentary compared to some clinical disciplines.

AIM

Our aim was to measure the occupation-related energy expenditure of a cohort of radiologists versus clinicians using a specialized pedometer.

METHODS

25 radiologists and 25 clinicians (15 surgeons, 8 physicians and 2 emergency physicians) were measured. The amount of steps walked, stairs climbed and calories burned on a given day from 9 a.m. to 5 p.m. were compared between the groups.

RESULTS

The difference in mean calorie usage per day was 320 greater, and steps walked per day 2,985 greater, in clinicians than in radiologists (p < 0.0001 for each).

CONCLUSION

Such a difference in calorie intake can have significant long-term health implications in terms of increased weight or BMI. Means of combating this deficit are discussed.

Capecitabine and lapatinib uptake in surgically resected brain metastases from metastatic breast cancer patients: a prospective study

BACKGROUND

Breast cancer brain metastases (BCBM) are challenging complications that respond poorly to systemic therapy. The role of the blood-tumor barrier in limiting BCBM drug delivery and efficacy has been debated. Herein, we determined tissue and serum levels of capecitabine, its prodrug metabolites, and lapatinib in women with BCBM resected via medically indicated craniotomy.

METHODS

Study patients with BCBM requiring surgical resection received either single-dose capecitabine (1250 mg/m(2)) 2-3 h before surgery or 2-5 doses of lapatinib (1250 mg) daily, the last dose 2-3 h before surgery. Serum samples were collected serially on the day of surgery. Drug concentrations were determined in serum and BCBM using liquid chromatography tandem mass spectrometry.

RESULTS

Twelve patients were enrolled: 8 for capecitabine and 4 for lapatinib. Measurable drug levels of capecitabine and metabolites, 5'-deoxy-5-fluorocytidine, 5'-deoxy-5-fluorouridine, and 5-fluorouracil, were detected in all BCBM. The ratio of BCBM to serum was higher for 5-fluorouracil than for capecitabine. As for lapatinib, the median BCBM concentrations ranged from 1.0 to 6.5 µM. A high variability (0.19-9.8) was noted for lapatinib BCBM-to-serum ratio.

CONCLUSIONS

This is the first study to demonstrate that capecitabine and lapatinib penetrate to a significant though variable degree in human BCBM. Drug delivery to BCBM is variable and in many cases appears partially limiting. Elucidating mechanisms that limit drug concentration and innovative approaches to overcome limited drug uptake will be important to improve clinical efficacy of these agents in the central nervous system. Trial registration ID: NCT00795678.

John Thomas sign--a memorable but misleading sign in hip fractures

OBJECTIVE

The John Thomas sign is a favourite of medical students and theorizes that in femoral neck fractures, the male member will lie to the side of the fracture on the plain radiograph. The aim of this study was to evaluate the accuracy, and examine the phenomenon of eponymous signs. We sought to answer the following questions: (1) How accurate is the sign in the context of a consecutive series of male patients with hip fractures? (2) Is there a relationship between side and size of penile lie and the side of fracture?

HYPOTHESIS

That the accuracy of the John Thomas sign is, like many eponymous signs, spurious.

MATERIALS AND METHODS

Two hundred male AP pelvis radiographs were examined, of which 100 had a hip fracture and compared these against 100 control films that did not. Age at presentation, and the side, length and angle of penile lie were measured.

RESULTS

The results show two findings: that the accuracy of the supposed "sign" is less accurate than the toss of a coin; and that left lie and left-sided fractures are more common. We fail to show a relationship between side of fracture, John Thomas size or degree of angulation.

CONCLUSION

John Thomas sign is no better than the toss of a coin in relation to hip fractures, and is not related to side of fracture, or penile attitude. We propose that the side of lie observed in male fractures may be as a result of handedness or natural underlying body asymmetry rather than as a result of the fracture.

LEVEL OF EVIDENCE

Level III Case control study.

