Bone mineral density in adolescent elite ballet dancers

BACKGROUND

Data documenting BMD in pre-professional adolescent ballet dancers is limited. This cross-sectional study assesses bone mineral density (BMD) in young adolescent elite ballet dancers and compares BMD values between males and females (with and without normal menarche) and body composition between dancers with and without low Z-score.

METHODS

Cross-sectional study of third year ballet students (female=23; male=15; mean age 14.7 years; SD: 0.5) of The Royal Ballet School of Antwerp (Belgium) training 22 hours a week. They completed questionnaires and underwent dual energy X-ray absorptiometry (DXA) to measure BMD and body composition. Each female participant completed questionnaires assessing menstrual status.

RESULTS

DXA revealed that 12 out of 38 (32%) of the dancers had Z-score <-1. On average, male dancers had a lower BMD compared to an age-matched reference population (mean Z-score -0.9; SD 0.5), with 7 out of 15 having Z-score <-1. Overall, absolute BMD values were highest in the legs, followed by spine and arms. Dancers with Z-score <-1 had a significantly lower total mass. 43% of female ballet dancers had not yet had their first period and 39% had oligomenorrhea, but no significant differences between groups was detected.

CONCLUSIONS

A third of adolescent elite ballet dancers had low to very low Z-score. Nearly 2 out of 3 dancers with a Z-score <-1 were males, showing that low BMD is not limited to female dancers. Among female dancers menstrual dysfunction was frequent, without apparent impact on BMD or body composition in the studied age group.

Ovarian cancer unmasked by technetium-99m bone scintigraphy and single-photon emission computed tomography-computed tomography

We report a case of a 30-year-old female patient with a painless palpable nodule in the chest wall, evaluated for osseous involvement by technetium-99m (Tc-99m) bone scintigraphy. A whole-body scan revealed numerous sites of increased tracer accumulation throughout the thorax, abdomen, and pelvis. Subsequent single-photon emission computed tomography-computed tomography (SPECT-CT) of the abdomen and pelvis showed no abnormal uptake in the bone; however, significant nonosseous tracer accumulation in calcified soft tissue metastases was noted. Pathology confirmed a high-grade ovarian papillary serous adenocarcinoma. Extraosseous uptake of bone-seeking agents in the body is often incidental findings and can be explained by various benign and malignant conditions with soft tissue calcification. In our case report, this unusual finding on bone scintigraphy was highly suggestive for malignancy, initially not considered during the clinical evaluation of the patient. It also illustrates the usefulness of additional hybrid SPECT-CT to precisely localize extraosseous uptake of Tc-99m methylene diphoshonate.

The predictive value of sentinel node biopsy in early breast cancer after neo-adjuvant chemotherapy: A prospective study

OBJECTIVE

A sentinel Node (SN) has replaced axillary lymph node dissection (ALND) in patients with clinically node negative axilla (cN0). SN after Neo-adjuvant chemotherapy (NACT) is feasible but not accurate in clinically node positive (cN1-3) patients. The goal of this study is to determine the negative predictive value (NPV) of SN in cN0 breast cancer after NACT. A secondary endpoint is to determine if ALND can be avoided after NACT regardless of the pre-treatment clinical staging of the axilla, in case of a normalization of the ¹⁸F-fluoro-2-deoxy-glucose positron emission tomography scan (PET-CT scan).

DESIGN

A single institution prospective study regarding the negative predictive value of the SN in breast cancer after NACT was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital from 29/03/2010 until 01/12/2015 (Study number: B30020108368). Inclusion criteria for study participation were: breast cancer, age above 18 years, female, tumor stages T2-T4 N0-3 or T1N1-N3. All patients were staged by a mammography, ultrasound of the axilla, MRI of the breast, PET-CT scan and bone scintigraphy. They received NACT consisting of 12 cycles of paclitaxel or 4 cycles of docetaxel followed by dose dense doxorubicin or epirubicin/cyclofosfamide or vice versa as a standard initial treatment. After 6 weeks, a PET-CT scan was performed for early tumour response evaluation. At the day of operation, a ⁹⁹mTC-labelled nanocolloid was used to identify the SN. During the surgery the SN were removed separately together with a complete ALND.

