Old World Screwworm myiasis: First report of auricular Chrysomya bezziana myiasis in a dog in Singapore

A German Shepherd dog was presented to a referral practice for screwworm myiasis affecting the ear. The successful management involved killing the larvae with afoxolaner plus milbemycin oxime and using video otoscopy to completely remove dead larvae. To the best of our knowledge, this is the first case report of auricular myiasis by Chrysomya bezziana in a dog in Singapore and the first report of video otoscopic management of myiasis.

Deep Learning vs. Handcrafted Radiomics to Predict Chemoradiotherapy Response for Locally Advanced Cervical Cancer

PURPOSE/OBJECTIVE(S)

To predict CRT response in locally advanced cervical cancer (LACC) with handcrafted radiomics (HCR) and deep learning radiomics (DLR) using pretreatment MRI. Furthermore, we investigate whether the incorporation of clinical factors improves prediction performance.

MATERIALS/METHODS

Two hundred and fifty-two patients with LACC are enrolled. All patients are treated with external beam radiotherapy, followed by high-dose-rate intracavitary brachytherapy with concurrent cisplatin. The patients are randomly divided into two independent groups for the training (167 patients) and test datasets (85 patients). Contrast-enhanced T1- and T2-weighted MR scans are obtained. Patients in the training and test sets have similar characteristics in terms of age, tumor size, FIGO stage, HPV infection status, or CRT response. For HCR analysis, 1890 imaging features are extracted and a support vector machine classifier with a five-fold cross-validation is trained using training dataset to predict CRT response and validated using test dataset. For DLR analysis, a 3-dimensional convolutional neural network was trained and validated using test dataset.

RESULTS

A comparison of the DLR and HCR models reveals that the DLR model exhibits better prediction performance than the HCR model for the test dataset (AUC = 0.721 vs. 0.597, p = 0.097). The incorporation of clinical factors could improve performance in both DLR and HCR models.

CONCLUSION

The DLR models outperform the HCR models in predicting CRT responses in patients with LACC. Combining clinical factors and MRI may improve the prediction performance in both HCR and DLR analyses.

Irradiation with 590-nm yellow light-emitting diode light attenuates oxidative stress and modulates UVB induced change of dermal fibroblasts

Recently, light-emitting diode (LED)-based devices have emerged as effective and safe tools for the treatment of photoaged skin. However, few studies have been conducted to elucidate the underlying mechanism behind the effect on photoaging of LED light. In this study, we induced photoaging of human dermal fibroblasts (HDFs) with Ultraviolet B (UVB) irradiation and evaluated the ability of 590 nm LED radiation to induce recovery from oxidative stress, restore collagen formation, and regulate inflammatory changes. Photoaging was induced in cultured human dermal fibroblasts (HDFs) using UVB irradiaton of 50 mJ/cm² . Then, the photoaged HDFs were irradiated with LED using a custom-built 590 nm LED device which emits light with an intensity of 38 mW/cm² (irradiated for 900 s with 34.2 J/cm² of total energy). LED irradiation significantly attenuated UVB-induced reactive oxygen species generation and UVB-induced phosphorylation of JNK, c-Fos, and c-Jun. In addition, the procollagen levels were recovered significantly, and MMP-9 levels were significantly suppressed after LED irradiation. The UVB-induced phosphorylation levels of NF-κB and pro-inflammatory enzyme COX-2 also significantly decreased. Our results suggest that 590-nm yellow light irradiation may be an effective and safe anti-oxidative and anti-inflammatory treatment modality for photoaged skin.

Randomized, double-blind, active-controlled, multicentre, phase III clinical trial with two stages to assess the safety and efficacy of letibotulinum toxin a vs. onabotulinum toxin a for subjects with moderate to severe crow's feet

BACKGROUND

Letibotulinum toxin A (LeBA) was approved by the Ministry of Food and Drug Safety (known as the Korea Food & Drug Administration) for cosmetic indications in 2012. However, the efficacy and safety of this newly introduced LeBA have not been investigated in crow's feet lines (CFL) treatment and standardization before its universal use.

OBJECTIVE

The aim of this multicentre, double-blind, randomized, parallel, active-controlled Phase III clinical trial with two stages (ClinicalTrials.gov identifier: NCT03408236) was to investigate the non-inferiority of LeBA vs. the existing onabotulinum toxin A (OnBA) for the treatment of CFL.

METHODS

A total of 240 subjects were randomized to either the test (LeBA) or control (OnBA) group. At the baseline and at weeks 4 while maximum smiling (primary efficacy assessment), 8, 12 and 16, investigator's on-site evaluation, independent evaluator, evaluation by the subjects, subjects' satisfaction assessment and safety assessment were performed.

RESULTS

At week 4, the response rate of primary efficacy assessment was 69.75% and 68.33% in the test (LeBA) and control (OnBA) groups, respectively, without a significant difference. Other minor secondary evaluation results showed significant differences suggesting that LeBA offered better improvement than OnBA, but the overall results did not show significant differences between the two groups.

CONCLUSION

This study showed that LeBA was as effective and safe as OnBA for the treatment of CFL at the same doses.

Abstract P2-14-01: The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 TRIAL

Background: In women with breast cancer receiving neoadjuvant chemotherapy, residual cancer burden (RCB) predicts distant recurrence and survival. In those with high risk tumors, locoregional recurrence (LRR) remains a concern, and has been associated with type of local therapy received. We evaluated the impact of local therapy on LRR in the ISPY-2 TRIAL.

Methods: Data were analyzed in Stata 14.2, using Chi2 test, log rank test, and a Cox proportional hazards model. RCB was considered a categorical variable (0/1 versus 2/3), as described in prior publications. Breast surgery categories were lumpectomy +/- radiotherapy, or mastectomy +/- radiotherapy. Axillary surgery was defined as sentinel lymph node (SLN) surgery (≤6 nodes removed) or axillary dissection (>6 nodes).

Results: Follow up data from the I-SPY2 TRIAL were available for 630 patients (median follow up 2.76 yrs, range 0.4-7.2). Type of local therapy was significantly associated with clinical stage at presentation, with stage III patients most frequently undergoing mastectomy + radiation (p<0.001). Women with higher RCB were more likely to undergo mastectomy than those with lower RCB (61.3% vs 48.8% mastectomy rate, p=0.002), and more likely to receive adjuvant radiotherapy (62.0% vs 53.9%, p=0.048). There was no association between clinical stage, type of surgery, or radiotherapy and LRR (Table). Higher RCB was significantly associated with LRR, with 3 year locoregional recurrence free rate of 95.1% in RCB 0/1 versus 89.9% in RCB 2/3 (p=0.003).

In a Cox model adjusting for clinical stage, tumor subtype, surgical therapy, RCB status, nodal radiation, and age, significant predictors for LRR were tumor subtype and RCB status. Hazard ratio (HR) for LRR in those with RCB 0/1 was 0.39 compared to those with RCB 2/3 (95% CI 0.17-0.87, p=0.021). There was no difference in LRR between breast conservation and mastectomy; within the breast conservation group, those who had lumpectomy alone had higher hazard of LRR compared to those having lumpectomy + radiation (HR 3.1, 95% CI 1.1-9.2, p=0.043).

Conclusions: Extent of surgical therapy was not associated with local tumor control, regardless of advanced tumor stage at presentation. Rather, tumor biology and response to therapy were the best predictors of LRR. These data highlight the opportunity to minimize the morbidity of extensive surgical therapy for patients with excellent response to systemic therapy.

LRR rates by clinical features and treatment status FrequencyLRR RateP valueClinical Stage  0.5I240 (47.5%)5.8% II185 (36.6%)8.7% III80 (15.8%)6.3% Tumor Subtype  0.014ER+PR+Her2-161 (26.4%)3.1% ER+PR-Her2-56 (9.2%)3.6% Her2+176 (28.9%)6.3% Triple negative216 (35.5%)11.1% Local therapy  0.169Lumpectomy85 (13.5%)11.8% Lumpectomy with radiation198 (31.4%)5.6% Mastectomy173 (27.5%)5.2% Mastectomy with radiation174 (27.6%)8.6% Axillary surgery  0.23None5 (0.8%)20% SLN329 (52.2%)5.8% ALND296 (47%)8.5% Axillary radiation  0.535Yes42 (6.7%)9.5% No588 (93.3%)7.0% Axillary management  0.2No surgery or radiation5 (0.8%)20.0% SLN312 (50%)5.3% SLN+Axillary radiation17 (2.7%)8.3% ALND271 (43%)10.3% ALND+Axillary radiation25 (4%)5.4% RCB  0.0020/1293 (50.1%)3.8% 2/3292 (49.9%)10.3% 

Citation Format: Silverstein J, Suleiman L, Yau C, Price ER, Singhrao R, Yee D, DeMichele A, Isaacs C, Albain KS, Chien AJ, Forero-Torres A, Wallace AM, Pusztai L, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Leyland-Jones B, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, I-SPY 2 TRIAL Consortium, Berry DA, Asare SM, Esserman LJ, Boughey JC, Mukhtar RA. The impact of local therapy on locoregional recurrence in women with high risk breast cancer in the neoadjuvant I-SPY2 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 P2-14-01.

