Breast-Conserving Surgery Guided with Magnetic Seeds vs. Wires: A Single-Institution Experience

PURPOSE

The aim of this study is to describe our initial experience using magnetic seeds (Magseed®) to guide breast-conserving surgery in non-palpable breast lesions and compare the use of magnetic seed with wires to guide breast-conserving surgery in terms of clinical and pathological characteristics.

METHODS

We performed a retrospective study including all breast-conserving surgeries for non-palpable breast lesions under 16 mm from June 2018 to May 2021. We compared breast-conserving surgeries guided with magnetic seeds (Magseed®) to those guided with wires, analyzing tumor and patient characteristics, surgical time, and pathological results of the surgical specimens.

RESULTS

Data from 225 cases were collected, including 149 cases guided by magnetic seeds and 76 cases guided by wires. The breast lesion was localized in every case. Both cohorts were similar regarding clinical and pathological characteristics. We found significant statistical differences (p < 0.02) in terms of the median volume (cm3) of the excised specimen, which was lower (29.3%) in the magnetic seed group compared with the wire group (32.5 [20.5-60.0]/46.0 [20.3-118.7]). We did not find significant differences regarding surgical time (min) or the affected or close margins.

CONCLUSION

In our experience, the use of magnetic seed (Magseed®) is a feasible option to guide breast-conserving surgery of non-palpable lesions and enabled us to resect less breast tissue.

Presurgery motor level assessment for prediction of motor level at birth in fetuses undergoing prenatal repair of open spina bifida: time to abandon anatomical level in counseling

OBJECTIVES

First, to investigate the correlation between prenatal presurgery anatomical and motor levels of the lesion with motor level at birth in cases undergoing prenatal repair of open spina bifida and, second, to identify factors leading to a loss of two or more motor levels between the presurgery and postnatal assessments.

METHODS

This was an observational study of singleton pregnancies undergoing prenatal repair of open spina bifida, conducted between March 2011 and May 2022. All fetuses underwent an ultrasound assessment at 20-24 weeks of gestation to determine the motor and anatomical levels of the lesion before surgery. The anatomical level of the lesion was defined as the highest open posterior vertebral arch. The motor level was determined by systematic observation of the lower limb movements and was defined as the most distal active muscle present. Prenatal repair was performed at 23-26 weeks. At birth, motor level was assessed by a rehabilitation specialist by physical examination. Cases of intrauterine death or termination of pregnancy and those delivered at other sites were excluded from the neonatal assessment. The agreement between presurgery motor level and motor level at birth, and between presurgery anatomical level and motor level at birth, was assessed using the weighted kappa index (wκ). Logistic regression analysis was used to assess factors leading to a loss of two or more motor levels between the presurgery and postnatal assessments.

RESULTS

Presurgery motor and anatomical levels were assessed in 61 fetuses at a median gestational age of 22.7 (interquartile range (IQR), 21.6-24.4) weeks. Prenatal repair was performed at a median gestational age of 24.6 (IQR, 23.7-25.7) weeks. Motor level at birth was assessed in 52 neonates after exclusion of nine fetuses due to loss to follow-up or fetal loss. There was moderate agreement between presurgery motor level and motor level at birth (wκ = 0.42; 95% CI, 0.21-0.63), with a median difference of 0 (IQR, -2 to 9) levels. Factors leading to a loss of two or more motor levels between the presurgery ultrasound assessment and postnatal examination were higher presurgery anatomical level (odds ratio (OR), 0.59 (95% CI, 0.35-0.98); P = 0.04) and larger difference between the anatomical and motor levels before surgery (OR, 1.85 (95% CI, 1.12-3.06); P = 0.017). None of the other ultrasound, surgery-related or neonatal variables assessed was associated significantly with a loss of two or more motor levels. There was slight agreement between the presurgery anatomical level of the lesion and motor level at birth (wκ = 0.07; 95% CI, -0.02 to 0.15).

