Utility of Stereotactic Body Radiation Therapy in Establishing Local Control for Patients With Invasive Breast Cancer Not Undergoing Definitive Surgery

PURPOSE

Surgery is the backbone of breast cancer (BC) treatment. For patients who cannot undergo surgery, improving local control (LC) of the primary tumor is paramount. To that end, this study explored the role of stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS

Between 2015 and 2022, 21 nonsurgical candidates (10 metastatic, 11 stage IA-IIIC) received 23 SBRT courses to primary BC. Seven were analyzed retrospectively; 15 are currently enrolled in a prospective study. SBRT (40 Gy/5 fractions) was delivered every other day. Follow-up imaging was reviewed. Acute (≤3 months) and late toxicities were evaluated using Common Terminology Criteria for Adverse Events, version 5. LC and overall survival (OS) were estimated using Kaplan-Meier curves.

RESULTS

Median age was 78.4 years (45.9-97.3). Median follow-up was 14.7 months (3.3-70.3). Median pre-SBRT index lesion size was 3.1 cm (0.5-14.5) and planning treatment volume was 32.4 cc (11.5-522.4). Initial posttreatment imaging performed at a median 4.0 months (0.6-11.9) post-SBRT demonstrated median decrease in index lesion size of 20.8% (0%-100%); SUV reduction of 65.2% (20.8%-100%). Second follow-up scans at a median 7.8 months post-SBRT showed 62% (0%-100%) and 88% (33.3%-100%) median reduction in tumor size and SUV, respectively, compared with pre-SBRT values. The estimated LC rate was 100% at 6 months and 93.3% at 12, 24, and 36 months. Local progression occurred in 1 case 9.5 months after SBRT, after an initial response. Regional progression occurred in 4 cases (17.4%) at a median 18.6 months (5.2-22.7) post-SBRT. Six patients (35.3%) developed distant progression at a median 2.7 months (0.9-16.2). The estimated OS was 85.7% at 6 months, 69.6% at 12 months, and 63.8% at 24 and 36 months. The rates of acute toxicity were G1: 47.8%, G2: 4.3%, G3: 8.7%, and G4: 0%.

CONCLUSIONS

Definitive SBRT for primary BC resulted in good LC in nonsurgical patients and was well-tolerated. Considering the pattern of progression, additional approaches to improve regional/distant control should be investigated.

Biomarkers and Strain Echocardiography for the Detection of Subclinical Cardiotoxicity in Breast Cancer Patients Receiving Anthracyclines

The optimal surveillance and management strategies for breast cancer patients receiving anthracycline therapy are limited by our incomplete understanding of the role of biomarkers heralding the onset of cardiotoxicity. The purpose of this study was to determine whether there is a temporal correlation between cardiac biomarkers and subclinical left ventricular dysfunction in breast cancer patients receiving anthracycline chemotherapy. Thirty-one females between 46 and 55 years old with breast cancer treated with anthracycline chemotherapy were prospectively enrolled. Cardiac biomarkers were correlated with echocardiography with speckle tracking at baseline, post-anthracycline therapy, and 6 months post-anthracycline chemotherapy. Subclinical cardiotoxicity was defined as ≥ 10% reduction in global longitudinal strain (GLS). There was a relative reduction in left ventricular ejection fraction (LVEF) ≥ 10% in 5/30 (17%) and 7/27 (26%) patients post-anthracycline therapy and 6 months post-anthracycline therapy, respectively. Subclinical cardiotoxicity was noted in 8/30 (27%) and 10/26 (38%) patients post-anthracycline and 6 months post-anthracycline therapy, respectively. Baseline N-terminal pro B-type natriuretic peptide (NT-proBNP) was the strongest predictor of LVEF (ρ = -0.45; p = 0.019), with post-therapy NT-proBNP values illustrating similar predictive value (ρ = -0.40; p = 0.038). Interim changes in suppression of tumorigenicity 2 (ST2) and galectin-3 correlated with a 6-month change in LVEF (ρ = -0.48; p = 0.012 and ρ = -0.45; p = 0.018, for ST2 and galectin-3, respectively). Changes in galectin-3 from baseline to mid-therapy paralleled changes in GLS. NT-proBNP, ST2, and galectin-3 correlate with reduced LVEF among breast cancer patients receiving anthracycline therapy. Additional trials focusing on a cardiac biomarker approach may provide guidance in the early diagnosis and management of anthracycline-induced cardiotoxicity.

Blood plasma derived extracellular vesicles (BEVs): particle purification liquid chromatography (PPLC) and proteomic analysis reveals BEVs as a potential minimally invasive tool for predicting response to breast cancer treatment

PURPOSE

Circulating blood plasma derived extracellular vesicles (BEVs) containing proteins hold promise for their use as minimally invasive biomarkers for predicting response to cancer therapy. The main goal of this study was to establish the efficiency and utility of the particle purification liquid chromatography (PPLC) BEV isolation method and evaluate the role of BEVs in predicting breast cancer (BC) patient response to neoadjuvant chemotherapy (NAC).

METHODS

PPLC isolation was used to separate BEVs from non-EV contaminants and characterize BEVs from 17 BC patients scheduled to receive NAC. Using LC-MS/MS, we compared the proteome of PPLC-isolated BEVs from patients (n = 7) that achieved a pathological complete response (pCR) after NAC (responders [R]) to patients (n = 10) who did not achieve pCR (non-responders [NR]). Luminal MCF7 and basaloid MDA-MB-231 BC cells were treated with isolated BEVs and evaluated for metabolic activity by MTT assay.

RESULTS

NR had elevated BEV concentrations and negative zeta potential (ζ-potential) prior to receipt of NAC. Eight proteins were enriched in BEVs of NR. GP1BA (CD42b), PECAM-1 (CD31), CAPN1, HSPB1 (HSP27), and ANXA5 were validated using western blot. MTT assay revealed BEVs from R and NR patients increased metabolic activity of MCF7 and MDA-MB-231 BC cells and the magnitude was highest in MCF7s treated with NR BEVs.

CONCLUSION

PPLC-based EV isolation provides a preanalytical separation process for BEVs devoid of most contaminants. Our findings suggest that PPLC-isolated BEVs and the five associated proteins may be established as predictors of chemoresistance, and thus serve to identify NR to spare them the toxic effects of NAC.

Sulindac Improves Stiffness and Quality of Life in Women Taking Aromatase Inhibitors for Breast Cancer

PURPOSE

To examine benefit of sulindac for relief of musculoskeletal symptoms (MSS) in patients stable on aromatase inhibitors (AIs).

METHODS

Sulindac was evaluated at 150 mg twice daily for effects on MSS at 3, 6, 9, and 12 months in 50 postmenopausal women stable on AI therapy for a median of 12.5 months for hormone receptor-positive breast cancer. A separate, non-randomized group of 50 similar patients was observed for change in MSS over 12 months. MSS severity was assessed using the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index and Brief Pain Inventory Short Form (BPI-SF). The Functional Assessment of Cancer Therapy-General form (FACT-G) measured quality of life (QOL). Change in MSS and QOL across time was assessed in each group using linear mixed effects models.

RESULTS

Stiffness, not pain, was the main complaint at baseline. At 12 months, sulindac patients reported decreases (improvements) in mean (95% CI) Total WOMAC score [- 5.85 (- 9.73, - 1.96)] and WOMAC pain [- 5.40 (- 10.64, - 0 .18)], Stiffness [- 9.53 (- 14.98, - 4.08)] and Physical Function [- 5.61 (- 9.62, - 1.60)] subscales, but not BPI-SF worst pain. Among sulindac patients with higher baseline MSS severity, 35% experienced ≥ 50% improvement in Total WOMAC and Total FACT-G scores [6.18 (2.08, 10.27); P = 0.003]. For the observation group, MSS and QOL did not improve over 12 months, even among those with higher baseline MSS severity.

CONCLUSIONS

Sulindac may relieve MSS in AI patients, especially physical function and stiffness. Randomized controlled trials should further evaluate NSAIDs on AI-MSS and AI adherence.

TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION

NCT01761877, December, 2012.