Abstract PD1-01: Trilaciclib (T), a CDK4/6 inhibitor, dosed with gemcitabine (G), carboplatin (C) in metastatic triple negative breast cancer (mTNBC) patients: Preliminary phase 2 results

Background: Cytotoxic chemotherapy-induced damage of hematopoietic stem and progenitor cells (HSPCs) results in acute toxicities consisting of multi-lineage myelosuppression, and late onset toxicities consisting of progressive bone marrow suppression with increased incidence of therapy-related myeloid neoplasms. T is an IV CDK4/6 inhibitor in development to preserve HSPC and immune system function during cytotoxic chemotherapy (myelopreservation). Proof of concept for myelopreservation with T was observed in a randomized, placebo-controlled Phase 2 trial in small-cell lung cancer patients receiving 1st-line chemotherapy. This trial in mTNBC patients (NCT02978716) was designed to explore the utility of T in combination with GC.

Methods: This Phase 2, randomized, open-label study enrolled patients in the US and EU with mTNBC who had received 0-2 prior systemic cytotoxic therapies in the locally recurrent or metastatic setting and had no symptomatic brain metastases. Patients were randomized (1:1:1) to GC alone (Group 1) or T plus GC (Group 2) using a standard schedule (D1, 8 every 21 days) or to an alternative schedule (T on D1, 2, 8 and 9 with GC on D2 and 9 every 21 days; Group 3). On those days when both T and GC were scheduled, T was administered iv prior to GC infusion. Prophylactic growth factors were not administered in cycle 1; otherwise supportive care was allowed as needed. Primary objectives were safety and tolerability; tumor response was evaluated using RECIST v1.1 and PFS and OS were assessed. Myelopreservation endpoints reflecting the potential effects of T on multiple cellular lineages include occurrence of Grade 4 neutropenia (primary), RBC and platelet transfusions (primary), and lymphocyte counts with immune profiling (secondary and exploratory). A signature of CDK4/6 independence developed from preclinical data will be used to evaluate archival tumor tissue samples and data analysis is ongoing.

Results: 95 patients were dosed; median age 57 years (range 32,86), ECOG PS 0 (53%) or 1 (47%), 25% had liver metastases at baseline, and approximately 50% had received no systemic therapy in the recurrent/metastatic setting. Fifty-five patients remain on treatment. Disease progression was the most common reason for drug discontinuation (22/40; 55%). Overall the most common (≥ 25%) TEAEs were anemia (47%), nausea (35%), fatigue (34%), neutropenia (32%), platelet count decreased (25%), and vomiting (25%). The most frequent (≥ 15%) Grade 3 or 4 TEAEs were hematologic toxicities, i.e. neutropenia (28%), anemia (21%), neutrophil count decreased (21%) and thrombocytopenia (16%). These were also the most frequent drug-related TEAEs observed. Tumor efficacy data are being evaluated.

Conclusions: This trial, assessing the myelopreservation effects of T when combined with GC in patients with mTNBC, has completed enrollment. Myelopreservation data, immune profiling, as well as ORR and preliminary PFS results will be presented by study arm at the meeting.

Citation Format: O'Shaughnessy J, Wright GS, Thummala AR, Danso MA, Popovic L, Pluard TJ, Cheung E, Han HS, Daniel BR, Vojnovic Z, Vasev N, Ling M, Richards DA, Wilks ST, Milenkovic D, Sorrentino JA, Roberts PJ, Bomar M, Yang Z, Antal JM, Malik RK, Morris SR, Tan A. Trilaciclib (T), a CDK4/6 inhibitor, dosed with gemcitabine (G), carboplatin (C) in metastatic triple negative breast cancer (mTNBC) patients: Preliminary phase 2 results [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 PD1-01.

Abstract P2-07-03: Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden

Background: Patients achieving a pathologic complete response (pCR) following neoadjuvant therapy have significantly improved event-free survival relative to those who do not; and pCR is an FDA-accepted endpoint to support accelerated approval of novel agents/combinations in the neoadjuvant treatment of high risk early stage breast cancer. Previous studies have shown that recurrence risk increased with increasing burden of residual disease (as assessed by the RCB index). As well, these studies suggest that patients with minimum residual disease (RCB-I class) also have favorable outcomes (comparable to those achieving a pCR) within high risk tumor subtypes. In this study, we assess whether integrating RCB with MRI functional tumor volume (FTV), which in itself is prognostic, can improve prediction of distant recurrence free survival (DRFS); and identify a subset of patients with minimal residual disease with comparable DRFS as those who achieved a pCR. Imaging tools can then be used to identify the subset that will do well early and guide the timing of surgical therapy.

Method: We performed a pooled analysis of 596 patients from the I-SPY2 TRIAL with RCB, pre-surgical MRI FTV data and known follow-up (median 2.5 years). We first assessed whether FTV predicts residual disease (pCR or pCR/RCB-I) using ROC analysis. We applied a power transformation to normalize the pre-surgical FTV distribution; and assessed its association with DRFS using a bi-variate Cox proportional hazard model adjusting for HR/HER2 subtype. We also fitted a bivariate Cox model of RCB index adjusting for subtype; and assessed whether adding pre-surgical FTV to this model further improves association with DRFS using a likelihood ratio (LR) test. For the Cox modeling, penalized splines approximation of the transformed FTV and RCB index with 2 degrees of freedom was used to allow for non-linear effects of FTV and RCB on DRFS.

Result: Pre-surgical MRI FTV is significantly associated with DRFS (Wald p<0.00001), and more effective at predicting pCR/RCB-I than predicting pCR alone (AUC: 0.72 vs. 0.65). Larger pre-surgical FTV remains associated with worse DRFS adjusting for subtype (Wald p <0.00001). The RCB index is also significantly associated with DRFS adjusting for subtype (Wald p<0.00001). Adding FTV to a model containing RCB and subtype further improves association with DRFS (LR p=0.0007). RCB-I patients have excellent DRFS (94% at 3 years compared to 95% in the pCR group). Efforts are underway to identify an optimal threshold for dichotomizing pre-surgical FTV and FTV change measures for use in combination with pCR/RCB-I class to generate integrated RCB (iRCB) groups as a composite predictor of DRFS.

Conclusion: Pre-surgical MRI FTV is effective at predicting minimal residual disease (RCB0/I) in the I-SPY 2 TRIAL. Despite the association between FTV and RCB, FTV appears to provide independent added prognostic value (to RCB and subtype), suggesting that integrating MRI volume measures and RCB into a composite predictor may improve DRFS prediction.

Citation Format: Hylton NM, Symmans WF, Yau C, Li W, Hatzis C, Isaacs C, Albain KS, Chen Y-Y, Krings G, Wei S, Harada S, Datnow B, Fadare O, Klein M, Pambuccian S, Chen B, Adamson K, Sams S, Mhawech-Fauceglia P, Magliocco A, Feldman M, Rendi M, Sattar H, Zeck J, Ocal I, Tawfik O, Grasso LeBeau L, Sahoo S, Vinh T, Yang S, Adams A, Chien AJ, Ferero-Torres A, Stringer-Reasor E, Wallace A, Boughey JC, Ellis ED, Elias AD, Lang JE, Lu J, Han HS, Clark AS, Korde L, Nanda R, Northfelt DW, Khan QJ, Viscusi RK, Euhus DM, Edmiston KK, Chui SY, Kemmer K, Wood WC, Park JW, Liu MC, Olopade O, Tripathy D, Moulder SL, Rugo HS, Schwab R, Lo S, Helsten T, Beckwith H, Haugen PK, van't Veer LJ, Perlmutter J, Melisko ME, Wilson A, Peterson G, Asare AL, Buxton MB, Paoloni M, Clennell JL, Hirst GL, Singhrao R, Steeg K, Matthews JB, Sanil A, Berry SM, Abe H, Wolverton D, Crane EP, Ward KA, Nelson M, Niell BL, Oh K, Brandt KR, Bang DH, Ojeda-Fournier H, Eghtedari M, Sheth PA, Bernreuter WK, Umphrey H, Rosen MA, Dogan B, Yang W, Joe B, I-SPY 2 TRIAL Consortium, Yee D, Pusztai L, DeMichele A, Asare SM, Berry DA, Esserman LJ. Refining neoadjuvant predictors of three year distant metastasis free survival: Integrating volume change as measured by MRI with residual cancer burden [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 P2-07-03.

Abstract P3-11-07: Exploratory biomarker analysis from a phase II, multicenter, randomized trial of eribulin plus gemcitabine(EG) versus paclitaxel plus gemcitabine(PG) as first-line chemotherapy for human epidermal growth factor receptor 2 (HER2)- negative metastatic breast cancer(MBC): Korean cancer study group trial (KCSG BR13-11)

Introduction : A phase II, multicenter, randomized clinical trial of the comparison between eribulin plus gemcitabine (EG) and paclitaxel plus gemcitabine (PG) as first-line chemotherapy for patients with human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer (MBC) found EG was less neurotoxic, but had similar efficacy of PG. In this study, we performed exploratory biomarker analysis of the impact of genetic alterations on the efficacy according to EG and PG chemotherapy.

