Abstract P1-15-02: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Schwab R, Clark A, Yau C, Wolf D, Chien AJ, Majure M, Ewing C, Wallace A, Roesch E, Helsten T, Forero A, Stringer-Reasor E, Vaklavas C, Nanda R, Jaskowiak N, Boughey J, Haddad T, Han H, Lee C, Albain K, Isaacs C, Elias A, Ellis E, Shah P, Lang J, Lu J, Tripathy D, Kemmer K, Yee D, Haley B, Korde L, Edmiston K, Northfelt D, Viscusi R, Khan Q, I-SPY 2 Consortium, Symmans WF, Perlmutter J, Hylton N, Rugo H, Melisko M, Wilson A, Singhrao R, Asare S, van't Veer L, DeMichele A, Berry D, Esserman L. Withdrawn [abstract].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 P1-15-02.

Abstract P4-02-05: Diagnostic value of breast MRI in evaluating total extent of disease when non-calcified DCIS is present in stereotactic core biopsy samples

PURPOSE

To compare the extent of disease as seen on mammography, breast MRI and final surgical pathology in all patients with non-calcified DCIS identified on stereotactic core biopsy. Can MRI provide useful diagnostic information to the surgeon when mammographically occult DCIS is present.

METHOD AND MATERIALS

All patients with stereotactic core biopsies performed at the University of Chicago from 2010 to 2017 were retrospectively reviewed. Patients with pathology demonstrating DCIS in non-calcified cores on stereotactic biopsy were further selected based on whether they had a subsequent breast MRI and definitive surgical treatment. A total of 76 patients met these criteria. All patients undergoing stereotactic core biopsy had at least six 9-gauge cores removed, all of which were radiographed and separated based on whether calcifications were present or absent. Select patients with documented DCIS in the non-calcified cores had a MRI. All patients with MRI underwent a routine diagnostic protocol consisting of one pre- and five post-contrast bilateral, fat suppressed T1 sequences along with a non-fat suppressed T2 sequence. Final surgical treatment was subsequently determined and performed by the breast surgeon.

RESULTS

76 women met all criteria for this study. In 16/76 (21%) of the cases, MRI revealed greater extent of disease than was detected via mammography, and led to change in management in half of those cases (8/76 - 11%). In all 16 of these cases, final surgical pathology confirmed the MRI-detected extent of disease. In 52/76 (68%) of the cases, MRI confirmed the extent of disease detected on mammography and final surgical pathology. In 8/76 (11%) of the cases, MRI showed little to no abnormal enhancement at site of mammographically detected calcifications, even though final surgical pathology confirmed presence of residual disease.

CONCLUSION

The presence of non-calcified DCIS in stereotactic core biopsy samples raises the suspicion for the presence of mammographically occult disease. Breast MRI performed in this setting shows that in majority (82% -68/76) of the cases, MRI can either confirm or even advantageously reveal greater extent of disease than was initially detected on mammography. Furthermore, there can be a change in management due to the breast MRI findings.

CLINICAL RELEVANCE/APPLICATION

Breast MRI can be a useful diagnostic tool for the surgeon when non-calcified DCIS is present in stereotactic core biopsy samples.

Citation Format: Sheth D, Bao J, Abe H, Jaskowiak N. Diagnostic value of breast MRI in evaluating total extent of disease when non-calcified DCIS is present in stereotactic core biopsy samples [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-02-05.

Abstract OT1-04-06: NRG-BR002: A phase IIR/III trial of standard of care therapy with or without stereotactic body radiotherapy (SBRT) &/or surgical ablation for newly oligometastatic breast cancer

Background:

The current standard of care for metastatic breast cancer patients (pts) is to deliver palliative chemotherapy, biologic &/or hormonal therapy when appropriate, with radiation &/or surgery reserved for the management of symptomatic or non-responsive (mets). For selected pts with limited metastatic (met) disease, mets-directed ablative therapy, with either surgical resection or high dose conformal radiotherapy (in addition to standard systemic therapies) to lung, liver, CNS adrenal, & multiple organs has been shown to result in long-term disease control numerically superior to systemic therapy alone. NRG-BR002 is a randomized Phase II trial to evaluate stereotactic body radiotherapy (SBRT) &/or surgical resection (SR) of all met sites in newly oligometastatic breast cancer in addition to standard systemic therapy.

