Evaluation of Cerebral Vasoreactivity by SPECT and Transcranial Doppler Sonography using the Acetazolamide Test

Bei 29 Patienten (3 Kontrollpersonen, 26 Patienten mit zerebrovaskulärer Erkrankung) wurde prospektiv die Hirn-SPECT mit 99mTC-HMPAO und bei 20 Patienten (3 Kontrollpersonen, 17 Patienten mit ZVK) die transkranielle Dopplersonographie (TCD) vor und nach i. v. Gabe von Azetazolamid durchgeführt. Die Sensitivität der Hirn-SPECT erhöhte sich mit Azetazolamid von 62% auf 77%. Bei Patienten mit reversiblem neurologischem Defizit wurde eine Verbesserung von 50% auf 71 %, bei Patienten mit persistierendem Defizit von 75% auf 83% beobachtet. Die Ergebnisse der Hirn-SPECT und der TCD stimmten in der Beurteilung der zerebro-vaskulären Reservekapazität in 91% der Hemisphären überein. Die Korrelation zwischen den beiden Methoden war statistisch signifikant.

HMPAO-SPECT bei Demenz vom Alzheimer-Typ und Major Depression mit mnestischen Störungen

Ziel der vorliegenden Untersuchung war es, zu prüfen, ob die HMPAO-SPECT zur Differenzierung zwischen der Demenz vom Alzheimer-Typ (DAT) und der Major Depression (MD) beitragen kann. Es wurden ECT-Befunde von 77 Patienten mit Gedächtnisstörungen beurteilt, davon hatten 48 eine DAT und 29 eine MD. Zunächst wurden die Defekte in der SPECT einer Hirn-Region zugeordnet und der Grad der Ausprägung (-1/-2/-3) bewertet. Anschließend wurden die einzelnen Befunde in eine von 7 Befundkategorien eingeordnet. In einigen dieser 7 Gruppen ergaben sich deutliche Häufungen der Fälle mit DAT bzw. MD. 35% aller DAT-Patienten wiesen bilaterale Defekte mit deutlicher (>-1) parietaler/parietotemporaler Minderperfusion auf, dagegen zeigte kein Patient mit MD dieses Muster. Unilaterale Defekte wiesen 62% der MD-, aber nur 31% der DAT-Patienten auf. Die Untersuchung zeigt, daß nur 35% der Patienten mit DAT das bislang als »pathognomonisch« bezeichnete Befundmuster aufwiesen. Dieses Perfusionsmuster kann aber - wenn es vorliegt - als sicheres Kriterium zur Abgrenzung gegen eine MD gewertet werden. Darüber hinaus lassen sich keine eindeutigen (»krankheitstypischen«) Perfusionsmuster erkennen, wenngleich unilaterale Defekte mehr auf eine MD hindeuten.

99mTc-MAA-Anreicherung in der Leber bei cavo-portalem Shunt über eine rekanalisierte Vena umbilicalis

Bei der Lungenperfusionsszintigraphie einer Patientin mit Vena-cava-superior-Verschluß fand sich eine deutliche MAA-Anreicherung in Teilen der Leber. Als Ursache konnte ein Kollateralkreislauf über Venen der Abdominalwand und eine rekanalisierte Vena umbilicalis ermittelt werden. Unter externer Bestrahlung von Lymphomen des oberen Mediastinums kam es zu einem raschen Rückgang des cavo-portalen Shunt-Volumens.

Lymphoscintigraphy in breast cancer patients –comparison of peritumoural and intradermal injection

Aim of this study was to determine whether the sentinel lymph nodes (SLNs) can be accurately identified in breast cancer patients with intradermal injection of the radiotracer above the primary tumour in comparison to peritumoural injection. Methods: In 45 women with breast cancer we performed lymphoscintigraphy on two separate days. We injected Tc-99m nanocolloid on the first day peritumourally, and on a separate day intradermally. The results of both investigations using different injection sites were compared in order to determine the number and location of SLNs. Results: The SLN identification rate using peritumoural injection was 71% (32 of 45 patients) and 96% (43 out of 45 patients) using intradermal injection. In 62% (28 of 45 patients) the number and location of the SLNs were identical. In 97% (31 of 32 patients) in whom a SLN was detected using peritumoural injection, the same SLNs reappeared with intradermal injection. There were no false negative findings with the peritumoural administration of tracer whereas the intradermal administration approach resulted in a false negative rate of 13%. Conclusion: In women with breast cancer the reproducibility of lymphoscintigraphy using peritumoural and intradermal injection sites was 62%. The intradermal injection modality enables the detection of a SLN in patients where the peritumoural injection failed but it has the disadvantage of a higher false negative rate in comparison to the peritumoural injection technique.