Abstract PS5-37: The feasibility of obtaining oncotype DX breast recurrence score® results from metastatic sites of patients with hormone receptor positive metastatic breast cancer

Background: Identifying when to start CDK4/6 inhibitors or use chemotherapy in hormone receptor positive (HR+) metastatic breast cancer (MBC) remains challenging. The 21-gene Oncotype DX Breast Recurrence Score® test is validated to predict chemotherapy benefit in early stage HR+ breast cancer but has not been studied for use in the MBC setting.Objective: To assess the feasibility of obtaining Recurrence Scores from metastatic sites after standard of care biopsy in HR+, HER2 negative patients and correlate Recurrence Score results from matched primary breast cancer when available. Methods: A total of 48 metastatic biopsies were retrieved retrospectively from the residual tissue of patients with primary HR+, HER2 negative breast cancer. This included 36 from bone and 12 from other sites [liver (7), lung (1), rectum (1), brain (1), skin (2)]. Slides were sent to Genomic Health Inc. for RNA isolation and Recurrence Score result determination using standardized protocols. Recurrence Score results were available for 18 matched primary and metastatic biopsy samples. The percent success rate for Recurrence Score result was determined for the various metastatic sites and results compared between matched primary and metastatic site. Results: Recurrence Score results were obtained in 48% of metastatic biopsies (23 of 48 samples) including bone (17), liver (4), lung (1), and skin (1). Reasons for Recurrence Score failure included insufficient RNA (17), poor quality RNA (1), failed QC (4), and other (3). The mean Recurrence Score from the 23 metastatic sites was 35 (range: 1–66). Notably, 70% (16/23) of successful metastatic biopsies yielded Recurrence Scores in the high-risk range (>25). None of the 23 metastatic biopsies gained HER2 by RT-PCR. Among the 18 paired samples, higher recurrence score results were observed in all but three of the metastatic biopsy samples with mean Recurrence Score results of 20 (range 7 to 41) for the primary and 35 (range 1-66) for the metastatic site. For paired samples, 72% of metastatic biopsies yielded Recurrence Scores >25 compared to 17% of primary sample. Primary Recurrence Scores were not predictive of metastatic scores (r2=0.052). Estrogen receptor (ER) expression status was conserved in 87% whereas progesterone receptor (PR) was lost in 69% of the metastatic lesion. Among the pairs, 5 had de novo metastatic disease. In these, the Recurrence Score was higher in the metastatic biopsy in each case compared to the matched primary (mean 36 versus 23, respectively). Among de novo cases, there was 100% concordance in ER positive and HER2 negative expression and only 60% concordance in PR expression between primary and metastatic sites.

Conclusion: Using standard of care metastatic biopsy samples, a Recurrence Score result was successfully generated in 48% of samples including bone. This small series demonstrates wide variability in Recurrence Score results in metastatic disease with overall higher scores, common loss of PR, and minimal correlation to matched primary disease. Further examination of the potential significance of the Recurrence Score for treatment decisions in the metastatic setting requires additional tissue sampling during biopsy as insufficient RNA was the primary reason for failure.

Citation Format: Julie Anne L Gemmill, Patricia Thompson, Rebecca Batiste, Caterina Vacchi-Suzzi, Christina Preece, Jules Cohen, Lea Baer, Carolyn Mies, Michelle Turner, Christy A Russell, Alison Stopeck. The feasibility of obtaining oncotype DX breast recurrence score® results from metastatic sites of patients with hormone receptor positive metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS5-37.

L-methylfolate augmentation of selective serotonin reuptake inhibitors (SSRIS) for major depressive disorder: Results of two randomized, double-blind trials

Introduction

Two randomized, controlled trials of L-methylfolate augmentation of SSRIs for major depressive disorder (MDD) were conducted using a novel study design (sequential parallel comparison design- SPCD).

Objectives/aims

To evaluate the efficacy of L-methylfolate augmentation using the Hamilton Depression Rating Scale.

Methods

In study one (TRD-1), 148 outpatients with SSRI-resistant MDD were enrolled in a 60-day, SPCD study, divided into two 30-day periods (phases 1 and 2). Patients were randomized 2:3:3 to receive L-methylfolate (7.5mg/d in phase 1, 15mg/d in phase 2), placebo in phase 1 followed by L-methylfolate 7.5mg/d in phase 2, or placebo for both phases. Study two (TRD-2) involved 75 patients and was identical in design to TRD-1 except for the dose of L-methylfolate (15mg only).

Results

In the TRD-1 Study, L-methylfolate 7.5 mg/d was not found to be more effective than placebo. In phase 1 of the TRD-2 Study, 37% of patients on L-methylfolate 15mg/d responded and 18% of placebo patients responded, while in phase 2 among placebo non-responders, the response rates were 28% on L-methylfolate 15mg/d and 9.5% on placebo. When phases 1 and 2 were pooled according to the SPCD model, the difference in response rates was statistically significant in favor of L-methylfolate (p = 0.0399). The rates of spontaneously reported AEs and rates of study discontinuation appear r comparable between L-methylfolate and placebo in both studies. Rates of study discontinuation were also comparable

Conclusions

These studies suggest that L-methylfolate 15 mg/d may be a safe and effective augmentation strategy for inadequate response to SSRIs.

Abstract P6-11-09: Need for increased awareness in high incidence areas of premenopausal de novo stage IV breast cancer

Introduction: Breast cancer is the most common cancer in women. In 2013, 5% of US women presenting with de novo Stage IV breast cancer cases were under age 40, and 16% under age 50. The purpose of our study was to analyze changes in demographics and clinical characteristics of patients with de novo Stage IV breast cancer at our tertiary care institution with a focus on younger women.

Methods: Our study is a retrospective chart review of 159 female patients who presented with de novo Stage IV breast cancer to our institution during years 2007-2019. Patients with recurrent Stage IV breast cancer were excluded. Charts of patients were reviewed and the following data was recorded: age at diagnosis, race, insurance, menopausal status, symptoms, family history, how cancer was diagnosed, prior breast imaging, genetics testing, tumor histology, and sites of metastasis. Data was further subdivided into younger (under age 50) and older (over age 69) groups.

Results: Data analysis revealed median age of 61 and range of 26-92. 14/159 women (9%) diagnosed with de novo stage IV breast cancer were younger than 40. 40/159 (25%) were younger than 50, and 119/159 (75%) were age 50 or older. Over the last decade, proportion of younger women presenting with de novo Stage IV breast cancer did not change, while 86% increase was seen in older age group.

Among younger women, 72% were Non-Hispanic Whites, 10% Hispanic and 12% Black. Over the last decade, proportion of non-Hispanic whites younger than 50 with de novo Stage IV disease decreased by 38%, 50% increase was seen in Blacks and four-fold increase in Hispanics.

Majority of women noted a breast mass prior to diagnosis, 72% of younger group and 75% older group. 35% of younger group presented with additional symptoms such as bone pain compared to 52% older women. 27% of younger group initially presented with an ulcerated breast lesion compared to 47% older group.

Proportion with family history of breast cancer was similar, 57% in younger group and 52% older group.

90% of younger women had invasive ductal cancer. Tumors were hormone receptor positive in 65% of younger women compared to 82% older group.

90% of younger women were insured, compared to 100% older group. 60% of younger group were diagnosed by their primary care physician compared to 42% older group.

17% younger women had prior breast imaging. All women younger than 50 were offered genetics testing, 10% elected to undergo testing. Of those women, 18% under age 40 and 31% under age 50 were found to have deleterious mutations.

Conclusion: Our study analyzed the demographics and clinical characteristics of younger patients presenting with de novo metastatic breast cancer over the last 10 years. In our tertiary center serving a suburban area, the proportion of women younger than 40 with de novo Stage IV breast cancer was 9% compared to 5% nationwide. Similarly, the proportion younger than 50 was 25% compared to 16% nationwide.

Overall, the proportion of younger women presenting with de novo Stage IV breast cancer has not significantly changed over the past decade. This stability is particularly interesting in view of recent changes in area demographics in which the Hispanic population has increased by 2% over the past 4 years. In our study, the racial breakdown did significantly change with 38% decrease in non-Hispanic whites while 50% increase was seen in Blacks and four-fold increase in Hispanics.