RESULTS

A total of 150 patients were enrolled in our study of which 129 were eligible for analysis. 53 patients had a positive SN of which 32 have a positive axillary lymph nodes (ALN), positive predictive value (PPV) was 60%; 76 patients had a negative SN of which 6 had a positive ALN (NPV 92%). The sensitivity is 84% and the specificity 76% with a false omission rate (FOR) of 8%. In total 45 patients ALN were clinical negative and no suspect lymph nodes were seen on ultrasound, MRI and PET-CT scan) and 45 patients had negative a SN, with no ALN and 2 patients had a positive SN of which 1 patients had axillary involvement (NPV 100%). The FOR of cN1: 5%, cN2: 37%, cN3 33%. A total of 22 patients out of 84 patients (26%) of which 15/49 cN1 (30%), 6/23 (26%) cN2, 1/12 (8%) have after 6 weeks of chemotherapy and normalization on PET-CT scan. A total of 17 patients had a negative SN and ALN. The FOR was in this group was 0%.

CONCLUSION

A SNB should become the standard after NACT if case of a cN0. If after NACT the PET CT has normalized, no ALND should be performed if the SN is negative.

Estimation of the future remnant liver function is a better tool to predict post-hepatectomy liver failure than platelet-based liver scores

INTRODUCTION

Recently, there has been increasing interest in the preoperative prediction and prevention of post-hepatectomy liver failure (PHLF). This is a particular concern in colorectal liver metastases (CRLM), when surgery follows potentially hepatotoxic chemotherapy. Platelet-based liver scores (PBLS) such as APRI and FIB-4 are predictive of chemotherapy-associated liver injury (CALI) and PHLF. Estimation of the future liver remnant function (eFLRF) by combining ^99mTc-Mebrofenin Hepatobiliary Scintigraphy (HBS^BSA) with future liver remnant volume ratio (FLRV%), is predictive of PHLF and related mortality. We hypothesized that a HBS^BSA based formula was a better predictor for PHLF than PBLS in chemotherapy-pretreated CRLM.

METHODS

Between 2012 and 2016, 140 patients underwent liver resection for CRLM following systemic therapy. HBS^BSA, FLRV%, eFLRF and PBLS were calculated and compared for their value in predicting PHLF.

RESULTS

eFLRF and FLRV% had a better predictive value for PHLF than HBS^BSA alone and APRI and FIB-4 (AUC = 0.800, 0.843 versus 0.652, 0.635 and 0.658 respectively). In a subgroup analysis (Oxaliplatin all, Oxaliplatin ≥ 6 cycles, Irinotecan all and Irinotecan ≥ 6 cycles), eFLRF was the only factor predictive for PHLF in all subgroups (all: p ≤ 0.05). Prediction of HBS^BSA for chemotherapy associated steato-hepatitis (CASH) reached almost significance (p = 0.06). FIB-4 was predictive for sinusoidal obstruction syndrome (SOS) (p = 0.011). Only weak correlation was found between HBS^BSA and PBLS.

CONCLUSION

eFLRF is a better predictor of PHLF than PBLS or HBS^BSA alone. PBLS seem to measure other aspects of liver function or damage than HBS^BSA.

Abstract P2-01-02: The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study

Background

SNB has replaced axillary lymph node dissection (ALND) in those patients (pts) with clinically node negative axilla. This has reduced the morbidity, in particular lymphedema considerable. SLN after NACT is feasible but not accurate in clinically node positive (cN1-3) pts (false negative rate around 10%). Therefore, continuous efforts have to been made in randomized prospective studies to improve the detetion rate of SNB in order to avoid the morbidity of ALND. The purpose of this study is to determine the negative predictive value of the sentinel node in breast cancer after NACT.