Residual kidney function after donor nephrectomy

Aim: We evaluated the long-term residual renal function after donor nephrectomy using 99mTc-mercaptoacetyltriglycin (MAG3)-clearance. Donors, methods: Altogether 49 kidney donors were examined using 99mTc-MAG3-clearance after nephrectomy for donation to a relative (m:f = 11:38; age 55±27 years). The donors were examined 16±8 years postoperatively (1.5-26 years). 42 donors (86%) showed normal creatinine values, whereas the other seven (14%) exhibited slightly elevated levels. 20 donors were examined pre- and postoperatively and compared intraindividually. The kidney function was compared to the age adapted normal values of healthy persons with two kidneys (67–133% of age related mean). Results: After nephrectomy all donors showed a normal perfusion, good secretion, merely physiological intrarenal transit and a normal elimination from the kidneys. The 99mTc-MAG3-clearance was 69 ±15% of the normal mean value of healthy carriers of two kidneys regardless of the gender. 20 donors with a preoperative examination showed a significantly reduced total renal function from 84 ± 15% of the mean normal value preoperatively to 60 ± 15% postoperatively (p <0.0005). 15 donors of this group exhibited a significant functional increase of the residual kidney from 40% initially to 60% after nephrectomy (p = 0.003). No correlation was found between the initial 99mTc-MAG3-clearance measured prior to nephrectomy and the clearance levels after nephrectomy. Also, no correlation between the preoperative 99mTc- MAG3-clearance and the postoperative serum creatinine values could be observed. Altogether, 22% of the donors (11/49) developed arterial hypertension 10 ± 8 years after donation (1-23 years). This corresponds to the normal age prevalence of hypertension in the carriers of two kidneys. Three donors suffered from arterial hypertension prior to the operation. Conclusion: Kidney donors with normal or slightly elevated creatinine values postoperatively show a 99mTc- MAG3-clearance value of 69% of the mean value of healthy carriers of two kidneys. This may serve as a reference value for healthy carriers of one kidney. In our study we demonstrated a good compensation of the contralateral kidney via renal scintigraphy by means of 99mTc-MAG3-clearance.

Increased FDG bone marrow uptake after intracoronary progenitor cell therapy

Patients with coronary artery disease who undergo FDG PET for therapy monitoring after intracoronary progenitor cell infusion (PCT) show an increased bone marrow up-take in some cases. Aim of the study was to evaluate the systemic bone marrow glucose metabolism in this patient group after PCT. Patients, methods: FDG bone marrow uptake (BMU), measured as standardized uptake value (SUVmax) in the thoracic spine, was retrospectively evaluated in 23 control patients who did not receive PCT and in 75 patients who received PCT 3 ± 2.2 days before PET scanning. Five out of them were pretreated with granulocyte colony-stimulating factor (G-CSF) 5 days prior to PCT and 10 ± 1.2 days before PET scanning. In 39 patients who received only PCT without G-CSF and underwent PET therapy monitoring 4 months later, baseline and follow up bone marrow uptake were measured. Leucocytes, C-reactive protein (CRP) levels and the influence of nicotine consumption were compared with the BMU. Results: In patients (n = 70) who received PCT without G-CSF, BMU median (1.3) was slightly, but significantly higher than in the controls (1.0) (p = 0.02) regardless nicotine consumption. BMU did not change significantly 4 months later (1.2) (p = 0.41, n.s.). After G-CSF pretreatment, patients showed a significantly higher bone marrow uptake (3.7) compared to patients only treated with PCT (1.3) (p = 0.023). Leucocyte blood levels were significantly higher in patients with a BMU ≥ 2.5 compared to patients with a bone marrow SUVmax < 2.5 (p <0.001). CRP values did not correlate with the BMU (rho -0.02, p = 0.38). Conclusion: Monitoring PCT patients, a slightly increased FDG BMU may be observed which remains unchanged for several months. Unspecific bone marrow reactions after PCT may be associated with increased leucocyte blood levels and play a role in the changed systemic glucose BMU.

FDG uptake after intraarterial chemotherapy in head and neck cancer

Aim: The intraarterial chemotherapy (i.a. CHT) using high dose cisplatin combined with systemic neutralization in patients with head and neck cancer (HNSCC) is used to reduce the tumor volume preoperatively. Aim of the study is the evaluation of the influence of i.a. CHT on the metabolism of fluor-18-deoxyglucose (FDG) in the primary and lymph nodes (LN). The value of FDG positron emission tomography (PET) preoperative and as follow-up method after i.a. CHT is examined. Patients, methods: Altogether 16 patients with HNSCC underwent two preoperative FDG PET examinations: the baseline examination one week before and the follow-up three weeks after i.a. CHT. The SUVmax values of the primary and the LN and LN metastases were evaluated and compared with each other and the histopathology. Results: The SUVmax value of the primary decreased after i.a. CHT significantly from a median (25th percentile/ 75th percentile) of 6.4 (4.1/ 7.8) to 3.6 (2.4/ 6.7) (p = 0.01). In 11 out of 16 patients cervical LN metastases were detected. The cervical LN metastases showed a decrease of the SUVmax value from 3.6 (2.3/ 4.8) in the pretreatment examination to 2.3 (1.7/ 3.6) after i.a. CHT (p = 0.008). Only in one patient with LN metastases the SUVmax of the nodes increased. The histopathologically measured size of the LN metastases ranged from 2 to 30 mm. Non malignant LN did not reveal a significant SUVmax decrease after i.a. CHT (p = 0.13). Conclusions: As expected, primaries of HNSCC showed a significant reduction of SUV after i.a. CHT. Compared to the primary the SUVmax decrease in LN metastases was less, but also significant. Since cytotoxic levels of cisplatin do not occur systemic, postinflammatory reactions of the LN or a lymphatic drainage of the chemotherapeutic drug into the LN could be an explanation. PET for staging of HNSCC must thus be performed prior to i.a. CHT.