Finally, 90% of younger women were insured suggestive of sufficient access to care. In fact, a majority of the younger were initially diagnosed by their primary care physician. However, only a minority had prior breast imaging highlighting the need for increased awareness and education of both community and primary providers in areas of high incidence of premenopausal Stage IV breast cancer.

Citation Format: Lea Baer, Adam Khorasanchi, Alison Stopeck, Andrzej Kudelka, Jules Cohen. Need for increased awareness in high incidence areas of premenopausal de novo stage IV breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P6-11-09.

Abstract P2-08-29: Recent demographic changes show significant impact on age distribution and clinical characteristics of women presenting with de novo stage IV breast cancer

Introduction: Breast cancer is the most common cancer in women. In 2013, 16% of US women presenting with de novo Stage IV breast cancer cases were under age 50. The purpose of our study was to analyze the demographics and clinical characteristics of patients with de novo Stage IV breast cancer at our large tertiary care institution in the view of dramatic changes in the racial and ethnic makeup of Suffolk County, Long Island over the last 10 years.

Methods: Our study is a retrospective chart review of 159 female patients who presented with de novo Stage IV breast cancer to our institution during the years 2007-2019. Patients with recurrent Stage IV breast cancer were excluded. Charts of patients were reviewed and the following data was recorded: age at diagnosis, race, insurance status, menopausal status, presenting symptoms, family history, setting in which breast cancer was diagnosed, tumor histology, and sites of metastasis. Data was further subdivided into younger (under age 50) and older age groups (over age 69). Characteristics were compared using these groups.

Results: Data analysis revealed median age at diagnosis of 61, with a range between 26 and 92. 25% percent of women were under age 50, 50% ages 50-69 and 25% percent were 70 years of age or older. Over the last decade, proportion of younger women with de novo Stage IV breast cancer did not change significantly while there was a 14% increase in women presenting between ages 50 to 69, and 86% in the older subgroup.

80% were Non-Hispanic White, 9% Hispanic, 7% African-American. Over this past decade, non-Hispanic whites increased by 27%, 175% increase in Hispanics, and 20% increase in African-Americans. Overall, women were well-insured with 90% in younger group and 100% in older group having coverage at time of presentation. 60% of younger group were first diagnosed by their primary care physician compared to 42% of older group. Only 17% of younger group were diagnosed incidentally compared to 40% of older group. A majority of women had a known mass prior to diagnosis, 72% in younger group and 75% older group. 35% of younger group presented with other symptoms such as bone pain, weight loss compared to 52% of older group.

27% of younger women initially presented with an unrelated condition compared to 47% of older group. Proportion of patients with family history of breast cancer were similar, 57% in younger group and 52% in older group.

Overall, 26% were premenopausal. 73% had invasive ductal cancer. Majority had hormone receptor positive tumors, 65% in younger group compared to 82% older group. Finally, 54% of patients presented with multiple metastatic sites, 30% in both younger and older groups.

Conclusion: Our study analyzed the demographics and clinical characteristics of patients with de novo Stage IV breast cancer at our large tertiary care institution over the last 10 years.

The proportion of women 50 or younger diagnosed with de novo Stage IV breast cancer was 25% percent compared to 16% nationwide. The proportion of women presenting at age 70 or older has significantly increased over the past decade. This may be due to improving women’s life expectancy in the US but changes in patterns of screening of older women needs to be evaluated as well.

Over this past decade there was a 175% increase in Hispanic women presenting with de novo Stage IV breast cancer. This is in the setting of changing demographics of Suffolk County, Long Island which has increased its Hispanic population by 2% over the past 4 years according to census data. This dramatic change in mostly insured patients highlights the need for improved awareness and community outreach in this population.

Citation Format: Adam Khorasanchi, Lea Baer, Alison Stopeck, Andrzej Kudelka, Jules Cohen. Recent demographic changes show significant impact on age distribution and clinical characteristics of women presenting with de novo stage IV breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-08-29.

MRI Volume Changes of Axillary Lymph Nodes as Predictor of Pathologic Complete Responses to Neoadjuvant Chemotherapy in Breast Cancer

INTRODUCTION

Longitudinal monitoring of breast tumor volume over the course of chemotherapy is informative of pathologic response. This study aims to determine whether axillary lymph node (aLN) volume by magnetic resonance imaging (MRI) could augment the prediction accuracy of treatment response to neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

Level-2a curated data from the I-SPY-1 TRIAL (2002-2006) were used. Patients had stage 2 or 3 breast cancer. MRI was acquired pre-, during, and post-NAC. A subset with visible aLNs on MRI was identified (N = 132). Prediction of pathologic complete response (PCR) was made using breast tumor volume changes, nodal volume changes, and combined breast tumor and nodal volume changes with sub-stratification with and without large lymph nodes (3 mL or ∼1.79 cm diameter cutoff). Receiver operating characteristic curve analysis was used to quantify prediction performance.

RESULTS

The rate of change of aLN and breast tumor volume were informative of pathologic response, with prediction being most informative early in treatment (area under the curve (AUC), 0.57-0.87) compared with later in treatment (AUC, 0.50-0.75). Larger aLN volume was associated with hormone receptor negativity, with the largest nodal volume for triple negative subtypes. Sub-stratification by node size improved predictive performance, with the best predictive model for large nodes having AUC of 0.87.

CONCLUSION

aLN MRI offers clinically relevant information and has the potential to predict treatment response to NAC in patients with breast cancer.

Abstract P1-11-22: Aromatase inhibitors are significantly better tolerated by early stage breast cancer patients 75 or older and with significantly lower early discontinuation rate

Introduction:

Breast cancer is the most common cancer in women. In postmenopausal women with early stage estrogen receptor positive breast cancer, aromatase inhibitors (AI) are a common treatment option. AI's are reported to lead to a high early discontinuation rate in younger post-menopausal women due to poor tolerance. The most common side effects reported to lead to early discontinuation are arthralgia, hot flashes, fatigue, and night sweats. The reported tolerance to AI therapy in women age 75 or older is not well documented. Our study looks at women, ages 75 and older, diagnosed with early stage breast cancer who were placed on adjuvant AI therapy and focuses on tolerability, incidence of common side effects, rate of treatment changes, and on discontinuation rates.

Objective:

This study evaluates the tolerability, treatment side effects and the discontinuation rate of AI in women over the age of 75 with early stage breast cancer.

Methods:

Our study is a retrospective chart review of 58 patients' ages 75 to 95 with early stage breast cancer treated with adjuvant AI. Charts of patients were reviewed and duration of treatment, patient reported side effects, treatment changes, and discontinuation rate were recorded.

Results:

Data analysis showed that 36/55 (65.5%) of patients did not report significant side effects to AI. 6/55 (10.9%) patients required therapy changes due to side effects. 5/6 required one treatment change and 1/6 required multiple treatment changes. In 5/6 therapy was changed to another AI. Only 2/55 (3.6%) of patients discontinued therapy. In both patients who discontinued AI, therapy was discontinued due to medical complications unrelated to AI therapy. Average time to discontinuation was 11 months. The most common reported side effects were arthralgia 9/55 (16.4%), fatigue 3/55 (5.5%), hot flashes 4/55 (7.3%), rash 3/55 (5.5%) and hair thinning 3/55 (5.5%). The most common reported side effect which led to treatment change was arthralgia 4/6 (66.7%). With a median follow up time of 24 months, breast cancer specific mortality was 1/55 (1.8%).

Reported Side Effects on AIn=55 patientsPatients who noted symptomsPatients who changed therapy due to symptomsFatigue30Arthralgia94Hot flashes40Rash31Vaginal dryness10Hair thinning31

Conclusion:

Our study evaluated the tolerance of AI in older women diagnosed with early stage breast cancer. 36/55 (65.5%) of elderly patients reported no significant side effects suggesting that AI's are well tolerated in this population and the known side effects are significantly less common than previously reported in a younger cohort in whom arthralgia as well as vasomotor symptoms affect as many as 30% of women. This improved tolerance led to a significantly lower early discontinuation rate than previously reported in the younger cohort: discontinuation rate of 3.6% by 24 months in the 75 or older population versus 20% by 24 months in the younger cohort of post-menopausal women treated with AI.