Method

A single institution prospective study regarding the negative predictive value of the sentinel node in breast cancer after NACT was conducted in the Multidisciplinary Breast Clinic of the Antwerp University Hospital from 29/03/2010 untill 12-2015 (Study number: B30020108368). Inclusion criteria for study participation were: breast cancer, age above 18 years, female, tumor stages T2-T4 N0-3 or T1N1-N3. All pts were staged by a mammography, ultrasound of the axilla, MRI of the breast, 18F-fluoro-2-deoxy-glucose(18F-FDG) positron emission tomography (PET-CT) scan and bone scintigraphy. They received NACT consisting of 12 cycles of Paclitaxel or 4 cycles of Docetaxel followed by dose dense doxorubicin or epirubicin/cyclofosfamide or vice versa as a standard initial treatment. After 6 weeks a 18F-FDG PET-CT scan was performed for early tumor response evaluation. At the day of operation, all the pts had a preoperative injecting with a 99mTC-labelled nanocolloid in the peri-areolar region. A gamma detector was used to localize the SLN(s). All SLN(s) were removed and a complete ALND was performed.

Results

A total of 150 pts were enrolled in our study of which 129 were eligible for analysis. 53 pts had a positive SLN of which 32 have a positive axillary lymph nodes (ALN) (PPV 60%); 76 pts has a negative SLN of which 6 had a positive ALN (NPV 92%). The sensitivity is 84% and the specificity 76% with a false omission rate (FOR) of 8%. 45 pts had an initial clinical N0 (cN0 is defined as clinical negative and no suspect lymph nodes on ultrasound, on MRI breast and 18F-FDG-PET CT scan). 45 pts had negative SLN, with no ALN and 2 pts had a positive SNL of which 1 pts had axillary involvement (NPV 100%). The FOR of cN1: 5%, cN2: 37%, cN3 33%. A total of 22 pts out of 84 pts (26%) of which 15/49 cN1 (30%), 6/23 (26%) cN2, 1/12 (8%)have after 6 weeks of chemotherapy, 18F-FDG normalization on 18F-FDG PET-CT scan. A total of 17 pts had a negative SLN and ALN. The FOR was 0%

Conclusion

SNB after NACT in case of cN0 is very reliable with high NPV and low FOR. In case of 18F-FDG-PET CT normalization after 6 weeks of chemotherapy and a negative SLN, no ALND has to be performed.

Citation Format: Huizing M, Najim O, Dockx Y, Huyghe I, Van den Wyngaert T, van Goethem M, Verslegers I, Papadimitriou K, Altintas S, Baldewijns M, Trinh B, van Dam P, Tjalma W. The predictive value of sentinel node biopsy (SNB) in early breast cancer after neo-adjuvant chemotherapy (NACT): A prospective study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-02.

Measuring future liver remnant function prior to hepatectomy may guide the indication for portal vein occlusion and avoid posthepatectomy liver failure: a prospective interventional study

BACKGROUND

Estimation of the future liver remnant function (eFLRF) can avoid post-hepatectomy liver failure (PHLF). In a previous study, a cutoff value of 2.3%/min/m² for eFLRF was a better predictor of PHLF than future liver remnant volume (FLRV%). In this prospective interventional study, investigating a management strategy aimed at avoiding PHLF, this cutoff value was the sole criterion assessing eligibility for hepatectomy, with or without portal vein occlusion (PVO).

METHODS

In 100 consecutive patients, eFLRF was determined using the formula: eFLRF = FLRV% × total liver function (TLF). Group 1 (eFLRF >2.3%/min/m²) underwent hepatectomy without preoperative intervention. Group 2 (eFLRF <2.3%/min/m²) underwent PVO and re-evaluation of eFLRF at 4-6 weeks. Hepatectomy was performed if eFLRF had increased to >2.3%/min/m², but was considered contraindicated if the value remained lower.

RESULTS

In group 1 (n = 93), 1 patient developed grade B PHLF. In group 2 (n = 7) no PHLF was recorded. Postoperative recovery of TLF in patients with preoperative eFLRF <2.3%/min/m² occurred more rapidly when PVO had been performed.