Therapy of hepatocellular carcinoma with iodine-131-lipiodol

Aim: To evaluate the efficacy and tolerance of iodine- 131-lipiodol (131I-lipiodol) for hepatocellular carcinoma (HCC) in German long term patients and comparison with medically treated controls. Patients, Methods: 38 courses of intra-arterial 131I-lipiodol therapy with a total activity up to 6.7 GBq were performed in 18 patients with HCC (6 with portal vein thrombosis). Liver and tumour volume and lipiodol deposition were measured by computed tomography and 131I activity by scintigraphy. Therapeutic efficacy was determined by tumour volume change and matched-pairs analysis in comparison to medically (i.e. tamoxifen or medical support) treated patients. Results: Tumour volume decreased in 20/32 index nodules (63%) after the first course. Repeated therapy frequently resulted in further tumour reduction. Overall response to treatment was partial in 11 nodules, minor response in 4 nodules, and disease was stable in 12 and progressive in 5. Significant response was associated with pretherapeutic nodule volume up to 150 ml (diameter of 6.6 cm). Survival rate after 3, 6, 9, 12, 24 and 36 months was 78, 61, 50, 39, 17, and 6%. Matched-pairs analysis of survival revealed 131I-lipiodol to be superior to medical treatment. The most important side effect was a pancreatitis-like syndrome whereas overall tolerance was good. Conclusion: The long term results confirm that HCC therapy with 131I-lipiodol is effective and probably superior to medical treatment. Tumour nodules of up to 6 cm diameter are well suited for this therapy even in the presence of portal vein thrombosis.

Limitations of dual time point FDG-PET imaging in the evaluation of focal abdominal lesions

Aim: For the evaluation of the diagnostic potential of dual time point FDG positron emission tomography (PET) in patients with suspicious focal abdominal up-take, dual time point PET imaging was compared with clinical findings. Patients, methods: In a prospective study, 56 patients exhibiting a solitary suspicious, intense abdominal FDG uptake, underwent dual time point PET imaging for staging or restaging of different malignant tumors, maximal standardized uptake value (SUVmax) measurements included. The first acquisition was started 64.8 ± 19.5, the second 211.3 ± 52.5 min after FDG injection. The final diagnosis based on CT or MRT imaging and a follow-up period of 12.6 ± 2.8 months. Additionally, colonoscopy was done in 6 patients. In another 6 patients histopathology was obtained from CT guided biopsy. Results: Malignant focal abdominal lesions with a SUVmax <2.5 (n = 4) showed an uptake increase of ≥30%. In the remaining malignant cases with an uptake of ≥2.5 (n = 11), up-take increased in 64% and decreased in 36%. Malignant lesions showing FDG uptake decrease (n = 4) had an initial SUVmax value ≥2.5 and remained with a SUVmax ≥2.5 in the second imaging. In benign lesions with an initial SUVmax ≥2.5 (n = 31), the uptake increased in 17 patients (55%) and decreased in 14 patients (45%). All lesions which changed configuration (33%) were confirmed as benign (n = 5). Conclusion: Using dual time point PET abdominal lesions show a very hetergenous uptake pattern regardless of their dignity. Malignancy can only be reliably excluded in lesions which change their configuration and in lesions with an initial SUVmax value <2.5 combined with an SUV decrease in the delayed imaging. Particularly abdominal lesions which show an initial SUVmax ≥2.5 combined with a SUV increase in the delayed imaging are suspicious for malignancy and need further clarification.

Migrants and Refugees in Europe: Challenges, Experiences and Contributions

Due to the current geopolitical situation more refugees from crisis countries were and will be treated in Europe. In 2015 the number of displaced people reached an unprecedented level, with more than one million crossing into Europe. The migration itself can impair both mental and physical health. Therefore, the provision of medical care for refugees and migrants is a novel and major challenge for the health care systems in Europe. In this article we describe our experiences and contribution in providing medical care for refugees who have newly arrived in Stuttgart, Baden-Wuerttemberg, Germany. Furthermore, we report our experiences from a tertiary referral University center in Regensburg, Bavaria, Germany. We focus on challenges in both the outpatient and the inpatient setting, with a special focus on intensive care patients. In addition, we provide an overview about the spectrum of diseases in this specific patient cohort.

Sentinel Node Biopsy as Staging Tool in a Multimodality Treatment Approach to Cancer of the Oral Cavity and the Oropharynx

OBJECTIVES: Feasibility of sentinel lymph node (SLN) biopsy in head and neck cancer as a staging tool embedded in a multimodality regimen including neoadjuvant intraarterial chemotherapy.

STUDY DESIGN AND SETTING: 39 patients with oral and anterior oropharyngeal cancer classified N0 by [18F]FDG-PET underwent SLN scintigraphy. Selective SLN biopsy without elective neck dissection (ND) was performed, immediately followed by radical resection of the primary tumor. Histopathology included step-serial sections and immunocyto-chemistry.

RESULTS: Lymphoscintigraphy detected 104 spots. In 15 patients there was bilateral drainage. 114 SLN were excised due to additional intraoperative discrimination. 95% of visualised SLN could be removed. Histology was positive in 3 patients (8%), all underwent ND which yielded another positive node in 2 cases. Median observation time was 30 months. Two patients (5%) had a neck relapse in combination with a second primary.

CONCLUSIONS: SLN biopsy as only surgical staging tool seems to be feasible.

SIGNIFICANCE: Method promises reduction of elective ND and morbidity in N0 patients.

Resonant metasurfaces at oblique incidence: interplay of order and disorder

Understanding the impact of order and disorder is of fundamental importance to perceive and to appreciate the functionality of modern photonic metasurfaces. Metasurfaces with disordered and amorphous inner arrangements promise to mitigate problems that arise for their counterparts with strictly periodic lattices of elementary unit cells such as, e.g., spatial dispersion, and allows the use of fabrication techniques that are suitable for large scale and cheap fabrication of metasurfaces. In this study, we analytically, numerically and experimentally investigate metasurfaces with different lattice arrangements and uncover the influence of lattice disorder on their electromagnetic properties. The considered metasurfaces are composed of metal-dielectric-metal elements that sustain both electric and magnetic resonances. Emphasis is placed on understanding the effect of the transition of the lattice symmetry from a periodic to an amorphous state and on studying oblique illumination. For this scenario, we develop a powerful analytical model that yields, for the first time, an adequate description of the scattering properties of amorphous metasurfaces, paving the way for their integration into future applications.