Methods : This biomarker study was conducted using tumor samples from 40patients. When tissue collection was possible after disease progression, we performed paired sample analysis. Tumor DNA and RNA were extracted from formalin-fixed, paraffin-embedded tissues. To perform targeted deep sequencing, we used CancerScanTM, a 375 cancer gene panel. And we performed an nCounter expression assay for gene expression analysis using 730 PanCancer panel and 730 Immune panel.

Results: In total, we obtained 44 tissue samples from 40 patients. Twenty two patients were assigned in EG arm and 18 patients were in PG arm. Thirty-eight were at baseline and six after disease progression. Gene expression assay were performed in 44 tissue samples but only 31 samples were possible to be targeted deep sequencing.

We performed differently expressed gene(DEG) analysis for detecting the association between level of gene expression and disease progression. In this analysis, high expression of CCNE1, TGFB4 and BAMBI and low expression of DDB2, CD14 and SHC3 were associated with disease progression among 730 PanCancer panel genes (p<0.05, respectively). In terms of immune panel genes, most of immune related genes were highly expressed in a group without disease progression compared with that with disease progression. Only 2 genes, C8G and CD24 were highly expressed in a group with disease progression. Paired sample analysis showed that expression levels of THBS4 and CD27 decreased after disease progression while those of CCNE2 and FGFR4 increased.

In targeted deep sequencing, FAT3 (42.3%) was most frequently mutated gene followed by PKHD1, PIK3CA and TP53. Among mutated genes, EWSR1 mutation and upstream mutation of ETV1 were associated with disease progression, respectively (p<0.05, respectively). In mutation signature analysis, signature 1 (S, age related), S3(homologous recombination deficiency, HRD), S6 (mismatch repair, MMR), S20(MMR) and S21(microsatellite instability, MSI) were enriched in this population. Mutation signature 3 related to short disease free survival (p=0.0026).

Conclusion: In gene expression analysis, high expression of TGF-B signaling pathway related genes was associated with disease progression while high expression of immune related genes were related to prolonged disease free survival. In mutation analysis, EWSR1 and ETV1 mutations indicated short disease free interval and HRD mutation signature was also related to poor prognosis.

Citation Format: Kim J-Y, Lee EJ, Park KH, Im S-A, Kim S-B, Sohn SH, Lee KS, Chae YS, Lee KH, Kim JH, Im Y-H, Kim T-Y, Lee K-H, Ahn J-H, Kim GM, Park IH, Lee SJ, Han HS, Kim SH, Jung KH, Park YH. Exploratory biomarker analysis from a phase II, multicenter, randomized trial of eribulin plus gemcitabine(EG) versus paclitaxel plus gemcitabine(PG) as first-line chemotherapy for human epidermal growth factor receptor 2 (HER2)- negative metastatic breast cancer(MBC): Korean cancer study group trial (KCSG BR13-11) [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 P3-11-07.

Imputation of faulty magnetic sensors with coupled Bayesian and Gaussian processes to reconstruct the magnetic equilibrium in real time

A Bayesian with Gaussian process-based numerical method to impute a few missing magnetic signals caused by impaired magnetic probes during tokamak operations is developed such that the real-time reconstruction of magnetic equilibria, whose performance strongly depends on the measured magnetic signals and their intactness, is affected minimally. Likelihood of the Bayesian model constructed with Maxwell's equations, specifically Gauss's law for magnetism and Ampère's law, results in an infinite number of solutions if two or more magnetic signals are missing. This undesirable characteristic of the Bayesian model is remediated by coupling the model with the Gaussian process. Our proposed numerical method infers nine non-consecutive missing magnetic signals correctly in less than 1 ms suitable for the real-time reconstruction of magnetic equilibria during tokamak operations.

Abstract OT2-07-06: Phase Ib study to assess the safety, tolerability, and clinical activity of gedatolisib in combination with palbociclib and either letrozole or fulvestrant in women with metastatic or locally advanced/recurrent breast cancer (B2151009)

Background:Hormone receptor positive (HR+) disease is the most common subset of advanced breast cancer (BC). The majority of women with HR+ metastatic BC (MBC) develop resistance to endocrine therapy (ET), with a median survival of 2-3 years. A new strategy to treat HR+ MBC involves the combination of ET and a cyclin-dependent kinase 4/6 inhibitor (CDKi 4/6), which has demonstrated improved progression-free survival (PFS) in both first-and later-line MBC. Preclinical evidence in PI3K-mutant cell-line xenografts demonstrated that combinations of PI3K and CDK4/6i reduced intrinsic and adaptive resistance to ET, leading to tumor regression (Vara, 2004; Pfizer data). Inhibition of the PI3K/mTOR pathway by gedatolisib (G) may provide a new therapy to overcome ET resistance. These findings support developing the triplet combination of G with the CDKi 4/6 palbociclib (P)+letrozole (L) or fulvestrant (F) for the treatment of patients (pts) with ER+/HER2- BC.

Methods: This ongoing study in women with ER+/HER2- MBC, in first- and later-line settings, includes a dose-escalation (DE) to evaluate dose-limiting toxicities (DLTs, primary endpoint [pEP]) and determine the maximum tolerated dose and recommended phase 2 dose (RP2D) for a triplet regimen of G+P+L or G+P+F. The escalation rules follow the modified toxicity probability interval method (G doses: 180 and 215 mg IV weekly). Treatment assignment to the triplet is based on investigator decision and bone-only disease is permitted. After RP2D determination for each triplet, a 3-arm expansion for early signs of efficacy (ESOE) will investigate objective response rate (ORR) compared to historical controls [pEP] of Arm A) G+P+L in first-line, B) G+P+F in pts with no prior CDKi 4/6 in second-line and C) G+P+F in pts who have received prior CDKi 4/6. Pts receive G+P (125 mg oral daily for 21 days [D] on and 7 D off) + L (2.5 mg oral daily) or F (500 mg IM on D1, 15 of cycle [C] 1; D1 of C2 and then 500 mg IM on D1 of all 28-D cycles). Secondary endpoints include safety, tumor response (DE), PFS (ESOE), pharmacokinetics (PK), and biomarker correlations associated with the PI3K/mTOR pathway.

Results: 27 pts received G (180 mg/week) in combination with P+L (L cohort, n=12) or P+F (F cohort, n=15). Median prior therapies were: L cohort: 1 (range: 0-4); F cohort: 2 (range 1-5). The 3 most common, drug-related adverse events (%) were in L cohort: nausea (75), neutropenia (67), and stomatitis (67); F cohort: stomatitis (67), nausea (60), and neutropenia (53). C1 DLTs were: L cohort: grade (gr) 3 neutropenia (n=1); F cohort: gr 3 stomatitis (n=1). Preliminary rates of stable disease/partial response were: L cohort: 33%/16%; F cohort: 40%/13%. PK parameters and next-generation sequencing of PI3K-related mutations are pending.

Conclusions: G can be combined with P+L or P+F with manageable toxicity and promising preliminary antitumor activity, even in heavily pretreated pts. Dose escalation, followed by expansion for ESOE, is ongoing.

This study is sponsored by Pfizer. Editorial support was provided by Engage Scientific Solutions and was funded by Pfizer.

Citation Format: Forero A, Han HS, Dees EC, Wesolowski R, Bardia A, Kabos P, Kern KA, Perea R, Pierce KJ, Houk B, Rugo HS. Phase Ib study to assess the safety, tolerability, and clinical activity of gedatolisib in combination with palbociclib and either letrozole or fulvestrant in women with metastatic or locally advanced/recurrent breast cancer (B2151009) [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-07-06.

Abstract PD3-14: Phase 1 study of the antibody-drug conjugate SGN-LIV1A in patients with heavily pretreated triple-negative metastatic breast cancer

Background

LIV-1, a transmembrane protein and downstream target of STAT3, is highly expressed in breast cancer cells. It is associated with lymph node involvement and metastatic progression. SGN-LIV1A is an anti-LIV-1 antibody conjugated via a protease-cleavable linker to monomethyl auristatin E (MMAE). Upon binding to cell-surface LIV-1, SGN-LIV1A is internalized and releases MMAE, which disrupts microtubulin and induces apoptosis.

Methods

This ongoing, phase 1 study evaluates safety, tolerability, pharmacokinetics, and antitumor activity of SGN-LIV1A (q3wks IV) in women with LIV-1-positive, unresectable, locally advanced or metastatic breast cancer (LA/MBC) (NCT01969643). Patients (pts) with measurable disease and ≥2 prior cytotoxic regimens for LA/MBC are eligible. Pts with ≥ Grade 2 neuropathy are excluded. Response is assessed per RECIST v1.1; pts with stable disease (SD) or better can continue treatment until disease progression or intolerable toxicity. At completion of dose escalation in hormone receptor-positive/HER2-negative (HR+/HER2–) and triple-negative (TN) pts, expansion cohorts were opened to further evaluate safety and antitumor activity of monotherapy in TN pts. Tumor biopsies are evaluated for LIV-1 expression.

