Impact of microscopic extrathyroidal extension on differentiated thyroid cancer post-surgical risk of recurrence: a retrospective analysis

PURPOSE

In the last edition of the American Joint Committee on Cancer (AJCC) staging system, differentiated thyroid cancers (DTC) showing microscopic extrathyroidal extension (mETE) are considered comparable to intrathyroidal cancers for their clinical behavior and prognosis. The aim of the study is to evaluate the impact of this updated assessment of T, when applied to the postoperative recurrence risk stratification, according to the American Thyroid Association Guidelines (ATA-RR).

METHODS

One-hundred DTC patients who underwent total thyroidectomy were retrospectively evaluated. The downstaging of mETE was introduced in the definition of T, and the updated classification defined as modified ATA-RR (ATAm-RR). For each patient, post-surgical basal and stimulated thyroglobulin (Tg) levels, neck ultrasound (US) and post-ablative 131-I whole body scan (WBS) reports were considered. The predictive performance (PP) of disease recurrence was calculated both for each single parameter, as well as for all of them.

RESULTS

According to ATAm-RR classification, 19/100 patients (19%) were downstaged. ATA-RR proved a significant PP for disease recurrence (DR) (sensitivity 75.0%, specificity 63.0%, p = 0.023). However, ATAm-RR performed slightly better due to an increased specificity (sensitivity 75.0%, specificity 83.7%, p < 0.001). For both classifications, the PP was optimal when all the above-mentioned predictive parameters were considered.

CONCLUSION

Our results suggest that the new assessment of T considering mETE resulted in a downgrading of ATA-RR class in a significant number of patients. This provides a better PP for disease recurrence, and the best PP was obtained when considering the whole predictive variables together.

A High-throughput Screening of a Chemical Compound Library in Ovarian Cancer Stem Cells

BACKGROUND

Epithelial ovarian cancer has a poor prognosis, mostly due to its late diagnosis and the development of drug resistance after a first platinum-based regimen. The presence of a specific population of "cancer stem cells" could be responsible of the relapse of the tumor and the development of resistance to therapy. For this reason, it would be important to specifically target this subpopulation of tumor cells in order to increase the response to therapy.

METHOD

We screened a chemical compound library assembled during the COST CM1106 action to search for compound classes active in targeting ovarian stem cells. We here report the results of the high-throughput screening assay in two ovarian cancer stem cells and the differentiated cells derived from them.

RESULTS AND CONCLUSION

Interestingly, there were compounds active only on stem cells, only on differentiated cells, and compounds active on both cell populations. Even if these data need to be validated in ad hoc dose response cytotoxic experiments, the ongoing analysis of the compound structures will open up to mechanistic drug studies to select compounds able to improve the prognosis of ovarian cancer patients.

Abstract P6-13-15: Lyso-thermosensitive liposomal doxorubicin shows efficacy with minimal adverse events in patients with breast cancer recurrence at the chest wall

INTRODUCTION: Local-regional recurrence after definitive treatment of breast cancer is reported in 5 – 40 % of patients depending risk factors and initial treatment. Chest wall recurrence is associated with poor quality of life and limited treatment options. Lyso-thermosensitive liposomal doxorubicin (LTLD, Thermodox®) is an intravenously administered agent designed to selectively release doxorubicin when exposed to temperatures ≥39.5° C at a targeted tumor. Hyperthermia, the elevation of tissue temperature in the range of 40° C to 44° C, causes direct cytotoxicity, enhanced blood flow, and oxygenation. We are reporting the interim findings of an ongoing Phase I/II Study Evaluating the Maximum Tolerated Dose, Bioequivalence/Pharmacokinetics, Safety, and Efficacy of LTLD in Patients with Local-Regional Recurrent Breast Cancer. Final results will be presented in December.

METHODS: Patients with breast carcinoma on the chest wall with progression following radiation were eligible; prior chemotherapy and hormone therapy were allowed. LTLD was administered intravenously followed immediately by hyperthermia in up to two treatment fields for 1 hour per field for a goal of 40–42°C. Response was measured using clinical assessment, CT, and digital photos. All subjects were assessed for safety. Up to six cycles of LTLD/hyperthermia were administered depending on disease progression or tolerance. A total of 11 patients were enrolled on the Phase I portion of the study and 9 were evaluable for efficacy review. To date, 17 patients are enrolled on the Phase II portion of the study and 13 are evaluable for efficacy review. Once 12 patients are found to be evaluable for PK the primary endpoint of bioequivalence can be evaluated.

RESULTS: A dose of 50 mg/m2 was recommended by the DSMB at completion of the Phase I study. Seven subjects were dosed at 50mg/m2, two patients developed a localized reaction in the treatment area consisting of erythema, woody induration, and pain which resolved with discontinuation of treatment. Twenty patients were dosed at 40mg/m2 without recurrence of symptoms. To date, twenty-eight patients were enrolled in the phase I/II study; one subject was excluded due to dose modification following 2 cycles of ThermoDox at a dose of 50mg/m2 to 40mg/m2 at cycle 3. This subject had a durable partial response. The tables summarize the safety and efficacy data. All efficacy data is investigator reported.