Reference:

1 Wagner, L.I., Zhao, F., Goss, P.E. et al. Breast Cancer Res Treat (2018) 169: 537. https://doi-org.proxy.library.stonybrook.edu/10.1007/s10549-018-4713-2

Citation Format: Chaudhry B, Baer L, Kudelka A, Cohen J, Stopeck AT. Aromatase inhibitors are significantly better tolerated by early stage breast cancer patients 75 or older and with significantly lower early discontinuation rate [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-22.

Abstract P1-11-24: Aromatase inhibitors and bone health in women 75 and older treated for early stage breast cancer

Introduction:

Breast cancer is the most common cancer in women. In estrogen receptor positive breast cancers aromatase inhibitors (AI) are a common treatment option. AIs are associated with a reduction in bone mineral density, and patients with osteopenia at baseline have a higher risk of developing subsequent osteoporosis while on AI therapy. Women age 75 and older are a fast growing subset of breast cancer patients and commonly have osteopenia or osteoporosis at time of breast cancer diagnosis. Studies of long-term effects of AI on bone density in these older women who are at higher risk of osteoporosis and musculoskeletal events are lacking at this time.

Objective:

To evaluate the objective change in bone density in women over the age of 75 diagnosed with early stage breast cancer and treated with AI.

Methods:

A retrospective chart review of 49 patients ages 75 to 95 diagnosed with early stage breast cancer and treated with AI. Pretreatment DEXA scan results were recorded as well as prevalence of bone targeted therapy at the time of breast cancer diagnosis. Incidence of bone targeted therapy initiated subsequent to cancer diagnosis and changes in T score on follow up DEXA scans were collected as well. Incidence of musculoskeletal events and osteonecrosis of the jaw were recorded.

Results:

40/49 (81.6%) of study women were found to have osteopenia (23/49 [46.9%]) or osteoporosis (17/49 [34.7%]) on pre-treatment DEXA scans. Only 16/49 (32.7%) of patients were on bone-targeted treatment prior to breast cancer diagnosis. Of the patient with baseline osteoporosis, only 4/17 (23.5%) were on bone targeted treatment prior to breast cancer diagnosis. 25/49 (51%) of women were initiated on bone targeted therapy subsequent to breast cancer diagnosis and following review of pretreatment DEXA scan results. 5/49 (10.2%) of women were started on bisphosphonates and 7/49 (14.3%) were started on Denosumab. On the first subsequent DEXA scan at a median follow up of 2 years, 14/21(66.7%) of women were noted to have stable DEXA findings (defined as change in T score less than 0.5). 7/21 (33.3%) had a worsening T score on repeat DEXA. Of those patients with worsening T score, 3/7 (42.9%) changed categories (either from normal density to osteopenia or from osteopenia to osteoporosis. 3/49 (6%) of patients sustained a fracture while on AI therapy. There were no reported events of osteonecrosis of the jaw.

 Subsequent DEXA showing stabilitySubsequent DEXA showing worsening T scoreFractureBaseline Normal bone density1 (n=3)2 (n=3)1 (n=9)Baseline Osteopenia9 (n=12)3 (n=12)0 (n=12)Baseline Osteoporosis4 (n=6)2 (n=6)2 (n=17)

Conclusion:

Many elderly women are found to have osteopenia or osteoporosis at the time of breast cancer diagnosis and AI initiation. Most elderly patients had stable findings on subsequent bone density testing. Women with known osteoporosis initiated on bone-targeted therapy and AI did not have significant worsening in bone health. With appropriate treatment and monitoring elderly women with baseline decreased bone density can be treated safely with aromatase inhibitors.

Citation Format: Baer L, Chaudhry B, Kudelka A, Cohen J, Stopeck AT. Aromatase inhibitors and bone health in women 75 and older treated for early stage breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-24.

Managing dermatologic changes of targeted cancer therapy

Failure to control these dermatologic changes can lead to lower dosages of cancer agents or an interrupted course of Tx. These steps can help you to head off trouble.

Cancer Therapy-Related Cardiac Dysfunction and Heart Failure: Part 1: Definitions, Pathophysiology, Risk Factors, and Imaging

Advances in cancer therapy have resulted in significant improvement in long-term survival for many types of cancer but have also resulted in untoward side effects associated with treatment. One such complication that has become increasingly recognized is the development of cardiomyopathy and heart failure. Whether a previously healthy person from a cardiovascular perspective develops cancer therapy-related cardiac dysfunction or a high-risk cardiovascular patient requires cancer therapy, the team of oncologists and cardiologists must be better equipped with an evidence-based approach to care for these patients across the spectrum. Although the toxicities associated with various cancer therapies are well recognized, limitations to our understanding of the appropriate course of action remain. In this first of a 2-part review, we discuss the epidemiologic, pathophysiologic, risk factors, and imaging aspects of cancer therapy-related cardiac dysfunction and heart failure. In a subsequent second part, we discuss the prevention and treatment aspects, concluding with a section on evidence gap and future directions. We focus on adult patients in all stages of cancer therapy from pretreatment surveillance, to ongoing therapy, and long-term follow-up.

Cancer Therapy-Related Cardiac Dysfunction and Heart Failure: Part 2: Prevention, Treatment, Guidelines, and Future Directions

Success with oncologic treatment has allowed cancer patients to experience longer cancer-free survival gains. Unfortunately, this success has been tempered by unintended and often devastating cardiac complications affecting overall patient outcomes. Cardiac toxicity, specifically the association of several cancer therapy agents with the development of left ventricular dysfunction and cardiomyopathy, is an issue of growing concern. Although the pathophysiologic mechanisms behind cardiac toxicity have been characterized, there is currently no evidence-based approach for monitoring and management of these patients. In the first of a 2-part review, we discuss the epidemiologic, pathophysiologic, risk factors, and imaging aspects of cancer therapy-related cardiac dysfunction and heart failure. In this second part, we discuss the prevention and treatment aspects in these patients and conclude with highlighting the evidence gaps and future directions for research in this area.

Abstract OT2-6-06: Pre-surgical “window of opportunity” trial of metformin and atorvastatin in newly diagnosed operable breast cancer

Background: Breast cancer requires energy homeostasis shifts with enhanced anabolism to enable rapid growth and continued proliferation. The main energy regulatory system is the AMP-activated kinase (AMPK) pathway triggered by changes in the AMP/ATP ratio. AMPK pathway closely interacts with the PI3K/AKT signaling pathway, with both pathways affecting downstream function of the master regulator mTOR. “Window of opportunity” studies with metformin alone, an AMPK inhibitor, have resulted in mixed results in reducing tumor proliferation in women with early-stage operable breast cancer. Reduction in tumor proliferation has been demonstrated with statins alone (i.e. HMG CoA reductase inhibitors) in pre-surgical trials. Dual therapy with both metformin and atorvastatin demonstrate synergistic activity in preclinical studies in cancer cell lines, showing enhanced anti-proliferative effect. The purpose of this study is to determine the effects of dual therapy with metformin and atorvastatin in women with newly diagnosed BC between breast biopsy and surgery.

Trial Design: Patients (n = 40) will receive metformin 1500mg (500 mg am/1000 mg pm) and atorvastatin 80mg pm, for 2-4 weeks following a diagnostic biopsy and prior to surgery (goal: at least 2 weeks). The main eligibility criteria for this open-label, single-institution, pre-surgical trial include operable stage 0-III BC. Patients must have at least 1 cm of tumor based on palpation or imaging to ensure sufficient pre-treatment tissue. Patients not considered for neoadjuvant chemotherapy are eligible. Specific Aims: Our hypothesis is that pre-surgical metformin plus atorvastatin will result in a significant decrease in the tumor proliferation marker Ki-67. Ki-67 will be log-transformed ln(ki-67), per international guidelines. Secondary objectives include evaluation of functional proteomic changes, such as AMPK/mTOR pathway signaling and apoptosis, by reverse phase protein array (RPPA), as well as assessment of changes in serum insulin, lipids, and markers of the insulin growth factor pathway.