CONCLUSIONS

There is moderate agreement between fetal motor level of the lesion before prenatal repair of open spina bifida and motor level at birth, as opposed to only slight agreement between presurgery anatomical level and motor level at birth. A loss of two or more motor levels between the presurgery and postnatal assessments is associated with a higher presurgery anatomical level and with a larger difference between the presurgery anatomical and motor levels. Consequently, motor level, rather than the anatomical level, should be used for prenatal counseling. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Abstract P5-09-03: Real World Data on Neoadjuvant Endocrine Treatment and Ki67 Assessment in ER+/HER2- Breast Cancer. Results from a Single-Institution Prospective Cohort Study

Purpose: Neoadjuvant endocrine treatment (NET) has become a useful tool for the downstaging of luminal-like breast cancers in postmenopausal patients. It enables us to increase breast conserving surgery (BCS) rates and provides an opportunity for assessing in vivo NET effectiveness and studying any biological changes that may act as valid biomarkers. The purpose of this study was to evaluate the effectiveness of NET as well as to assess the role of Ki67 proliferation rate changes as an indicator of endocrine responsiveness.

Methods: From June 2016 to January 2022, a single-institution cohort of patients treated with NET and further surgery was evaluated. In patients with Ki67≥10%, a second core biopsy was performed after four weeks. Information regarding histopathological and clinical changes, as well as surgical management, was gathered.

Results: A total of 168 estrogen receptor positive (ER+)/HER2 negative patients were included. The median age at diagnosis was 69.5 years old (IQR: 16.0). The median treatment duration was 5.0 months (IQR: 4.0). Median maximum size in the surgical sample was 44.0% smaller than pretreatment size measured by ultrasound (p&lt;.0001), showing an inverse linear relationship with treatment duration. Median pretreatment Ki67 expression was 20.0% (IQR: 18.0) and was reduced to 5.0% (IQR: 8.0) after four weeks, and to 2.0% (IQR: 7.25) in the surgical sample (p&lt; 0.0001). Other significant downgrading changes were observed with respect to tumor grade (p&lt; 0.0001) and progesterone receptor (PR) expression (p&lt; 0.0001). BCS was performed on 145 patients (86.3%). One case of pathological complete response was recorded. A larger Ki67 fold-change after four weeks was significantly related to a PEPI score of 0 (p&lt; 0.002). No differences were observed between luminal A- and B-like tumors with regard to fold-change and PEPI score. No treatment abandonment was produced during the study.

Conclusions: In our cohort, NET has proven effective for tumor size and Ki67 downstaging. This results in a higher rate of conservative surgery, aids in therapeutic decision-making, provides prognostic information, and constitutes a safe and well-tolerated approach

Biological changes after NET

Patient and tumor characteristics

Citation Format: Covadonga Marti, Laura Frias, Adolfo Loayza, Elisa Moreno, Marcos Meléndez, Jose Ignacio Sanchez-Mendez. Real World Data on Neoadjuvant Endocrine Treatment and Ki67 Assessment in ER+/HER2- Breast Cancer. Results from a Single-Institution Prospective Cohort Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-09-03.

The Clinical Impact of Neoadjuvant Endocrine Treatment on Luminal-like Breast Cancers and Its Prognostic Significance: Results from a Single-Institution Prospective Cohort Study

Purpose: Neoadjuvant endocrine treatment (NET) has become a useful tool for the downstaging of luminal-like breast cancers in postmenopausal patients. It enables us to increase breast- conserving surgery (BCS) rates, provides an opportunity for us to assess in vivo NET effectiveness, and allows us to study any biological changes that may act as valid biomarkers. The purpose of this study was to evaluate the safety and effectiveness of NET, and to assess the role of Ki67 proliferation rate changes as an indicator of endocrine responsiveness. Methods: From 2016 to 2020, a single-institution cohort of patients, treated with NET and further surgery, was evaluated. In patients with Ki67 ≥ 10%, a second core biopsy was performed after four weeks. Information regarding histopathological and clinical changes was gathered. Results: A total of 115 estrogen receptor-positive (ER+)/HER2-negative patients were included. The median treatment duration was 5.0 months (IQR: 2.0−6.0). The median maximum size in the surgical sample was 40% smaller than the pretreatment size measured by ultrasound (p < 0.0001). The median pretreatment Ki67 expression was 20.0% (IQR: 12.0−30.0), and was reduced to 5.0% (IQR: 1.8−10.0) after four weeks, and to 2.0% (IQR: 1.0−8.0) in the surgical sample (p < 0.0001). BCS was performed on 98 patients (85.2%). No pathological complete responses were recorded. A larger Ki67 fold change after four weeks was significantly related to a PEPI score of zero (p < 0.002). No differences were observed between luminal A- and B-like tumors, with regard to fold change and PEPI score. Conclusions: In our cohort, NET was proven to be effective for tumor size and Ki67 downstaging. This resulted in a higher rate of conservative surgery, aided in therapeutic decision making, provided prognostic information, and constituted a safe and well-tolerated approach.