CONCLUSION

A predefined cutoff for preoperatively calculated eFLRF can be used as a tool for selecting patients prior to hepatectomy, with or without PVO, thus avoiding PHLF and PHLF-related mortality.

Preoperative ultrasound staging of the axilla make's peroperative examination of the sentinel node redundant in breast cancer: saving tissue, time and money

OBJECTIVE

To evaluate the role of preoperative axillary staging with ultrasound (US) and fine needle aspiration cytology (FNAC). Can we avoid intraoperative sentinel lymph node (SLN) examination, with an acceptable revision rate by preoperative staging?

DESIGN

This study is based on the retrospective data of 336 patients that underwent US evaluation of the axilla as part of their staging. A FNAC biopsy was performed when abnormal lymph nodes were visualized. Patients with normal appearing nodes on US or a benign diagnostic biopsy had removal of the SLNs without intraoperative pathological examination. We calculated the sensitivity, specificity and accuracy of US/FNAC in predicting the necessity of an axillary lymphadenectomy. Subsequently we looked at the total cost and the operating time of 3 models. Model A is our study protocol. Model B is a theoretical protocol based on the findings of the Z0011 trial with only clinical preoperative staging and in Model C preoperative staging and intraoperative pathological examination were both theoretically done. sentinel node, staging, ultrasound, preoperative axillary staging, FNAC, axilla RESULTS: The sensitivity, specificity and accuracy are respectively 0.75 (0.66-0.82), 1.00 (0.99-1.00) and 0.92 (0.88-0.94). Only 26 out of 317 (8.2%) patients that successfully underwent staging needed a revision. The total cost of Model A was 1.58% cheaper than Model C and resulted in a decrease in operation time by 9,46%. The benefits compared with Model B were much smaller.

CONCLUSION

Preoperative US/FNAC staging of the axillary lymph nodes can avoid intraoperative examination of the sentinel node with an acceptable revision rate. It saves tissue, reduces operating time and decreases healthcare costs in general.

Future remnant liver function estimated by combining liver volumetry on magnetic resonance imaging with total liver function on (99m)Tc-mebrofenin hepatobiliary scintigraphy: can this tool predict post-hepatectomy liver failure?

INTRODUCTION

Posthepatectomy liver failure (PHLF) is a major complication after hepatectomy with a high mortality rate and is likely to happen in insufficient liver remnant. We hypothesize that assessment of the estimated future liver remnant function (eFLRF), combining future remnant liver volume (FLRV) with total liver function (TLF), is an accurate formula for prediction of PHLF.

METHODS

88 patients undergoing hepatectomy were included. The ratio of the future liver remnant volume (FLRV%) was measured on MRI. TLF was estimated by liver clearance of (99m)Technetium (Tc)-mebrofenin on hepatobiliary scintigraphy (HBS). eFLRF was calculated by multiplying FLRV% by TLF. Cut-off values of FLRV% and eFLRF predicting PHLF, were defined by receiver-operating-characteristic (ROC) analysis.

RESULTS

PHLF occurred in 12 patients (13%). Perioperative mortality was 5/12 (41%). Multivariate analysis showed that FLRV% cut off at 40% was not an independent predictive factor. eFLRF cut off at 2.3%/min/m(2) was the only independent predictive factor for PHLF. For FLRV% vs. eFLRF, positive predictive value was 41% vs. 92% and Odds Ratio 26 vs. 836.

CONCLUSION

FRLF measured by combining FLRV% and TLF is a more valuable tool to predict PHLF than FLRV% alone. The cutoff of eFLRF can be used in clinical decision making.