Plasmonic heating with near infrared resonance nanodot arrays for multiplexing optofluidic applications

In this work, we show local laser-induced heating in fluids with gold nanodot arrays prepared by electron-beam lithography that cover resonances in the near infrared spectral range from 750 nm to 880 nm.

BLADE sequences in sagittal T2-weighted MR imaging of the cervical spine and spinal cord--lesion detection and clinical value

PURPOSE

Using the BLADE (PROPELLER) technique for T2-weighted MR imaging of the cervical spine has proven to be a reliable tool for reducing artifacts typically for this region. The aim of this study was to evaluate whether the application of BLADE sequences has an impact on the detection of small or low contrast spinal cord and epidural lesions.

MATERIALS AND METHODS

A standard TSE and a BLADE sequence were compared in 33 patients with 46 spinal cord and epidural lesions for T2-weighted sagittal imaging of the cervical spine. Image sharpness, visualization of the dura, reliability of spinal cord depiction as well as lesion contrast were evaluated by two independent readers. Additionally two experienced neuroradiologists selected in consensus the sequence they would prefer for diagnostic purposes. Statistical evaluations were performed using the sign and the χ2 test.

RESULTS

BLADE was significantly superior to TSE regarding image sharpness, visualization of the dura and reliability of spinal cord depiction. Regarding lesion contrast there was a positive trend towards the BLADE sequence. In 17 of 46 lesions, BLADE was judged superior to TSE, while TSE was favored in 10 lesions. In consensus reading both neuroradiologists preferred BLADE for overall image quality in 27 of 33 patients and for lesion contrast in 10 and TSE in 14 of the 33 patients, but 3 TSE sequences were rated as non-diagnostic regarding this criterion.

CONCLUSION

For the detection of even small and low-contrast spinal cord lesions, BLADE is at least equivalent to TSE, yielding better overall image quality and fewer non-diagnostic images.

What limits tool use in nonhuman primates? Insights from tufted capuchin monkeys (Sapajus spp.) and chimpanzees (Pan troglodytes) aligning three-dimensional objects to a surface

Perceptuomotor functions that support using hand tools can be examined in other manipulation tasks, such as alignment of objects to surfaces. We examined tufted capuchin monkeys' and chimpanzees' performance at aligning objects to surfaces while managing one or two spatial relations to do so. We presented six subjects of each species with a single stick to place into a groove, two sticks of equal length to place into two grooves, or two sticks joined as a T to place into a T-shaped groove. Tufted capuchins and chimpanzees performed equivalently on these tasks, aligning the straight stick to within 22.5° of parallel to the groove in approximately half of their attempts to place it, and taking more attempts to place the T stick than two straight sticks. The findings provide strong evidence that tufted capuchins and chimpanzees do not reliably align even one prominent axial feature of an object to a surface, and that managing two concurrent allocentric spatial relations in an alignment problem is significantly more challenging to them than managing two sequential relations. In contrast, humans from 2 years of age display very different perceptuomotor abilities in a similar task: they align sticks to a groove reliably on each attempt, and they readily manage two allocentric spatial relations concurrently. Limitations in aligning objects and in managing two or more relations at a time significantly constrain how nonhuman primates can use hand tools.

IORT with electrons as boost strategy during breast conserving therapy in limited stage breast cancer: long term results of an ISIORT pooled analysis

PURPOSE

Linac-based intraoperative radiotherapy with electrons (IOERT) was implemented to prevent local recurrences after breast conserving therapy (BCT) and was delivered as an intraoperative boost to the tumor bed prior to whole breast radiotherapy (WBI). A collaborative analysis has been performed by European ISIORT member institutions for long term evaluation of this strategy.

MATERIAL AND METHODS

Until 10/2005, 1109 unselected patients of any risk group have been identified among seven centers using identical methods, sequencing and dosage for intra- and postoperative radiotherapy. A median IOERT dose of 10 Gy was applied (90% reference isodose), preceding WBI with 50-54 Gy (single doses 1.7-2 Gy).

RESULTS

At a median follow up of 72.4 months (0.8-239), only 16 in-breast recurrences were observed, yielding a local tumor control rate of 99.2%. Relapses occurred 12.5-151 months after primary treatment. In multivariate analysis only grade 3 reached significance (p=0.031) to be predictive for local recurrence development. Taking into account patient age, annual in-breast recurrence rates amounted 0.64%, 0.34%, 0.21% and 0.16% in patients <40 years; 40-49 years; 50-59 years and ≥ 60 years, respectively.

CONCLUSION

In all risk subgroups, a 10 Gy IOERT boost prior to WBI provided outstanding local control rates, comparing favourably to all trials with similar length of follow up.