Sectoral multipole focused beams

We discuss the properties of pure multipole beams with well-defined handedness or helicity, with the beam field a simultaneous eigenvector of the squared total angular momentum and its projection along the propagation axis. Under the condition of hemispherical illumination, we show that the only possible propagating multipole beams are "sectoral" multipoles. The sectoral dipole beam is shown to be equivalent to the non-singular time-reversed field of an electric and a magnetic point dipole Huygens' source located at the beam focus. Higher order multipolar beams are vortex beams vanishing on the propagation axis. The simple analytical expressions of the electric field of sectoral multipole beams, exact solutions of Maxwell's equations, and the peculiar behaviour of the Poynting vector and spin and orbital angular momenta in the focal volume could help to understand and model light-matter interactions under strongly focused beams.

Optofluidic control of the dispersion of nanoscale dumbbells

Previous research has shown that gold nanoparticles immersed in water in an optical vortex lattice formed by the perpendicular intersection of two standing light waves with a π/2rad phase difference will experience enhanced dispersion that scales with the intensity of the incident laser. We show that flexible nanoscale dumbbells (created by attaching two such gold particles by means of a polymer chain) in the same field display different types of motion depending on the chain length and field intensity. We have not disregarded the secondary optical forces due to light scattering. The dumbbells may disperse, rotate, or remain trapped. For some values of the parameters, the (enhanced) dispersion possesses a displacement distribution with exponential tails, making the motion anomalous, though Brownian.

Prenatal ultrasound evaluation of segmental level of neurological lesion in fetuses with myelomeningocele: development of a new technique

OBJECTIVES

To report our preliminary experience in the use of prenatal ultrasound examination to assess lower-limb movements in fetuses with myelomeningocele. We aimed to determine the accuracy of this method to establish the segmental level of neurological lesion, as this is the best known predictor of the future ability to walk.

METHODS

This was a preliminary, observational study including fetuses with myelomeningocele operated on prenatally. The patterns of movements present and absent in the affected fetuses' lower limbs were evaluated systematically by ultrasound examination. According to the known nerve function associated with each muscle group, the segmental level of neurological lesion was established before birth. The agreement for the segmental levels assigned, between the prenatal ultrasound technique and the classical neurological clinical examination after birth (gold standard), was tested using the weighed kappa (wκ) index.

RESULTS

Seventy-one fetuses with myelomeningocele were evaluated at the Hospital Universitari Vall d'Hebron. After counseling, the parents opted for prenatal surgery (26 cases), termination of pregnancy (43 cases) or postnatal repair (two cases). Five patients did not fulfil the inclusion criteria for prenatal surgery and three were excluded after birth. In the 18 fetuses that underwent surgery and were analyzed, the agreement between prenatal and postnatal segmental levels assigned was 91.7% for the right limb (wκ = 0.80) and 88.9% for the left limb (wκ = 0.73).

CONCLUSIONS

The agreement found between prenatal and postnatal assignment of level of lesion in this preliminary study suggests that neurological sonographic evaluation is feasible before birth. This may provide accurate individualized information about the motor function and future ambulation prognosis of fetuses with myelomeningocele.

The validity of drug use responses in a household survey in Puerto Rico: comparison of survey responses with urinalysis

AIMS

The available evidence suggests that the validity of drug use responses in general population surveys is low. We have conducted a household survey to examine viral infections in the general population of Puerto Rico employing a number of procedures believed to increase the validity of drug use responses, as well as confidentiality and privacy: telling participants of toxicological verification of drug use prior to the interview, ACASI self-interviewing, and interviewing outside households in mobile examination units.

METHODS

The study employed a stratified cluster sample of 1654 adults 21 to 64 years old, 532 recruited while urine samples were being collected and 1122 recruited after urinalysis was discontinued due to budgetary reasons.

RESULTS

Drug use rates calculated from participants recruited while urinalysis was being conducted did not vary significantly to those derived from participants recruited after urinalysis was discontinued. Sensitivity of responses of drug use during the last three days was 80.0% for marihuana, 76.2% for cocaine, and 40.0% for heroin. The lower validity of heroin reports did not seem to be the result of underreporting as it was reported by more individuals than the test detected.

CONCLUSION

We conjecture that the reasonably good validity of the drug use responses might have been the result of the parent study being about a health issue other than drug use, and that interviewing was conducted outside households in mobile units. These findings buttress the value of conducting methodological trials to identify procedures which yield valid responses of drug use.