Trial Design & Eligibility

For the Ph IIR, eligible breast cancer pts with biopsy confirmed metastatic disease to < /= 2 sites will be randomized to receive either standard systemic therapy with mets directed therapy as needed ( control arm) versus ablative therapy of all met sites with either body SBRT &/or surgical resection (SR) ( per the treating physician discretion) to determine if there is an improvement median progression free survival (PFS). If this aim is met the trial continues as a Ph III to evaluate if SBRT/SR improves 5 year overall survival. Secondary aims include local control in the met site, new distant met rate, & technical quality. The primary translational endpoint tests whether < 5 CTCs (per 7.5ml of blood) is an independent prognostic (outcome) marker for improved PFS & OS in oligometastatic breast cancer.

Women are within 1 year of metastatic diagnosis, on first line systemic therapy without progression & the primary site disease is controlled. CNS mets are ineligible. ER/PR & HER-2 neu are required on either the primary or met site. Site radiation credentialing & a facility questionnaire are required. Randomization is to standard systemic therapy with local radiotherapy/ surgery for palliation when necessary vs ablative therapy of all mets with SBRT &/or SR.

Statistics:

For the Ph IIR portion to detect a signal for improved median PFS from 10.5 months to 19 months with 95% power & accounting for ineligible/lost pts, 146 pts will be required. For the Ph III, an additional 246, for a total of 402 pts will be required to definitively determine if ablative therapy improves 5-year overall survival from 28% to 42.5% (HR=0.67), with 85% power & a 1-sided type I error of 0.025. For the translational research, the number of pts accrued in the Ph IIR & Ph III portions will provide sufficient power ≥ 91% to detect whether < 5 CTC's is a prognostic marker for improved PFS & OS.

Present Accrual & Target Accrual

NRG BR002 activated 12/24/2014 with a target accrual of 146 pts for the Ph II component & 256 additional for the Ph III.

Contact Information:

Protocol: CTSU member web site https://www.ctsu.org. Enrollment: OPEN at https://open.ctsu.org.

Support:

Supported by NRG Oncology grants U10CA180868 & U10CA180822 from the National Cancer Institute (NCI).

Citation Format: Chmura SJ, Winter KA, Salama JK, Woodward WW, Borges VF, Al-Hallaq H, Martuszak M, Jaskowiak NT, Milano MT, Bandos H, White JR. NRG-BR002: A phase IIR/III trial of standard of care therapy with or without stereotactic body radiotherapy (SBRT) &/or surgical ablation for newly oligometastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT1-04-06.

Abstract OT3-03-04: NRG-BR002: A phase IIR/III trial of standard of care therapy with or without stereotactic body radiotherapy (SBRT) &/or surgical ablation for newly oligometastatic breast cancer

Background:

The current standard of care for metastatic breast cancer patients (pts) is to deliver palliative chemotherapy, biologic &/or hormonal therapy when appropriate, with radiation &/or surgery reserved for the management of symptomatic or non-responsive (mets). For selected pts with limited metastatic (met) disease, mets-directed ablative therapy, with either surgical resection or high dose conformal radiotherapy (in addition to standard systemic therapies) to lung, liver, CNS adrenal, & multiple organs has been shown to result in long-term disease control numerically superior to systemic therapy alone. NRG-BR002 is a randomized Phase II trial to evaluate stereotactic body radiotherapy (SBRT) &/or surgical resection (SR) of all met sites in newly oligometastatic breast cancer in addition to standard systemic therapy.

Trial Design & Eligibility

For the Ph IIR, eligible breast cancer pts who have received up to 6 months of first line systemic therapy without progression will be randomized to receive either standard systemic therapy with mets directed therapy as needed ( control arm) versus ablative therapy of all met sites with either body SBRT &/or surgical resection (SR) ( per the treating physician discretion) to determine if there is an improvement median progression free survival (PFS). If this aim is met the trial continues as a Ph III to evaluate if SBRT/SR improves 5 year overall survival. Secondary aims include local control in the met site, new distant met rate, & technical quality. The primary translational endpoint tests whether < 5 CTCs (per 7.5ml of blood) is an independent prognostic (outcome) marker for improved PFS & OS in oligometastatic breast cancer.

Women with pathologically confirmed met breast cancer to < /= 2 sites, with up to 6 months of standard first line systemic therapy & the primary site disease is controlled. CNS mets are ineligible. ER/PR & HER-2 neu are required on either the primary or met site. Site radiation credentialing & a facility questionnaire are required. Randomization is to standard systemic therapy with local radiotherapy/ surgery for palliation when necessary vs ablative therapy of all mets with SBRT &/or SR.

Statistics:

For the Ph IIR portion to detect a signal for improved median PFS from 10.5 months to 19 months with 95% power & accounting for ineligible/lost pts, 146 pts will be required. For the Ph III, an additional 246, for a total of 402 pts will be required to definitively determine if ablative therapy improves 5-year overall survival from 28% to 42.5% (HR=0.67), with 85% power & a 1-sided type I error of 0.025. For the translational research, the number of pts accrued in the Ph IIR & Ph III portions will provide sufficient power ≥ 91% to detect whether < 5 CTC's is a prognostic marker for improved PFS & OS.