Results

To date, 69 pts (18 HR+/HER2–, 51 TN) have received a median of 3 cycles (range, 1–12) of SGN-LIV1A at doses of 0.5–2.8 mg/kg. Median age was 56 yrs. Pts had a median of 3 prior cytotoxic regimens for LA/MBC; 58 had visceral disease and 37 had bone metastases. No dose-limiting toxicities (DLTs) occurred in 19 DLT-evaluable pts; maximum tolerated dose was not exceeded at 2.8 mg/kg. Expansion cohorts of TN pts were opened at 2.0 and 2.5 mg/kg. Treatment-emergent adverse events (AEs) reported in ≥25% of pts were fatigue (59%), nausea (51%), peripheral neuropathy (44%), alopecia (36%), decreased appetite (33%), constipation (30%), abdominal pain, diarrhea, and neutropenia (25% each). Most AEs were Grade 1/2; AEs ≥ Grade 3 included neutropenia (25%) and anemia (15%). Febrile neutropenia occurred in 2 pts whose total dose exceeded 200 mg per cycle, including 1 treatment-related death due to sepsis. No other treatment-related deaths occurred on-study. Seven pts discontinued treatment due to AEs. In dose escalation, activity was observed in 17 efficacy evaluable (EE) HR+/HER2- pts, with a disease control rate (DCR= CR+PR+SD) of 59% (10 SD), including 1 pt with SD ≥24 wks. Among the 44 EE TN pts (dose escalation plus expansion cohorts), the objective response rate (ORR) was 32% (14 PR) with a confirmed PR rate of 21%, DCR was 64% (14 PR, 14 SD), and clinical benefit rate (CBR=CR+PR+SD ≥24 wks) was 36% (16 pts). For TN pts, median PFS was 11.3 wks (95% CI: 6.1, 17.1); 10 pts remain on treatment.

Of 631 MBC tumor samples of all clinical subtypes evaluated for LIV-1, 91% were positive; 75% had moderate-to-high expression (H-score ≥100).

Conclusions

LIV-1 is expressed in almost all MBC tumors. SGN-LIV1A monotherapy was generally well tolerated and showed encouraging antitumor activity in heavily pretreated TN MBC, with a PR rate of 32%, confirmed PR rate of 21%, and CBR (≥24 wks) of 36%. Response duration data continue to evolve. Enrollment continues in the TN monotherapy expansion cohort.

Citation Format: Modi S, Pusztai L, Forero A, Mita M, Miller KD, Weise A, Krop I, Burris III H, Kalinsky K, Tsai M, Liu MC, Hurvitz SA, Wilks S, Ademuyiwa F, Diab S, Han HS, Kato G, Nanda R, O'Shaughnessy J, Kostic A, Li M, Specht J. Phase 1 study of the antibody-drug conjugate SGN-LIV1A in patients with heavily pretreated triple-negative metastatic breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD3-14.

Veliparib with temozolomide or carboplatin/paclitaxel versus placebo with carboplatin/paclitaxel in patients with BRCA1/2 locally recurrent/metastatic breast cancer: randomized phase II study

Background

Homologous recombination defects in BRCA1/2-mutated tumors result in sensitivity to poly(ADP-ribose) polymerase inhibitors, which interfere with DNA damage repair. Veliparib, a potent poly(ADP-ribose) polymerase inhibitor, enhanced the antitumor activity of platinum agents and temozolomide in early phase clinical trials. This phase II study examined the safety and efficacy of intermittent veliparib with carboplatin/paclitaxel (VCP) or temozolomide (VT) in patients with BRCA1/2-mutated breast cancer.

Patients and methods

Eligible patients ≥18 years with locally recurrent or metastatic breast cancer and a deleterious BRCA1/2 germline mutation were randomized 1 : 1 : 1 to VCP, VT, or placebo plus carboplatin/paclitaxel (PCP). Primary end point was progression-free survival (PFS); secondary end points included overall survival (OS) and overall response rate (ORR).

Results

Of 290 randomized patients, 284 were BRCA+, confirmed by central laboratory. For VCP versus PCP, median PFS was 14.1 and 12.3 months, respectively [hazard ratio (HR) 0.789; 95% CI 0.536-1.162; P = 0.227], interim median OS 28.3 and 25.9 months (HR 0.750; 95% CI 0.503-1.117; P = 0.156), and ORR 77.8% and 61.3% (P = 0.027). For VT (versus PCP), median PFS was 7.4 months (HR 1.858; 95% CI 1.278-2.702; P = 0.001), interim median OS 19.1 months (HR 1.483; 95% CI 1.032-2.131; P = 0.032), and ORR 28.6% (P < 0.001). Safety profile was comparable between carboplatin/paclitaxel arms. Adverse events (all grades) of neutropenia, anemia, alopecia, and neuropathy were less frequent with VT versus PCP.

Conclusion

Numerical but not statistically significant increases in both PFS and OS were observed in patients with BRCA1/2-mutated recurrent/metastatic breast cancer receiving VCP compared with PCP. The addition of veliparib to carboplatin/paclitaxel significantly improved ORR. There was no clinically meaningful increase in toxicity with VCP versus PCP. VT was inferior to PCP. An ongoing phase III trial is evaluating VCP versus PCP, with optional continuation single-agent therapy with veliparib/placebo if chemotherapy is discontinued without progression, in this patient population.

Clinical trial information

NCT01506609.

Phase II study of buparlisib (BKM120) and trastuzumab in patients with HER2+ locally advanced or metastatic breast cancer resistant to trastuzumab-based therapy

PURPOSE

A Phase Ib study in patients with trastuzumab-resistant, human epidermal growth factor receptor-2- (HER2)-positive advanced breast cancer defined the recommended Phase II dose of buparlisib as 100 mg/day in combination with 2 mg/kg weekly trastuzumab, and reported preliminary signs of clinical activity. Here we present results from the Phase II portion.

METHODS

Patients with trastuzumab-resistant, HER2-positive advanced breast cancer received buparlisib plus trastuzumab. Study endpoints included safety/tolerability and antitumour activity. The study was extended to include a Phase Ib dose-escalation phase, in which patients with progressive brain metastases also received capecitabine.

RESULTS

In the Phase II portion, of 50 patients treated with buparlisib and trastuzumab, the most common (≥ 30%) all-grade adverse events (AEs) were diarrhoea (54%), nausea (48%), decreased appetite, increased alanine aminotransferase (36% each), increased aspartate aminotransferase (34%), fatigue, rash (32% each), cough and hyperglycemia (30% each). One (2%) patient achieved complete response and four (8%) patients had confirmed partial responses [PR; including two patients with phosphatidylinositol 3-kinase (PI3 K) pathway-activated tumours]. Overall response rate (ORR) was 10%: the primary endpoint (ORR ≥ 25%) was therefore not met. In the Phase Ib portion, all patients with measurable brain lesions at baseline showed tumour shrinkage to some degree; due to low enrollment, maximum tolerated dose of buparlisib in combination with trastuzumab and capecitabine was not determined.

CONCLUSION

Buparlisib plus trastuzumab, as a chemotherapy-free regimen, demonstrated an acceptable safety profile but limited efficacy in patients with heavily pretreated, trastuzumab-resistant HER2-positive breast cancer, and in patients with progressive brain metastases also receiving capecitabine.

Toxicity profile differences of adjuvant docetaxel/cyclophosphamide (TC) between Asian and Caucasian breast cancer patients

AIM

For early-stage breast cancer, four cycles of docetaxel and cyclophosphamide (TC) was proven superior to doxorubicin plus cyclophosphamide in the US Oncology 9375 trial. Given primary prophylactic antibiotics, 5% febrile neutropenia was recorded in a population comprising 75.5% Caucasians. Smaller trials and retrospective studies reviewing TC use in Asian patients did not produce similar incidence rates. This study aims to discover the variable hematological toxicities with TC use in Caucasian and Asian patients.

METHODS

Breast cancer data was retrospectively reviewed for patients receiving adjuvant docetaxel 60-75 mg/m² plus cyclophosphamide 600 mg/m² from six countries (China, Hong Kong, Japan, Taiwan, Italy, and United States). Similar number of patients with relatively balanced baseline characteristics were chosen for analysis of hematological and nonhematological toxicities and survival data.

RESULTS

From March 2004 to July 2013, data of 227 patients (127 Asians and 100 Caucasian) patients were analyzed for treatment-related toxicities. During the four cycles of TC, Asians had a significantly higher rate of grade ≥2 neutropenia than Caucasians (45.7% vs 6.0%; P <0.001) and significantly more grade ≥3 neutropenia events were documented (respectively 30.7% vs 4.0%, P <0.001). The prophylactic use of G-CSF was similar; 26.0% in Asians and 28.0% in Caucasian (P = 0.764). There were no differences in nonhematological toxicities. No significant difference in disease-free survival was observed between Asians and Caucasians (log-rank P = 0.910).

CONCLUSIONS

Ethnic differences in toxicity profile exist between Asian and Caucasian patients given adjuvant TC. Over 30% Asians but less than 5% Caucasians experienced grade ≥3 neutropenia.