Statistical Methods: Paired t-tests will be calculated to assess modulations in ln(ki-67) before and after treatment. Compared to historical control, we will achieve 80% power with 40 patients, anticipating a -0.523 reduction of ln(ki-67) and standard deviation of 1.15 before and after metformin plus statin (significance level, p = 0.05). We will also be comparing changes in ln(ki-67) in the treated patients to historical controls matched by age, stage, and BMI, using a two-sample t-test at level 0.05. Frequency distributions and summary descriptive statistics will be calculated for all other biomarkers in the two groups. Correlations between all biomarkers and changes in Ki-67 proliferation marker will be analyzed in exploratory fashion. We will also explore differences in modulation of tumor proliferation and functional proteomics in grade III tumors as compared to other tumors. We anticipate accrual 2-3 patient/month, completing the trial within 18 months. Contact information: kk2693@columbia.edu.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-6-06.

Benefits of pulsatile flow in pediatric cardiopulmonary bypass procedures: from conception to conduction

This review on the benefits of pulsatile flow includes not only experimental and clinical data, but also attempts to further illuminate the major factors as to why this debate has continued during the past 55 years. Every single component of the cardiopulmonary bypass (CPB) circuitry is equally important for generating adequate quality of pulsatility, not only the pump. Therefore, translational research is a necessity to select the best components for the circuit. Generation of pulsatile flow depends on an energy gradient; precise quantification in terms of hemodynamic energy levels is, therefore, a necessity, not an option. Comparisons between perfusion modes should be done after these basic steps have been taken. We have also included experimental and clinical data for direct comparisons between the perfusion modes. In addition, we included several suggestions for future clinical trials for other interested investigators.

Bevacizumab increases risk for severe proteinuria in cancer patients

Treatment with the chemotherapeutic agent bevacizumab, a humanized mAb that neutralizes vascular endothelial growth factor, can lead to proteinuria and renal damage. The risk factors and clinical outcomes of renal adverse events are not well understood. We performed a systematic review and meta-analysis of published randomized, controlled trials to assess the overall risk for severe proteinuria with bevacizumab. We analyzed data from 16 studies comprising 12,268 patients with a variety of tumors. The incidence of high-grade (grade 3 or 4) proteinuria with bevacizumab was 2.2% (95% confidence interval [CI] 1.2 to 4.3%). Compared with chemotherapy alone, bevacizumab combined with chemotherapy significantly increased the risk for high-grade proteinuria (relative risk 4.79; 95% CI 2.71 to 8.46) and nephrotic syndrome (relative risk 7.78; 95% CI 1.80 to 33.62); higher dosages of bevacizumab associated with increased risk for proteinuria. Regarding tumor type, renal cell carcinoma associated with the highest risk (cumulative incidence 10.2%). We did not detect a significant difference between platinum- and non-platinum-based concurrent chemotherapy with regard to risk for high-grade proteinuria (P = 0.39). In conclusion, the addition of bevacizumab to chemotherapy significantly increases the risk for high-grade proteinuria and nephrotic syndrome.

High-grade proteinuria associated with bevacizumab in patients with renal cell cancer and non-renal cell cancer

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Background: Bevacizumab is a humanized monoclonal antibody that inhibits vascular endothelial growth factor. It is a widely used angiogenesis inhibitor in the treatment of renal cell cancer (RCC) and other solid tumors. Proteinuria is associated with significant morbidity and treatment interruptions. The overall risk for proteinuria is unclear. This study was conducted to determine the risk of developing proteinuria among RCC and non-RCC patients receiving bevacizumab. Methods: Databases from PUBMED and Web Science from January 1966 until July 2008 and abstracts presented at ASCO from January 2000 to July 2008 were searched to identify relevant studies. Studies included randomized controlled clinical trials in which standard anti-neoplastic therapy was administered with and without bevacizumab with available data for proteinuria. Summary incidence rate, relative risk (RR), and 95% confidence interval (CI) were calculated employing fixed or random effect models based upon the heterogeneity of included studies. Results: A total of 6,702 patients from 14 randomized controlled studies were included for analysis. The incidence of all-grade proteinuria in patients receiving bevacizumab was 19.3% (95% CI: 11.9–29.6%) with 2.3% (95% CI: 1.2–4.1%) being high-grade (grade 3 or 4). Patients treated with bevacizumab had an increased risk of developing high-grade proteinuria with RR of 6.3 (95% CI: 4.0–9.9) compared with controls. Risk may vary with dose of bevacizumab; significant difference may exist in patients receiving bevacizumab at 5 mg/kg/week (RR 9.1, 95% CI: 4.3–19.6, p < 0.001) and 2.5 mg/kg/week (RR = 5.1, 95%CI: 3.0–8.8, p < 0.001). The risk of high-grade proteinuria may also depend on tumor type; the incidence of high-grade proteinuria was 10.0% (95% CI: 4.3–22.4%) with a RR 48.7 (95% CI: 9.7–244.3) among 703 RCC patients compared with an incidence of 1.7% (95% CI: 0.09–3.2%) and RR of 5.2 (95% CI: 3.3–8.4) among 5,999 non-RCC patients. Conclusions: There is a significant risk for high-grade proteinuria in patients receiving bevacizumab. The risk may vary with bevacizumab dose and tumor type. RCC patients may have higher risk than non-RCC patients. Close monitoring and management are recommended for patients at high risk.

No significant financial relationships to disclose.

A screening and prevention programme serving an ethnically diverse population of women at high risk of developing breast and/or ovarian cancer

INTRODUCTION

We describe a screening and prevention programme primarily targeting under-served minority women at high risk of breast and/or ovarian cancer. Women attending this Bellevue Hospital Center (BHC) Clinic were either self-referred from a variety of special outreach programmes or referred internally by medical professionals caring for relatives or friends. Our objective was to delineate referral sources and preliminary risk-assessment findings in relation to demographic features in this population.

METHODS

Following a detailed family and personal history intake and physical examination, each woman on her initial visit is categorized into a low (standard) risk, high-risk or indeterminate-risk group. Women found to be at high risk of developing breast and/or ovarian cancers are referred for further testing, additional screening measures, or participation in chemoprevention trials. All other women are counselled concerning follow-up and lifestyle issues.

RESULT

Between 2003 and 2007, 171 women for whom complete information was obtained were analysed. Thirty-four of the women were Caucasians (19.8%) and 137 (80.2%) were ethnically diverse minority women. Sixty-two (36.2%) were found to be at high risk with a median age of 42 years. The majority of the high-risk women were referred to the clinic by medical professionals (58%), most of whom were from within the BHC health care system. In fact, one-fourth of the referrals were women who carried a diagnosis of cancer, mostly arising in the breast, and who were concerned with risks to other family members. Trends in genetic testing results indicate fewer mutations among high-risk Asians than among other ethnicities.

CONCLUSION

Accurate risk assessments and implementation of screening and prevention measures have been challenging during the first few years of operation. Nevertheless, the need for providing consultation from internal referrals and the potential for genetic and psychosocial research in an ethnically diverse population are powerful incentives for continuing to evolve these services.

Breast cancer clinical and translational research: analogies and implications for prostate cancer

Breast and prostate cancer, respectively, are the most common cancers in women and in men in the United States. The management of locally advanced prostate cancer involves a multidisciplinary approach, bearing similarity to the therapeutic approach to breast cancer. Better understanding of the molecular biology of these cancers and the identification of the role played by the cancer stem cells and the tumor microenvironment may translate into better clinical decision making regarding risk classification and treatment allocation. A systematic assessment is presented of the many parallel evolutions in defining and treating high-risk breast cancer as they pertain to prostate cancer.

Homocysteine levels and glucose metabolism in non-obese, non-diabetic chronic schizophrenia

OBJECTIVE

We studied a sample of schizophrenia out-patients to test the hypotheses that serum homocysteine concentrations would correlate positively with measures of glucose metabolism.

METHOD

Subjects underwent a nutritional assessment and fasting plasma, serum insulin and homocysteine tests.

