Does a Commercially Available Augmented Reality-based Portable Hip Navigation System Improve Cup Positioning During THA Compared With the Conventional Technique? A Randomized Controlled Study

BACKGROUND

Portable hip navigation systems have been developed to combine the accuracy of cup positioning by large console navigation systems with the ease of use and convenience of conventional surgical techniques. Although a novel augmented reality-based portable hip navigation system using a smartphone (AR navigation) has become available recently, no studies, to our knowledge, have compared commercially available AR navigation with the conventional technique. Additionally, no studies, except for those from designer-surgeon series, have demonstrated the results of AR navigation.

QUESTIONS/PURPOSES

(1) Does intraoperative use of commercially available AR navigation improve cup positioning compared with the conventional technique? (2) Are operative factors, clinical scores, and postoperative course different between the two groups?

METHODS

In this randomized trial, 72 patients undergoing THA were randomly assigned to undergo either commercially available AR navigation or a conventional technique for cup placement. All patients received the same cementless acetabular cups through a posterior approach in the lateral decubitus position. The primary outcome of the present study was cup positioning, including the absolute differences between the intended target and angle achieved, as well as the number of cups inside the Lewinnek safe zone. Our target cup position was 40° abduction and 20° anteversion. Secondary outcomes were operative factors, between-group difference in improvement in the Hip Disability and Osteoarthritis Outcome Score (HOOS), and the postoperative course, including the operative time (between the start of the surgical approach and skin closure), procedure time (between the first incision and skin closure, including the time to insert pins, registration, and transfer and redrape patients in the navigation group), time taken to insert pins and complete registration in the navigation group, intraoperative and postoperative complications, and reoperations. The minimum follow-up period was 6 months, because data regarding the primary outcome-cup positioning-were collected within 1 week after surgery. The between-group difference in improvement in HOOS, which was the secondary outcome, was much lower than the minimum clinically important difference for the HOOS. No patients in either group were lost to follow-up, and there was no crossover (the randomized treatment was performed in all patients, so there was no difference between an intention-to-treat and a per-protocol analysis).

RESULTS

The use of the commercially available AR navigation slightly improved cup positioning compared with the conventional technique in terms of the absolute difference between the desired and achieved amounts of cup abduction and anteversion (which we defined as "absolute differences"; median 1° [IQR 0° to 4.0°] versus median 5° [IQR 3.0° to 7.5°], difference of medians 4°; p < 0.001 and median 2° [IQR 1.9° to 3.7°] versus median 5° [IQR 3.2° to 9.7°], difference of medians 2°; p = 0.001). A higher proportion of cups were placed inside the Lewinnek safe zone in the navigation group than in the control group (94% [34 of 36] compared with 64% [23 of 36]; p < 0.001). Median operative times were not different between the two groups (58 minutes [IQR 49 to 72 minutes] versus 57 minutes [IQR 49 to 69 minutes], difference of medians 1 minute; p = 0.99). The median procedure time was longer in the navigation group (95 minutes [IQR 84 to 109 minutes] versus 57 minutes [IQR 49 to 69 minutes], difference of medians 38 minutes; p < 0.001). There were no differences between the two groups in improvement in HOOS (27 ± 17 versus 28 ± 19, mean difference -1 [95% CI -9.5 to 7.4]; p = 0.81). In the navigation group, no complications occurred in the pin sites; however, one anterior dislocation occurred. In the conventional group, one hip underwent reoperation because of a deep infection.

CONCLUSION

Although the use of commercially available AR navigation improved cup positioning in THA, the improvement in clinical scores and postoperative complication rates were not different between the two groups, and the overall magnitude of the difference in accuracy was small. Future studies will need to determine whether the improvement in the percentage of hips inside the Lewinnek safe zone results in differences in late dislocation or polyethylene wear, and whether such benefits-if any-justify the added costs and surgical time. Until or unless more compelling evidence in favor of the new system emerges, we recommend against widespread use of the system in clinical practice.

LEVEL OF EVIDENCE

Level Ⅱ, therapeutic study.

Measurement accuracy of the acetabular cup position using an inertial portable hip navigation system with patients in the lateral decubitus position

Accurate cup placement is critical to ensure satisfactory outcomes after total hip arthroplasty. Portable hip navigation systems are novel intraoperative guidance tools that achieve accurate cup placement in the supine position; however, accuracy in the lateral decubitus position is under debate. A new inertial portable navigation system has recently become available. The present study investigated the accuracy of measurements of the cup position in 54 patients in the lateral decubitus position using this system and compared it with that by a goniometer. After cup placement, cup abduction and anteversion were measured using the system and by the goniometer, and were then compared with postoperatively measured angles. Absolute measurement errors with the system were 2.8° ± 2.6° for cup abduction and 3.9° ± 2.9° for anteversion. The system achieved 98 and 96% measurement accuracies within 10° for cup abduction and anteversion, respectively. The system was more accurate than the goniometer for cup anteversion (p < 0.001), but not for abduction (p = 0.537). The system uses a new registration method of the pelvic reference plane and corrects intraoperative pelvic motion errors, which may affect measurement accuracy. In the present study, reliable and reproducible intraoperative measurements of the cup position were obtained using the inertial portable navigation system.

Soft-tissue tension during total hip arthroplasty measured in four patients and predicted using a musculoskeletal model

PURPOSE

Soft-tissue tension around the hip joint is related to the incidence of dislocation after total hip arthroplasty (THA), but it remains difficult to quantify the soft-tissue tension during surgery. In this study, a three-dimensional force sensor-instrumented modular femoral head was developed and used to quantify soft-tissue tension during THA. The forces at the hip joint were also calculated using a three-dimensional musculoskeletal computer model to validate the measured forces.

METHODS

Soft-tissue tension was investigated by measuring the hip joint forces and directions during intraoperative trialing in four patients through passive range of motion (ROM) from 0° extension to 90° flexion. A musculoskeletal model with THA, which was scaled to one of four patients, was developed. The hip joint forces were calculated under the same motion.

RESULTS

Through the passive ROM, the magnitude of soft-tissue tension was greatest when the hip was extended, decreased with flexion to 34°, and progressively increased to flexion at 90°. The mediolateral force component was relatively constant, but the supero-inferior and anterior-posterior force components changed significantly. Within-individual variations were small during three repeated cycles of measurement, but magnitudes varied significantly among patients. Similar force patterns and magnitudes were calculated by the musculoskeletal model.

CONCLUSIONS

This study demonstrates that it is possible to quantify soft-tissue tension and direction during THA with an instrumented head. There was general agreement between the calculated and measured forces in both pattern and magnitude. Including additional subject-specific details would further enhance agreement between the model and measured hip forces.

The effect of range of motion simulated with a patient-specific three-dimensional simulation analysis on dislocation after total hip arthroplasty

BACKGROUND

Dislocation continues to be a common complication following total hip arthroplasty (THA). Although previous studies of computed simulation analysis investigated the range of motion (ROM), it is unclear whether the ROM before impingement simulated using computed tomography-based 3-dimensional simulation analysis (simulated ROM) is related to dislocation after THA. It is also unclear what angles are required in computed simulation analyses for stable hips after THA. In this study, we compared the simulated ROM in patients with and without dislocation.

METHODS

16 patients with posterior dislocation were compared with 48 matched patients without dislocation. Risk factors including preoperative bone morphology of the hip, implant position, change of femoral offset, change of leg length, anterior aspect of the greater trochanter (GTa) length, and anterior inferior iliac spine length were also compared.