Abstract P6-12-15: Efficacy results of a phase 1/2 study of glucocorticoid receptor (GR) antagonist mifepristone (MIFE) in combination with eribulin in GR-positive triple-negative breast cancer (TNBC)

Background: GR is variably expressed in TNBC and high expression is associated with poor prognosis in estrogen receptor-negative (ER-) early stage breast cancer. Treatment with mifepristone (MIFE) potentiates the effectiveness of chemotherapy in GR+ TNBC xenografts. Enrollment is complete in this study of patients with GR+ TNBC treated at the recommended Phase 2 dose (RP2D) of MIFE in combination with eribulin. Objectives: To determine the safety, tolerability, pharmacokinetics (PK) and clinical activity of the MIFE plus eribulin combination in pts with GR+ TNBC at the RP2D. Methods: Eligibility: In Part 1 (dose finding), pts with solid tumors; in Part 2 (expansion phase), pts with TNBC (GR result required at time of screening in Part 1, but could be pending at time of screening in Part 2). Up to 5 prior chemotherapy regimens for advanced disease; ECOG PS 0-1; adequate end-organ function. Design: 3 + 3 dose escalation scheme. After a 7-day lead-in of oral daily MIFE alone, MIFE was continued daily and eribulin was given on days 1 and 8 of a 21-day cycle. GR+ was defined as &gt;10% of tumor cells with any intensity of GR staining. Results: 16 pts with metastatic breast cancer were treated in Part 1, and 21 pts with TNBC were treated in Part 2. Median age was 54 (range 30-81). MTD/RP2D was MIFE 300 mg/day + eribulin 1.1 mg/m2. Safety: DLT in Part 1 was neutropenia. Neutropenia occurred in 23/36 total patients (2 Grade [G] 1, 10 G3, 11 G4); 2 instances included neutropenic fever. Recovery of WBC was brisk with growth factor support. Neuropathy was observed in 8 pts (5 G1, 1 G2, 2 G3). Other most common AEs (fatigue, hypokalemia, nausea, alopecia) were mainly G1 or G2; among these, G3/G4 events were limited to fatigue (4 G3), hypokalemia (3 G3 and 1 G4) and nausea (1 G3). There were 2 instances of G1 vaginal bleeding. There was no impact of MIFE on eribulin PK. Efficacy: There were 23 evaluable pts with TNBC across Parts 1 and 2 treated at the RP2D: 21 GR+, 2 GR status unknown; median of 3 prior chemotherapy regimens; 1 patient had received prior eribulin. Responses were: 3 PR, 8 SD, 11 PD and one too early to assess. Median PFS was 9 weeks. Conclusions: MIFE plus eribulin was well tolerated and appears to be an active treatment regimen. Five TNBC patients had a PFS longer than the upper 95% CI for PFS (i.e., &gt;15 wks) reported by Aogi et al. for TNBC treated with eribulin (Annals of Oncology 2012?23:144148). Clinical trial information: NCT02014337.

Citation Format: Han HS, Wilks S, Paplomata E, Modiano MR, Becerra C, Braiteh FS, Spira AI, Pluard TJ, Richards DA, Conzen SD, Baker G, Fishman RS, Marcantonio A, O'Shaughnessy J, Nanda R. Efficacy results of a phase 1/2 study of glucocorticoid receptor (GR) antagonist mifepristone (MIFE) in combination with eribulin in GR-positive triple-negative breast cancer (TNBC) [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 P6-12-15.

Abstract OT1-01-12: A phase II, multicenter, randomized trial of eribulin plus gemcitabine (EG) vs. paclitaxel plus gemcitabine (PG) in patients with HER2-negative metastatic breast cancer as first-line chemotherapy

Background: Metastatic breast cancer (MBC) is an incurable disease and is needed to improve effective chemotherapy. Paclitaxel plus Gemcitabine (PG) combination chemotherapy is one of the preferred chemotherapeutic regimens for patients with MBC, and was found to be proper as a maintenance chemotherapy regimen with survival benefit and feasible toxicity profile. Eribulin mesylate is a non-taxane inhibitor of microtubule dynamics of the halichondrin class of antineoplastic drugs. A recent pooled analysis of two phase II studies with eribulin showed improved overall survival in in various patient subgroups with advanced/metastatic breast cancer who had previously received an anthracycline and a taxane. Furthermore, eribulin may have rational benefit compared with paclitaxel in terms of neurotoxicity. Therefore, Eribulin plus Gemcitabine (EG) combination chemotherapy may have less neurotoxocity comparing to PG.

Trial Design: Prospective randomized phase 2, open-label, two-arm, multi-center study comparing EG chemotherapy with PG chemotherapy for patients with HER-2 negative MBC as first-line chemotherapy.

Eligibility Criteria: Histologically confirmed breast cancer patients, at least 19 years of age, with no prior history of chemotherapy for metastatic, recurrent breast cancer with evaluable lesions (as per RECIST, 1.1) who have adequate hematologic, renal, and hepatic function. Patients either may or may not have a prior anthracycline containing regimen. Prior hormonal therapy as a treatment of metastatic disease is allowed.

Specific Aims:

The primary efficacy endpoint of the trial is Progression-Free Survival (PFS). The secondary efficacy endpoints are: Time to Treatment Failure (TTF); Overall Survival (OS); neuropathic scale (FACT for Taxane QOL assessment); toxicity; duration of response; Objective Response Rate (ORR); Clinical Benefit Rate. The exploratory endpoint of the study includes pharmacogenetic profile.

Statistical Methods:

The initial sample size of the present study was determined based on the data derived from a previous trial on PG maintenance chemotherapy design; 6-month PFS is 70% for PG chemotherapy. This design was hypothesized that EG chemotherapy would not be inferior to PG chemotherapy. Thus, estimated PFS for each arm is 70%. Based on this estimate, we would plan to recruit a total of 100 patients (50 per arm). Considering drop-out rate of 10%, total 112 MBC patients planned to be enrolled.

Present Accrual and Target Accrual:Enrollment has been completed as of March, 2016 with a target enrollment of 112 patients.

Contact information:Kyung Hae Jung MD, Ph.D. khjung@amc.seoul.kr

ClinicalTrials.gov Identifier: NCT02263495.

Citation Format: Park YH, Im S-A, Sohn JH, Lee KS, Chae YS, Lee KH, Kim J-H, Im Y-H, Ahn JS, Kim T-Y, Lee K-H, Kim S-B, Ahn J-H, Kim GM, Park IH, Lee SJ, Han HS, Kim SH, Jung KH. A phase II, multicenter, randomized trial of eribulin plus gemcitabine (EG) vs. paclitaxel plus gemcitabine (PG) in patients with HER2-negative metastatic breast cancer as first-line chemotherapy [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 OT1-01-12.

Abstract P4-22-02: Evaluation of veliparib (V) and temozolomide (TMZ) in a phase 2 randomized study of the efficacy and tolerability of V+TMZ or carboplatin (C) and paclitaxel (P) vs placebo (Plc)+C/P in patients (pts) with BRCA1 or BRCA2 mutations and metastatic breast cancer

Background: V is a potent, poly(ADP-ribose) polymerase (PARP) inhibitor that obstructs DNA damage repair. BRCA1/2 tumors are defective in homologous recombination, which leads to more error-prone mechanisms of DNA repair and increased sensitivity to PARP inhibition. V enhances the antitumor activity of alkylating agents such as TMZ in preclinical models. In addition, V+TMZ showed promising activity in a single-arm phase 2 study in pts with BRCA1/2 mutations. This phase 2 trial (NCT01506609) investigated the efficacy and tolerability of V+TMZ (or V+C/P) compared to Plc+C/P in pts with locally recurrent or metastatic breast cancer harboring a BRCA1 or BRCA2 mutation. Results from the primary analysis for the V+TMZ arm vs Plc+C/P are presented, and the V+C/P vs Plc+C/P results will be presented separately.

Methods: Male and female pts aged ≥18 years with histologically confirmed locally recurrent or metastatic breast cancer were randomized 1:1:1 to: 1) V 40 mg BID D1–7 + TMZ 150–200 mg/m2 QD D1–5, 28-D cycle; 2) V 120 mg BID D1–7 + C AUC 6, D3 and P 175 mg/m2, D3, 21-D cycle; 3) placebo BID D1–7 + C/P. Key eligibility criteria included known deleterious BRCA1/2 mutation, ≤2 prior chemotherapies for metastatic disease, no prior platinum agent, and no CNS metastases. Randomization was stratified by hormone receptor status, prior cytotoxic therapy (yes vs no), and ECOG PS (0–1 vs 2). The primary endpoint was progression-free survival (PFS) per RECIST 1.1 by independent review. Overall survival (OS), objective response rate (ORR), and safety/tolerability were also evaluated.

Results: A total of 290 pts (284 BRCA+ per central lab) were randomized (V+TMZ, n=94 [91 BRCA+]). Baseline demographics and disease characteristics were comparable among treatment arms; 41.3% of pts had triple-negative breast cancer (TNBC) and 31.7% had received &gt;2 prior regimens. Median study drug exposure was 6 cycles for the V+TMZ arm and 10 cycles for the Plc+C/P arm. Median PFS, median OS (interim), and ORR for V+TMZ were inferior to Plc+C/P (PFS 7.4 vs 12.3 mo, OS 19.1 vs 25.0 mo, and ORR 28.6% vs 61.3%). In pts with TNBC, median PFS was 5.5 (3.1–8.5) mo; 8.4 (6.8–10.6) mo for pts with non-TNBC. Treatment-emergent adverse events (AEs) of interest occurring differentially with V+TMZ are shown in Table 1. Grade ≥3 AEs in ≥30% of pts in the V+TMZ arm were thrombocytopenia (48%) and neutropenia (37%).

