Antireflux surgery in patients with gastroesophageal reflux but a negative 24-hour pH study: late outcomes

PURPOSE

Patients with gastroesophageal reflux disease often undergo a 24-hour pH test to confirm pathologic reflux before surgery. However, a negative pH test can occur in some individuals with reflux, and a case might still be made for antireflux surgery based on symptoms of reflux even in the absence of endoscopic esophagitis. The long-term outcomes in patients who underwent antireflux surgery despite negative preoperative test results were determined.

METHODS

Patients were selected from a prospective database. A total of 745 patients met the inclusion criteria, which included typical esophageal reflux symptoms, absence of a large hiatus hernia, preoperative 24-hour pH study performed, endoscopy, and postoperative symptom and satisfaction follow-up available at 5 years. Patients were divided into 3 groups based on 24-hour pH study and endoscopy results: negative pH and negative endoscopy (n = 65), negative pH and positive endoscopy (n = 72), and positive pH (n = 608). The negative pH and negative endoscopy group underwent surgery based on clinical assessment and typical esophageal reflux symptoms. Baseline and follow-up outcomes at 5 years were evaluated using 0 to 10 analog scores, which assessed heartburn, dysphagia, and satisfaction with the overall outcome. Data were analyzed to compare the groups.

RESULTS

The groups were well matched for demographics and preoperative symptom scores. At the median 5-year follow-up, clinical outcome scores were similar among the groups for heartburn, dysphagia, and overall satisfaction. The mean heartburn scores were 1.80 in the negative pH and negative endoscopy group, 1.88 in the negative pH and positive endoscopy group, and 1.91 in the positive pH group (P = .663). The mean satisfaction scores were high in all groups: 8.13, 7.31, and 7.72, respectively (P = .293).

CONCLUSION

No difference in clinical outcome scores was observed. The negative pH and negative endoscopy group had high satisfaction scores and low heartburn and dysphagia scores. Our findings support antireflux surgery in well-selected symptomatic patients with a negative preoperative pH test.

A Method for Increasing the Robustness of Stable Feature Selection for Biomarker Discovery in Molecular Medicine Developed Using Serum Small Extracellular Vesicle Associated miRNAs and the Barrett's Oesophagus Disease Spectrum

The biomarker development field within molecular medicine remains limited by the methods that are available for building predictive models. We developed an efficient method for conservatively estimating confidence intervals for the cross validation-derived prediction errors of biomarker models. This new method was investigated for its ability to improve the capacity of our previously developed method, StaVarSel, for selecting stable biomarkers. Compared with the standard cross validation method, StaVarSel markedly improved the estimated generalisable predictive capacity of serum miRNA biomarkers for the detection of disease states that are at increased risk of progressing to oesophageal adenocarcinoma. The incorporation of our new method for conservatively estimating confidence intervals into StaVarSel resulted in the selection of less complex models with increased stability and improved or similar predictive capacities. The methods developed in this study have the potential to improve progress from biomarker discovery to biomarker driven translational research.

Partial Fundoplication is Effective Treatment for Female Patients with Gastroesophageal Reflux and Scleroderma: A Multicenter Comparative Cohort Study

BACKGROUND

Patients with scleroderma often suffer from dysphagia and gastroesophageal reflux disease (GERD). Partial fundoplication is a validated anti-reflux procedure for GERD but may worsen dysphagia in scleroderma patients. Its utility in these patients is unknown. Here, we evaluate the efficacy and acceptability of partial fundoplication for the treatment of medically refractory GERD in patients with scleroderma.

METHODS

Analysis of a prospectively maintained database of patients who underwent fundoplication across 14 hospitals between 1991 and 2019. Perioperative outcomes, reintervention rates, heartburn, dysphagia, and patient satisfaction were assessed at 3 months, 1- and 3-years post-surgery.

RESULTS

A total of 17 patients with scleroderma were propensity score matched to 526 non-scleroderma controls. All underwent a partial fundoplication. Perioperative outcomes including complication rate, length of stay, and need for reoperation were similar between the two groups. Compared to baseline, both groups reported significantly improved heartburn at 3 months, 1- and 3-years following partial fundoplication. Surgery was equally effective at controlling heartburn across all follow-up timepoints in patients with or without scleroderma. Dysphagia to solids was more common in patients with scleroderma than controls at 3-months post-surgery, but was not significantly different to controls at 1- and 3-year follow-up. Satisfaction scores were high and comparable between both groups across all postoperative timepoints, with 100% of patients with scleroderma reporting that their initial choice to undergo surgery was correct.

CONCLUSIONS

Partial fundoplication controls reflux and is associated with a transient period of dysphagia to solids in patients with scleroderma. This approach is safe, effective and acceptable for patients with scleroderma and medically refractory GERD.

Litigation in breast surgery: unique insights from the English National Health Service experience

Background

The increase in medical negligence claims against the National Health Service (NHS) over the past decade has had a detrimental impact on limited financial and human resources that could otherwise be available for direct clinical care. The aim of this study was to review litigation claims in breast surgery as part of the national Getting It Right First Time quality improvement initiative, with the aim of identifying opportunities to improve clinical practice and patient safety.

Methods

All general and plastic surgical claims notified to NHS Resolution between April 2012 and April 2018 were reviewed. Claims related specifically to breast surgery were retrieved manually, and case summaries were analysed independently by two breast surgeons.

Results

From 6915 claims, 449 relating to breast surgery were identified and reviewed. The mean(s.d.) claimant age was 46(13) years. The median number of claims over the 6-year period per NHS trust was 2 (range 0–22). The most frequent causes of litigation were dissatisfaction with cosmetic outcome (121 claims, 26.9 per cent) and patient-reported delays in diagnosis (121, 26.9 per cent). A large proportion of claims related to breast implant surgery (78, 17.4 per cent), and issues regarding consent/communication were common (69, 15.4 per cent). The estimated annual cost of breast surgery litigation claims ranged from £5.57 to £9.59 million (€6.35–11.02 million).

Conclusion

Patient-reported delays in diagnosis and dissatisfaction with cosmetic outcome are the most common causes of litigation related to breast surgery. These key themes should be the focus for workforce learning, with the aim of improving patient care and experience.