Observations on the effects of inhaled isoflurane in long-term sedation of critically Ill children using a modified AnaConDa©-system

Long-term intravenous sedation may present problems due to dependence and side effects. Medical records of children who were administered isoflurane were reviewed. 15 patients (9 boys, 6 girls) with a mean age of 11.8 month (+2.4) were analysed.Analgesia and sedation was given in mean 9.7+1.1 days before commencing inhalation using a modified application device (AnaConDa©). Administration was given over a period of 7.2+1.4 days. Depth of sedation was monitored by using Comfort- and Hartwig-scores. Observations included continuous monitoring of heart-rate, pulse oxymetry, blood pressure and cerebral tissue oxygenation.Within 4 h post administration of isoflurane a satisfactory increase in the depth of sedation was seen and kept till extubation. 6/15 patients received tracheostomies during the observation period. None of the patients observed suffered life-critical events of the modified application of isoflurane proceeded without complications. Ketamine and clonidine infusion rates were significantly reduced (p<0.005) as well as the use and overall infusion rate of midazolam, γ-hydroxy butyrate, fentanyl and morphine (p<0.05).Isoflurane inhalation may provide an additional option for long-term sedation in a specific group of critically ill infants but neurodegenerative toxic effects will have to be taken into account when using volatile anesthetics at any time during infancy.

[Perfusion brain imaging with SPECT-technique. German Guideline S1]

This paper describes the guideline for perfusion brain imaging with SPECT-technique published by the Association of the Scientific Medical Societies in Germany (AWMF).The purpose of this guideline is to provide practical assistance for indication, examination procedures, findings and their interpretation also reflecting the present state of the art. Information and instruction are given regarding indication, preparation of the patients and examination procedures of brain perfusion SPECT, including preparation and quality control of the tracer as well as the radiation dosimetry, technical performance of image acquisition with the gamma-camera and image processing. Also advices for interpretation of findings are given. In addition, possible pitfalls are described.

Hirnperfusions-SPECT mit 99mTc-Radiopharmaka

This paper describes the guideline for perfusion brain imaging with SPECT-technique published by the Association of the Scientific Medical Societies in Germany (AWMF). The purpose of this guideline is to provide practical assistance for indication, examination procedures, findings and their interpretation also reflecting the present state of the art. Information and instruction are given regarding indication, preparation of the patients and examination procedures of brain perfusion SPECT, including preparation and quality control of the tracer as well as the radiation dosimetry, technical performance of image acquisition with the gamma-camera and image processing. Also advices for interpretation of findings are given. In addition, possible pitfalls are described.

Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABCSG-12 randomised trial

BACKGROUND

Analysis of the Austrian Breast and Colorectal Cancer Study Group trial-12 (ABCSG-12) at 48 months' follow-up showed that addition of zoledronic acid to adjuvant endocrine therapy significantly improved disease-free survival. We have now assessed long-term clinical efficacy including disease-free survival and disease outcomes in patients receiving anastrozole or tamoxifen with or without zoledronic acid.

METHODS

ABSCG-12 is a randomised, controlled, open-label, two-by-two factorial, multicentre trial in 1803 premenopausal women with endocrine-receptor-positive early-stage (stage I-II) breast cancer receiving goserelin (3.6 mg every 28 days), comparing the efficacy and safety of anastrozole (1 mg per day) or tamoxifen (20 mg per day) with or without zoledronic acid (4 mg every 6 months) for 3 years. Randomisation (1:1:1:1 ratio) was computerised and based on the Pocock and Simon minimisation method to balance the four treatment arms across eight prognostic variables (age, neoadjuvant chemotherapy, pathological tumour stage; lymph-node involvement, type of surgery or locoregional therapy, complete axillary dissection, intraoperative radiation therapy, and geographical region). Treatment allocation was not masked. The primary endpoint was disease-free survival (defined as disease recurrence or death) and analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00295646; follow-up is ongoing.

FINDINGS

At a median follow-up of 62 months (range 0-114.4 months), more than 2 years after treatment completion, 186 disease-free survival events had been reported (53 events in 450 patients on tamoxifen alone, 57 in 453 patients on anastrozole alone, 36 in 450 patients on tamoxifen plus zoledronic acid, and 40 in 450 patients on anastrozole plus zoledronic acid). Zoledronic acid reduced risk of disease-free survival events overall (HR 0.68, 95% CI 0.51-0.91; p=0.009), although the difference was not significant in the tamoxifen (HR 0.67, 95% CI 0.44-1.03; p=0.067) and anastrozole arms (HR 0.68, 95% CI 0.45-1.02; p=0.061) assessed separately. Zoledronic acid did not significantly affect risk of death (30 deaths with zoledronic acid vs 43 deaths without; HR 0.67, 95% CI 0.41-1.07; p=0.09). There was no difference in disease-free survival between patients on tamoxifen alone versus anastrozole alone (HR 1.08, 95% CI 0.81-1.44; p=0.591), but overall survival was worse with anastrozole than with tamoxifen (46 vs 27 deaths; HR 1.75, 95% CI 1.08-2.83; p=0.02). Treatments were generally well tolerated, with no reports of renal failure or osteonecrosis of the jaw. Bone pain was reported in 601 patients (33%; 349 patients on zoledronic acid vs 252 not on the drug), fatigue in 361 (20%; 192 vs 169), headache in 280 (16%; 147 vs 133), and arthralgia in 266 (15%; 145 vs 121).

INTERPRETATION

Addition of zoledronic acid improved disease-free survival in the patients taking anastrozole or tamoxifen. There was no difference in disease-free survival between patients receiving anastrozole and tamoxifen overall, but those on anastrozole alone had inferior overall survival. These data show persistent benefits with zoledronic acid and support its addition to adjuvant endocrine therapy in premenopausal patients with early-stage breast cancer.

FUNDING

AstraZeneca; Novartis.

Characterization of microvascularization of liver tumor lesions with high resolution linear ultrasound and contrast enhanced ultrasound (CEUS) during surgery: First results

AIM

Evaluation of high resolution linear ultrasound and intra-operative linear contrast enhanced ultrasound (CEUS) and its benefit for the detection and characterization of tumor lesions.