[Autonomic dysfunction in children with traumatic brain injury]

INTRODUCTION

Autonomic dysfunction syndrome following traumatic brain injury is a situation involving adrenergic hyperactivity produced by the lack of control over the autonomous nervous system at a central level. The difficulties involved in its therapeutic management make it even more important.

CASE REPORTS

We report the cases of a boy and a girl aged 6 and 12 years, respectively, who had suffered a severe traumatic brain injury with important brain damage that included diencephalic and mesencephalic compromise and areas of diffuse axonal injury. From the acute phase onwards, they presented episodes of hypertension, tachycardia, excessive sweating and spasticity in the form of attacks that initially led to a differential diagnosis between sepsis, opiate and/or benzodiazepine withdrawal syndrome and epilepsy. The length of time spent in coma was very long and the attacks went on throughout the awakening phase almost until the moment they were discharged from hospital, despite trying different treatments. In our cases, orally administered baclofen and midazolam seemed to be the most effective.

CONCLUSIONS

Autonomic dysfunction is difficult to manage. There are no standardised treatments and speculation continues with regard to its true promoter. We might think that the central injury is the cause of the process and that the autonomic dysfunction increases the secondary lesion and contributes to the functional worsening. If we take into account that the survival rate of the children is high despite the severity of the injuries and although the dysautonomia can be self-limiting with time, we believe that its treatment is essential if the ultimate aim is to minimise the sequelae.

Abnormal immunological response to Mycobacterium tuberculosis antigens in a patient with chronic myelocytic leukemia and active tuberculosis

The pathogenic mechanisms of immunosuppression leading to susceptibility of Mycobacterium tuberculosis (MT) infection in chronic myelocytic leukemia (CML) are not clear. To address this issue, we measured the proliferative response, variation of T cell subpopulations (CD4+, CD8+, TCR-V delta 2 and TCR-V beta 8 T cells) and the cytokine profile (IL-1 beta, IL-2, IL-4, IL-6, IL-10, TNF-alpha, IFN-gamma) after MT stimulation of peripheral blood mononuclear cells (PBMC) in a patient with concomitant CML and active pulmonary tuberculosis. The results were compared to four patients with active pulmonary tuberculosis and no other coexistent diseases. The immunologic response to phytohemagglutinin (PHA) was also evaluated. In contrast to controls, the CML PBMC failed to proliferate in response to MT antigens. Mycobacterium-reactive CD4+, V delta 2 and V beta 8 T cells did not expand after MT stimulation of the CML PBMC. In MT antigens-stimulated cultures from the CML patient, IL-2 was not produced and mild reduction of IL-1 beta and INF-gamma were observed. In contrast, IL-10 was markedly elevated in these cultures. Similarly, PHA-stimulated PBMC from the CML patient showed no expansion of CD4+ and CD8+. T cells. In these cell cultures, INF-gamma concentration in supernatants was decreased and IL-10 was significantly elevated. This study suggests that patients with CML may present a profound immunosuppression of essential cellular and molecular immune effectors, a scenario which might contribute to the development of active tuberculosis. These findings further support the need of establishing immunotherapeutic modalities with potential value for myeloproliferative disorders.

Risk behaviors, HIV seropositivity, and tuberculosis infection in injecting drug users who operate shooting galleries in Puerto Rico

This study was designed to assess HIV risk behaviors, HIV seroprevalence, and tuberculosis (TB) infection in shooting gallery managers in Puerto Rico. The subjects were 464 injection drug users (IDUs), of whom 12.5% reported managing shooting galleries. The median frequency of drug injection was higher in shooting gallery managers than in nonmanagers. A trend was observed for purified protein derivative (PPD) reactivity to increase according to the length of time spent as a gallery manager, but this trend was not statistically significant. However, anergy rates increased significantly with increase in the number of months spent as shooting gallery manager (p = .021). Multivariate analyses showed that IDUs reporting shooting gallery management experience of > or = 25 months were more likely to be infected with HIV. Prevention programs need to emphasize strategies to protect the health of shooting gallery clients and, in particular, shooting gallery managers. Additional studies are required to determine effective strategies for reducing the risk of HIV and TB infection in shooting galleries.