Five Year Follow-up of a Randomized Controlled Trial of Laparoscopic Repair of Very Large Hiatus Hernia With Sutures Versus Absorbable Versus Nonabsorbable Mesh

OBJECTIVE

To determine whether absorbable or nonabsorbable mesh repair of large hiatus hernias is followed by less recurrences at late follow-up compared to sutured repair.

SUMMARY OF BACKGROUND DATA

Radiological recurrences have been reported in up to 30% of patients after repair of large hiatus hernias, and mesh repair has been proposed as a solution. Earlier trials have revealed mixed outcomes and early outcomes from a trial reported previously revealed no short-term advantages for mesh repair.

METHODS

Multicentre prospective double-blind randomized controlled trial of 3 methods of hiatus hernia repair; sutures versus absorbable mesh versus nonabsorbable mesh. Primary outcome - hernia recurrence assessed by barium meal X-ray and endoscopy at 3-4 years. Secondary outcomes - clinical symptom scores at 2, 3, and 5 years.

RESULTS

126 patients were enrolled - 43 sutures, 41 absorbable mesh, and 42 nonabsorbable mesh. Clinical outcomes were obtained at 5 years in 89.9%, and objective follow-up was obtained in 72.3%. A recurrent hernia (any size) was identified in 39.3% after suture repair, 56.7% - absorbable mesh, and 42.9% - nonabsorbable mesh (P = 0.371). Clinical outcomes were similar at 5 years, except chest pain, diarrhea, and bloat symptoms which were more common after repair with absorbable mesh.

CONCLUSIONS

No advantages were demonstrated for mesh repair at up to 5 years follow-up, and symptom outcomes were worse after repair with absorbable mesh. The longer-term results from this trial do not support mesh repair for large hiatus hernias.

Long-term follow-up of two randomized trials comparing laparoscopic Nissen 360° with anterior 90° partial fundoplication

BACKGROUND

The side-effects of Nissen fundoplication have led to modifications, including partial fundoplications such as an anterior 90° wrap. Five-year follow-up of two randomized trials suggested fewer side-effects following anterior 90° partial fundoplication, but better reflux control after Nissen fundoplication. However, longer-term outcomes have not been reported. This study combined data from previous trials to determine 10-year outcomes.

METHODS

From 1999 to 2003, 191 patients were enrolled in two randomized trials comparing anterior 90° partial versus Nissen fundoplication. Trial protocols were similar, and data were combined to determine long-term clinical outcomes. Patients completed annual questionnaires assessing dysphagia, heartburn, medications, satisfaction and other symptoms. Visual analogue scales (0-10), a composite dysphagia score (0-45) and yes/no responses were used.

RESULTS

Of the 191 patients, 152 (79·6 per cent) were available for 10-year follow-up. After anterior 90° fundoplication, patients reported less dysphagia to solids (score 2·03 versus 3·18 for the Nissen procedure; P = 0·037). Heartburn scores were lower after Nissen fundoplication (1·90 versus 2·83 for anterior 90° fundoplication; P = 0·035) and fewer patients required proton pump inhibitors (PPIs) (22 versus 39 per cent respectively; P = 0·035). Satisfaction scores were similar for both anterior 90° and Nissen groups (7·45 versus 7·36 respectively; P = 0·566), and the majority considered their original decision for surgery to be correct (86 versus 84 per cent; P = 0·818).

CONCLUSION

After 10 years, both procedures achieved similar success as measured by global satisfaction measures. Patients who had a Nissen fundoplication reported more dysphagia, whereas more heartburn and PPI consumption were reported after anterior 90° fundoplication. Registration numbers: ACTRN12607000298415 and ACTRN12607000304437 (http://www.anzctr.org.au/).

A comparative analysis of British and American Society of Echocardiography recommendations for the assessment of left ventricular diastolic function

At present there are two recognised guidelines for the echocardiographic assessment of left ventricular diastolic function provided by the British Society of Echocardiography and American Society of Echocardiography/European Association of Cardiovascular Imaging. However, no direct comparison of these guidelines has been performed to establish whether they provide similar diastolic grading. One hundred and eighty-nine consecutive patients in sinus rhythm who underwent transthoracic echocardiography for a primary indication of either heart failure assessment or assessment of left ventricular systolic function were extracted from our database (McKesson Cardiology). Left ventricular diastolic function assessment was performed using both guidelines and the results were compared. Chi-square, Kappa score and one-way ANOVA were used to evaluate the data at a level of P < 0.05. The most frequent outcome was unclassifiable diastolic function with significantly more patients being labelled unclassified with the British compared to American guidelines (47.4 vs 20.5%, P < 0.0001). Having excluded all unclassifiable patients, a significant difference still existed between the two guidelines with a higher proportion of grade one outcomes awarded by the ASE/EACVI guidelines. When grading subcategories were individually compared, there was significantly more grade one diastolic gradings awarded by American compared to the British guidelines (40.7 vs 20.1%, P < 0.0001). In 47% of patients it was not possible to grade diastolic function using the British guidelines, compared to 21% using the American guidelines. For those patients where grading was possible, there was a significant difference in patients classified with normal and grade one diastolic function when using British and American guidelines.

Identification of microRNA Biomarkers of Response to Neoadjuvant Chemoradiotherapy in Esophageal Adenocarcinoma Using Next Generation Sequencing

BACKGROUND

Clinical trials report improved overall survival following neoadjuvant chemoradiotherapy in patients undergoing surgery for esophageal adenocarcinoma, with a 10-15% survival improvement. MicroRNAs (miRNAs) are small noncoding RNAs that are known to direct the behavior of cancers, including response to treatment. We investigated the ability of miRNAs to predict outcomes after neoadjuvant chemoradiotherapy.

METHODS

Endoscopic biopsies from esophageal adenocarcinomas were obtained before neoadjuvant chemoradiotherapy and esophagectomy. miRNA levels were measured in the biopsies using next generation sequencing and compared with pathological response in the surgical resection, and subsequent survival. miRNA ratios that predicted pathological response were identified by Lasso regression and leave-one-out cross-validation. Association between miRNA ratio candidates and relapse-free survival was assessed using Kaplan-Meier analysis. Cox regression and Harrell's C analyses were performed to assess the predictive performance of the miRNAs.