RESULTS

Males had a significantly higher homocysteine levels than females (7.69 +/- 1.42 microM vs. 6.63 +/- 1.40 microM; P = 0.02). Comparing subjects with normal fasting glucose (NFG) (glucose < 100 mg/dl) and impaired fasting glucose (IFG) (> or = 100 mg/dl) subjects with IFG (mean 8.2 +/- 1.5 microM) had significantly higher homocysteine levels than those with NFG (mean 7.2 +/- 1.4 microM, P = 0.03). IFG was also associated with greater mean values for a Homeostatic Model Assessment-Insulin Resistance (HOMA-IR) (P = 0.002) and diastolic blood pressure (P = 0.045).

CONCLUSION

The group with IFG had higher fasting serum homocysteine concentrations than those with NFG which supports a connection to an important cardiovascular risk factor.

Association between gravitational force and tissue metabolism in periparturient rats

Recently, interest in mammalian reproduction and offspring survival in altered gravity has been growing. Because successful lactation is critical for mammalian neonate survival, we have been studying the effect of gravity metabolism. We have shown an exponential relationship between glucose metabolic rate in mammary tissue of periparturient rats and an increase in gravity load. In this study we showed that changes in mammary metabolic rate due to gravity force were accompanied by a decrease in glucose metabolism in adipose tissue and by a reduced size of adipocytes. We assume that these changes are likely due to changes in prolactin or leptin levels related to altered gravity load.

Cerebral metabolic correlates as potential predictors of response to anterior cingulotomy for obsessive compulsive disorder

BACKGROUND

As interventions for severe, treatment-refractory obsessive compulsive disorder (OCD), neurosurgical procedures are associated with only modest efficacy. The purpose of this study was to identify cerebral metabolic correlates as potential predictors of treatment response to anterior cingulotomy for OCD.

METHODS

Clinical data were analyzed in the context of a retrospective design. Subjects were 11 patients who underwent stereotactic anterior cingulotomy for OCD. Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) before and at approximately 6 months postoperative. Preoperative F-18-fluorodeoxyglucose-positron emission tomography (FDG-PET) data were available. Statistical parametric mapping methods were used to identify loci of significant correlation between preoperative regional cerebral metabolism and postoperative reduction in Y-BOCS scores.

RESULTS

One locus within right posterior cingulate cortex was identified, where preoperative metabolism was significantly correlated with improvement in OCD symptom severity following cingulotomy. Specifically, higher preoperative rates of metabolism at that locus were associated with better postoperative outcome.

CONCLUSIONS

A possible predictor of treatment response was identified for patients with OCD undergoing anterior cingulotomy. Further research, utilizing a prospective design, is indicated to determine the validity and reliability of this finding. If confirmed, an index for noninvasively predicting response to cingulotomy for OCD would be of great value.

Erectile dysfunction is a marker for cardiovascular complications and psychological functioning in men with hypertension

The aim of this study was to investigate the incidence of cardiovascular complications in hypertensive patients with erectile dysfunction (ED). An anonymous questionnaire was mailed to 467 and received from 104 hypertensive male patients. Despite the low response rate of 22%, the following interesting findings could be observed: 70.6% of the patients who responded suffered from ED. The hypertensive patients with ED had significantly higher prevalence of cardiovascular complications (P < 0.05). The correlation between depression and low quality of life as well as between ED and low sexual satisfaction was also statistically significant (P = 0.05). ED in hypertensive patients can be considered as a marker for cardiovascular complications in this patient group.

Probing striato-thalamic function in obsessive-compulsive disorder and Tourette syndrome using neuroimaging methods

In summary, contemporary pathophysiological models of OCD and related disorders implicate CSTC circuitry. In this chapter, we have reviewed relevant concepts related to implicit learning and more specifically, the use of an implicit sequence learning paradigm as a probe of striato-thalamic function. An initial PET investigation of patients with OCD confirmed a priori hypotheses of failure to recruit right striatum, despite the absence of a performance deficit (22). A modified version of the SRT was studied in conjunction with fMRI and yielded reliable right-lateralized striatal activation in a cohort of 10 male subjects, with clear spatial dissociation of caudate and putamen activation foci (119). Subsequent studies in our laboratory suggest that this paradigm also yields a reliable temporal window of thalamic deactivation, and hence a means for assessing thalamic gating in human subjects (120). Finally, as presented in this chapter, preliminary data from the fMRI-SRT in patients with OCD and TS as well as normal control subjects appear to replicate and extend the findings from our original PET-SRT study in OCD. Future investigations in our laboratory will seek to elaborate upon these preliminary results. In particular, we intend to study psychiatric comparison groups to establish the generalizability and/or specificity of these findings across disorders. Within OCD, we hope to explore the relationship between abnormal brain-activation patterns and symptom dimensions (34). Further, by studying subjects with remitted OCD who have been successfully treated, we hope to determine whether the observed brain-activation abnormalities represent state or trait markers. Finally, we have already begun to test a hypothesis of parallel processing deficiency in OCD by using a dual-task version of the SRT that makes simultaneous demands on implicit and explicit information processing systems (128). It is our hope that this program of research will yield new insights about OCD and related disorders, including TS. Most importantly, as other teams of investigators pursue complementary lines of inquiry, it is our wish that collective efforts in this field will lead to improved diagnosis and treatment, if not cure or prevention, for those who are afflicted with these illnesses.

The Skin Picking Impact Scale (SPIS): scale development and psychometric analyses

The Skin Picking Impact Scale (SPIS) is a self-report instrument developed to assess the psychosocial consequences of repetitive skin picking. An initial 28-item scale was administered to 31 individuals with severe self-injurious skin picking and 78 individuals with non-self-injurious skin picking. Item difficulty levels and part-whole correlations resulted in a 10-item scale with good internal consistency. SPIS scores for those with self-injurious skin picking were significantly higher than for those with non-self-injurious skin picking. SPIS scores for those with self-injurious skin picking correlated with duration of daily picking, satisfaction during picking, and shame subsequent to picking, as well as Beck Depression Inventory and Beck Anxiety Inventory scores. Sensitivity and specificity analyses indicate that a scale cutoff score of 7 optimally discriminates individuals with self-injurious skin picking from those with non-self-injurious skin picking.

Home-based behavior therapy for obsessive-compulsive disorder: a case series with data

The effectiveness of "home-based" exposure and response prevention was assessed in a series of 11 subjects with obsessive-compulsive disorder (OCD). Patients received 24 treatment sessions in a range of natural settings and situations. Sixty-four percent of the patients responded to behavior therapy in these settings, and 36% achieved lasting improvements in their OCD symptoms. Implications for the impact on consumers of this seldom-used application of behavior therapy are discussed and some recommendations for future research are made.

The Skin Picking Scale: scale construction and psychometric analyses

OBJECTIVE

This paper reports on the development of the Skin Picking Scale (SPS), a six-item paper-and-pencil measure for the assessment of skin picking.

METHODS

28 severe self-injurious and 77 non-self-injurious skin pickers initially completed an eight-item severity scale modeled after the Yale--Brown Obsessive--Compulsive Scale (Y-BOCS).

RESULTS

Group comparisons and part--whole correlations for individual scale items resulted in a six-item scale with a total score range of 0--24. A Cronbach's alpha coefficient of.80 indicated moderate internal consistency for the scale. Construct validity was demonstrated by significant correlations between SPS total scale scores and self-reported average duration of skin picking episodes. Significant correlations were also reported between SPS total scale scores and both Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI) scores, as well as self-reported intensity of emotions during the picking process. Lastly, sensitivity and specificity analyses suggest that a SPS cut-off score of 7 differentiates severe self-injurious and non-self-injurious skin pickers.

CONCLUSION

The SPS is a valid and reliable self-report scale for the assessment of severity in medical and psychiatric patients who endorse skin picking.

A magnetic resonance imaging study of regional cortical volumes following stereotactic anterior cingulotomy

The purpose of this study was to test the hypothesis that orbitofrontal cortical volume would be reduced following anterior cingulotomy for obsessive-compulsive disorder (OCD). Whole brain cortical parcellation was performed on magnetic resonance imaging (MRI) data from nine patients, before and 9 (+/-6) months following anterior cingulotomy. No significant volumetric reductions were found in the orbitofrontal cortex. Exploratory findings of reduced volume in ventral temporo-fusiform and posterior cingulate regions were consistent with chance differences, in the face of multiple comparisons. Therefore, though the circumscribed lesions of anterior cingulotomy have recently been associated with corresponding volumetric reductions in the caudate nucleus, no comparable volumetric reductions are evident in cortical territories. Taken together, these results are most consistent with a model of cingulo-striatal perturbation as a putative mechanism for the efficacy of this procedure. While limitations in sensitivity may have also contributed to these negative findings, the methods employed have previously proven sufficient to detect cortical volumetric abnormalities in OCD. The current results may reflect a relatively diffuse pattern of cortico-cortical connections involving the neurons at the site of cingulotomy lesions. Future functional neuroimaging studies are warranted to assess possible cortical or subcortical metabolic changes associated with anterior cingulotomy, as well as predictors of treatment response.