RESULTS

The mean flexion angle, internal-rotation at 90° flexion (IR) angle, cup anteversion based on the anterior pelvic plane (APP), tilt-adjusted cup anteversion and GTa length were significantly different between patients with dislocation and patients without dislocation (p = 0.033, 0.002, 0.010, 0.047, 0.046). A receiver-operating characteristic curve analysis suggested cutoff points for flexion angle, IR angle, cup anteversion based on the APP, tilt-adjusted cup anteversion and GTa length, of 114.5°, 45.5°, 19.5°, 12.0° and 15.3 mm.

CONCLUSIONS

This study suggests that preoperative planning to achieve a larger simulated ROM, flexion angle and IR angle, may reduce the risk of posterior dislocation. This study also suggests that fine-tuning of cup anteversion and/or trimming of the overhanging GTa during preoperative planning may reduce the risk of posterior dislocation.

Accuracy of a portable accelerometer-based navigation system for cup placement and intraoperative leg length measurement in total hip arthroplasty: a cross-sectional study

Background

Complications after total hip arthroplasty (THA) are frequently the consequence of malpositioned components or leg length discrepancy after surgery. Recently, a new version of a portable, accelerometer-based hip navigation system (New HipAlign) was made available with a change in the method of measuring cup abduction and the addition of a leg length measurement function. The purposes of this study were to investigate cup positioning and to examine the accuracy of leg length measurement with New HipAlign.

Methods

Cups were implanted and intraoperative leg length change was measured using New HipAlign in 60 THAs through a posterior approach in the lateral decubitus position. The cup position and radiographic leg length change were determined postoperatively on pelvic radiograph and computed tomography scans. We previously compared cup positioning with a previous version of a portable, accelerometer-based hip navigation system (Previous HipAlign) and conventional surgical techniques. Cup positioning in this study was compared with the results of out previous study using Previous HipAlign.

Results

The mean cup abduction of 40.3° ± 4.9° (range, 26° to 53°) and the mean cup anteversion of 15.8° ± 5.6° (range, 6.7° to 29.5°) were found. The deviation of the postoperative measured angles from the target cup position was 3.7° ± 3.3° for cup abduction and 5.9° ± 3.6° for cup anteversion. 56/60 of the cups were inside the Lewinnek safe zone. Compared with our previous study using Previous HipAlign, there were no significant differences with regard to cup abduction, cup anteversion, the deviation from the target cup position for cup abduction, the value of deviation for cup anteversion, and the number of cups inside the Lewinnek safe zone (P = 0.218, 0.334, 0.651, 0.797, 0.592). The mean difference between the intraoperative and radiographic leg length changes was + 0.8 ± 3.4 mm. There was significant correlation between the intraoperative and radiographic leg length changes (r = 0.804, P = 0.000).

Conclusions

Use of New HipAlign allowed for accurate cup placement and reliable leg length measurement during THA.

Trial registration

Clinical trial is defined as ‘any research study that prospectively assigns human participants or groups of humans to one or more health-related interventions to evaluate the effects on health outcome’ by the World Health Organization (WHO). Because this study is not a clinical trial, trial registration is not needed.

A simple angle-measuring instrument for measuring cemented stem anteversion during total hip arthroplasty

Background

During total hip arthroplasty (THA), the accurate placement of the femoral components is an important determinant of the success of the procedure. This study assessed the accuracy of cemented stem placement using a new angle-measuring instrument. The primary objective was to investigate the accuracy of the intraoperative measurements of cemented stem anteversion obtained using the angle-measuring instrument. Our secondary objective was to evaluate the accuracy of stem positioning performed using the angle-measuring instrument.

Methods

We compared the intraoperative stem anteversion measurements obtained using the angle-measuring instrument with postoperative stem anteversion measurements obtained using computed tomography in 149 hips (measurement accuracy). We also compared the target angle and postoperative stem anteversion in 105 hips (implantation accuracy).

Results

The mean amount of intraoperative stem anteversion was 37.9° ± 10.1°, and the mean amount of postoperative stem anteversion was 37.0° ± 10.4°. The mean measurement accuracy was 0.9° ± 6.1°, and the absolute measurement accuracy was 4.9° ± 3.7°. The correlation coefficient for the relationship between the intraoperative and postoperative stem anteversion measurements was 0.824 (p = 0.000). The mean amount of target angle was 37.4° ± 7.6°, and the mean amount of postoperative stem anteversion was 35.9° ± 9.1°. The mean implantation accuracy was 1.4° ± 5.6°, and the mean absolute implantation accuracy was 4.3° ± 3.6°. The correlation coefficient for the relationship between the target angle and postoperative stem anteversion was 0.795 (p = 0.000).

Conclusions

The angle-measuring instrument measured intraoperative stem anteversion accurately, and cemented stem was implanted accurately during THA with the angle-measuring instrument.

Portable Accelerometer-Based Navigation System for Cup Placement of Total Hip Arthroplasty: A Prospective, Randomized, Controlled Study

BACKGROUND

Malposition of the acetabular component during total hip arthroplasty (THA) is associated with increased risk of dislocation, reduced range of motion, and accelerated wear. The purpose of this study is to compare cup positioning with a portable, accelerometer-based hip navigation system and conventional surgical technique.

METHODS

In a prospective, randomized, clinical study, cups were implanted with a portable, accelerometer-based hip navigation system (navigation group; n = 55) or conventional technique (conventional group; n = 55). THA was conducted in the lateral position and through posterior approach. The cup position was determined postoperatively on pelvic radiograph and computed tomography scans.

RESULTS

An average cup abduction of 39.2° ± 4.6° (range, 27° to 50°) and an average cup anteversion of 14.6° ± 6.1° (range, 1° to 27.5°) were found in the navigation group, and an average cup abduction of 42.9° ± 8.0° (range, 23° to 73°) and an average cup anteversion of 11.6° ± 7.7° (range, -12.1° to 25°) in the conventional group. A smaller variation in the navigation group was indicated for cup abduction (P = .001). The deviations from the target cup position were significantly lower in the navigation group (P = .001, .016). While only 37 of 55 cups in the conventional group were inside the Lewinnek safe zone, 51 of 55 cups in the navigation group were placed inside this safe zone (P = .006). The navigation procedure took a mean of 10 minutes longer than the conventional technique.

CONCLUSION

Use of the portable, accelerometer-based hip navigation system can improve cup positioning in THA.

Abstract OT1-05-04: Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial)

Background: It is well known that the prognosis of non pCR TNBC patients was poor after anthracycline and taxan treatment. For such patients, capecitabine seems to be effective to reduce recurrence based on the HR 0.58 of the CREATE X trial (Masuda, N. et al. Adjuvant Capecitabine for Breast Cancer after Preoperative Chemotherapy. N Engl J Med. 376, 2147. 2017) . However, the target of capecitabine is still unclear for TNBC. We classified non pCR tumors as BRCAness and Sporadic using BRCAness test(MRC-Holland, Amsterdam, the Netherlands). The recurrence rate of the BRCAness group was about 70%. Carboplatine is expected to be effective against BRCAness tumors, as it is a DNA damaging agent. In this study BRCAness can be checked just before carboplatin treatment using surgical specimens. Then the efficacy of carboplatin will be directly known to make comparison between DFS in the carboplatin group and that of the observation group.

Trial design: This is anopen label, randomized phase III study that will enroll TNBC with residual invasive cancer after surgery with preoperative chemotherapy including both anthracycrine and taxan. Patients are randomly assigned to either the carboplatin group or observation group. The patients in the carboplatin group are treated with carboplatin at AUC 6 and those in the observation group are observed at only 3 years.