Combined Phase I/II Safety DataSafety Data40 mg/m2 (N=20)50 mg/m2 (N=7)Any AE Event (n, %)17 85.07 100.0Grade 3+ AE (n, %)10 50.06 85.7Serious AE (n, %)5 25.03 42.9Hematological AE (n, %)10 50.07 100.0Deaths due to AE (n, %)0 0.00 0.0

Combined Phase I/II Efficacy DataEfficacy Data40 mg/m2 (N=20)50 mg/m2 (N=7)Responders (Partial & Complete) (n, %)10 50.03 42.9Complete Response (n, %)5 25.01 14.3Partial Response (n, %)5 25.02 28.6Durable Response (lasting ≥ 3 months) (n, %)3 15.00 0.0

CONCLUSION: These findings suggest that LTLD at a dose of 40 mg/m2 combined with hyperthermia offers a promising and well tolerated treatment option for patients with recurrent chest wall disease from breast cancer. Additional data will be presented based on full trial accrual.

Citation Format: Rugo H, Pabbathi H, Shrestha S, Aithal S, Borys N, Musso L, Zoberi I. Lyso-thermosensitive liposomal doxorubicin shows efficacy with minimal adverse events in patients with breast cancer recurrence at the chest wall. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-13-15.

Painful 20 fingers' onychodistrophy

Psoriatic onycho-pachydermo-periostitis (POPP) is a rare subset of psoriatic arthritis. It is usually localized to the hands and it is characterized by onychodistrophy, soft tissue thickening above the distal phalanx and periosteal reaction. The resolution is very slow due to the involvement of nails and bone. Low dose methotrexate and anti-tumor necrosis factor-α (anti-TNF-α) agents are the suggested therapies. We report a case of a 53-year-old man affected by palmo-plantar slight psoriatic dermatitis, who presented a rapid onset of POPP. Rx imaging showed enthesitis and a moderate phalanx erosion with articular spaces narrowing and swollen periosteal reaction. A magnetic resonance imaging test of the hands showed an initial stage of synovitis and extensive periostitis of the distal phalangeal tufts. The patient has been treated with oral methotrexate for a month with a rapid clinical improvement and pain reduction. As POPP at first manifests as a painful onycodistrophy, it can easily be confused with bacterial perionyxis. The delay in making the correct diagnosis, and therefore, the delay in giving a proper treatment would mean the progressive articular erosion and the permanent invalidation of the patient's ability to use his hands.

[Neurolytic block of the celiac plexus and splanchnic nerves with computed tomography. The experience in 150 cases and an optimization of the technic]

INTRODUCTION

CT-guided celiac plexus and splanchnic nerve neurolytic blocks are procedures for pain relief in patients with upper abdominal malignancies. In the last 20 years, the technique has been modified by the introduction of CT guidance providing improved precision and safety. We report our personal experience and provide suggestions for technique optimization.

MATERIALS AND METHODS

In 1991-1998 we performed 150 celiac plexus and/or splanchnic nerve neurolytic blocks with ethyl alcohol in 144 cancer patients; the procedure was repeated in 6 patients. In 69% of cases the patient had a pancreatic lesion. We prefer an anterior approach with very thin needles (22 Gauge). The sites of alcohol injection (celiac plexus, splanchnic nerves or both) are chosen after evaluation of anatomy by preliminary CT scans, or during the procedure, depending on alcohol (mixed with a contrast agent) spread.

RESULTS

The mean duration of the procedure ranged 50 min (1991) to 22 min (1998). 48 hours after the block we obtained major pain relief in 79% of cases. After 15 days, 21% of patients had no pain (drugs: none), 29% had mild pain (therapy: non-steroid anti-inflammatory drugs), 32% had marked pain (therapy: non-steroid anti-inflammatory drugs and, occasionally, opioids), 18% had severe pain (only opioid therapy). Pain relief was more frequent in splanchnic nerve blocks.

DISCUSSION

Our experience confirms that neurolytic celiac plexus and/or splanchnic nerve block is a good choice in the treatment of upper abdominal cancer pain. We would also like to add that: 1) celiac plexus block with CT guidance (with the needle tip positioned anterior to aorta) and splanchnic nerve block (with the needle tip positioned posterior to diaphragmatic crura) are no longer two separated techniques, but they can be chosen and combined according to patients needs. 2) All procedures can be performed with anterior approach, in supine position, with a single thin needle, allowing to reach the target without any complication, even after puncturing stomach, liver, bowel, pancreas or aorta. 3) With CT guidance, even splanchnic nerve neurolysis is a low-risk technique, which should be adopted in all cases of insufficient alcohol spread in the celiac plexus. 4) When the operators are skilled and experienced enough, the time required for the block can be significantly decreased to nearly the time required for US-guided or fluoroscopic-guided procedures.