RESULTS

Two miRNA ratios (miR-4521/miR-340-5p and miR-101-3p/miR-451a) that predicted the pathological response to neoadjuvant chemoradiotherapy were found to be associated with relapse-free survival. Pretreatment expression of these two miRNA ratios, pretreatment tumor differentiation, posttreatment AJCC histopathological tumor regression grading, and posttreatment tumor clearance/margins were significant factors associated with survival in Cox regression analysis. Multivariate analysis of the two ratios together with pretherapy factors resulted in a risk prediction accuracy of 85% (Harrell's C), which was comparable with the prediction accuracy of the AJCC treatment response grading (77%).

CONCLUSIONS

miRNA-ratio biomarkers identified using next generation sequencing can be used to predict disease free survival following neoadjuvant chemoradiotherapy and esophagectomy in patients with esophageal adenocarcinoma.

Abstract P3-01-13: FNAC: A predictor of final number of involved nodes at axillary clearance

BACKGROUND:

A vital part of pre-operative breast cancer assessment is axillary staging. Fine needle aspiration cytology (FNAC) is performed on clinically or radiologically positive axillary nodes in breast cancer. Our study looks at the sensitivity of performing FNAC in these patients and whether positive FNAC of axillary nodes can predict the final number of diseased nodes on completion axillary clearance (ANC).

METHODS:

All primary breast cancer patients undergoing FNAC between Oct 2009 to Oct 2011 were identified from electronic computer records. Data was collected on FNAC positivity, whether sentinel lymph node biopsy (SLNB) was performed, total number of nodes harvested at ANC and also the total number of diseased nodes at ANC. Patients who underwent neoadjuvant chemotherapy after a positive FNAC were analysed separately.

RESULTS:

Of the 230 patients who underwent FNAC, 130 were positive (56.5%). Of those who had a negative FNAC, 32% had a positive SLNB. We compared the ANC results of those who were FNAC positive (Group 1) with those who were FNAC negative but SLNB positive (Group 2). There was no significant difference in the mean number of harvested nodes at ANC between the two groups (mean= 17, p=0.14 on t-test). There was a significant difference in the number of diseased nodes in group 1 (mean = 7 nodes) compared with group 2 (mean = 3 nodes). In group 1, 56% of patients had 4 ≥ diseased nodes compared with 8.5% of patients in group 2. Neoadjuvant chemotherapy was given to 28 patients with a positive FNA. In this cohort, the mean number of positive nodes at axillary clearance was 2 and 10 % of patients had 4≥ diseased nodes on ANC. There was no significant difference in mastectomy versus breast conserving surgery rates between FNA positive and negative patients (p= 0.28 on Chi Square). The sensitivity of performing an FNAC was 81% in this study.

Outcome of Patients undergoing Axillary Fine Needle Aspiration Cytology Group 1:FNAC positiveGroup2: FNAC negative, SLNB positive Mean No Harvested Nodes at ANC1816p=0.14Mean No of diseased nodes at ANC73p&lt;0.05% of Patients with 4 or more diseased nodes at ANC568.5p&lt;0.05% of Patients who had Breast Conserving Surgery5453p=0.28Key: FNAC:fine needle aspiration cytology, SLNB: Sentinel lymph node biopsy, ANC: Axillary clearance

CONCLUSION:

This study provides a predictor of the number of diseased axillary nodes in those with positive FNAC preoperatively. Over 50% of patients with a positive FNA have four or more diseased nodes compared with less than 10% in the FNAC negative but SLNB positive group. After neoadjuvant chemotherapy, FNA positive patients have a similar disease burden in the axilla as the FNAC negative but SLNB positive patients. This information can help to guide pre-operative discussions on the likely disease burden and need for adjuvant therapies such as chemotherapy and radiotherapy. Being able to predict the need for radiotherapy in particular can guide surgical decisions regarding type and timing of reconstructions to reduce the risk of surgical complications.

Citation Format: Khan A, Hussain N, Irvine T. FNAC: A predictor of final number of involved nodes at axillary clearance [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 P3-01-13.

Search for Nucleon and Dinucleon Decays with an Invisible Particle and a Charged Lepton in the Final State at the Super-Kamiokande Experiment

Search results for nucleon decays p→e^{+}X, p→μ^{+}X, n→νγ (where X is an invisible, massless particle) as well as dinucleon decays np→e^{+}ν, np→μ^{+}ν, and np→τ^{+}ν in the Super-Kamiokande experiment are presented. Using single-ring data from an exposure of  273.4  kton·yr, a search for these decays yields a result consistent with no signal. Accordingly, lower limits on the partial lifetimes of τ_{p→e^{+}X}>7.9×10^{32} yr, τ_{p→μ^{+}X}>4.1×10^{32} yr, τ_{n→νγ}>5.5×10^{32} yr, τ_{np→e^{+}ν}>2.6×10^{32}  yr, τ_{np→μ^{+}ν}>2.2×10^{32} yr, and τ_{np→τ^{+}ν}>2.9×10^{31} yr at a 90% confidence level are obtained. Some of these searches are novel.

Outcome for Asymptomatic Recurrence Following Laparoscopic Repair of Very Large Hiatus Hernia

BACKGROUND

Radiological follow-up following repair of large hiatus hernias have identified recurrence rates of 20-30%, although most are small and asymptomatic. Whether patients will eventually develop clinical problems is uncertain. This study evaluated the outcome for individuals identified with an asymptomatic hiatus hernia following previous repair vs. asymptomatic controls.

METHODS

One hundred fifteen asymptomatic patients who had previously undergone sutured repair of a large hiatus hernia and then underwent barium meal X-ray 6-60 months after surgery within a clinical trial were identified and divided into two cohorts: with (n = 41) vs. without (n = 74) an asymptomatic hernia. Heartburn, dysphagia, and satisfaction with surgery were assessed prospectively using a standardized questionnaire applying analogue scales. Consumption of antisecretory medication and revision surgery were also determined. To determine the natural history of asymptomatic recurrent hiatus hernia, outcomes for the two groups were compared at 1 and 5 years and at most recent (late) follow-up.