Eligibility criteria:

1) ER and PgR&lt;1%, HER2 0, 1+ or 2+ with FISH negative on core needle biopsy before the chemotherapy and surgical specimens.

2) Preoperative chemotherapy including both anthracycrine and taxan.

3) Residual invasive cancer on breast tumors or lymph node metastasis in surgical specimens.

4) 20-79 year old women.

5) No chemotherapy within 5 years.

6) Not bilateral breast cancer, without metastasis, no prior breast cancer.

7) No severe bone marrow suppression.

Specific aims:Primary objective is DFS (Disease Free Survival). Secondary objectives are overall survival and safety.

STATISTICAL METHODS:

The 3 years recurrence rate of the observation group was estimated as 40% and hazard ratio at 0.58 based on the CREATE X trial. For both groups, 135 patients are necessary. This study is powered to approximately 80% to test the superiority of carboplatin group at a 2-sided α=0.05 using a stratified log-rank test.

Activation Date:22ndMarch 2018. No patients had been enrolled till 3rd July.

Citation Format: Tanino H, Suzuki M, Kaise H, Miyashita M, Chishima T, Hayashi M, Miyoshi Y, Futamura M, Ohtani S, Nagahashi M, Ohta T, Kosaka Y, Ishikawa T, Hasegawa Y, Kubota T, Sangai T, Iwatani T, Yamada A, Akazawa K, Kohno N. Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial) [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 OT1-05-04.

Hip stability after total hip arthroplasty predicted by intraoperative stability test and range of motion: a cross-sectional study

BACKGROUND

Dislocation continues to be a common complication following total hip arthroplasty (THA). A larger intraoperative range of motion (ROM) is believed to minimize dislocation risk, and intraoperative stability tests have been used to assess the ROM. However, it is not clear whether or not intraoperative stability tests can predict hip stability after THA. It is also unclear which angles are required in intraoperative stability tests. We investigated the usefulness of intraoperative stability tests, and other risk factors to predict hip stability after THA.

METHODS

Patients operated by single surgeon at one hospital from June 2009 to December 2013 were evaluated. This study included 185 hips with 32 mm metal femoral head. The range of internal rotation with 90° hip flexion (IR angle) was measured as an intraoperative stability test. The variables studied as risk factors included age, height, weight, gender, cerebral dysfunction, preoperative diagnosis, history of previous hip surgery, and IR angle.

RESULTS

Mean IR angle was statistically different between patients with dislocation and patients without dislocation (59.5° vs 69.6°: p = 0.006). Cerebral dysfunction and a history of previous hip surgery were statistically related with prevalence of dislocation (p = 0.021, and p = 0.011). The receiver-operating characteristic curve analysis suggested that the cutoff points for IR angle were 51° and 67°. Dislocation rate in larger IR angle group was significantly lower than the rate in smaller IR angle group when patients were divided by 51° (p = 0.002). Logistic regression analyses showed that significant risk factors were cerebral dysfunction (OR: 5.3 (95%CI 1.1-25.9); p = 0.037), history of previous hip surgery (OR: 8.6 (95%CI 1.2-63.0); p = 0.035), and IR angle (OR: 10.4 (95%CI 1.9-57.1); p = 0.007).

CONCLUSIONS

The results showed that intraoperative stability test, especially the IR angle, was a useful method to predict hip stability after THA, and a larger intraoperative ROM reduced the likelihood of dislocation. 51° and 67° were indicated as cutoff points for IR angle. Cerebral dysfunction and a history of previous hip surgery are also risk factors for the incidence of dislocation after THA.

TRIAL REGISTRATION

This is a retrospective study, not a clinical trial defined by the World Health Organization (WHO).

Disappearance Curves for Tumor Markers after Resection of Intrathoracic Malignancies

Determination of the standard elimination kinetics of tumor markers will be helpful in the diagnosis of malignancies. We analyzed the disappearance curves for serum tumor marker levels after resection of intrathoracic malignancies. Serum levels of CEA, SLX, AFP, CA 19-9, SCC, TPA and CYFRA were measured several times after surgery in a total of 40 patients. To obtain precise biological half-lives, we applied non-linear least square analysis, taking into consideration the possibility of residual tumor cells. Disappearance curves were monophasic for CEA, SCC, TPA, CYFRA and SLX and biphasic for CA 19-9 and AFP. Temporary elevation of serum levels after surgery was observed for SCC, TPA and CYFRA. The average half-lives of CEA, SLX, SCC, TPA and CYFRA were 1.5 days, 2.7 days, 2.2 hours, 2.5 hours and 1.5 hours, respectively. The average half-life of CA 19-9 was 0.5 days in the first compartment and 4.3 days in the second compartment, while that of AFP was 1.0 days and 6.3 days, respectively. These values will be helpful in the interpretation of serum tumor marker levels after surgery.

Dynamic femoral head translations in dysplastic hips

BACKGROUND

Developmental dysplasia of the hip is an important disease leading to osteoarthritis. Recently, researchers have focused on hip instability as a potentially important dynamic factor for osteoarthritis, but the detailed kinematics of dysplastic hips during weight-bearing gait have not been reported. The purpose of this research is to contrast femoral translation in contralateral healthy hips and dysplastic hips during weight-bearing stepping.

METHODS

Twelve dysplastic hips and eight healthy hips were investigated. Hip joint kinematics were analyzed using 3D-2D model-image registration with dynamic fluoroscopic images of each hip during a stepping-in-place activity. Femoral translation relative to the acetabular center was quantified as instability.

FINDINGS

Total femoral head translations were significantly different between dysplastic and contralateral healthy hips. Mean translation was 1.0mm in dysplastic hips and 0.4mm in contralateral healthy hips during swing-phase, and consisted of inferior translation during early swing phase with a complementary superior translation just before foot strike. Total femoral translation was significantly correlated to several radiographic indices of hip dysplasia.

INTERPRETATION

Superior translations of the femur during the end of swing phase may result in altered articular contact mechanics, abnormal stresses on the labrum and lost lubricant sealing. All of these factors may contribute to joint degeneration and osteoarthritis in dysplastic hips.

Abstract P5-16-10: Zoledronic acid combined with neoadjuvant chemotherapy for HER2-negative early breast cancer (JONIE 1 trial): Survival outcomes of a randomized multicenter phase 2 trial

BACKGROUND and AIM:

Findings from a randomized phase 2 JONIE1 trial in women with HER2-negative early breast cancer have shown that the addition of zoledronic acid (ZOL) to neoadjuvant chemotherapy (CT) has potential anticancer benefits in postmenopausal and triple-negative breast cancer patients. We report the data for the prespecified secondary endpoint of disease-free survival (DFS).

METHODS:

We enrolled women with HER2-negative early breast cancer and randomly assigned them to receive CT or CT+ZOL (CTZ). All patients received 4 cycles of FEC100 (fluorouracil 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2), followed by 12 cycles of paclitaxel at 80 mg/m2 weekly. ZOL (4 mg) was administered 3-4 times weekly for 7 weeks to the CTZ group patients. Definitive surgery was performed 3-4 weeks after the last paclitaxel dose. The primary endpoint was pathological complete response (pCR). The secondary endpoints were the clinical response rates, rate of breast-conserving surgery, safety, and DFS (defined as the time from randomization to disease occurrence or death). The trial is registered as UMIN000003261 (www.umin.ac.jp/english/) with ongoing follow-up.