Longitudinal follow-up of naturalistic treatment outcome in patients with trichotillomania

BACKGROUND

Little is known about the longitudinal course of treatment outcome in patients with trichotillomania. The authors conducted a second follow-up assessment on a cohort of hair pullers previously studied.

METHOD

Forty-four subjects completed a hair-pulling questionnaire and paper-and-pencil measures of hair-pulling severity and impact, psychosocial functioning, depression, anxiety, and self-esteem. Mean time elapsed between the first and second follow-up assessment was 2.5 years (index evaluation to first follow-up = 3.5 years).

RESULTS

Twenty-seven subjects (61.4%) had active treatment since the first follow-up. No significant changes in hair pulling, depression, anxiety, or psychosocial functioning were reported from first to second follow-up. Self-esteem scores significantly worsened during this period (p = .000). A trend toward worsening also existed for psychosocial impact scores. Comparison of scores at index evaluation with second follow-up still showed significant improvement over time for hair pulling (p = .001) but significant worsening in self-esteem (p = .000). Treatment and responder status were unrelated to clinical functioning, with the exception of depression and psychosocial impact.

CONCLUSION

Although hair pullers exhibit initial improvement with treatment, scale scores plateau or worsen by second follow-up. Significant worsening in self-esteem at second follow-up may be related to the absence of further improvements in hair-pulling severity. Future research should focus on the interrelationships among self-esteem, depression, and hair pulling during treatment for this disorder.

Is age at symptom onset associated with severity of memory impairment in adults with obsessive-compulsive disorder?

OBJECTIVE

Age at onset is a potentially important marker for neurobiological features of obsessive-compulsive disorder (OCD). This study examined the relationship between age at symptom onset and memory impairment in adults with OCD.

METHOD

The authors used the Rey-Osterrieth Complex Figure Test and the California Verbal Learning Test to compare memory functioning of 37 adult OCD patients with self-reported childhood onset of symptoms (onset at less than 18 years of age) with that of 31 patients with adult-onset symptoms.

RESULTS

No differences were found between the two groups on any of the verbal and nonverbal memory measures.

CONCLUSIONS

Self-reported age at symptom onset is not associated with memory performance in adult patients with OCD according to tests previously found to be sensitive to frontal-striatal system dysfunction and impairment in OCD. Such dysfunction appears to be a consistent feature of OCD in adults, regardless of age at initial symptom onset.

Volume reduction in the caudate nucleus following stereotactic placement of lesions in the anterior cingulate cortex in humans: a morphometric magnetic resonance imaging study

OBJECT

The goal of this study was to test hypotheses regarding changes in volume in subcortical structures following anterior cingulotomy.

METHODS

Morphometric magnetic resonance (MR) imaging methods were used to assess volume reductions in subcortical regions following anterior cingulate lesioning in nine patients. Magnetic resonance imaging data obtained before and 9 +/- 6 months following anterior cingulotomy were subjected to segmentation and subcortical parcellation. Significant volume reductions were predicted and found bilaterally within the caudate nucleus, but not in the amygdala, thalamus, lenticular nuclei, or hippocampus. Subcortical parcellation revealed that the volume reduction in the caudate nucleus was principally referrable to the body, rather than the head. Furthermore, the magnitude of volume reduction in the caudate body was significantly correlated with total lesion volume.

CONCLUSIONS

Taken together, these findings implicate significant connectivity between a region of anterior cingulate cortex (ACC) lesioned during cingulotomy and the caudate body. This unique data set complements published findings in nonhuman primates, and advances our knowledge regarding patterns of cortical-subcortical connectivity involving the ACC in humans. Moreover, these findings indicate changes distant from the site of anterior cingulotomy lesions that may play a role in the clinical response to this neurosurgical procedure.

Hypertension is associated with severe erectile dysfunction

PURPOSE

The prevalence and severity of erectile dysfunction in patients with hypertension need to be further evaluated. We evaluate medical and hypertension status, and erectile function in patients with hypertension.

MATERIALS AND METHODS

The International Index of Erectile Function, which is a detailed questionnaire, including well established components to evaluate patient medical history, hypertension status and erectile dysfunction, was mailed to 476 male patients of the outpatient Hypertension Center of Columbia Presbyterian Medical Center.

RESULTS

The questionnaire was completed by 104 (22.3%) patients, and mean age was 62.2 years (range 34 to 75). Of the patients 84.8% were sexually active and 68. 3% had various degrees of erectile dysfunction, which was mild in 7. 7%, moderate in 15.4% and severe in 45.2%. Compared to the general population of erectile dysfunction cases in the literature our study population with hypertension had a higher incidence of severe erectile dysfunction. Although correlations of antihypertensive medications with incidence of erectile dysfunction did not reach statistical significance, there was a clear trend with patients treated with diuretics and beta-blockers having the highest incidence and those treated with alpha-blockers having the lowest incidence of erectile dysfunction.

CONCLUSIONS

In addition to the observation that erectile dysfunction is more prevalent in patients with hypertension than in an age matched general population, our study shows that it is more severe in those with hypertension than in the general population.

Reliability and validity of a scoring system for measuring organizational approach in the Complex Figure Test

The Rey-Osterrieth Complex Figure Test (RCFT) is a widely-used measure of visuospatial construction and nonverbal memory. One of the critical aspects of this test is that organizing the figure into meaningful perceptual units during copy enhances its subsequent free recall from memory. This study examined the psychometric properties of a new system for quantifying the organizational approach to the RCFT figure and compared it to another compatible scoring system. We investigated interrater reliability of both systems and explored the influences of copy organization and copy accuracy on immediate recall. Seventy-one participants meeting DSM-IV criteria for obsessive-compulsive disorder and 55 healthy control participants completed the copy and immediate free recall condition of the RCFT. Interrater reliability was evaluated by Kappa coefficients and Pearson correlations. The effects of copy organization and copy accuracy on immediate recall were evaluated using multiple regression analyses. Results indicated that the organizational approach could be assessed with high reliability using both scoring systems. Organization during copy was a strong predictor for subsequent free recall from memory using both approaches. Multiple regression analysis indicated that all organizational elements were not equally predictive of memory performance. This new system represents a very simple and reliable approach to scoring organization on the RCFT, since it requires the identification of only 5 figure components. These characteristics should contribute to its clinical utility.

Relation of factor-analyzed symptom dimensions of obsessive-compulsive disorder to personality disorders

OBJECTIVE

To assess the relation between symptom dimensions of obsessive-compulsive disorder (OCD) and comorbid personality disorders (PDs).

METHOD

The scores of 75 OCD outpatients on five previously identified symptom dimensions were entered into multiple regression models as predictors of: 1) the presence of any type of PD; 2) the number of PDs; 3) the presence of any cluster A, B or C PD; and 4) the presence of each individual PD.

RESULTS

Twenty-eight patients (37.3%) met criteria for one or more PDs. High scores on the 'Hoarding' dimension were strongly related to the presence of any Axis II diagnosis, and to the number of PDs. Cluster C PDs (especially obsessive-compulsive and avoidant) had the highest partial correlations with 'Hoarding'. These results were independent of OCD symptom severity.

CONCLUSION

Previous conflicting findings about the prevalence of certain PDs in OCD might be due in part to differences in the constitution of the particular patient groups studied.