Conclusions: V+TMZ provided durable responses, with less neutropenia, alopecia, and neuropathy than Plc+C/P; however, PFS, OS, and ORR were inferior in the TMZ arm compared to C/P.

Table 1Treatment-Emergent AEs, n (%)V+TMZ, n=93Plc+C/P, n=96Neutropenia46 (50)71 (74)Alopecia10 (11)55 (57)Peripheral neuropathy11 (12)56 (58)Thrombocytopenia73 (79)67 (70)Nausea70 (75)56 (58)

Citation Format: Diéras V, Han HS, Robson ME, Palácová M, Marcom PK, Jager A, Bondarenko I, Citrin D, Campone M, Telli ML, Domchek SM, Friedlander M, Kaufman B, Ratajczak C, Coates A, Bonnet P, Qin Q, Qian J, Giranda VL, Shepherd SP, Puhalla S, Isakoff SJ. Evaluation of veliparib (V) and temozolomide (TMZ) in a phase 2 randomized study of the efficacy and tolerability of V+TMZ or carboplatin (C) and paclitaxel (P) vs placebo (Plc)+C/P in patients (pts) with BRCA1 or BRCA2 mutations and metastatic breast cancer [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 P4-22-02.

Relationship between Total Fruit and Vegetable Intake and Self-Reported Knee Pain in Older Adults

OBJECTIVES

Knee pain is one of the most common symptoms of knee osteoarthritis (OA) that affects the quality of life in the older adults, and identifying the contributing factors of knee pain is important. We hypothesized that higher fruit and vegetable consumption might be associated with the severity of knee pain lower prevalence of severe knee pain by affecting pain perception in the knee joint. Therefore, we investigated the relationship between self-reported knee pain and the consumption of fruits vegetables, carotenoids and vitamin C and self-reported knee pain.

DESIGN

Nationally representative cross sectional study.

SETTING

2010-2011 rounds of the Korean National Health and Nutrition Examination Survey.

PARTICIPANTS

A total of 6588 subjects aged ≥50 years were participated.

METHODS

Severity of knee pain was estimated using a 10-point numeric rating scale (NRS). Daily intake of fruits, vegetables, and vitamins were estimated using data from 24-hour recalls and food frequency questionnaires.

RESULTS

The NRS scores of knee pain decreased significantly with increasing fruit and vegetable intake quartiles. A multivariate logistic regression analysis showed that the fourth quartile of vegetable and fruit consumption was associated with decreased prevalence of severe knee pain (OR 0.59, 95% CI 0.48-0.73) compared with first quartile of vegetable and fruit consumption; however, carotenoids and vitamin C consumption was not associated with the severity of knee pain.

CONCLUSIONS

In conclusion, severe knee pain was independently associated with fruit and vegetable consumption. Our findings suggest that intake of whole fruits and vegetables may help improve knee pain in older adults.

Adnexal torsion in early pregnancy after assisted reproduction: can the adnexa be saved?

Adnexal torsion occurs when the ovary and fallopian tube twist on the axis created between the infundibulopelvic ligament and the utero-ovarian ligament. The symptoms are mostly unspecific and diagnosis is therefore not simple. Early diagnosis is essential to preserve organ function and fertility. The increased use of assisted reproductive technologies has led to an increase in the risk of adnexal torsion, particularly in pregnant women or women with ovarian hyperstimulation syndrome (OHSS). A gestational age eight-week pregnant woman who received in vitro fertilization (IVF) came to the clinic and was suspected of adnexal torsion. The patient underwent an operation and the biopsy histologically confirmed ischemia. Here the authors report a case with comparison to other studies, the early diagnosis, and early operation that could save adnexa.

A prospective study on symptom generation according to spicy food intake and TRPV1 genotypes in functional dyspepsia patients

BACKGROUND

Capsaicin is an ingredient of red peppers that binds to transient receptor potential vanilloid subtype 1 (TRPV1), and Koreans eat more capsaicin-rich food than do Japanese. This study aimed to compare symptom generation according to TRPV1 genotypes and the intake of spicy foods.

METHODS

Consecutive functional dyspepsia (FD) patients who were evaluated at Konkuk University Medical Centre (Korea) and Keio University Hospital (Japan) were included. Questionnaires on spicy food intake, patient assessment of gastrointestinal symptoms (PAGI-SYM), patient assessment of quality of life, and hospital anxiety and depression scale were provided. Blood was sampled for the detection of TRPV1 polymorphisms, and upper gastrointestinal endoscopy was performed with biopsies.

KEY RESULTS

Of 121 included subjects, 35 and 28 carried the TRPV1 CC and GG genotypes, respectively, with the prevalence rates not differing between Japan and Korea. The prevalence of FD subtypes did not differ with the spicy food intake, TRPV1 genotypes, or Helicobacter pylori infection. Neither TRPV1 polymorphisms nor H. pylori infections were related to scores on the PAGI-SYM questionnaires, but spicy food intake was positively correlated with the scores for stomach fullness (p = 0.001) and retching (p = 0.001). Using the linear regression analysis, stomach fullness was associated with spicy food intake (p = 0.007), whereas retching was related to younger age (p < 0.001) and female gender (p = 0.014).

CONCLUSIONS & INFERENCES

Upper gastrointestinal symptoms are more common in subjects with a higher consumption of spicy foods, younger age and female gender, regardless of TRPV1 genotypes and the H. pylori infection status. Capsaicin-rich foods may induce stomach fullness.

Polysaccharide-based nanoparticles for theranostic nanomedicine

Polysaccharides are natural biological molecules that have numerous advantages for theranostics, the integrated approach of therapeutics and diagnostics. Their derivable reactive groups can be leveraged for functionalization with a nanoparticle-enabling conjugate, therapeutics (small molecules, proteins, peptides, photosensitizers) and/or diagnostic agents (imaging agents, sensors). In addition, polysaccharides are diverse in size and charge, biodegradable and abundant and show low toxicity in vivo. Polysaccharide-based nanoparticles are increasingly being used as platforms for simultaneous drug delivery and imaging and are therefore becoming popular theranostic nanoparticles. The review focuses on the method of nanoparticle formation (self-assembled, physical or chemical cross-linked) when engineering polysaccharide-based nanoparticles for theranostic nanomedicine. We highlight recent examples of polysaccharide-based theranostic systems from literature and their potential for use in the clinic, particularly chitosan- and hyaluronic acid-based NPs.

Effects of intraoperative protective lung ventilation on postoperative pulmonary complications in patients with laparoscopic surgery: prospective, randomized and controlled trial

BACKGROUND

Respiratory functions are usually impaired during pneumoperitoneum for laparoscopic surgery. This randomized, controlled and single-blinded study was performed to evaluate whether intraoperative protective lung ventilation influences postoperative pulmonary complications after laparoscopic hepatobiliary surgery.

METHODS

Sixty-two patients were randomized to receive either conventional ventilation with alveolar recruitment maneuver (tidal volume of 10 ml/kg with inspiratory pressure of 40 cmH2O for 30 s after the end of pneumoperitoneum, group R), or protective lung ventilation (low tidal volume of 6 ml/kg with positive end-expiratory pressure [PEEP] of 5 cmH2O, group P). Induction and maintenance of anesthesia were done with balanced anesthesia. Respiratory complications such as atelectasis, pneumonia or desaturation were observed postoperatively. The length of hospital stay, arterial blood gas analysis, peak inspiratory pressure and hemodynamic variables were also recorded. Results are presented as mean ± SD or number of patients (%).

RESULTS

Postoperative pulmonary complications (P = 0.023) and desaturation below 90 % (P = 0.016) occurred less frequently in group P than in group R. Eight patients of group R and 3 patients of group P showed atelectasis. Pneumonia was diagnosed in 1 patient of group R. No differences were observed in the length of hospital stay, arterial blood gas analysis (pH, PaO2, PaCO2 and PAO2) and hemodynamic variables except PAO2, AaDO2 and peak inspiratory pressure between the two groups.

CONCLUSION

Protective lung ventilation (low tidal volume with PEEP) during pneumoperitoneum was associated with less incidences of pulmonary complications than conventional ventilation with alveolar recruitment maneuver after laparoscopic hepatobiliary surgery.

Non-invasive determination of the immune physiological state of reindeer (Rangifer tarandus) in the Greater Khingan Mountains, China

Immunoglobulin and cortisol levels are good indicators of well-being and living status in animals. In this study, the concentrations of fecal immunoglobulins A ([IgAF]), G ([IgGF]), and M ([IgMF]), and cortisol ([cortisolF]) were examined by enzyme-linked immunosorbent assay in reindeer of the Greater Khingan Mountains of Inner Mongolia, China. [IgAF] was significantly higher than [IgGF] and [IgMF], and [IgGF] was significantly higher than [IgMF] (P < 0.05). Both [IgAF] and [IgGF] were higher in the Adult group than in Aged or Infant groups, and higher in the Young than Infant group (P < 0.05). The four age group [IgMF]s were not significantly different (P > 0.05). [IgAF], [IgGF], and [IgMF] in each age group were higher in females than in males, with a significant difference in the Young group (P < 0.05). The Infant group had the highest [cortisolF], and the Adult group the lowest; [cortisolF] was significantly higher in the Infant group than in other age groups (P < 0.05). In each age group, [cortisolF] was higher in females than males, and there were significant differences among the Infant, Young, and Aged groups (P < 0.05). A significant negative correlation was observed between [cortisolF] and [IgAF] and [IgGF] (P > 0.05). Overall physical condition was better in the Adult and Young groups than in the Aged and Infant groups as determined by the comprehensive analysis of fecal Ig levels in the four age groups, with the Infant group the worst.