Impact of lymph node ratio (LNR) on prognosis of early breast cancer

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Background: Breast cancer is currently staged according to the TNM (tumors, nodes, metastases) classification of the American Joint Committee on Cancer (AJCC) Staging System. Lymph node ratio (LNR, the ratio of positive axillary lymph nodes to the total number of nodes examined) may provide additional prognostic information to that provided by TNM scores. Furthermore, LNR may potentially identify subpopulations within the traditional AJCC stages that are at increased risk of adverse outcomes. Methods: We performed a single institution retrospective study of all patients diagnosed with early breast cancer between January 2000 and January 2011. Patients were divided into low- (≤0.14), intermediate- (0.15-0.39) and high-risk (≥0.4) LNR groups. We assessed the impact of LNR and conventional AJCC staging parameters on overall survival (OS) and disease-free survival (DFS). Results: 786 patients were included in the analsyis, 238 of whom were node positive. As expected nodal status according to pathologic nodal (pN) stage was prognostic for OS and DFS with OS decreasing from 88.3% in pN1 patients to 40.8% in those with pN3 disease (p<0.001). LNR was also significantly associated with prognosis. OS decreased from 94% in the low-risk LNR group to 64% in the high-risk group, while DFS decreased from 92% in the low-risk LNR group to 50% in the high-risk (p<0.001). When Stage III patients were divided into low- and high-risk LNR groups, OS decreased from 100% in the low LNR group to 63% in the high LNR group (p<0.05). Similarly, DFS decreased from 96% in the low LNR group to 56% in the high LNR group (p<0.05). A similar trend was not observed when Stage III patients were stratified according to pN status. LNR was also found to be prognostic when pN1 patients were divided into low- and high-risk LNR groups. Although both LNR and nodal status were significantly associated with OS and DFS on univariate analysis, LNR retained its significance on multivariate analysis, while nodal status did not. Conclusions: LNR can identify subpopulations within the traditional AJCC staging that are at higher risk of adverse outcomes. These findings should be examined in larger retrospective studies and, if validated, be considered as a stratification factor in future adjuvant trials.

Cost implications of reactive versus prospective testing for dihydropyrimidine dehydrogenase (DPD) deficiency in patients with colorectal cancer

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Background: DPD is an enzyme encoded by the DPYD gene involved in the metabolism of the chemotherapy drug 5-fluorouracil (5FU) and the oral 5FU prodrug capecitabine. Patients (pts) with DPYD mutations are at risk of severe toxicities from standard dose 5FU, although they may safely receive lower dose therapy with careful monitoring and dose escalation. Methods: In this retrospective study we identified all pts starting 5FU-based chemotherapy for colorectal cancer (CRC) at our institution between Jan 1 2010 and Dec 31 2012. During this time DPD testing was usually performed in a reactive manner, typically for pts experiencing severe toxicities. We reviewed the charts of pts who tested positive for DPYD mutations and assessed the financial implications of their hospitalizations with toxicity. These costs were compared to the costs which would have incurred if all pts starting such therapy had been proactively tested. Results: A total of 134 pts started first-line 5FU-based chemotherapy for CRC over the study period, 66 in the adjuvant setting and 68 for metastatic disease. 31 pts had DPYD mutation testing performed. 6 tests (19% of those tested, 4.5% of the total population) revealed heterozygote DPYD mutations. 5 pts had already experienced severe treatment-related toxicity resulting in cessation of therapy, while one was tested prospectively and received chemotherapy with dose reduction ab initio. The total cost related to hospitalization with toxicity for these 5 pts was €155,083. At €177 per test, the cost to prospectively test all pts starting first-line 5FU-based therapy over the time period would have been €23,718 representing a saving of €131,365 through avoiding these admissions alone. 4 pts who tested positive for DPYD mutations were receiving adjuvant therapy and none restarted therapy following severe toxicity early in their therapy. 2 pts subsequently relapsed with metastatic disease. Conclusions: Prospective testing for DPYD mutations in pts with CRC starting 5FU-based therapy for the first time represents a considerable cost-saving opportunity, in addition to potentially avoiding prolonged hospitalization and morbidity for a sizeable minority of pts.