FINDINGS:

Of the 188 patients enrolled, 95 were assigned to the CT group and 93 to the CTZ group. The mean (95% CI) DFS time of the CT group was 5.15 years (4.83-5.47) and that of the CTZ group was 5.38 years (5.11-5.66). The 3-year DFS rate was 84.6% (95% CI 77.2-92.0) in the CT group and 90.7% (84.6-96.8) in the CTZ group with no significant difference (p = 0.120). The particular benefit from ZOL for the neoadjuvant CT seen as improvement of the pCR rate was indicated in the 3-year DFS period for triple-negative cancer cases (CT vs CTZ: 70.6% vs 94.1%), but not for postmenopausal cases.

CONCLUSIONS:

ZOL slightly improved DFS when combined with CT. Although a significant difference was not found in this study, plans are underway for conducting a combined analysis of 3 neoadjuvant CT trials together with ZOL. The improvement of the pCR rate may be associated with DFS in triple-negative cases. Previous studies have shown that ZOL was more efficacious in an estrogen-suppressed condition. However, the short-term application of ZOL in this study may not be sufficient to improve the outcome in postmenopausal patients.

Citation Format: Ishikawa T, Akazawa K, Hasegawa Y, Tanino H, Horiguchi J, Miura D, Hayashi M, Takao S, Kim SJ, Yamagami K, Miyashita M, Konishi M, Shigeoka Y, Suzuki M, Taguchi T, Kubota T, Kohno N. Zoledronic acid combined with neoadjuvant chemotherapy for HER2-negative early breast cancer (JONIE 1 trial): Survival outcomes of a randomized multicenter phase 2 trial [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 P5-16-10.

Abstract P4-09-25: Exploring immunomodulatory effects of zoledronic acid in breast cancer from clinical trial result of neoadjuvant chemotherapy with zoledronic acid: JONIE-1 study

Background: We previously reported that the addition of zoledronic acid (ZOL) to neoadjuvant chemotherapy (CT) is potentially beneficial in postmenopausal patients with triple-negative breast cancer (BC) in JONIE-1 Study (0% pCR rate in CT versus 50% in CT combing ZOL [CTZ], p=0.029). In order to find biomarkers of response to ZOL, a pilot study was performed using 30 core needle biopsy (CNB) samples at diagnosis from JONIE-1 study. We found that Src activation was highly associated with pCR compared to non-pCR especially in CTZ group. CD8+ TIL was also highly associated with pCR compared to non-pCR. None of CD8+ TIL low patients resulted in pCR in CT group but four out of ten CD8+ TIL low patients experienced pCR in CTZ group. From the result of pilot study, we consider Src activation as a promising biomarker for response to chemotherapy especially in combination with ZOL; however, Src inhibition by ZOL in vivo and the mechanism to explain tumor inhibition is unknown. Because ZOL was effective even in CD8+ TIL low group, the possibility of immune response alteration by ZOL still remains. Not all tumors with Src activation and CD8+ TIL had benefit from ZOL, emphasizing the need for additional markers of response. In the present study, we focused on Src and multiple molecules relating to cancer immune response and analyzed associations with pCR.

Patients and Methods: We investigated the relationship between clinicopathological features and tumor shrinkage in Stage IIA-IIIB HER-2-negative BC patients from the JONIE-1 adjuvant phase III trial comparing CT (FEC100 q3w × 4 cycles followed by weekly paclitaxel for 12 cycles) versus CT combining ZOL (4mg q3-4w). To access Src activation, HLA class I expression, PD-1 and PD-L1 expression, we performed immunohistochemistry (IHC) and stained slides were evaluated by pathologists. Infiltration of immature dendritic cells, macrophages, cytotoxic T cells, and regulatory T cells in the tumor were assessed by IHC as well. Formalin fixed, paraffin embedded CNB sample at diagnosis and surgical specimen after neoadjuvant CT were processed for HE staining and IHC using primary antibodies as follows; anti-Src Ab (36D10), anti-pan HLA-class I Ab (EMR8-5), anti-CD8 Ab (Clone C8/144B), anti-FOXP3 Ab (Clone 236A/E7), anti-CD68 Ab (Clone PGM1), anti-CD1a Ab (Clone O10).

Results: All IHC were successfully performed. Stained slides are now under evaluation by pathologist. Associations between clinicopathological features and the effect of CT with ZOL will be under investigation.

Discussion: Src activation was observed in more than 70% of triple negative BC. Multiple cellular functions of Src are mediated by Ras which is the main target of ZOL in osteoclasts. It has been reported that ZOL reverted tumor-infiltrating macrophages (TAM) phenotype from M2 to M1. Moreover, recent study showed that the activation Src and MAPK in melanoma cells promotes PD-L1 expression. Therefore the addition of ZOL might help cytotoxic T cells infiltrate the tumor for inhibiting tumor growth. We will present the results and discuss antitumor effects of ZOL through immunomodulation at the meeting.

Citation Format: Sangai T, Sato E, Ishikawa T, Kaise H, Hasegawa Y, Miura D, Takao S, Suzuki M, Tanino H, Horiguchi J, Akazawa K, Yamada A, Kohno N. Exploring immunomodulatory effects of zoledronic acid in breast cancer from clinical trial result of neoadjuvant chemotherapy with zoledronic acid: JONIE-1 study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-25.

Abstract P3-07-50: Early and accurate prediction of pathological response by magnetic resonance imaging and ultrasonography in patients undergoing neoadjuvant chemotherapy for operable breast cancer

Background: Neoadjuvant chemotherapy (NAC) reduces tumor size, and increases the frequency of breast-conserving surgery in operable breast cancers. Response predictions to NAC are made based on diagnostic imaging.

Although various studies have reported the optimal timing for diagnostic imaging, this still remains unclear.

Purpose: To identify the optimal timing of diagnostic imaging for the response prediction to NAC, and to evaluate the accuracy of response prediction.

Methods: We evaluated 146 cases enrolled in the JONIE-1 study (a randomized controlled trial comparing zoledronic acid plus chemotherapy with chemotherapy alone as a NAC in patients with HER2-negative primary breast cancer). The chemotherapy regimen was FEC100×4 courses followed by weekly paclitaxel 80×12 courses (± zoledronic acid). Statistical analysis of the association between the tumor reduction ratio and the histopathological response and the prediction of pathological complete response (pCR) was performed using JMP software. The maximum tumor diameter was evaluated using magnetic resonance imaging and ultrasound on each patient 3 times (before NAC, after FEC treatment, after NAC) and tumor reduction ratios were calculated.

Results: The average age of the patients was 49.8 years old. The menopause status was pre-menopause in 84 patients, and post-menopause in 58 patients. Regarding the subtype classification, 116 patients were of the luminal type (Lum) and 26 patients were triple negative (TN), and the Ki-67 labeling index had a median of 25% (1%-93%).

Pathological examination demonstrated that 16 patients had pCR(11.3%, Lum, 9;TN: 7), and 126 patients had non-pCR (88.7%, Lum:107; TN:19). Seven patients had clinical-CR (4.8%, Lum: 4; TN: 3) at post-FEC, and 26 patients (17.8%, Lum: 20; TN: 6) at post-NAC. The prediction of pCR at post-FEC and post-NAC was evaluated by single variable analysis, resulting in an AUC (0.75645) p=0.0017 at post-FEC, and AUC (0.76563) p=0.0001 at post-NAC. The sensitivity / specificity / positive predictive value / negative predictive value were 0.625 / 0.873 / 0.385 / 0.948 at post-FEC, 0.250 / 0.976 / 0.571 / 0.911 at post-NAC, respectively. In TN cases, the values were 0.714 / 0.947 / 0.833 / 0.900 in post-FEC, and 0.429 / 1.000 / 1.000 / 0.826 in post-NAC.