RESULTS

Outcomes were available at 1 year for 98.2% and 5 years or the latest follow-up (range 6-237 months) for 100%. Heartburn and dysphagia scores were low and satisfaction scores high in both groups at all follow-up points, but heartburn scores and medication use were higher in the recurrent hernia group. At late follow-up, 94.6% of the recurrent hernia group vs. 98.5% without a hernia regarded their original decision for surgery to be correct. Two patients in recurrent hernia group underwent revision surgery.

CONCLUSIONS

Patients with an initially asymptomatic recurrent hiatus hernia are more likely to report heartburn and use antisecretory medication at later follow-up than controls. However, overall clinical outcomes remain good, with high satisfaction and low surgical revision rates. Additional interventions to reduce the risk of recurrence might not be warranted.

Search for neutrinos from annihilation of captured low-mass dark matter particles in the sun by super-kamiokande

Super-Kamiokande (SK) can search for weakly interacting massive particles (WIMPs) by detecting neutrinos produced from WIMP annihilations occurring inside the Sun. In this analysis, we include neutrino events with interaction vertices in the detector in addition to upward-going muons produced in the surrounding rock. Compared to the previous result, which used the upward-going muons only, the signal acceptances for light (few-GeV/c^{2}-200-GeV/c^{2}) WIMPs are significantly increased. We fit 3903 days of SK data to search for the contribution of neutrinos from WIMP annihilation in the Sun. We found no significant excess over expected atmospheric-neutrino background and the result is interpreted in terms of upper limits on WIMP-nucleon elastic scattering cross sections under different assumptions about the annihilation channel. We set the current best limits on the spin-dependent WIMP-proton cross section for WIMP masses below 200  GeV/c^{2} (at 10  GeV/c^{2}, 1.49×10^{-39}  cm^{2} for χχ→bb[over ¯] and 1.31×10^{-40}  cm^{2} for χχ→τ^{+}τ^{-} annihilation channels), also ruling out some fraction of WIMP candidates with spin-independent coupling in the few-GeV/c^{2} mass range.

Search for trilepton nucleon decay via p→e+νν and p→μ+νν in the Super-Kamiokande experiment

The trilepton nucleon decay modes p→e+νν and p→μ+νν violate |Δ(B-L)| by two units. Using data from a 273.4 kt yr exposure of Super-Kamiokande a search for these decays yields a fit consistent with no signal. Accordingly, lower limits on the partial lifetimes of τp→e+νν>1.7×10(32) years and τp→μ+νν>2.2×10(32) years at a 90% confidence level are obtained. These limits can constrain Grand Unified Theories which allow for such processes.

First indication of terrestrial matter effects on solar neutrino oscillation

We report an indication that the elastic scattering rate of solar B8 neutrinos with electrons in the Super-Kamiokande detector is larger when the neutrinos pass through Earth during nighttime. We determine the day-night asymmetry, defined as the difference of the average day rate and average night rate divided by the average of those two rates, to be [-3.2 ± 1.1(stat) ± 0.5(syst)]%, which deviates from zero by 2.7 σ. Since the elastic scattering process is mostly sensitive to electron-flavored solar neutrinos, a nonzero day-night asymmetry implies that the flavor oscillations of solar neutrinos are affected by the presence of matter within the neutrinos' flight path. Super-Kamiokande's day-night asymmetry is consistent with neutrino oscillations for 4 × 10(-5)  eV(2) ≤ Δm 2(21) ≤ 7 × 10(-5) eV(2) and large mixing values of θ12, at the 68% C.L.

Twenty years of experience with laparoscopic antireflux surgery

BACKGROUND

There are few reports of large patient cohorts with long-term follow-up after laparoscopic antireflux surgery. This study was undertaken to evaluate changes in surgical practice and outcomes for laparoscopic antireflux surgery over a 20-year period.

METHODS

A standardized questionnaire, prospectively applied annually, was used to determine outcome for all patients undergoing laparoscopic fundoplication in two centres since commencing this procedure in 1991. Visual analogue scales ranging from 0 to 10 were used to assess symptoms of heartburn, dysphagia and satisfaction with overall outcome. Data were analysed to determine outcome across 20 years.

RESULTS

From 1991 to 2010, 2261 consecutive patients underwent laparoscopic fundoplication at the authors' institutions. Follow-up ranged from 1 to 19 (mean 7.6) years. Conversion to open surgery occurred in 73 operations (3.2 per cent). Revisional surgery was performed in 216 patients (9.6 per cent), within 12 months of the original operation in 116. There was a shift from Nissen to partial fundoplication across 20 years, and a recent decline in operations for reflux, offset by an increase in surgery for large hiatus hernia. Dysphagia and satisfaction scores were stable, and heartburn scores rose slightly across 15 years of follow-up. Heartburn scores were slightly higher and reoperation for reflux was more common after anterior partial fundoplication (P = 0.005), whereas dysphagia scores were lower and reoperation for dysphagia was less common (P < 0.001). At 10 years, satisfaction with outcome was similar for all fundoplication types.

CONCLUSION

Laparoscopic Nissen and partial fundoplications proved to be durable and achieved good long-term outcomes. At earlier follow-up, dysphagia was less common but reflux more common after anterior partial fundoplication, although differences had largely disappeared by 10 years.

Impact of participation in randomized trials on outcome following surgery for gastro-oesophageal reflux

BACKGROUND

Patients may be unwilling to participate in clinical trials if they perceive risks. Outcomes were evaluated following surgery for gastro-oesophageal reflux in patients recruited to randomized trials compared with patients not in trials.

METHODS

This study compared outcomes of patients who had surgery for reflux within or outside randomized trials between 1994 and 2009. The choice of procedure outside each trial was according to surgeon or patient preference. Clinical outcomes were determined 1 and 5 years after surgery using a standardized questionnaire, with analogue scales to assess heartburn, dysphagia and overall satisfaction. Subgroup analysis was undertaken for those aged less than 75 years undergoing laparoscopic Nissen fundoplication.