Three Different Locations of a Sentinel Node Highlight the Importance of Performing a Sentinel Node Biopsy in Breast Cancer Recurrence

A local breast cancer recurrence or a new breast cancer in the previously treated breast is a staging challenge. Staging is important to tailor the local and the systemic treatment. Earlier treatment(s) can disrupt the primary lymphatic drainage. After the disruption, new lymphatic drainage pathways are often created. The identification of these new pathways together with their sentinel node(s) (SN) is important for retreatment. A fluorodeoxyglucose positron emission tomography-computerized tomography could be useful to identify the involved node(s), but, unfortunately, there is no evidence to support this. Ideally, in the case of a recurrence, an SN biopsy should be performed in order to identify the “new” draining lymph node(s). This new draining SN(s) can be located in unexpected places, and tumor invasion will lead to a change in the management.

18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) as early imaging biomarker of axillary sentinel lymph node (SLN) status in locally advanced node-positive breast cancer (NPBC) patients (pts) receiving neoadjuvant chemotherapy (NACT)

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Background: Use of FDG-PET in the early evaluation of NACT for NPBC is currently under investigation. The aim of this study is to assess FDG-PET in NPBC pts receiving NACT in order to identify a subset of pts that can be spared axillary lymph node dissection (ALND) in case of response. Methods: All pts (period 2009-2011) had [cT2 (≥3cm)-T4, pN1-3], and no prior BC treatment. All pts received 8 cycles (cy) of NACT +/- trastuzumab. FDG-PET was performed at baseline and after 2 cy. After NACT, mastectomy with SLN and ALND was peformed. As primary endpoint, the change in maximum standardized uptake value (SUVmax) in the primary tumor (PT) and ALNs was compared with pathological response (Jonckheere-Terpstra test). Logistic regression was used to determine the predictive value of a 50% reduction in SUVmax on pathological response and SLN status. Results: Forty-one pts were evaluable for the primary endpoint and 31 pts had successful SN procedures. The median age was 49.8 years (range 27-75). Overall, 9.8% (4/41; 95% CI 2.7 – 23.1) of pts had progressive disease (PD), 7.3% (3/41 ; 95% CI 1.5 – 19.9 ) stable disease (SD), 53.7% (22/41; 95% CI 37.4 – 69.3) partial response (PR), and 21.9% (9/41; 95% CI 10.6 – 37.6) a complete pathological response (pCR). A linear trend existed between pCR and higher decreases in SUVmax of the PT site (p=0.008), but not with lymph node SUVmax (p=0.294). The odds of achieving a pCR, increased significantly when SUVmax of the PT decreased with >50% (OR 10.7; 95% CI 1.2 - 98.0; p=0.03), but not lymph node SUVmax (OR 4.75; 95% CI 0.82 - 27.5; p=0.08). Achieving a true negative SLN status was more likely with >50% reductions in PT SUVmax (OR 41.2; 95% CI 4.0 - 421.9; p= 0.002). A reduction of >50% in nodal SUVmax was not predictive of negative SLN status (OR 3.33; 95% CI 0.66 - 16.8; p=0.1). Conclusions: Early changes in PT metabolism imaged with FDG-PET after only 2 cy of NACT is a promising biomarker in the management of the axilla in NPBC. Molecular imaging of PT biology and to a lesser extent of axillary lymph nodes using FDG-PET warrants further study.

Predictability of intranasal pharmacokinetics in man using pre-clinical pharmacokinetic data with a dopamine 3 receptor agonist, PF-219061

(R)-3-(4-propylmorpholin-2-yl) phenol (PF-219061) is a potent, selective agonist of the dopamine 3 receptor for the treatment of female sexual dysfunction. In vivo, PF-219061 exhibits liver blood flow clearance in both rat and dog. Oral bioavailability was 0.7% in dog and less than 5% in rat. Intranasal dosing was investigated to improve bioavailability. Pre-clinical assessments in rat and dog demonstrated intranasal bioavailabilities of 16-38% in rat and 54-61% in dog with very rapid absorption. It was predicted that an intranasal dose in man would give approximately 25-50% bioavailability. The clinical data verified the preclinical predictions demonstrating rapid absorption and approximately dose-proportional increases in exposure. The intranasal bioavailability in man was estimated to be 26-38%. These findings indicate the potential utility of intranasal dosing as a route that circumvents the first-pass effects for PF-219061 resulting in high exposures.