[Post-traumatic pseudoaneurysm of the common carotid artery]

The authors report their experience of one single case of carotid pseudo-aneurysm consequent on cervical trauma. The treatment required the substitution of the interested carotid segment by PTFE no. 6. This case is a rare event but the surgeon must always keep it in mind in the presence of cervical trauma.

Erectile Impotence from Veno-Occlusive Dysfunction: Our Experience and Present Diagnostic-Therapeutic Indications

The authors evaluate erectile impotence from veno-occlusive dysfunction, concentrating on diagnostic techniques, both invasive and non-invasive, and appropriate treatment. In particular dynamic testing is reviewed, where a vasoactive drug, Papaverine or more recently PGE1, is injected into one of the corpora cavernosa. Measurement of blood flow velocity with Doppler ultrasonography allows a functional evaluation, while radiographic images during cavernosography give an anatomical view of the erectile abnormality. A review of case histories and partial follow-up of patients has confirmed the actual precision of the diagnostic methods and various therapeutic approaches.

[Composite bypass using endarterectomized autologous superficial femoral artery. A valid concept in the extension of lower limb salvage surgery]

Saphenous vein is nowadays the material of choice performing on femoro-distal revascularisation; when this is not available, it is important to use a material which gives the closest approximation of an ideal conduit and for same time an easy handling during the execution of the anastomosis. Although vein's degenerative alterations are very rare, it has now been shown that there is widespread destruction of the endothelium among infrainguinal vein grafting, producing a relatively thrombogenic surface. These factors may contribute to the initial failure rate of these bypasses. For this reason we suggest to employ a segment of thromboendarterectomized SFA (superficial femoral artery) as a distal part of a composite bypass. Twenty-four composite bypasses were performed using three different methods over a total of 123 femoro-distal revascularizations. Eighteen months follow-up showed more than 50% and more than 75% patency rate comparing type B (graft or thromboendarterectomized SFA + autogenous saphenous vein) and type C (thromboendarterectomyied SFA + graft). We believe, waiting for a wider follow-up, that this technique could be a valid alternative to a femoro-distal revascularization when saphenous vein is not available.

[Prognostic value of the equivalents of transitory myocardial ischemia evaluated by exercise thallium-201 myocardial scintigraphy in an ambulatory population of 367 patients with a maximum 5-year follow-up]

From 1-1-1981 to 3-31-1985, 367 subjects (227 males and 140 females) were examined by means of TL-201 myocardial scintigraphy for diagnostic purpose. A follow-up period, 5 years maximum, was run in order to assess the prognostic value of the three equivalents of transient myocardial ischemia which can be demonstrated by the test (angina, reversible hypoperfusion, and ST-T segment changes). The end points were myocardial infarction and/or sudden death. Three-hundred fifty-four patients complied (96%). During the observation period 9 severe ischemic events (SIE) occurred: 5 myocardial infarctions and 4 sudden deaths. As far as the predictivity of SIE is concerned, the "t" test for independent samples showed a statistically significant difference between the group of patients with no signs of ischemia and the group with positive scintiscan (p less than 0.05) and with the three equivalents of ischemia all together (p less than 0.05). Moreover, in the sub-group of patients with pathological scintigraphic results the probability for SIE to occur was statistically different in the patients with no hypoperfusion in the region supplied by the anterior descending coronary artery and in those with pathological scintigraphic findings in that region (p less than 0.05). In our opinion, the above data demonstrate the pathological signs noticeable with stress myocardial TL-201 scintiscan to have prognostic value.

[Intravenous ethyl alcohol in metabolic resuscitation]

Intravenously administered ethyl alcohol may be effective as analgesic and hypotensive peripheric vasoactive drug. In the Intensive Care Departments parenteral ethanol administration is infrequent because no "sure dosage" can be suggested in adults and children. Liver, kidney and C.N.S. diseases can worsen; foetopathy can follow. Drug-ethanol interaction may be particularly important for some patients admitted in Intensive Care Departments. Often the potential caloric support cannot be fully utilized ("empty" calories) and seldom hyperventilation, hyperlactacidemia and impaired protein synthesis can follow.

[Anesthesia problems of the multiply-injured patient]

Anaesthesia in the case of subjects with multiple injuries is commonly a short-term emergency measure, in which a certain time is available for the implementation of intensive antishock therapy, or else anaesthesia for deferred emergency situations. Since the introduction of ketamine and althesin, the anaesthesiological risk has greatly reduced. Althesin has the best therapeutic index of all anaesthetics and the least myocardial toxicity. It also reduces intracranial pressure. Ketamine offers considerable neurovegetative protection. A personal technique, in which althesin with without althesin, is the drug of choice, is described.