RESULTS

Some 417 patients entered six randomized trials evaluating surgery for reflux and 981 underwent surgery outside the trials. The trial group contained a higher proportion of men and younger patients, and patients in trials were more likely to have undergone Nissen fundoplication. At 1 year, patients in the trials had slightly lower heartburn scores and less abdominal bloating, but otherwise similar outcomes to those not in the trials. At 5 years there were no differences, except for a slightly higher dysphagia score for liquids in the trial group. For the subgroup analysis, demographic data were similar for both groups. There were no differences at 1 year, but at 5 years patients enrolled in the trials had higher scores for dysphagia for liquids and heartburn. All of the statistically significant differences were thought unlikely to be clinically relevant.

CONCLUSION

Participation in a randomized trial assessing surgery for reflux did not influence outcomes.

P3-07-28: One Step Nucleic Acid Amplification (OSNA) for Intraoperative Molecular Detection of Lymph Node Metastases and Micro-Metastases in Breast Cancer

Introduction: Ideally, intraoperative sentinel lymph node analysis in breast cancer should be automated, concordant with histopathology and practically applicable. One step nucleic acid amplification (OSNA), a highly sensitive intraoperative assay of cytokeratin 19 mRNA, is used for the detection of sentinel lymph node (SLN) macro- and micro-metastases in breast cancer. Guildford adopted the intraoperative OSNA “live” in December 2008 after undertaking a multicentre evaluation of its accuracy and high concordance with histopathology and here we present our two year data since its introduction.

Methods: Data was collected prospectively from 2008–10. All patients eligible for sentinel node biopsy were offered OSNA and operations were performed by five consultant breast surgeons. On detection of micro-metastasis (+) and positive but inhibited metastases a level 1 axillary nodal clearance (ANC) and for a macro-metastasis (++), a level 3 ANC was performed.

Results: 471 patients had 999 SLN analysed, median age being 61. All except one were females. 72% (n=340) had wide local excision, 26% (n=120) underwent mastectomy and 2% (8) SNB alone. Mean tumour size was 18.3 mms. 80% (n=371) of the cases were IDC and 55% (n=256) had grade II tumour. 34% (n=161/471) had positive SLN who had further ANC. Of these, 48% (n=78/161) had macro-metastases, 37% (n=59/161) had micro-metastases and 15% (n=24/161) had positive but inhibited results. 17% (10/59) of the patients with micrometastases had positive non-SLN (NSLN), four (4/59, 6.8%) had four positive nodes (SLN+NSLN) thus receiving adjuvant radiotherapy. 8% (2/24) of those with positive but inhibited results and 39% (30/78) of those with macro-metastases had positive NSLN.

Conclusion: Over a third of patients had OSNA positive SLN and underwent axillary surgery at the same operation. This technique eliminates the need for a second operation in sentinel lymph node positive patients and avoids the anxious wait for results in all, streamlining the patient's cancer journey. OSNA upstages patients with micro-metastases and long term studies are needed to determine the clinical relevance of molecular micro-metastatic disease.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-28.

Prognosis of synchronous bilateral breast cancer

Background

The prognosis of patients with synchronous bilateral breast cancer (SBBC) is usually based on the tumour with the worst pathological features. There is little evidence in the literature for this assumption, potentially impairing reasoned decisions on optimal adjuvant therapy.

Methods

This was a case–control study in which 68 women with SBBC were matched with 128 women with unilateral breast cancer. Both the GuysRisk prognostic model and the Nottingham Prognostic Index were used to determine the bilateral tumour with the poorer prognosis. Controls were matched for age, menopausal status, date of diagnosis, histological type and grade, and oestrogen receptor and axillary node status.

Results

Both prognostic models indicated the same side tumour with the worst prognosis. Kaplan–Meier survival curves for both disease-free and overall survival showed no significant difference in outcome between the two groups.

Conclusion

Prognosis was determined by the tumour with the worst prognosis, with no additional worsening of outcome incurred from the second tumour.

A small rise in CEA is sensitive for recurrence after surgery for colorectal cancer

OBJECTIVE

Rise in carcinoembryonic antigen (CEA) above normal limits can indicate recurrent colorectal cancer. The aim of this study was to evaluate whether a small rise in CEA, even within normal limits was a sensitive indicator of recurrence.

METHOD

150 patients aged 22-87 years were followed up for a mean of 27 months after colorectal surgery with CEA 3 and 6 monthly computerized tomography. We analysed whether a rise in CEA > 1 ng/ml correlated with recurrence of metastases.

RESULTS

Forty-six of 139 patients in final analysis had recurrent disease. A rise in CEA > 1 had a predictive value of 74% for recurrence or metastases (sensitivity 80%, specificity 86%). These findings were similar whether or not the CEA was normal preoperatively.

CONCLUSION

If CEA is measured after surgery for colorectal cancer, a rise of >1 in the patient's postoperative value is predictive for recurrence or metastases with an overall sensitivity of 80% and specificity of 86%. Previous studies have recognized the role of large rises in CEA in predicting recurrence but this study shows that small changes in CEA may be significant even if these levels would be traditionally within 'normal' limits.

Telephonic management of rectal bleeding in young adults: a prospective randomized controlled trial

OBJECTIVE

The majority of young adults referred with rectal bleeding to a colorectal specialist clinic have a very low risk of serious disease such as cancer, and a high chance of gaining symptom relief by simple dietary changes. To determine whether young low-risk patients with rectal bleeding can be managed with a structured telephonic interview and dietary advice, rather than an outpatient visit.

METHOD

A single-blinded, prospective, randomized controlled trial was performed in two stages. Patients under 40 years with rectal bleeding only were offered inclusion. Part-I trial: Patients were interviewed on telephone by the colorectal nurse specialist (CNS) and randomized to receive dietary advice (Advice Group) or not (Control Group). All patients were seen in clinic 6 weeks later by a doctor 'blinded' to their trial status. Part-II trial: Patients were interviewed on telephone by the CNS and again randomized to an Advice Group or a Control Group. The Control Group were seen in clinic 6 weeks later. The Advice Group were telephoned again 6 weeks later, and if their bleeding had stopped, were not brought to clinic. All patients were tracked for a year after the study to ensure no adverse diagnoses came to light.