Low temperature activation of CO removal by O3-assisted catalysis

Catalytic CO oxidation was activated at low temperature by injecting O3 as an additive. It was empirically confirmed that CO removal rate was dramatically enhanced by supplying a small amount of O3, and the reaction temperature was almost half that required for CO oxidation when using a catalyst only. By optimizing the concentration of O3, catalytic CO oxidation could be achieved within 1 min at low operational temperature. The removal rate of CO was sensitive to the concentration of O3, and a deduced reaction mechanism is discussed to explain how catalytic CO oxidation is activated but subsequently deactivated at higher O3 concentration. Moreover, the presence of C3H8 and C3H6 were considered to evaluate the effects of each gas on the enhancement of CO removal rate by O3. Finally, the rate of CO removal was evaluated with increasing O3 concentration for practical applications such as the cold-start problem in automobile engines.

Genetic differences between the wild and hatchery-produced populations of Korean short barbeled grunter (Hapalogenys nitens) determined with microsatellite markers

Short barbeled grunter, Hapalogenys nitens, is an economically important fishery resource. In Korea, this fish is in the early stage of domestication, and it has been regarded as the candidate marine fish species for prospective aquaculture diversification. This study presents a preliminary investigation of the future viability of sustainable fry production from short barbeled grunter. We used 12 polymorphic nuclear microsatellite DNA loci to analyze the possible genetic variability between the wild and hatchery-produced populations of short barbeled grunter from Korea and identified 91 alleles. Compared to the wild population, significant genetic changes including reduced genetic diversity (average allele number: 7.42 vs 3.75; average expected heterozygosity: 0.713 vs 0.598, Wilcoxon signed-rank test; P < 0.05) and differentiation [overall fixation index (FST) = 0.088, P < 0.01] occurred in the hatchery-produced population, as indicated by the observation of allele richness, unique allele, heterozygosity, FST, and results of molecular analysis of variance. These findings indicate that genetic drift may have promoted the differentiation between these 2 populations, which may have negative effects on sustainable fry production. Therefore, genetic variations of the wild and hatchery-produced populations should be monitored and subjected to control inbreeding through a commercial breeding program. The information presented by this paper would provide a useful genetic basis for future sustainable culturing planning and management of H. nitens.

Influence of therapeutic hypothermia on regeneration after cerebral ischemia

The protective effect of therapeutic hypothermia in cerebral ischemia is well accepted in experimental models, and some clinical studies show that there is benefit in humans as well. Long-term observations in animal and clinical studies have documented recovery of neurological function following hypothermia treatment. Diminished damage by hypothermic protection should contribute to the recovery in many ways, but hypothermia appears to enhance regeneration of brain tissue as well. Since regeneration of the brain after damage initiates within hours and is active days and weeks after stroke, prolonged hypothermia might affect regenerative processes which have been documented to occur in these time frames. As there is a lack of data at the basic and clinical levels, the mechanism of neuroregeneration by hypothermia is unclear. Yet, we speculate that hypothermia enhances regeneration by positively influencing neurogenesis, angiogenesis, gliogenesis and synapse/circuit formation after stroke. In this chapter, we will provide up-to-date data from experimental studies and clinical reports on the effect of therapeutic hypothermia on neuroregeneration, with perspectives on future research.

Resumption or persistence of menstruation after cytotoxic chemotherapy is a prognostic factor for poor disease-free survival in premenopausal patients with early breast cancer

BACKGROUND

We investigated the relationship between resumption or persistence of menstruation after cytotoxic chemotherapy (RM) and disease-free survival (DFS) in premenopausal patients with early breast cancer.

METHODS

Medical records from 872 patients who received cytotoxic chemotherapy for stage I to III breast cancer were retrospectively reviewed.

RESULTS

The median patient age was 41 years (range, 21-54) and the median follow-up duration was 6.2 years (range, 0.7-10.4). Six hundred ninety-two patients (79.4%) were hormone receptor (HR) positive and the majority of these received tamoxifen therapy after completing chemotherapy. The chemotherapy-induced amenorrhea (CIA) rate was 76.7% (n = 669), and 51.8% (n = 452) experienced RM during the follow-up period. One hundred twenty-one (13.9%) patients had persistent menstruation without CIA. DFS was significantly affected by younger age at diagnosis (≤35 years) (P = 0.013), tumor size > 2 cm (P < 0.001), node positivity (P < 0.001), HR negativity (P < 0.001), HER2 positivity (P = 0.010), and RM (P < 0.001). HR negativity [hazard ratio 1.7, 95% confidence interval (CI) 1.2-2.4, P = 0.006], tumor size > 2 cm (hazard ratio 2.1, 95% CI 1.4-3.0, P < 0.001), node positivity (hazard ratio 3.0, 95% CI 2.0-4.7, P < 0.001), and RM (hazard ratio 1.8, 95% CI 1.2-2.7, P = 0.004) remained significant factors for DFS on multivariate analysis.

CONCLUSIONS

A considerable proportion of premenopausal patients treated with chemotherapy experienced RM after CIA. RM was a poor prognostic factor for DFS in premenopausal patients with early breast cancer.

Comprehensive histologic analysis of interstitial lipolysis with the 1444 nm wavelength during a 3-month follow-up

A number of near-infrared wavelengths have been proposed and studied for laser lipolysis, but the histologic evaluation of tissue response to laser lipolysis during long-term follow-up has been lacking. A 1444 nm Nd:YAG laser with better absorption in both fat and water has recently attracted attention. The present study was designed to investigate the comprehensive histopathology of 1444 nm Nd:YAG laser-assisted lipolysis at different energy levels during a 3-month follow-up. Laser lipolysis was performed on porcine fat tissue in vivo using a 1444 nm Nd:YAG laser (AccuSculpt®, Lutronic Corporation, Ilsan, Republic of Korea) and the total energies delivered interstitially to 10x10 cm² areas were 750 J, 1500 J, 2250 J, 3000 J, 3750 J, 4500 J, and 5250 J. Biopsy samples were taken and histologically analyzed immediately after biopsy and at 1, 2, 4, and 12 weeks postoperatively. With a fluence setting above 3000J/100 cm², inflammation was severe and remained by the 3-month follow-up, resulting in severe scarring of the fat tissue. Below this energy level, mild lobular inflammation in the early phase biopsy had resolved with no scarring by the 3-month follow-up. No histologic changes in the epidermis or dermal connective tissue were present. This study suggested that controlling the energy level is important for clinical applications of laser lipolysis with no significant complications.

Laparoscopic hepatectomy for a modified right graft in adult-to-adult living donor liver transplantation

BACKGROUND

We performed a modified right hepatectomy completely by laparoscopic techniques preserving the middle hepatic vein (MHV) branches in adult-to-adult living donor liver transplantation (LDLT).

PATIENTS AND METHODS

Two young women (24 and 25 years old) volunteered to be live donors for their parents who had hepatocellular carcinomas. As the donors expressed concerns about scarring, we performed a laparoscopic procedure using a hand port device. Mobilization of the right liver and the hepatic parenchymal transection were performed under pneumoperitoneum. Parenchymal transection was performed using a laparoscopic ultrasonic aspirator without the Pringle maneuver. During parenchymal transection, major MHV branches >5 mm were preserved using Hem-o-lock clips. The graft was extracted through the hand port site. On the back table, the 3 MHV branches were reconstructed using an artificial vascular graft. The livers were transplanted without complications.

RESULTS

The operative times for the donors were 765 and 898 minutes. The donors did not require transfusions or reoperation; they were discharged on postoperative days 10 and 14 with normal liver functions.

CONCLUSION

A hepatectomy performed completely by laparoscopic techniques for a right graft with preservation of the MHV branches was technically feasible.

High incidence of false-positive PET scans in patients with aggressive non-Hodgkin's lymphoma treated with rituximab-containing regimens

BACKGROUND

Positron emission tomography (PET) is a powerful predictor of relapse and survival in non-Hodgkin's lymphomas (NHLs) based on studies carried out in the prerituximab era. Little is known about the predictive power of PET in rituximab-treated patients.

PATIENTS AND METHODS

Patients with aggressive B-cell NHL with baseline and follow-up PET studies were included. Clinical characteristics, PET and computed tomography scans, biopsy results, and outcomes were reviewed. PET was defined as positive if higher than mediastinal or background activity was observed.