MATERIAL AND METHODS

Twenty patients were investigated preoperatively regarding tumor detection using CT (n = 8) or MRI (n = 12) and image fusion (VNav) (n = 3). All patients had surgery for their hepatic tumor (hepatocellular carcinoma (HCC), cholangiocellular carcinoma (CCC), metastasis, and adenoma). Ultrasound was performed intra-operatively first with B-scan using a convex probe. Than multifrequency linear transmitters (6-9 MHz, 6-15 MHz, LOGIQ E9, GE) were applied for B-scan, coulor coded Doppler sonography (CCDS) and Power Doppler followed by dynamic CEUS with Contrast Harmonic Imaging (CHI) after bolus injection of a maximum of 15 mL SonoVue®.

RESULTS

In 9 cases with the use of intra-operative CEUS additional tumor lesions (diameter 4-15 mm) could be detected and were histologically confirmed after surgical resection (7 cases) or intra-operative biopsy (2 cases). Using intraoperative CEUS 64 tumor lesions could be detected compared to 51 tumor lesions detected by preoperative CT or MRI (p < 0.05). Using the 6-15 MHz multifrequency linear transducer with CHI, arterial perfusion of adenomas, neuroendocrine metastases and HCC lesions was detectable. In 3 cases a resection was not achievable. Two of these cases were treated with radio frequency ablation (RFA). The other case had no curable option due to multifocal tumor manifestation.

CONCLUSION

The intra-operative use of high-resolution linear transducer techniques with CEUS offers new diagnostic perspectives for an effective liver surgery.

Abstract P4-10-06: 10-Years Results of Intraoperative Electron Radiotherapy (IOERT) in Boost Modality in Breast Cancer Patients Treated with Breast Conserving Surgery

Introduction:

The aim of this nonrandomized study was to compare the ipsilateral breast tumor recurrence rates in patients with invasive breast cancer, who had been treated with breast conserving surgery and whole breast irradiation and conventional boost or intraoperative electron radiotherapy boost (IOERT).

Patients and Methods:

378 patients were included in the study, 188 patients in group 1 (conventional boost) and 190 patients in group 2 (IOERT boost). Patients were comparable with regard to age, menopausal status, tumor size, histological type, grading and axillary lymph node status. Included were patients with invasive breast cancer pT1 and pT2, N0, N1, N2, M0, and breast conserving surgery with clear margins &gt;3mm. Excluded were patients with DCIS only, patients with invasive breast cancers larger than pT2, patients after primary systemic therapy and patients with multicentric disease. All patients (group 1 and group 2) received postoperative whole breast irradiation of 51-56.1 Gy. Group 1 received postoperative electron boost irradiation of 12 Gy after whole breast irradiation and group 2 received one intraoperative electron boost of 9 Gy in a single fraction during surgery before whole breast irradiation. Results:

The 10-years actuarial rates of ipsilateral breast tumor recurrence (IBTR), true local recurrence (TLR), distant recurrence (DR) and disease free survival (DFS) were 7.1% (95%CI, 3.2-11.0%), 4.8% (95%CI, 1.5-8.0%), 14,2% (95%CI, 9.1-19.4%) and 82.4% respectively in group1 and 2.7% (95%CI, 0.0-5.9%, P=0.062), 0.7% (95%CI, 0.0-2.0%, P=0.016), 13.6% (95%CI, 5.0-22.2%, P=0.90) and 84.0% (P= 0.76) respectively in group 2.

Conclusion:

Patients treated with IOERT boost and whole breast irradiation achieve excellent local control rates at 10 years and exhibit statistically significant decreased true local recurrence rates compared to patients treated with whole breast irradiation and conventional electron boost.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P4-10-06.

Sentinel lymph node biopsy is precise after primary systemic therapy in stage II-III breast cancer patients

BACKGROUND

Sentinel lymph node biopsy (SLNB) without axillary lymph node dissection (ALND) in SLN negative patients is a standard of care for most breast cancer patients. SLNB for axillary staging after primary systemic therapy (PST) is still under discussion because of possibly reduced accuracy, while data are lacking. The purpose of this study was to evaluate the accuracy of SLNB after PST.

MATERIALS AND METHODS

A total of 185 breast cancer patients were treated with PST; 160 patients received preoperative chemotherapy, and 25 patients received preoperative endocrine therapy. Thus, 143 of 160 patients with preoperative chemotherapy and 22 of 25 patients with preoperative endocrine therapy were eligible for evaluation. The combination of blue dye and radioactive tracer was used for identification of SLNs. All patients received SLNB and axillary lymph node dissection (ALND). Pathologic assessment of SLNs was performed and compared to non-SLN status.

RESULTS

Pathologic complete response rates and breast conserving therapy rates were 15.4 and 78.3% in the preoperative chemotherapy group and 0 and 77.3% in the preoperative endocrine therapy group, respectively. Identification rate, sensitivity, overall accuracy, and false-negative rate were 81.1% (116 of 143), 91.7% (55 of 60), 95.7% (111 of 116), and 8.3% (5 of 60) in the preoperative chemotherapy group and 77.3% (17 of 22), 90.0% (9 of 10), 94.1% (16 of 17), and 10.0% (1 of 10) in the preoperative endocrine therapy group, respectively.

DISCUSSION

SLNB after primary systemic therapy is accurate, and the results are comparable to those of primary SLNB. SLNB after PST could spare ALND in up to 40% of patients with primary positive axillary lymph nodes and should be considered as a standard for axillary staging in those patients.