RESULTS

Part-I trial: 63 of 89 eligible patients were contactable and none refused the study. Seventy per cent of the Advice Group compared with 33% (P = 0.001) of the Control Group had symptomatic improvement when seen in clinic. Approximately 30% of each group required further treatment. Part-II trial: 54 of 94 eligible patients were contactable. However a further nine declined to enter the trial; 90% of patients in the Advice Group had improved at 6 weeks as judged by telephone interview compared with 56% of patients in the Control Group (P = 0.024) who were seen in clinic. The 90% of patients who improved in the Advice Group did not need to come to clinic to be seen. In both parts of the trial, the CNS identified a small number of patients with urgent symptoms at interview and brought them to clinic. The majority had anal fissures or haemorrhoids although in Part-II, one patient had ulcerative colitis and one had colorectal cancer.

CONCLUSION

Telephonic consultation is an effective way of identifying those patients with urgent symptoms among a cohort of young adults referred to the hospital with rectal bleeding. Telephonic dietary advice leads to resolution of rectal bleeding in the majority of patients without urgent symptoms.

Surface integration of velocity vectors from 3D digital colour Doppler: an angle independent method for laminar flow measurements

BACKGROUND

The study was designed to test the angle independence of a dynamic three-dimensional digital colour Doppler method for laminar flow measurement. The technique acquired three-dimensional data by rotational acquisition and used surface integration of Doppler vector velocities and flow areas in time and space for flow computation.

METHOD

A series of pulsatile flows (peak flow 55-180 ml/s) through a curved tube were studied with reference flow rates obtained using an ultrasonic flow meter. Colour Doppler imaging was performed at three angles to the direction of flow (20 degrees, 30 degrees, 40 degrees), using a multiplane transoesophageal probe controlled by an ATL HDI5000 system. Integration of digital velocity vectors over a curved three-dimensional surface across the tube for each of the 11 flow rates at each angle was performed off-line to compute peak flow.

RESULTS

Peak flow rates correlated closely (r=0.99) with the flow meter with the mean difference from the reference being -0.8+/-2 x 4 ml/s, 0.9+/-2.6 ml/s, 1.0+/-2 x 3 ml/s for 20 degrees, 30 degrees and 40 degrees respectively. Comparison of the three angle groups showed no significant differences (P=0.15, ANOVA). When sampled obliquely, the flow area on the curved surface increased while the velocities measured decreased.

CONCLUSION

Surface integration of velocity vectors to compute three-dimensional Doppler flow data is less angle dependent than conventional Doppler methods.

Dobutamine stress echocardiography for the detection of myocardial viability in patients with left ventricular dysfunction taking beta blockers: accuracy and optimal dose

OBJECTIVE

To assess the accuracy of dobutamine stress echocardiography (DSE) and the optimal dose of dobutamine to detect myocardial viability in patients with ischaemic left ventricular (LV) dysfunction who are taking beta blockers, using the recovery of function six months artery revascularisation as the benchmark.

PATIENTS

17 patients with ischaemic LV dysfunction (ejection fraction < 40%) and chronic treatment with beta blockers scheduled to undergo surgical revascularisation.

SETTING

Regional cardiothoracic centre.

METHODS

All patients underwent DSE one week before and resting echocardiography six months after revascularisation. A wall motion score was assigned to each segment for each dobutamine infusion stage, using the standard 16 segment model of the left ventricle. The accuracy of DSE to predict recovery of resting segmental function was calculated for low dose (5 and 10 microg/kg/min) and for a full protocol of dobutamine infusion (5 to 40 microg/kg/min).

RESULTS

Of the 272 segments studied, 158 (58%) were dysfunctional at rest, of which 79 (50%) improved at DSE and 74 (47%) recovered resting function after revascularisation. Analysis of results with a low dose showed a significantly lower sensitivity and negative predictive value than with a full protocol (47% v 81%, p < 0.001 and 65% v 82%, p < 0.05, respectively). The accuracy in the full protocol analysis was comparable with that reported in patients no longer taking beta blockers but was significantly lower than that in the low dose analysis (78% v 66%, p < 0.001).

CONCLUSIONS

Findings suggest that beta blocker withdrawal is not necessary before DSE when viability is the clinical information in question. However, a completed protocol with continuous image recording is required to detect the full extent of viability.

Quantification of aortic regurgitation by real-time 3-dimensional echocardiography in a chronic animal model: computation of aortic regurgitant volume as the difference between left and right ventricular stroke volumes

BACKGROUND

The accuracy of conventional 2-dimensional echocardiographic and Doppler techniques for the quantification of valvular regurgitation remains controversial. In this study, we examined the ability of real-time 3-dimensional (RT3D) echocardiography to quantify aortic regurgitation by computing aortic regurgitant volume as the difference between 3D echocardiographic-determined left and right ventricular stroke volumes in a chronic animal model.

METHODS

Three to 6 months before the study, 6 sheep underwent surgical incision of one aortic valve cusp to create aortic regurgitation. During the subsequent open chest study session, a total of 25 different steady-state hemodynamic conditions were examined. Electromagnetic (EM) flow probes were placed around the main pulmonary artery and ascending aorta and balanced against each other to provide reference right and left ventricular stroke volume (RVSV and LVSV) data. RT3D imaging was performed by epicardial placement of a matrix array transducer on the volumetric ultrasound system, originally developed at the Duke University Center for Emerging Cardiovascular Technology. During each hemodynamic steady state, the left and right ventricles were scanned in rapid succession and digitized image loops stored for subsequent measurement of end-diastolic and end-systolic volumes. Left and right ventricular stroke volumes and aortic regurgitant volumes were then calculated and compared with reference EM-derived values.

RESULTS

There was good correlation between RT3D left and right ventricular stroke volumes and reference data (r = 0.83, y = 0.94x + 2.6, SEE = 9.86 mL and r = 0.63, y = 0.8x - 1.0, SEE = 5.37 mL, respectively). The resulting correlation between 3D- and EM-derived aortic regurgitant volumes was at an intermediate level between that for LVSV and that for RVSV (r = 0.80, y = 0.88x + 7.9, SEE = 10.48 mL). RT3D tended to underestimate RVSV (mean difference -4.7 +/- 5.4 mL per beat, compared with -0.03 +/- 9.7 mL per beat for the left ventricle). There was therefore a small overestimation of aortic regurgitant volume (4.7 +/- 10.4 mL per beat).