RESULTS

In all, 51 patients (diffuse large B cell-38; mantle cell lymphoma-13) treated with rituximab-containing regimens were included. For 13 of 40 patients (32.5%), mid-therapy PET studies were positive and 9 of 48 patients (18.7%) had positive posttherapy PET. The positive predictive value (PPV), negative predictive value (NPV), sensitivity (Se), and specificity (Sp) of the mid-therapy PET for predicting relapse were 33% [95% confidence interval (CI) 19% to 49%], 68% (95% CI 51% to 81%), 33% (95% CI 6% to 76%), and 68% (95% CI 49% to 82%), respectively. For posttherapy PET, the relapse PPV, NPV, Se and Sp were 19% (95% CI 9% to 33%), 81% (95% CI 67% to 91%), 13% (95% CI 0.6% to 53%), and 80%(95% CI 64% to 90%), respectively.

CONCLUSIONS

Compared with previous reports in prerituximab era, addition of rituximab resulted in reduced PPV and sensitivity of mid- and posttherapy PET in patients with aggressive B-cell NHL.

High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement

We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004. Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening. Post-operatively, the mean maximum flexion was 136 degrees (110 degrees to 140 degrees) in the loosened group and 125 degrees (95 degrees to 140 degrees) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group. These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion.

Domain switching kinetics in disordered ferroelectric thin films

We investigated domain kinetics by measuring the polarization switching behaviors of (111)-preferred polycrystalline Pb(Zr,Ti)O3 films, which are widely used in ferroelectric memories. Their switching behaviors at various electric fields and temperatures could be explained by assuming the Lorentzian distribution of logarithmic domain-switching times. We suggested that the local field variation due to dipole defects at domain pinning sites could explain the Lorentzian distribution.

Development of a broadband telemedical network based on internet protocol in the Asia-Pacific region

OBJECTIVES

To promote the exchange of knowledge and standardization of medical procedures and medical systems in the Asia-Pacific region, we established a medical network with high-quality moving images over broadband Internet lines in February 2003.

METHODS

Real-time teleconferences and live demonstrations with medical-quality videos, broadcast via the Digital Video Transport System, have been used to teach surgical techniques and other medical procedures across national borders. The Asia-Pacific Advanced Network (APAN) committee in August 2005 formally approved our proposal to establish a medical working group within APAN. The network was expanded by the launch of the Trans-Eurasia Information Network 2 in 2006. By the end of 2006, we had conducted 82 events, in 10 countries in the Asia-Pacific region. The multi-station event has increased every year.

RESULTS

There have been no serious transmission problems or ethical conflicts so far. With these experiences and current achievements, we hope to extend this advanced network system to the entire Asia-Pacific.

CONCLUSION

This system is a promising and very useful tool for the standardization of medical system and procedures across national borders. Drawing upon these experiences and current achievements, we hope to extend this advanced network system to the entire Asia-Pacific region.

Differential expression of manganese superoxide dismutase, copper/zinc superoxide dismutase, and catalase in gastric adenocarcinoma and normal gastric mucosa

AIMS

The biologic significance of antioxidant enzymes (AOEs) in gastric adenocarcinoma is still unclear. The aims of this study was to investigate the differential expression of AOEs in gastric carcinoma cells and non-cancerous counterparts and the relationship with the various clinicopathologic variables in gastric cancer patients.

METHODS

Expression status of MnSOD, Cu/ZnSOD, and catalase was evaluated immunohistochemically in 120 paired gastric cancer and adjacent non-cancerous tissue. The tissues were fixed in absolute methanol immediately after surgical resection and immunohistochemistry was performed by microprobe system using tissuemicroarray slides.

RESULTS

All AOEs revealed moderate to strong immunoreactivity in the parietal and intestinal metaplastic cells. Stromal cells in both cancer and non-cancerous tissue expressed MnSOD and catalase but Cu/ZnSOD. Immunoreactivity of MnSOD and catalase was increased in gastric carcinoma cells compared to their non-cancerous counterparts and revealed an association with intestinal type adenocarcinomas whereas immunoreactivity of Cu/ZnSOD did not reveal significant difference between cancer and non-cancerous mucosal cells.

CONCLUSIONS

Expression of MnSOD, Cu/ZnSOD, catalas in gastric cancer cells and non-cancerous counterparts was different and increased MnSOD and possibly catalase may in part be responsible for the increased risk of intestinal type adenocarcinoma of the stomach.

Laparoscopic repair of various types of biliary-enteric fistula: three cases

Biliary-enteric fistula is one of the reasons for converting from laparoscopic cholecystectomy (LC) to open surgery. Here we present three cases of various types of biliary-enteric fistula treated successfully by laparoscopic surgery. Two cases were diagnosed preoperatively, and the remaining case intraoperatively. The first patient had a cholecystoduodenal fistula with a common bile duct stone. The second patient had cholecystocolic and choledochoduodenal fistulas with a common bile duct stone, and the third patient had a cholecystogastric fistula. The fistulas were repaired laparoscopically by intracorporeal suturing or with an endoscopic linear stapling device. All the patients had good postoperative courses without any postoperative complication. Our experience has shown us that with advances in surgical skills and instruments, laparoscopic surgery for biliary-enteric fistula can be adopted as the first treatment choice regardless of the preoperative diagnosis.

Studies of a novel human thrombomodulin immobilized substrate: surface characterization and anticoagulation activity evaluation

Immobilization of the anticoagulative or antithrombogenic biomolecule has been considered as one of the important methods to improve the blood compatibility of artificial biomaterials. In this study, a novel immobilization reaction scheme was utilized to incorporate the human thrombomodulin, an endothelial cell associated glycoprotein, onto the cover glass surface with an aim to develop an anticoagulative substrate. Trichlorotriazine and amino-terminated silane were employed as the coupling agents, while the polyethylene glycol with a molecular weight of 1500 was used as the spacer in this reaction scheme. Protein C activation assay indicated the immobilized human thrombomodulin still has this coenzymatic activity but is lower, possibly due to the conformation variation by the coupling agents. In vitro platelet adhesion assay has demonstrated the surface with immobilized human thrombomodulin is much less platelet-activating than others. Therefore, the novel reaction scheme proposed here is very promising for future development of an anticoagulative silicon or cover glass substrate (e.g. implantable sensor or biochip) by the immobilization of antithrombogenic protein, such as the human thrombomodulin in this study.

Antiproliferative mechanism of retinoid derivatives in ovarian cancer cells

Retinoid derivatives have been implicated for the growth regulation of ovarian cancer cells. However, the molecular mechanisms are not yet fully defined. To dissect detailed mechanisms of each derivative, four ovarian cancer cells (A2774, PA-1, OVCAR-3, SKOV-3) were treated with all-trans retinoic acid (ATRA), 9-cis retinoic acid (9-cis RA), 13-cis RA, or 4-hydroxyphenyl retinamide (4-HPR). When treated with 1 microm, HPR inhibits most effectively the growth of all four cells. Depending on cell types treated, IC(50) values were 0.7-2.7 microm for 4-HPR, and 2.7-9.0 microm for other retinoid derivatives. DNA fragmentation assay indicated that the antiproliferative effect of HPR could be mediated by apoptosis. Transcription assays coupled with transient transfection in OVCAR-3 cells indicated that ATRA, 9-cis RA, and 13-cis RA were active for all RAR/RXR subtypes, whereas 4-HPR was only active for RARgamma. However, 4-HPR exerted the strongest suppression on AP-1 (c-Jun) activity. As expected from AP-1 data, in vitro invasion assays showed that HPR blocked effectively the migration of OVCAR-3 cells. Thus, 4-HPR showed not only more potent antiproliferative activity than any other retinoid derivatives used, but also effectively inhibited the invasion, probably through the suppression of AP-1 activity. Taken together coupled with its selective activity only for RARgamma, these results suggest that 4-HPR could be less toxic, and very effective anticancer drugs for late stage ovarian cancer.

Endoscopic transsphenoidal approach through a widened nasal cavity for pituitary lesions

We operated upon 12 patients with macroadenoma and two with Rathke's cleft cyst using an endoscope through a nasal speculum. Pure endoscopic endonasal transsphenoiolal approach (TSA) was performed in nine patients and endoscope-assisted microscopic endo nasal TSA in five. A thin-bladed nasal speculum was used to achieve a wide, almost midline, pathway without an incision at the septal mucosa. This made it possible to convert from the endoscopic to the microscopic approach and vice versa at any time during operation as the occasion demanded. In 10 of the 12 patients with macroadenoma, adenomas were removed totally and did not recur during the mean follow-up period of 24 months. Two adenomas could not be removed totally due to their invasiveness. In two of five patients who underwent endoscope-assisted microscopic TSA for macroadenoma, the endoscope could visualise residual tumour at blind corners after microscopic tumor removal. Two patients with Rathke's cleft cyst did not show recurrence. No patient showed sinonasal or endocrinological complications. Versatile use of the endoscope through a widened nasal cavity using a nasal speculum is a promising tool for the treatment of pituitary lesions.

Squamous cell lung cancer with solitary subungual metastasis

Subungual metastasis resulting from internal malignancies is an extremely rare event. A few cases of subungual metastasis from lung cancer have been reported. However, subungual metastasis arising from lung cancer without any other form of distant metastases has not been reported. The misdiagnosis of a solitary subungual metastases as a benign inflammatory lesion is an important problem as it may cause the misdiagnosis of a lower stage of lung cancer. We may be reporting the first case of a subungual metastasis from lung cancer without any other distant metastases.