Conclusions: Diagnostic imaging evaluation performed after FEC treatment was useful for the prediction of pCR. Furthermore, the reliability was high in Triple Negative Sub type, but is affected by the existence of residual tumors in Luminal type.

Citation Format: Kaise H, Ishikawa T, Miura D, Hasegawa Y, Horiguchi J, Hayashi M, Takao S, Kim SJ, Tanino H, Miyashita M, Konishi M, Shigeoka Y, Yamagami K, Suzuki M, Taguchi T, Akazawa K, Kohno N. Early and accurate prediction of pathological response by magnetic resonance imaging and ultrasonography in patients undergoing neoadjuvant chemotherapy for operable breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-50.

Early weight-bearing after periacetabular osteotomy leads to a high incidence of postoperative pelvic fractures

BACKGROUND

It has not been shown whether accelerated rehabilitation following periacetabular osteotomy (PAO) is effective for early recovery. The purpose of this retrospective study was to compare complication rates in patients with standard and accelerated rehabilitation protocols who underwent PAO.

METHODS

Between January 2002 and August 2011, patients with a lateral center-edge (CE) angle of < 20°, showing good joint congruency with the hip in abduction, pre- or early stage of osteoarthritis, and age younger than 60 years were included in this study. We evaluated 156 hips in 138 patients, with a mean age at the time of surgery of 30 years. Full weight-bearing with two crutches started 2 months postoperatively in 73 patients (80 hips) with the standard rehabilitation protocol. In 65 patients (76 hips) with the accelerated rehabilitation protocol, postoperative strengthening of the hip, thigh and core musculature was begun on the day of surgery as tolerated. The exercise program included active hip range of motion, and gentle isometric hamstring and quadriceps muscle sets; these exercises were performed for 30 minutes in the morning and 30 minutes in the afternoon with a physical therapist every weekday for 6 weeks. Full weight-bearing with two axillary crutches started on the day of surgery as tolerated. Complications were evaluated for 2 years.

RESULTS

The clinical results at the time of follow-up were similar in the two groups. The average periods between the osteotomy and full-weight-bearing walking without support were 4.2 months and 6.9 months in patients with the accelerated and standard rehabilitation protocols (P < 0.001), indicating that the accelerated rehabilitation protocol could achieve earlier recovery of patients. However, postoperative fractures of the ischial ramus and posterior column of the pelvis were more frequently found in patients with the accelerated rehabilitation protocol (8/76) than in those with the standard rehabilitation protocol (1/80) (P = 0.013).

CONCLUSION

The accelerated rehabilitation protocol seems to have advantages for early muscle recovery in patients undergoing PAO; however, postoperative pelvic fracture rates were unacceptably high in patients with this protocol.

Abstract P3-09-03: Final result of randomised controlled phase II study of the efficiency of palonosetron, aprepitant, and dexamethasone for day1 with or without dexamethasone on days2 and 3

Background: Emesis is one of the major non-hematologic toxicity caused by chemotherapy. The control of Chemotherapy Induced Nausea and Vomiting (CINV) is conducted to a life lengthening. Recently, CINV is controlled by the second generation 5-HT3 receptor blocker (Palonosetron; PALO) and a NK-1 receptor antagonist (Aprepitant; APR). It has been shown that dexamethasone (DEX) with 5-HT3 receptor blocker improves acute / delayed CINV. However, it has not been determined the medication schedule for DEX with PALO and APR. The purpose of this study is evaluated the efficiency of palonosetron, aprepitant and dexamethasone for day1 with or without dexamethasone on days2 and 3. This is final result of current study.

Methods: Breast cancer patients who administered anthracyclin drug regimen have been eligible from April, 2011 to June, 2013. The patients were randomised to group A (PALO/APR/DEX one day) and group B (PALO/APR/DEX three days).

Trial designAprepitant125mg80mg80mg  Palonosetron0.75mg    dexamethasone9.9mg6.6 mg or placebo6.6 mg or placebo  Chemotherapydo    days12345

Eighty patients were estimate as study samples. The primary endpoint was a complete response (CR) rate of vomiting, the secondary endpoint was a complete control (CC) rate of vomiting.

Results: Eighty two patients were enrolled in this study. There was not inferiority about CR rate of five days after chemotherapy (81.1% of group A, 82.1% of group B). CC rate of group A (62.2%) was better than that of group B (46.2%). However, CC rate was no significant difference between group A and B. There was no significant difference about any level of nausea between group A and B.

Conclusions: One day of dexamethasone with Palonosetron and Aprepitant treatment is enough to control the emesis of high emetogenic chemotherapeutic agents.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-09-03.

Long-term results of conventional varus half-wedge proximal femoral osteotomy for the treatment of osteonecrosis of the femoral head

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years.

Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally.

Intermediate to long-term results of periacetabular osteotomy in patients younger and older than forty years of age

BACKGROUND

The treatment of middle-aged patients with periacetabular osteotomy remains controversial. The goal of the present retrospective study was to analyze the intermediate to long-term functional and radiographic results of periacetabular osteotomy in patients below and above the age of forty years.

METHODS

Between February 1990 and December 2004, 166 periacetabular osteotomies were performed in 146 patients. We evaluated 158 hips in 139 patients who had a mean age of thirty-two years at the time of surgery. The mean duration of follow-up was eleven years (range, five to twenty years). We compared thirty-six patients (forty-one hips) who were forty years of age or older with 103 patients (117 hips) who were younger than forty years of age at the time of surgery.

RESULTS

The average Harris hip score increased from 70 points preoperatively to 90 points postoperatively. The mean Harris hip scores at the time of the five-year follow-up were similar in the older and younger groups (p = 0.57), although the latest follow-up scores were significantly higher in the younger group than in the older group (91 compared with 88 points; p = 0.02). The average modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function score (with 0 representing the worst score and 100 representing the best score) was higher for the younger group than for the older group (92 compared with 90 points; p = 0.03). Kaplan-Meier analysis with progression of the Tönnis grade of osteoarthritis as the end point showed a ten-year survival rate of 90.8% (95% confidence interval, 88.3% to 93.3%) and a fifteen-year survival rate of 83.0% (95% confidence interval, 78.5% to 87.5%); the ten-year survival rates in the younger and older groups were 94.4% and 81.3%, respectively, and the fifteen-year survival rates were 86.9% and 71.2%, respectively (p = 0.025).

CONCLUSIONS

Periacetabular osteotomy yielded similar results for the two groups at the time of the five-year follow-up, although the results for the older group deteriorated thereafter. Decrease in physical function due to aging and increased susceptibility to the progression of osteoarthritis may be responsible for the poorer results over time in the older group.

The Chiari pelvic osteotomy for patients with dysplastic hips and poor joint congruency

We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001).

We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.

Use of a genetic algorithm for multiobjective design optimization of the femoral stem of a cemented total hip arthroplasty

There are many designs of the femoral stem of a cemented total hip arthroplasty, and mechanical failure of the stem is caused by several factors related to the cement, such as failure of the cement. Optimization of the shape of the stem, especially multiobjective optimization, is required to solve these design problems because a cement fracture is caused by multiple factors. The objective of this study was to determine a stem geometry considering multiple factors at the same time. A three-dimensional finite element model of the proximal femur was developed from a composite femur. A total of four objective functions--two objective functions, the largest maximum principal stress of proximal and distal sections in the cement mantle, for each of the two boundary conditions, walking and stair climbing--were used. The neighborhood cultivation genetic algorithm was introduced to minimize these objective functions. The results showed that the geometry that leads to a decrease in the proximal cement stress and the geometry that leads to a decrease in the distal cement stress were not the same. However, the results of the walking and the stair climbing conditions matched. Five dominant stem designs were considered to be the Pareto solution, and one design was identified as the "better design" for all objective functions. It was shown that multiobjective optimization using a genetic algorithm may be used for optimizing the shape of the femoral stem in order to avoid cement fracture.