CONCLUSION

Quantification of aortic regurgitation through the computation of ventricular stroke volumes by RT3D is feasible and shows good correlation with reference flow data. This method should also be applicable to the quantification of other valvular lesions or single site intracardiac shunts where a difference between right and left ventricular cavity stroke volumes is produced.

Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure

AIMS

To determine the effectiveness and safety of topical glyceryl trinitrate (GTN) in the management of acute anal fissure in children.

METHODS

Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose. Patients took laxatives alone for a further 10 weeks. Each week a research nurse telephoned families to assess pain scores and give advice. Main outcome measures were validated standardised pain scores and time to painless defaecation.

RESULTS

Forty subjects were recruited from 46 eligible children; 31 children completed the trial (13 in the GTN group and 18 in the placebo group). No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups. Similarly, there were no significant differences in pain scores between the two groups over the 16 week study period. However, in both groups pain scores had decreased significantly. There were no differences in the incidence of rectal bleeding, faecal soiling, presence of visible fissure, skin tag, or faecal loading at outpatient review at the time of recruitment, or at 6 weeks and 16 weeks. No serious adverse effects were observed.

CONCLUSIONS

This study suggests that 0.2% GTN paste is ineffective in the treatment of acute anal fissures in childhood. However the overall fissure healing rate is high (84%) with associated reduction in pain scores, suggesting that a nurse based treatment programme can achieve a high rate of fissure healing.

Clinical significance of the length of the pterygopalatine fissure in dental anesthesia

OBJECTIVE

This study determined the average length of the pterygopalatine fissure by using human cadavers. Recommendations are made to improve the success of maxillary nerve block injections.

MATERIALS AND METHODS

Pterygopalatine fissures were dissected, exposing the maxillary nerve trunk in 47 human cadavers. The length of the fissure was measured from the maxillary nerve to the buccal sulcus. The angle between the fissure and the occlusal plane was also recorded.

RESULTS

The average fissure length was 36.7 mm, making an approximately 60 degrees angle to the occlusal plane. Fissures from females were statistically significantly shorter than those from males. There was no difference with respect to ethnic group. Cadaver length was the best predictor of fissure length.

CONCLUSIONS

Depth of penetration with a needle that is longer than that normally available is necessary to predictably ensure a successful maxillary nerve block.

Noninvasive assessment of left ventricular isovolumic contraction and relaxation with continuous wave Doppler aortic regurgitant velocity signals: an in vivo validation study

The purpose of this study was to provide fundamental in vivo validation of a method with the use of aortic regurgitant (AR) jet signals recorded with continuous wave (CW) Doppler for assessing left ventricular (LV) isovolumic contraction and relaxation. Preliminary studies have suggested that analysis of CW Doppler AR velocity signals permits the estimation of LV positive and negative dP/dt. We studied 19 hemodynamically different states in 6 sheep with surgically induced chronic aortic regurgitation. CW AR velocity spectra and high-fidelity LV and aortic pressures were recorded simultaneously. Rates of LV pressure rise and fall (RPR and RPF) were calculated by determining the time interval between points at 1 m/s and 2.5 m/s in the deceleration and acceleration slopes of the CW Doppler AR velocity envelope (corresponding to a pressure change of 21 mm Hg). RPR and RPF calculated by CW Doppler analysis for each state were compared with the peak positive dP/dt and negative dP/dt, obtained from the corresponding high-fidelity LV pressure curve, respectively. The LV peak positive and negative dP/dt derived by catheter ranged from 817 to 2625 mm Hg/s and from 917 to 2583 mm Hg/s, respectively. Multiple regression analysis showed that Doppler RPR correlated well with catheter peak positive dP/dt (r = 0.93; mean differences, -413 +/- 250 mm Hg/s). There was also good correlation and agreement between Doppler RPF and the catheter peak negative dP/dt (r = 0.89; mean difference, -279 +/- 239 mm Hg/s). Both Doppler-determined RPR and RPF underestimated their respective LV peak dP/dt. CW Doppler AR spectra can provide a reliable noninvasive estimate of LV dP/dt and could be helpful in the serial assessment of ventricular function in patients with aortic regurgitation.

Validation of a digital color Doppler flow measurement method for pulmonary regurgitant volumes and regurgitant fractions in an in vitro model and in a chronic animal model of postoperative repaired tetralogy of Fallot

OBJECTIVES

The purpose of this study was to validate a digital color Doppler (DCD) automated cardiac flow measurement method for quantifying pulmonary regurgitation (PR) in an in vitro and a chronic animal model of the right ventricular outflow tract of postoperative tetralogy of Fallot (TOF).

BACKGROUND

There has been no reliable ultrasound method that can accurately quantitate PR.

METHODS

We developed an in vitro model of mild pulmonary stenosis and wide-open PR that mimics the patterns of flow seen in patients with postoperative TOF. Thirteen different forward and regurgitant stroke volumes (RSVs) across the noncircular shaped cross-sectional outflow tract flow area were estimated using the DCD method in two orthogonal planes. In six sheep with surgically created PR, 24 different hemodynamic states with PR strictly quantified by electromagnetic probes were also studied.

RESULTS

The RSVs and regurgitant fractions (RFs) obtained by the DCD method using average values from two orthogonal planes correlated well with reference values (RSV: r = 0.99, mean difference = 0.02 +/- 0.39 ml/beat for in vitro model; r = 0.97, mean differences = 1.79 +/- 1.84 ml/beat for animal model, RF: r = 0.98, mean difference = -1.10 +/- 4.34% for in vitro model; r = 0.94, mean difference = 2.73 +/- 6.75% for animal model). However, the DCD method using a single plane had limited accuracy for estimating pulmonary RFs and RSVs.

CONCLUSIONS

The DCD method using average values from two orthogonal planes provides accurate estimation of RSVs and RFs and should have clinical importance for serially quantifying PR in patients with postoperative TOF.