Phase II study of pertuzumab, trastuzumab, and weekly paclitaxel in patients with HER2-overexpressing metastatic breast cancer (MBC)

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Background: Pertuzumab (P) is a monoclonal antibody which binds to extracellular domain II of HER2 distally from trastuzumab (H), disrupting HER2 dimerization and signaling. The CLEOPATRA phase III trial showed that HP + docetaxel in HER2+ MBC prolonged progression-free survival (PFS) compared to placebo + H + docetaxel. We report preliminary results of a phase II study to evaluate the safety and efficacy of weekly paclitaxel (T) with HP (THP). Methods: Patients (pts) with HER2+ MBC with 0-1 prior treatment (Rx) are eligible. Pts receive weekly (w) paclitaxel (80mg/m2), q3w trastuzumab (loading dose 8mg/kg → 6mg/kg), and q3w pertuzumab (flat loading dose 840mg → flat dose 420mg). The primary endpoint is PFS at 6 months (mo). Secondary endpoints include response, safety (including cardiac events), and tolerability. Evaluable pts are those who have started study Rx and are assessed at 6 mo for PFS. Left ventricular ejection fraction (LVEF) is monitored by echocardiogram every 3 mo. Cardiac events are defined as symptomatic LV systolic dysfunction (LVSD), non-LVSD cardiac death, or probable cardiac death. Results: As of 5-1-12, 33 of the planned 69 pts were enrolled; 16 were evaluable at 6 mo. Of the 16 pts, G 3/4 toxicities included sepsis (1pt, 6%), cholecystitis (1pt, 6%), fatigue (1pt, 6%), skin ulceration (1pt, 6%) and cystic macular degeneration (1 pt with prior prolonged Rx with paclitaxel, 6%). G 1/2 toxicities included alopecia (16 pts, 100%), fatigue (15 pts, 94%), ALT/AST elevation (14 pts, 88%), neuropathy (14 pts, 88%), diarrhea (12 pts, 75%), rash (9 pts, 56%), nail changes (8 pts, 50%), nausea (7 pts, 44%), mucositis (7 pts, 44%), and dry skin (6 pts, 38%). Median LVEF was 63% at baseline, 60% at 3 mo and 58% at 6 mo. There were no cardiac events. At 6 mo, 12/16 pts (75%) were progression-free (2 CR, 7 PR and 3 SD); 4 pts progressed. Conclusions: Our single-center phase II study continues to accrue, with no significant diarrhea or signal of increased cardiac toxicity to date. If the estimate of activity is similar to results with docetaxel in CLEOPATRA, this will provide support for THP as an alternative option in this setting.

Tolerability and toxicity profile of chemotherapy with oxaliplatin in combination with infusional fluorouracil (FOLFOX) and capecitabine (XELOX) in a community oncology setting

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Background: Chemotherapy regimens combining oxaliplatin with infusional fluorouracil (folfox) and capecitabine (xelox) have been found to be superior to fluoropyrimidine chemotherapy alone in colon cancer and are also useful in other gastrointestinal tumor types, including gastro-oesophageal cancers. We retrospectively assessed the tolerability and deliverability of the folfox and xelox regimens in a community oncology setting. Methods: Patients (pts) receiving folfox or xelox chemotherapy for gastrointestinal malignancies over a five year period from 2006 to 2011 were identified through a pharmacy database. Patient and tumour characteristics were recorded. For each regimen, delays in planned chemotherapy administration (>3 days) as well as dose reductions were recorded. Reasons for dose modification and/or treatment discontinuation were recorded. Regimens were compared for these outcomes using Fisher's exact test for categorical variables and unpaired t-test for continuous variables. Results: Of 138 pts with adequate information for assessment, 94 received folfox and 44 received xelox. Pts who received folfox were more likely to experience dose delays (64% vs. 36%, 2-sided p=0.003). The mean dose delays during folfox and xelox were not significantly different (12.2 vs. 10.8 days, t-test p=0.657). Pts who received folfox were less likely to require any dose reductions during therapy (31% vs. 50%, 2-sided P=0.038). Similar numbers of pts receiving folfox and xelox required dose reductions of oxaliplatin (27% vs. 32%, 2-sided p=0.548), while fewer pts receiving folfox required dose reductions of the fluoropyrimidine component (14% vs. 39%, 2-sided p=0.002). Conclusions: We found that more pts required dose delays during treatment with infusional fluorouracil-based versus capecitabine-based oxaliplatin regimens. However, the infusional regimen was associated with considerably less dose reductions, largely related to the fluoropyrimidine component. We favour infusional fluoropyrimidine-based chemotherapy unless other factors (e.g., distance to the oncology unit) support oral fluoropyrimidine use.