Cemented calcar replacement femoral component in revision hybrid total hip arthroplasty

We evaluated intermediate-term to long-term survival of cemented calcar replacement femoral components in hybrid revision total hip arthroplasty. We followed up 52 hips in 50 patients for a mean of 11.4 years. Six (12%) femoral components had been revised: 2 for aseptic loosening, 2 for periprosthetic fracture, and 2 for deep infection. One additional femoral component was definitely loose. The number of previous revision operations (P = .004), preoperatively poorer femoral bone stock (P = .005), and postoperative poor cement mantle grading (P = .003) were significant factors for failure. Kaplan-Meier analysis revealed that the 15-year survival rate was 90% with mechanical failure as the end point. This technique remains a reasonable option for the first-time revision, especially for older and less active patients.

Porous-coated cementless acetabular components without bulk bone graft in revision surgery

We previously reported the average 9.3-year (range, 5-13 years) results of 74 patients (83 hips) with porous-coated acetabular components that were placed without bulk bone graft at revision surgery. Since the previous report, 7 patients (7 hips) died before the minimum follow-up of 10 years, and 1 patient (1 hip) was lost to follow-up. We now report the average 15.6-year (range, 10-20 years) results for 66 patients (75 hips). Three additional acetabular components were removed or revised again: 2 for infection and 1 for dislodgement of the polyethylene liner from the metal shell. Overall, 7 (7%) components required removal or repeat revision. No shell was revised for aseptic loosening, and none was categorized as loose during the entire follow-up period.

Use of a deep polyethylene liner for the treatment of recurrent dislocation

Modular component exchange is one of several viable options for treating instability after total hip arthroplasty (THA). Recently, we reported that polyethylene liners retrieved from stable THAs had significantly deeper cup articular geometry than liners retrieved from dislocated THAs. Modular liner exchange with implantation of a deeper cup articulation for the treatment of THA instability may be an option in certain cases. We describe the use of modular liner exchange with implantation of a custom polyethylene liner with a deepened articular geometry for surgical treatment of recurrent dislocation after primary THA in a 70 year old patient. The patient did not feel unstable and no symptoms of subluxation or dislocation have been experienced in the 3 years of follow-up subsequent to treatment. Surgeons should consider the articular geometry of the polyethylene liner as an important design parameter, and we recommend that deeper polyethylene liners be considered for treatment of recurrent dislocation after primary THA.

Hybrid total hip arthroplasty using specifically-designed stems for patients with developmental dysplasia of the hip. A minimum five-year follow-up study

A 4-U hybrid total hip arthroplasty (THA) system was specifically designed for patients with developmental dysplasia of the hip (DDH). Straight stem with an appropriate offset and various size variations are advantages. We followed 128 hips in 124 patients, 13 men and 111 women, for a mean of 6.5 years (range, 5.0-7.5 years). Two acetabular and femoral components in two patients had been revised for infection, one acetabular component had been revised for recurrent dislocation, and one femoral component had been revised for periprosthetic femoral fracture. None of the acetabular or femoral components were revised for loosening or were found to be loose at follow-up. The Harris hip score increased from a preoperative average of 42 points to 88 points at the most recent follow-up. Primary THA using the 4-U system had a good mid-term result in patients with DDH. This system could be applied for all patients including those with the narrowest and deformed femurs.

Association between dislocation, impingement, and articular geometry in retrieved acetabular polyethylene cups

We used a novel analysis technique and retrieved acetabular polyethylene liners to investigate relationships between impingement damage, dislocation history, and polyethylene liner geometry. Forty-eight polyethylene liners with neutral rim elevation were visually assessed for peripheral rim damage consistent with impingement between the liner rim and femoral component. Liner articular geometry was measured using a digital stylus, and the geometric relationships between the liner rim and center of the femoral head were characterized by lip height, head center inset, and head penetration into the polyethylene liner. Thirteen (27%) retrieved liners had rim impingement damage and 12 (25%) had a history of dislocation. The proportion of liners with impingement was not significantly different among dislocated and stable liners. Lip height, head center inset, and head penetration were not significantly different between liners with and without impingement damage. Dislocated liners had a significantly shorter head center inset, with significantly less head penetration because of shorter functional duration. Designing polyethylene liners with a sufficiently deep articular surface that exceeds 0.95 mm may prove beneficial for decreasing the prevalence of early dislocation, independent of impingement damage.

Health-related quality of life in patients with systemic lupus erythematosus after medium to long-term follow-up of hip arthroplasty

Health-related quality of life (HRQOL) of systemic lupus erythematosus (SLE) patients with hip arthroplasty after medium to long-term follow-up has not been reported. We conducted a retrospective study for SLE patients with osteonecrosis of the femoral head (ONF). Forty-seven consecutive arthroplasties were performed in 36 patients. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Medical Outcome Survey Short Form 36 (SF-36) and Harris hip score were evaluated. Two patients died before the four-year follow-up and two patients were lost to follow-up. The remaining 43 hips in 32 patients with an average age at surgery of 35 years and an average follow-up of 12.0 years (range 4.0-25.0) were assessed. Bipolar hemiarthroplasty was performed for 18 hips in 12 patients, and total hip arthroplasty (THA) was performed for 25 hips in 20 patients. The mean WOMAC scores for pain and function at the recent followup were 90.8 +/- 8.5points and 79.0 +/- 18.3 points. Patients with THA had significantly high scores in SF-36 physical functioning (P < 0.05) and bodily pain (P < 0.03) compared to those with bipolar hemiarthroplasty. Although improvement could not reach the level of general population, the hip arthroplasty contributed to support HRQOL of SLE patients.

Tight fit technique in primary hybrid total hip arthroplasty for patients with hip dysplasia

This article presents the midterm results of hybrid total hip arthroplasty for patients with hip dysplasia by use of a tight fit technique for the femoral component. We followed up 113 hips in 99 patients for a mean of 11 years. All final femoral rasps used in this study overrasped by 0.5 to 1.0 mm for stem insertion, resulting in relatively thin cement mantles. Both components of one hip were removed because of infection. The other 5 acetabular components were revised for osteolysis, recurrent dislocation, or dislodgement of the polyethylene liner. No femoral component was revised for aseptic loosening. We conclude that the tight fit technique using a canal-filling stem may produce good long-term results for patients with hip dysplasia.

Three-dimensional computer-aided design based design sensitivity analysis and shape optimization of the stem using adaptive p-method

The number of stem designs for total hip arthroplasty is increasing, and occasionally design changes have yielded unexpected clinical results. At present, we are not able to clearly identify which parameter of the stem is most important, and the optimum value of many parameters. The goals of this study were to identify which parameter is most important, to understand the effect of design change, and to find the optimum stem shape. For this purpose, we used adaptive p-method together with three-dimensional computer-aided design software program for the design sensitivity analysis (DSA) and shape optimization of the stem. The results suggested that increasing the lateral and medial width of the distal cross-section together with decreasing the medial-lateral width and the medial radius of the distal cross-section from the default value would lead to a decrease in the largest maximum principal stress of the distal cement. The medial width of middle cross-section, however, was not so simple. The result of DSA suggested that decreasing this parameter from the default value decreased the stress in the distal cement, but the optimum shape was obtained by increasing this parameter. The method used in this study will assist our engineers and surgeons in the process of modifying and optimizing the stem design.