Characteristics of memory dysfunction in body dysmorphic disorder

Although body dysmorphic disorder (BDD) is receiving increasing empirical attention, very little is known about neuropsychological deficits in this disorder. The current study investigated the nature of memory dysfunction in BDD, including the relationship between encoding strategies and verbal and nonverbal memory performance. We evaluated 17 patients with BDD and 17 healthy controls using the Rey-Osterrieth Complex Figure Test (RCFT) and the California Verbal Learning Test (CVLT). BDD patients differed significantly from healthy controls on verbal and nonverbal learning and memory indices. Multiple regression analyses revealed that group differences in free recall were statistically mediated by deficits in organizational strategies in the BDD cohort. These findings are similar to patterns previously observed in obsessive-compulsive disorder (OCD), suggesting a potential relationship between OCD and BDD. Studies in both groups have shown that verbal and nonverbal memory deficits are affected by impaired strategic processing.

Self-treatment of obsessive-compulsive disorder guided by manual and computer-conducted telephone interview

While on a waiting list for treatment by therapist-guided exposure and ritual prevention (ERP), patients with obsessive-compulsive disorder (OCD) did self-treatment at home guided by a manual plus a computer-driven telephone interview system (BT STEPS). Of 21 patients who used the system for at least three weeks while on the waiting list, one improved so much that subsequent therapist-guided ERP was unnecessary. Progress of the rest with the system predicted later progress with therapist-guided ERP. Improvement after using the system was similar to that of 20 matched historical controls who had had therapist-guided ERP without the prior use of BT STEPS. Outpatient users of BT STEPS needed less subsequent clinician-guided time than did their matched controls. In this pilot study, patients with OCD improved nearly as much with home self-treatment guided by a manual plus computer, as with treatment guided by a behaviour therapist.

Repetitive skin-picking in a student population and comparison with a sample of self-injurious skin-pickers

The prevalence of skin-picking and its associated characteristics were documented in a nonclinical sample of 105 college students. Subjects completed a self-report skin-picking inventory and several paper-and-pencil scales. Students who endorsed skin-picking were compared to a clinical sample of self-injurious skin-pickers (n = 31) reported on previously. Of the student subjects, 78.1% (n = 82) endorsed some degree of skin-picking and four subjects satisfied criteria for severe, self-injurious picking. Student subjects significantly differed from the clinical sample-of self-injurious skin-pickers in the duration, focus, and extent of picking, techniques used, reasons for picking, associated emotions, and picking sequelae.

Subjective imagery in obsessive-compulsive disorder before and after exposure therapy. Pilot randomised controlled trial

BACKGROUND

Distressing mental imagery is hard to study experimentally in obsessive--compulsive disorder (OCD).

AIMS

To develop a way to assess mental imagery in OCD during functional magnetic resonance imaging (fMRI).

METHOD

A small randomised study, controlled for type and order of mental imagery and for treatment condition (exposure therapy guided by a computer or by a therapist, or relaxation guided by audio-tape). Before and after treatment, during fMRI scanning, patients imagined previously-rehearsed scenarios that evoked an urge to ritualise or non-OCD anxiety or a neutral state, and rated their discomfort during imagery.

RESULTS

The method evoked greater discomfort during OCD imagery and anxiety (non-OCD) imagery than during neutral imagery. Discomfort was reduced by cancelling imagery. Discomfort during OCD imagery (but not during anxiety non-OCD imagery) fell after exposure therapy but not after relaxation.

CONCLUSIONS

Results showed differences between OCD and non-OCD images and their change after successful treatment, and confirmed clinical suggestions that cancelling images reduced OCD discomfort. The method's success paves the way for further studies of mental imagery in OCD: for instance, during fMRI.

Strategic processing and episodic memory impairment in obsessive compulsive disorder

There is evidence that nonverbal memory problems in obsessive compulsive disorder (OCD) are mediated by impaired strategic processing. Although many studies have found verbal memory to be normal in OCD, these studies did not use tests designed to stress organizational strategies. This study examined verbal and nonverbal memory performance in 33 OCD patients and 30 normal control participants with the Rey-Osterrieth Complex Figure Test and the California Verbal Learning Test. OCD patients were impaired on verbal and nonverbal measures of organizational strategy and free recall. Multiple regression modeling indicated that free recall problems in OCD were mediated by impaired organizational strategies used during learning trials. Therefore, verbal and nonverbal episodic memory deficits in OCD are affected by impaired strategic processing. Results are consistent with neurobiological models proposing frontal-striatal system dysfunction in OCD.

Development of a brief screening instrument: the HANDS

BACKGROUND

The present study was designed to develop a briefer screening scale of approximately 10 items which maintained the validity of the Zung Self-Rating Depression Scale in a sample similar to that attending National Depression Screening Day (NDSD), as well as a more general audience.

METHODS

We first administered 70 items from a variety of existing rating scales to 40 subjects who answered an ad for depressed subjects and 55 who answered an ad for non-depressed subjects, all of whose diagnoses were confirmed by the Structured Clinical Interview for DSM-IV (SCID). Based on the correlation between each item and the diagnostic criterion, we reduced the number of items to 17 which we then administered to another 45 subjects who answered an ad similar to that used for NDSD and also underwent a SCID interview. Based on these results, we arrived at the final 10-item Harvard Department of Psychiatry/NDSD scale (HANDS) with the assistance of the item-response theory. The items are scored for frequency of occurrence of each symptom over the past 2 weeks. Total scores range from 0 to 30.

RESULTS

The 10-item scale (HANDS) has good internal consistency and validity: a cutpoint score of 9 or greater gave sensitivity of at least 95% in both studies. Although specificity was lower for all scales in the self-selected population, the HANDS performed at least as well as the 20-item Zung Scale, the 21-item Beck Depression Inventory-II and the 15-item Hopkins Symptom Depression Checklist.

CONCLUSION

The 10-item HANDS performs as well as other widely used longer self-report scales and has the advantage of briefer administration time.

The relationship between semantic organization and memory in obsessive-compulsive disorder

BACKGROUND

A variety of evidence suggests that frontostriatal dysfunction is involved in obsessive-compulsive disorder (OCD). This evidence includes both neuroimaging findings and results from studies using neuropsychological assessments. Previous studies have documented nonverbal memory deficits in individuals with OCD, whereas verbal learning and memory were less affected.

METHODS

The present study examined both verbal and nonverbal memory in a sample of 17 untreated outpatients with OCD. We also evaluated the effects of encoding strategies which are believed to be mediated by frontostriatal system functioning.

RESULTS

OCD patients were significantly impaired in both verbal and nonverbal memory performance. This deficit was correlated with impairments in organizational and semantic clustering strategies at the time of encoding.

CONCLUSIONS

Deficits in organizational strategies are consistent with frontostriatal dysfunction models in OCD.

Sensory phenomena in obsessive-compulsive disorder and Tourette's disorder

BACKGROUND

Recent studies have suggested that obsessive-compulsive disorder (OCD) is a heterogeneous disorder with some forms related to tics and Tourette's disorder. The present study was undertaken to investigate the sensory phenomena in patients with OCD and/or Tourette's disorder to determine if these phenotypic features represent valid clinical indices for differentiating tic-related OCD from non-tic-related OCD.

METHOD

We evaluated 20 adult outpatients with OCD, 20 with OCD plus Tourette's disorder, and 21 with Tourette's disorder, using a semistructured interview designed to assess several definitions of sensory phenomena reported in the literature. DSM-III-R criteria were used for the OCD and Tourette's disorder diagnoses.

RESULTS

Sensory phenomena including bodily sensations, mental urges, and a sense of inner tension were significantly more frequent in the 2 Tourette's disorder groups when compared with the OCD alone group. Feelings of incompleteness and a need for things to be "just right" were reported more frequently in the OCD plus Tourette's disorder group compared with the other 2 groups.

CONCLUSION

Sensory phenomena may be an important phenotypic measure for grouping patients along the OCD-Tourette's disorder spectrum. Sensory phenomena include bodily and mental sensations. Bodily sensations include focal or generalized body sensations (usually tactile, muscular-skeletal/visceral, or both) occurring either before or during the patient's performance of the repetitive behaviors. These sensations are more frequently found in patients with OCD plus Tourette's disorder than in patients with OCD alone. Mental sensations include urge only, energy release (mental energy that builds up and needs to be discharged), incompleteness, and just-right perceptions. They are all more frequently found in patients with OCD plus Tourette's disorder than in patients with OCD alone.