Understanding the electric and magnetic response of isolated metaatoms by means of a multipolar field decomposition

We introduce a technique to decompose the scattered near field of two-dimensional arbitrary metaatoms into its multipole contributions. To this end we expand the scattered field upon plane wave illumination into cylindrical harmonics as known from Mie's theory. By relating these cylindrical harmonics to the field radiated by Cartesian multipoles, the contribution of the lowest order electric and magnetic multipoles can be identified. Revealing these multipoles is essential for the design of metamaterials because they largely determine the character of light propagation. In particular, having this information at hand it is straightforward to distinguish between effects that result either from the arrangement of the metaatoms or from their particular design.

Asymmetric transmission of linearly polarized light at optical metamaterials

We experimentally demonstrate a three-dimensional chiral optical metamaterial that exhibits an asymmetric transmission for forwardly and backwardly propagating linearly polarized light. The observation of this novel effect requires a metamaterial composed of three-dimensional chiral meta-atoms without any rotational symmetry. Our analysis is supported by a systematic investigation of the transmission matrices for arbitrarily complex, generally lossy media that allows deriving a simple criterion for asymmetric transmission in an arbitrary polarization base. Contrary to physical intuition, in general the polarization eigenstates in such three-dimensional and low-symmetry metamaterials do not obey fixed relations and the associated transmission matrices cannot be symmetrized.

[Characterization and management of incidentally detected solitary pulmonary nodules]

How to deal with solitary pulmonary nodules (SPN) which are incidentally detected by computed tomography (CT) is an increasingly important task in the era of modern multislice CT. This paper reviews the morphological and functional characteristics and their value for discrimination between benign and malignant SPNs. In particular, the importance of nodule size, growth rate, margin morphology, density, calcifications or fatty components within the nodules, the significance of cavitations or aerobronchograms, enhancement patterns at dynamic contrast-enhanced CT and findings on positron emission tomography (PET) are discussed. The Bayesian analysis to calculate the probability of malignancy is presented. Finally, flow charts demonstrate the national and international recommendations for nodule management.

Oligomeric forms of single chain immunoglobulin (scIgG)

Assembly of immunoglobulin G (IgG) molecules from two heavy and two light chains can be facilitated by connecting the light chain to the heavy chain by an oligopeptide linker. Production of the anti-lysozyme D1.3-single chain (sc) IgG1 in HEK293T cells yielded up to 8 mg/L functional scIgG polypeptide. Size exclusion chromatography of material purified by protein-A affinity chromatography revealed that the majority of the D1.3-scIgG1 molecules were 150 kDa monomers, with a K(D) of 1.8 x 10(-10) M measured by surface plasmon resonance; however, significant fractions of scIgG dimers and oligomers with molecular masses of 300 kDa and >600 kDa, respectively, were identified. The oligomerization resulted in an increased avidity. The observed oligomerization capability may allow new approaches for the generation of bispecific/multivalent antibodies.

Non-Sentinel Lymph Node Status of Patients with T1/T2 Breast Cancer and Micrometastasis in the Sentinel Lymph Node

Background: Micrometastatic disease in the sentinel lymph node is still an indication for complete axillary lymph node dissection. To further reduce morbidity in breast cancer patients the omission of complete axillary lymph node dissection in patients with micrometastasis in the sentinel lymph node would be desirable.Methods: We retrieved our data-base and looked for the non-sentinel lymph node status in patients with micrometastasis in the sentinel lymph node.Patients with primary T1/T2 breast cancer and sentinel lymph node biopsy were examined for their sentinel lymph node status. Patients with a micrometastasis in the sentinel lymph node, who received a complete axillary lymph node dissection were eligible for evaluation. Patients with a micrometastisis in the sentinel lymph node, who did not receive complete axillary lymph node dissection and patients after primary systemic therapy were excluded.Results: 103 patients were eligible for evaluation. All patients had micrometastases (0,2 to 2,0mm) in the sentinel lymph nodes. In total 15/103 patients (14.6%) had a further metastasis in one or two non-sentinel lymph nodes. 8/103 patients (7.8%) had one macrometastasis in a non-sentinel lymph node with sizes from 2.1mm to 5.0mm. 3/103 patients (2.9%) had a micrometastasis in two non-sentinel lymph nodes and 4/103 patients (3.9%) had one micrometastasis in one non-sentinel lymph node.Mean age of the patients was 57 years, 34 (33%) being premenopausal and 69 (67%) being postmenopausal. 22 patients (21.4%) received immediate axillary dissection after sentinel lymph node biopsy, but 81 patients (78.6%) had a secondary axillary lymph node dissection after the final pathological report. In 19 patients (18.4%) the micrometastasis in the sentinel lymph node could be detected by frozen sections, in 77 patients (74.8%) by serial sections at 250µm in the paraffin embedded sentinel lymph node and in 22 patients (21.4%) by immunohistochemistry only.Discussion: As long as we are lacking reliable methods for predicting the non-sentinel lymph node status for patients with micrometastases in the sentinel lymph node, and as long as the impact of micrometastases in the axilla are subject of debate, axillary lymph node dissection should be performed after sentinel lymph node biopsy with micrometastases in the sentinel lymph node.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1034.

BLADE in sagittal T2-weighted MR imaging of the cervical spine

BACKGROUND AND PURPOSE

Image quality and diagnostic reliability of T2-weighted MR images of the cervical spine are often impaired by several kinds of artifacts, even in cooperative patients. The aim of this study was to evaluate if BLADE sequences might solve these problems in a routine patient collective.