Resistant mechanisms of anthracyclines--pirarubicin might partly break through the P-glycoprotein-mediated drug-resistance of human breast cancer tissues

Juliano and Ling initially reported the expression of a 170 kDa glycoprotein in the membrane of Chinese hamster ovarian cells in 1976, and named this glycoprotein P-glycoprotein (P-gp) based on its predicted role of causing "permeability" of the cell membrane. After much research on anthracycline-resistance, this P-gp was finally characterized as a multidrug-resistant protein coded by the mdr1 gene. Multidrug resistance associated protein (MRP) was initially cloned from H69AR, a human small cell-lung carcinoma cell line which is resistant to doxorubicin (DXR) but does not express P-gp. MRP also excretes substrates through the cell membrane using energy from ATP catabolism. The substrate of MRP is conjugated with glutathione before active efflux from cell membrane. Recently, membrane transporter proteins were re-categorized as members of "ATP-Binding Cassette transporter"(ABC-transporter) superfamily, as shown at http://www.med.rug.nl/mdl/humanabc.htm and http://www.gene.ucl.ac.uk/nomenclature/genefamily/abc.html. A total of ABC transporters have been defined, and MDR1 and multidrug resistance associated protein 1 (MRP1) were reclassified as ABCB1 and ABCC1, respectively. Their associated superfamilies include 11 and 13 other protein, in addition to ABCB and ABCC, respectively. Lung resistance-related protein (LRP) is not a member of the superfamily of ABC transporter proteins, because it shows nuclear membrane expression and transports substrate between nucleus and cytoplasm. LRP was initially cloned from a non-small cell lung carcinoma cell line, SW1573/2R120 which is resistant to DXR, vincristine, etoposide and gramicidin D and does not express P-gp. The mechanisms of resistance remains unclear, and why some resistant cell lines express P-gp and others express MRP and/or LRP is likewise unclear.

Fixation with poly-L-lactic acid screws in hip osteotomy: 68 hips followed for 18-46 months

This study evaluated 68 consecutive hip osteotomies in 61 patients using absorbable poly-L-lactic acid screws for fixation. 47 hips underwent a rotational acetabular osteotomy, 17 hips Chiari's pelvic osteotomy, and 4 hips transtrochanteric rotational osteotomy. Cortical screws were used to transfix the osteotomized acetabulum, and cancellous screws to reattach the intraoperatively osteotomized greater trochanter. The average age at surgery was 35 (12-49) years. The mean duration of follow-up was 32 (18-46) months. All the osteotomized acetabulums united well, but 4 of 54 trochanteric osteotomies failed to unite.

Differential expression of rat brain caspase family proteins during development and aging

It is well recognized that caspases are essential effector molecules for carrying out apoptosis in eukaryotic cells. The expression of rat brain caspase family proteins (caspase-2, -3, -6, -7, -8, -9, 10) in development and aging was assessed using immunochemical detection. All of these caspases were expressed in the rat brain. Immunoblot analysis of brain extracts from embryonic day 19 (E19) to postnatal 96-week-old rats indicated that cytosolic caspase-3, -7, -8, and -10 were highly expressed at E19, and decreased after birth. In contrast, cytosolic caspase-2, -6, and -9 were constitutively expressed from the early stages to 96 weeks of age. These results show that the expression of rat brain caspase family proteins is differentially regulated during the development and aging.

The sphericity of the bearing surface in total hip arthroplasty

This study evaluated the sphericity of bearing surfaces in total hip arthroplasty. The out-of-roundness of metal femoral heads, the inner surface of polyethylene liners, and commercially available ball bearings was measured. The hip prostheses were obtained directly from the manufacturers. The sphericity of the bearing surfaces was significantly inferior to that of the ball bearings. The sphericity of the femoral head on the sagittal plane was inferior to that on the transverse plane. Several significant differences were found among different manufacturers. The sphericity of the femoral head on the sagittal plane and that of polyethylene significantly improved in 1999 and 2000 compared with those in 1995. Further improvement is desirable, however, because good sphericity is expected to prolong the functional performance of the prosthesis after total hip arthroplasty.

Differential subcellular localization of caspase family proteins in the adult rat brain

The distribution of the caspase family (caspase-2, -3, -6, -7, -8, -9, -10) was assessed using immunochemical detection of subcellular fractions of 8-week-old rat brain tissues. The present study demonstrated that the relative protein level of caspase-2, -3, -6, -8 and -10 was highest in the soluble cytosolic fraction, while that for caspase-9 was highest in the nucleus. We also found that caspase-3 and -6 were present at high levels and caspase-2, -8 and -9 at moderate levels in the nerve endings fraction as well as in the soluble cytosolic fraction. These results suggest that rat brain caspases are differentially expressed in the subcellular fractions of the rat brain, and that caspases not only contribute to the regulation of neuronal death, but also to synaptic plasticity.

Acquisition of multidrug resistance in recurrent breast cancer demonstrated by the histoculture drug response assay

Recurrent breast cancer has a very poor response rate to chemotherapy. To understand the degree of acquisition of multidrug resistance in recurrent disease, 24 recurrent breast tumors and 127 primary tumors were evaluated and compared for chemosensitivity in the histoculture drug response assay (HDRA). The evaluation rate was 98.8%. The HDRA utilizes 3-dimensional culture of human tumors on collagen-gel rafts. Doxorubicin (DXR), 5-fluorouracil (5-FU) and mitomycin C (MMC) were tested as standard agents and cisplatin (CDDP) as a candidate agent on surgical specimen of breast cancer in the HDRA. In vitro drug exposure in the HDRA was for 7 days. At the end of the assay, tumor response was assessed by the reduction of 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT). The mean inhibition rates of primary tumors vs. recurrent tumors were 57.9% and 38.6% for DXR (p<0.0005); 59.9% and 42.8% for MMC (p<0.01); 49.0% and 33.4% for 5-FU (p<0.01); and 34.5% and 16.0% for CDDP (p<0.005), respectively. The recurrent cases were pretreated clinically with CAF (cyclophosphamide, DXR and 5-FU), CEF (cyclophosphamide, epirubicin and 5-FU) or CMF (cyclophosphamide, methotrexate and 5-FU). In the CAF and CEF group, the HDRA sensitivity to CDDP was significantly lower in recurrent disease (p<0.005) than that of primary breast cancer suggesting that one agent can induce resistance to another. This is further suggested by the fact that 64.7% of the recurrent cases were resistant to all 4 agents tested as opposed to 27% of the primary cases and that only 5.9% of the recurrent cases were sensitive to three or more agents as opposed to 18% of the primary cases. The correlation of the HDRA results to clinical outcome in the study was 80.0% with 15 cases evaluated consisting of 5 true positives, 3 false positives, 7 true negatives and no false negatives. Thus, the HDRA gives useful clinical information, in particular for the specific individualized treatment design necessary to overcome the multidrug resistance problem of recurrent breast cancer.