Mycobacterium tuberculosis infection among crack and injection drug users in San Juan, Puerto Rico

This study aims to determine the prevalence of Mycobacterium tuberculosis infection and its association with HIV and other health risk factors among drug users. A sample of 716 IDUs and crack users were enrolled from community sites. Consenting subjects were tested for HIV serum antibody status. Drug users with an unknown PPD status were administered a PPD skin test and an anergy panel of three antigens (Candida, mumps and tetanus). Overall, 68 (10.3%) were reactive to the PPD skin test, 240 (34.7%) were HIV positive and 195 (29.5%) showed cutaneous anergy. Participants infected with tuberculosis (TB) were more likely to be HIV seropositive, and to have a history of incarceration and residential drug treatment than those not infected. In addition, TB infection was more prevalent among intravenous drug users (IDUs) and shooting gallery managers. These findings suggest that drug users should be considered at high risk for TB and HIV infection. Innovative programs to monitor both infections among drug users are needed to arrest what can become a dual epidemic of HIV and TB in the near future.

Physeal injuries in myelomeningocele patients

Epiphysiolysis from a series of 253 patients under regular control in the Spina Bifida Unit at our hospital has been analysed from 1967 to the present time. From that total there have been 18 physeal fractures in 9 of the myelomeningocele patients. The clinical characteristics, diagnostic difficulties and therapeutic criteria for this type of lesion are considered, and we suggest the need to use suitable orthoses whenever the patient is able to walk, and to temporarily increase the level of orthotisation in patients if the physis of the knee is affected.

HLA in Chileans with intrahepatic cholestasis of pregnancy

A possible association between intrahepatic cholestasis of pregnancy (ICP) and human-leukocyte histocompatibility (HLA) antigens--used as genetic markers--was studied in 100 women with ICP compared to 100 multiparous women without a past history of the disease. Because we previously found a higher frequency of ICP in women with an overt Araucanian Indian descent than in Chilean Caucasoids, women from both ethnic groups were studied. Among the 37 specificities of the HLA system studied (17 of HLA-A, 16 of HLA-B, and 4 of HLA-C series), only HLA-BW16 showed a tendency to be more frequent in women with ICP rather than in control women. This finding appears to be related with ethnic origin and not ICP, HLA-BW16 was significantly more frequent in women with Araucanian Indian descent (43.4%) than in Chilean Caucasoids (16.3%) (p less than 0.01). The high frequency of HLA-BW16 in the predominantly Caucasoid population in Chile, in comparison with Caucasians in Europe and in North America, may be another indicator of their ethnic admixture with aborigine groups. The high frequency of HLA-BW16 reported in North American Indian-admixed groups (16%) suggests that HLA-BW16 may be a genetic characteristic common to some aboriginal populations in North and South America.

Distribution of HLA histocompatibility antigens, ABO blood groups and Rh antigens in alcoholic liver disease

The distribution of 16 antigens of the HLA-A and 15 antigens of the HLA-B series of HLA system, the blood groups ABO, and Rh antigens were studied in 40 alcoholics with cirrhosis, 18 alcoholics without cirrhosis, and in normal control subjects. The group of alcoholics with cirrhosis showed a significantly high frequency of HLA-B13 (corrected P less than 0.01) when compared with normal subjects, while the frequency of HLA-B13 was similar to normal in alcoholics without cirrhosis. On the basis of these findings, its seems that the carriers of HLA-B13 are more susceptible to liver damage caused by alcohol. Both groups of alcoholics and the normal controls had a similar distribution of ABO blood groups and Rh antigens.

Immunity to antigenically related salmonellae: effects of humoral factors on the bactericidal activity of normal and immune peritoneal exudate cells

Immunity against Salmonella enteritidis and Listeria monocytogenes was studied by measuring in vitro the bactericidal activity of peritoneal exudate cells (PEC) of control (normal PEC) and S. typhi Ty2-immune (immune PEC) mice. Specific immune serum, anti-S. tyhphi Ty2, heat inactivated at 56 degrees C for 30 min, significantly inhibited the growth of S. enteritidis only with immune PEC. These opsonic factors had no effect upon the activity of normal PEC. That such inhibition could not be demonstrated in Listeria experiments, either with immune or normal PEC, suggests that S. enteritidis was specifically recognized, in vitro, by the thermostable opsonin anti-S. typhi Ty2 and that macrophages from immune PEC were more efficient in inhibiting bacterial growth than those from normal PEC. Thus, the interaction between macrophages and the microorganism seems to play an essential role in cell-mediated as well as humoral immunity.