In vitro validation of tissue Doppler left ventricular regional wall velocities by using a novel balloon phantom

To investigate the validity and accuracy of tissue Doppler imaging (TDI) using a novel balloon phantom, validation of TDI myocardial velocity measurements has been carried out indirectly from conventional M-mode images. However it is not a true and independent gold standard. We described a new TDI validation method by using a specially developed left ventricular balloon model mounted in a water bath and constructed using two pear-shaped balloons. It was connected to a pulsatile flow pump at 8 stroke volumes (50-85 ml/beat). The displacement and velocity of the balloon walls were recorded simultaneously by video imaging and TDI on a GE-Vingmed System Five with a 5 MHz phased array probe at the highest frame rates available. Conventional M-mode and 2-D imaging verified that our balloon model mimicked the shape and wall motion of left ventricle. There was a good correlation and agreement between the maximum video excursion of the anterior and posterior walls of the phantom and the results of the temporal integration of digital distance data by TDI (Anterior wall: r = 0.97, SEE = 0.24 mm, mean +/- s = 0.04 +/- 0.24 mm; Posterior wall: r = 0.95, SEE = 0.22 mm, mean +/- s = 0.03 +/- 0.24 mm). Analysis of the velocity profile by the TDI method showed that the velocity at each measured point was correlated well with the velocity obtained from the video images (Anterior wall: r = 0.97, SEE = 0.30 mm, mean +/- s = -0.04 +/- 0.28 mm; Posterior wall: r = 0.97, SEE = 0.30 mm, mean +/- s = 0.04 +/- 0.28 mm). Our balloon model provided a new independent method for the validation of TDI data. This study demonstrated that the present TDI system is reliable for measuring wall motion distance and velocity.

Direct computation of multiple 3D flow convergence isovelocity surfaces from digital 3D reconstruction of colour Doppler data of the flow convergence region: an in vitro study with differently shaped orifices

AIMS

Evaluation of the accuracy of direct computation of multiple three-dimensional (3D) flow convergence (FC) isovelocities by using digital reconstruction of colour Doppler data of the flow convergence region.

METHODS AND RESULTS

We used a conventional ultrasound system (ATL HDI 3000) connected to a computer workstation via Ethernet link. The digital 3D datasets were directly transferred to a Silicon Graphic Imaging Octane workstation for later measurement. We generated nine pulsatile flows (20-60 ml/beat), with peak flow rates (67-180 ml/s), through three orifices (circular, rectangular and triangular, S=0.24 cm(2)). The 3D reconstructions of FC surface areas from multi-threshold velocities, including aliasing velocities were analysed to quantify the peak flow rate. For all orifices, linear regression demonstrated excellent correlation between the 3D calculated and electromagnetic flow meter recorded data. While there was a high correlation for 3D computation of flow rate from the single best Nyquist of 24 cm/s (r=0.97-0.98, SEE=7 .75-12.58 ml/s), the ability to average three threshold velocities (15, 18 and 24 cm/s) yielded an improved correlation (r=0.98-0.99, SEE=5.70-7.73 ml/s).

CONCLUSIONS

Direct computation of multiple 3D FC isovelocities from digital reconstruction of colour Doppler data of the FC region provides the potential to accurately quantify the complex asymmetric spatial flow events at any selected velocity.

Effects of transmyocardial laser revascularization by using a prototype pulsed CO2 laser on contractility and perfusion of chronically ischemic myocardium in a porcine model

The purpose of this study was to test a new prototype pulsed CO2 laser to be used for transmyocardial laser revascularization (TMR). We wanted to determine whether it can reduce thermal damage and mitigate induced ischemia with improvement in contractile reserve of the heart as evidenced by contrast echocardiography at rest and under dobutamine stress. TMR is an emerging surgical strategy for treatment of myocardial ischemia not amenable to conventional percutaneous or surgical revascularization. Eleven pigs underwent ameroid occluder placement at the origin of the circumflex coronary artery. Six weeks later, occlusion of the circumflex coronary artery was documented. TMR was then carried out on 10 pigs by using a prototype pulsed CO2 laser that delivered 8-12 joules in 1.5 ms with a spot size of 1 mm. Six weeks after TMR, the pigs were restudied. The animals developed significant ischemia after 6 weeks of ameroid occlusion, at rest (p = 0.01) and at peak stress (p = 0.004). Wall motion for the ischemic segments improved significantly 6 weeks after TMR at peak stress (p = 0.02). TMR results in an improvement in wall motion in our model of chronic ischemia and improves wall motion score index more during induced stress than at rest.

Comparison of ventricular volume and mass measurements from B- and C-scan images with the use of real-time 3-dimensional echocardiography: studies in an in vitro model

BACKGROUND

Real-time 3-dimensional (3D) echocardiography avoids geometric assumptions in volume analysis and permits immediate visualization in any plane without the need for cardiac or respiratory gating or computation time. This study compared the accuracy of volume and mass assessments between standard long-axis (B-scan) and short-axis (C-scan) views in a simplified but quantifiable left ventricular phantom.

METHODS AND RESULTS

The model comprised an inner balloon within an outer balloon separated by ultrasonographic gel. First, to mimic different chamber volumes, 12 volumes (40 to 180 mL) of water within the inner balloon were scanned with a real-time 3D system. Second, 10 volumes (80 to 170 mL) of gel were inserted between the balloons to mimic varying cardiac mass, and the gel volume space (mass) was calculated by subtracting the inner from the outer balloon volume. "Chamber" and "mass" measurements for both B and C scans correlated closely with the actual values (r = 0.99). However, chamber volumes from C scans were consistently less than B-scan values (mean difference from reference for C scans: -5.2 +/- 1.2 mL, P <.0001; for the 2 orthogonal B scans: 0.03 +/- 1.4 mL and -0.9 +/- 1.5 mL, respectively, P = NS). Similarly, for gel volume measurements, B-scan results were closer to actual mass volumes (mean difference 0. 3 +/- 2.5 and 1.7 +/- 2.9 mL) than those of C scans, which tended to underestimate (-4.5 +/- 2.5 mL, P <.0001).

CONCLUSION

Our study suggests that real-time 3D echocardiography should provide an accurate means of determining chamber volumes and cardiac mass. However, measurements performed from B-scan views may be closer to the actual values than those from C-scan views, presumably since they are less highly influenced by distortions related to lateral resolution.