Alterations of phospholipase C isozymes in rat cerebral cortex through hyperoxia

The effect of hyperoxia on the level of three phospholipase C (PLC) isozymes (beta1, gamma1, delta1) was assessed in the rat cerebral cortex. When the rats were exposed to 100% oxygen for 60 h, there was a significant reduction in the catalytic activity of low molecular weight phosphotyrosine phosphatase, which was susceptible to activity loss under oxidative stress. The result suggests that oxidative stress is induced in the rat cerebral cortex through hyperoxia. The protein levels of PLC-beta1 and -delta1 were significantly increased in the cerebral cortex where oxidative stress had been induced, although that of PLC-gamma1 was not altered. There was no significant difference in the total PLC activity of the cerebral cortex between hyperoxia and control rats. Using gel filtration chromatography, it was revealed that the PLC-beta1 activity in the cerebral cortex of the hyperoxia rats was higher than that in the control rats, but the PLC-delta1 activity in the former did not differ from that in the latter, despite an increase in the PLC-delta1 protein level. These findings suggest that the PLC-beta1 and -delta1 protein levels of brain tissues are increased by oxidative stress, and that the increased PLC-delta1 molecule is less active.

Bisphosphonate therapy for bone metastases from breast cancer: clinical results and a new therapeutic approach

BACKGROUND

We evaluated the usefulness of bisphosphonate (BIS) monotherapy, the safety of rapid infusion of BIS and the efficacy of BIS-sequential therapy for bone metastases from breast cancer.

PATIENTS AND METHODS

Twenty-nine patients with bone metastasis or invasion were treated with BIS monotherapy. Each BIS (pamidronate 30 mg, alendronate 10 mg, or incadronate 10 mg) was infused over 30 minutes every two weeks a median of 12 times.

RESULTS

With BIS therapy, five patients (17%) showed partial response of the bone lesions, and eighteen patients (64%) had pain relief. Of the nine patients treated with BIS-sequential therapy, one (11%) showed a partial response of the bone metastases, three (33%) had pain relief, and one (11%) showed a decrease in the serum tumor marker level.

CONCLUSION

BIS therapy is effective against bone metastases from breast cancer, and rapid infusion of BIS is both safe and convenient for patients. BIS-sequential therapy can be a unique therapeutic option in some cases.

[Non-small cell lung cancer with liver metastasis responsive to gemcitabine--a case report]

A 56-year-old male patient underwent a right upper lobectomy and lymph node dissection for non-small cell lung cancer in March 1994. Multiple lung metastases in the right lung were found 45 months after the operation, and chemotherapy with docetaxel was administered. A liver metastasis was detected 11 months later, and it was refractory to docetaxel. Therefore, the patient was treated with cisplatin, mitomycin C and vinorelbine, which resulted in no change to the liver metastasis. He was next treated with gemcitabine, which resulted in a partial response of the liver metastasis. The adverse effects of gemcitabine were Grade 3 thrombocytopenia and Grade 2 neutropenia. The response duration for gemcitabine therapy was three months.

[A case of docetaxel-resistant breast cancer responsive to paclitaxel therapy]

A 73-year-old woman underwent docetaxel therapy for lung metastasis from breast cancer after having received CAF therapy. Because of the progressive disease due to secondary resistance to docetaxel, the patient was given three courses of paclitaxel therapy (60 mg/m2, day 1, 8, 15 and 22, repeated every 6 weeks). The paclitaxel therapy brought about no adverse effects and a 51%-reduction in the size of the metastatic lung tumor (PR). Although the duration of the response to the paclitaxel therapy was limited to about one month due to progression of a brain metastasis, paclitaxel therapy may be effective against docetaxel-resistant breast cancer.

Chemosensitivity of breast cancer lymph node metastasis compared to the primary tumor from individual patients tested in the histoculture drug response assay

Lymph node metastasis is often the first indication of the aggressiveness of breast cancer. Effective chemotherapy in breast cancer depends on targeting the metastatic component of the disease. In order to optimize chemotherapy in the metastatic target of breast cancer, the histoculture drug response assay (HDRA) was performed on surgical specimens of primary tumor and axillary lymph node metastasis from 30 breast cancer patients. The surgical specimens were cut into approximately 10 mg pieces, and placed onto the collagen gel sponges in the medium containing previously-determined cutoff concentrations of doxorubicin (DXR), 5-fluorouracil (5-FU), cisplatin (DDP), and mitomycin C (MMC). After incubation for 7 days, the chemosensitivity of the tumor fragments was evaluated with the 3-(4,5-dimethythiazol2yl)-2,5-diphenyl-2H tetrazolium bromide (MTT) endpoint. The lymph node metastases were more resistant than the primary tumor for DXR, 5-FU, and MMC (p < 0.05) but not for CDDP. The data suggest that both primary tumor and metastases from individual patients should be tested in the HDRA to enhance clinical efficacy of chemotherapy.

Activation of NADPH oxidase in Alzheimer's disease brains

The present study is the first to show that superoxide (O(-)(2)) forming NADPH oxidase is activated in Alzheimer's disease (AD) brains by demonstrating the marked translocation of the cytosolic factors p47-phox and p67-phox to the membrane. In conjunction with a recent in vitro study showing that amyloid beta activates O(-)(2) forming NADPH oxidase in microglia, where these phox proteins are localized in this study, the present results suggest that, in AD, NADPH oxidase is activated in microglia, resulting in the formation of reactive oxygen species which can be toxic to neighboring neurons in AD.

Increase in phospholipase C-delta1 protein levels in aluminum-treated rat brains

The effect of administration of aluminum to rats on the level of three phospholipase C (PLC) isozymes (beta1, gamma1, and delta1) was assessed in a variety of brain tissues. After exposure to aluminum, a statistically significant increase in malondialdehyde, an index of lipid peroxidation, was observed. In addition, there was a significant reduction in the catalytic activity of low molecular weight phosphotyrosine phosphatase, which loses its activity during oxidative stress. This suggests that oxidative stress is induced in brain tissues exposed to aluminum. The protein level of PLC-delta1, but not that of PLC-beta1 or -gamma1, was significantly increased in brains where oxidative stress had been induced. The total PLC activity in aluminum-treated rat brains was significantly higher than that in control brains. These results suggest that PLC-delta1 protein levels in brain tissues are increased by the induction of oxidative stress, giving an explanation for its up-regulation in Alzheimer's disease.

[Histoculture drug response assay on non-small cell lung cancer]

We examined the chemosensitivity of non-small cell lung cancer (NSCLC) tissues to CDDP, 5-FU, ADM, MMC, ETP and SN38 using histoculture drug response assay (HDRA). One-hundred and thirty surgical specimens from NSCLC patients who were not given preoperative chemotherapy were used. The inhibition indexes of CDDP, 5-FU, MMC, ADM, ETP and SN38 were 39.1 +/- 18.2%, 48.0 +/- 19.7%, 63.3 +/- 17.7%, 47.6 +/- 22.0%, 36.9 +/- 21.1%, and 37.9 +/- 25.2%, respectively. Inhibition indexes were above the cutoff level, i.e., 'judged sensitive,' in 40 cases (31.3%) for CDDP, 34 cases (27.4%) for 5-FU, 54 cases (44.3%) for MMC, 36 cases (33.0%) for ADM, 29 cases (29.8%) for ETP, and 34 cases (37.4%) for SN38, respectively. In almost one-third of patients, the inhibition indexes of all drugs were under cutoff levels. Correlations between in vitro chemosensitivity data and patient responses to chemotherapy were obtained from 16 evaluable patients, and a 44.4% true positive rate and a 100% true negative rate were observed. Our results with HDRA for NSCLC showed a high incidence of intrinsic multidrug resistance. HDRA may help doctors to avoid non-effective chemotherapy for NSCLC patients.