Glutamine preconditioning protects against local and systemic injury induced by orthopaedic surgery

INTRODUCTION

Long bone surgery represents a significant surgical insults, and may cause severe local and systemic sequalae following both planned and emergent surgery. Glutamine offers pharmacological modulation of injury through clinically acceptable preconditioning. This effect has not been previously demonstrated in an orthopaedic model.

AIMS

The aim of the study was to test the hypothesis that glutamine preconditioning protects against the local and systemic effects of long bone trauma in a rodent model.

METHODS

Thirty two adult male Sprague-Dawley rats were randomised into four groups: Control group which received trauma without preconditioning; Normal Saline preconditioning 1 hour before trauma; Glutamine preconditioning 1 hour before trauma; Glutamine preconditioning 24 hours prior to trauma. Trauma consisted of bilateral femoral fracture following intramedullary instrumentation. Blood samples were taken before the insult, and at an interval four hours following this. Bronchioalveolar lavage (BAL) was performed, with skeletal muscle and lung harvested for evaluation.

RESULTS

Glutamine pre-treated rats had lower Creatine Kinase levels, less creatinine elevation, and a significant reduction in neutrophil infiltration into BAL fluid. Glutamine pre-treated rats showed less muscle and lung oedema. This effect was more pronounced for the group which received glutamine 24 hours before trauma.

CONCLUSION

Preconditioning with a single bolus of intravenous glutamine prior to planned orthopaedic intervention affords loco-regional and distal organ protection. We believe these finding have significant implications for elective orthopaedic surgery where significant soft tissue and long bone manipulation is anticipated.

Current or recent pregnancy is associated with adverse pathologic features but not impaired survival in early breast cancer

BACKGROUND

Pregnancy-associated breast cancer (PABC) may be defined as breast cancer diagnosed during pregnancy or within 1 year of giving birth. Conflicting data exist regarding the impact of pregnancy on clinical features and prognosis of breast cancer.

METHODS

A single-institution retrospective chart review was performed of 99 patients identified with PABC between 1992 and 2007. Non-PABC controls were matched 2:1 to PABC cases by year of diagnosis and age. The differences in clinical features were compared between cases and controls using chi-square tests. Univariate and multivariate analyses were performed to assess the effect of PABC on survival.

RESULTS

Of the 99 PABC cases, breast cancer was diagnosed during pregnancy in 36 patients, and after delivery in 63. PABC cases were more likely than controls to be negative for estrogen receptor (59% vs 31%, P < .0001) and negative for progesterone receptor (72% vs 40%, P < .0001). Cases were also more likely to have advanced T class (P = .0271) and N class (P = .0104) and higher grade tumors (P = .0115). With a median follow-up of 6.3 years for cases and 4.7 years for controls, overall survival did not differ between cases and controls (P = .0787). On multivariate analysis, the independent prognostic factors for overall survival were estrogen receptor status (P = .0031) and N class (P = .0003). The diagnosis of PABC was not an independent prognostic factor (P = .1317).

CONCLUSIONS

PABC is associated with more adverse tumor features than non-PABC matched for age and year of diagnosis. After correcting for pathologic features, the diagnosis of PABC is not in itself an adverse prognostic factor for survival.

A five-year review of publication productivity among Irish orthopaedic units

BACKGROUND

The academic productivity of trainees, consultants and institutions is frequently judged by the quantity of articles published in peer-reviewed medical journals.

AIM

To assess the publication history of Irish orthopaedic units over a 5-year period, and to identify patterns of publication.

METHODS

A PubMed search was performed of each consultant affiliated with each orthopaedic unit in the country for between 2004 and 2008. Publications were classified by individual, institution, publication type and impact factor.

RESULTS

Over the 5 years of the study, 239 papers were published from 19 orthopaedic units, in 69 different journals. Fifty-six consultants had at least one senior author publication, with seven consultants having more than ten. Impact factors of the journals targeted varied considerably and reveals an interesting duality among authors when opting for profile or prestige.

CONCLUSION

We feel this study represents a comprehensive and novel review of the state of publishing in a surgical specialty.