MATERIALS AND METHODS

TSE and BLADE sequences were compared in 60 patients for T2-weighted sagittal imaging of the cervical spine. Image sharpness, motion artifacts, truncation artifacts, metal artifacts, CSF flow phenomena, contrast of anatomic structures (vertebral body/disk, spinal cord/CSF), and diagnostic reliability of spinal cord depiction were evaluated by 2 independent readers. Another 2 readers selected the sequence they would prefer for diagnostic purposes. Statistical evaluations were performed by using the Wilcoxon and the chi(2) test; differences with P < .05 were regarded as statistically significant.

RESULTS

BLADE was significantly superior to TSE regarding image sharpness, image contrast, diagnostic reliability of spinal cord depiction, motion artifacts, CSF flow phenomena, and truncation artifacts; for metal artifacts no significant improvements were found. In 50 of 60 patients, BLADE was preferred for diagnostic purposes, and TSE was favored in 3 patients. The number of examinations that were nondiagnostic due to impaired spinal cord depiction was reduced from 12 in TSE to 3 in BLADE, and nondiagnostic examinations due to overall motion artifacts were reduced from 2 to 1.

CONCLUSIONS

Using the BLADE sequence for sagittal T2-weighted imaging of the cervical spine proved to be advantageous to reduce various kinds of artifacts.

Polarization-independent negative-index metamaterial in the near infrared

We present and evaluate theoretically and experimentally a design for a negative-index metamaterial that is termed the "Swiss cross" structure. Compared with the established fishnet structure, the proposed design eliminates the drawback of polarization-dependent effective optical parameters. The new design is fabricated by means of e-beam technology and experimentally analyzed using spectroscopic techniques. The thorough comparison with numerical simulations reveals an effective refractive index of n=-1.9 at an operational wavelength of 1400 nm that is independent of the incident polarization. The resonances of the system are comprehensively discussed.

Endocrine therapy plus zoledronic acid in premenopausal breast cancer

BACKGROUND

Ovarian suppression plus tamoxifen is a standard adjuvant treatment in premenopausal women with endocrine-responsive breast cancer. Aromatase inhibitors are superior to tamoxifen in postmenopausal patients, and preclinical data suggest that zoledronic acid has antitumor properties.

METHODS

We examined the effect of adding zoledronic acid to a combination of either goserelin and tamoxifen or goserelin and anastrozole in premenopausal women with endocrine-responsive early breast cancer. We randomly assigned 1803 patients to receive goserelin (3.6 mg given subcutaneously every 28 days) plus tamoxifen (20 mg per day given orally) or anastrozole (1 mg per day given orally) with or without zoledronic acid (4 mg given intravenously every 6 months) for 3 years. The primary end point was disease-free survival; recurrence-free survival and overall survival were secondary end points.

RESULTS

After a median follow-up of 47.8 months, 137 events had occurred, with disease-free survival rates of 92.8% in the tamoxifen group, 92.0% in the anastrozole group, 90.8% in the group that received endocrine therapy alone, and 94.0% in the group that received endocrine therapy with zoledronic acid. There was no significant difference in disease-free survival between the anastrozole and tamoxifen groups (hazard ratio for disease progression in the anastrozole group, 1.10; 95% confidence interval [CI], 0.78 to 1.53; P=0.59). The addition of zoledronic acid to endocrine therapy, as compared with endocrine therapy without zoledronic acid, resulted in an absolute reduction of 3.2 percentage points and a relative reduction of 36% in the risk of disease progression (hazard ratio, 0.64; 95% CI, 0.46 to 0.91; P=0.01); the addition of zoledronic acid did not significantly reduce the risk of death (hazard ratio, 0.60; 95% CI, 0.32 to 1.11; P=0.11). Adverse events were consistent with known drug-safety profiles.

CONCLUSIONS

The addition of zoledronic acid to adjuvant endocrine therapy improves disease-free survival in premenopausal patients with estrogen-responsive early breast cancer. (ClinicalTrials.gov number, NCT00295646.)

Ipsilateral breast tumor recurrence rates in breast cancer patients treated with preoperative chemotherapy, breast conserving surgery and intraoperative radiotherapy with electrons

Abstract #5156

Introduction: Ipsilateral breast tumor recurrence (IBTR) rates are reported to be increased in patients treated with breast conserving surgery after preoperative chemotherapy. Aim of this study was to evaluate the IBTR rate in patients who were treated with preoperative chemotherapy followed by breast conserving surgery and intraoperative radiotherapy with electrons (IOERT).&#x2028; Patients and Methods: 84 patients with clinical stage II or III breast cancer were included in the study. Patients received 3 to 6 cycles of anthracyclin/taxane containing preoperative chemotherapy. All patients had breast conserving surgery with sentinel node biopsy and axillary lymph node dissection and received intraoperative radiotherapy with 9 Gy to the 90% reference isodose as an anticipated boost radiation. Whole breast radiotherapy (WBRT) was performed after surgery for all patients.&#x2028; Results: Pathologic complete response was achieved in 18/84 (21%) patients. Mean resection volume was 250 ml. After a median follow-up of 30.5 months (range 6 – 77 months) no IBTR could be observed. One patient developed a locoregional recurrence in the axilla and nine patients developed distant disease, five of those died of disease. Three patients developed contralateral breast cancer. 71 patients are alive without evidence of disease.&#x2028; Conclusion: Breast conserving surgery with IOERT in boost modality after preoperative chemotherapy is a reliable tool for the prevention of IBTR. The period between IOERT and WBRT is short as no adjuvant chemotherapy is necessary. Cosmetic outcome is excellent.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5156.