Present Accrual & Target Accrual

NRG BR002 activated 12/24/2014 with a target accrual of 146 pts for the Ph II component & 256 additional for the Ph III.

Contact Information:

Protocol: CTSU member web site https://www.ctsu.org. Enrollment: OPEN at https://open.ctsu.org.

Support:

Supported by NRG Oncology grants U10CA180868 & U10CA180822 from the National Cancer Institute (NCI).

Citation Format: Chmura SJ, Winter KA, Salama JK, Woodward WA, Borges VF, Al-Hallaq H, Matuszak M, Jaskowiak NT, Milano MT, Bandos H, White JR. NRG-BR002: A phase IIR/III trial of standard of care therapy with or without stereotactic body radiotherapy (SBRT) &/or surgical ablation for newly oligometastatic breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT3-03-04.

The Effect of Preoperative MRI on Mastectomy Rates in Breast Cancer Patients

Background: Currently, there are two primary surgical options for the treatment of early stage breast cancer: modified radical mastectomy and breast conserving surgery (BCS) with post-surgical radiation. Numerous studies have shown that there is no survival difference between the two surgical treatments, however, in recent years, there is data to suggest that mastectomy rates have been on the rise. While many factors undoubtedly influence surgical management decisions in breast cancer patients, the effect of routine use of preoperative breast MRI may be a contributor to the rise in mastectomy rates. Methods: Breast cancer patients who were treated surgically and received a preoperative MRI were identified using a database from the University of Chicago Department of Radiology, which contains information on over 4200 patients who have received breast MRI since 2002. These patients were cross-referenced with data from the University of Chicago Cancer Registry, which contains information regarding type of surgical treatment, surgeon, stage of cancer at time of diagnosis and surgical stage for all breast cancer patients treated at the University of Chicago Hospitals from 2000-2007. Annual mastectomy rates from 2000-2007 were calculated and compared using Pearson's Chi Square test. Annual mastectomy rates were stratified by mean age at diagnosis and stage of disease. Mastectomy rates prior to routine use of preoperative MRI (2000-2002) and after routine use of preoperative MRI (2005-2007) were calculated for breast cancer patients under 45 and over 45 years of age and rates were compared using Fisher's exact test. Results: A total of 1,404 patients received surgical treatment for a new diagnosis of breast cancer between 2000 and 2007 at the University of Chicago Hospitals. Results to date indicate that mastectomy rates across all years are not significantly different (p = 0.315). Results also indicate that the mean age at diagnosis of patients who receive mastectomy as the initial surgical treatment for their breast cancer is higher than those who receive BCS from 2000-2002, but is lower than those who receive BCS from 2003-2007. In addition, breast cancer patients under the age of 45 have higher rates of mastectomy since the routine use of preoperative MRI which trends toward statistical significance (p = 0.0598). Conclusion: These preliminary results indicate that overall mastectomy rates at the University of Chicago Hospitals are not increasing in concordance with the increased use of preoperative MRI testing, but that younger breast cancer patients may have higher rates of mastectomy in the MRI era.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4019.

Phase I study of preoperative chemoradiation therapy in unresectable locally advanced breast cancer (LABC)

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Introduction: Therapy of unresectable LABC is challenging due to the need to resect local disease and prevent distant metastases. We conducted a phase I trial to determine the maximum tolerated dose of preoperative vinorelbine (VIN) combined with paclitaxel (P) and radiation (XRT). Methods: Eligible patients (pts) had unresectable LABC, ECOG performance 0–2 and adequate organ function. Prior chemotherapy and metastatic disease were permitted. All pts received weekly bolus P 80 mg/m2 and concurrent XRT at 2.0 Gy daily for 5 days in a week-on/week-off (WO/WO) schedule for 12 weeks. A planned 59 -70 Gy were delivered to the breast, chest wall and supraclavicular regions. In dose level 2, VIN 15 mg/m2 /week was added. Results: Twenty-six pts were enrolled from July 1999-July 2005 with a median age of 51 years (range 24–69); 9 pts had stage IV disease, 17 pts had stage IIIB disease, and 13 pts had received prior chemotherapy. VIN was not tolerated due to grade (G) 4 neutropenia despite GCSF; however single-agent P and concurrent XRT was well-tolerated. Thus, 7 pts in the final cohort received P/XRT without GCSF. This regimen was well-tolerated; toxicities seen included: G3 in-field skin desquamation 4/7; G4 lymphopenia 7/7, G3 infection 1/7; G3 wound dehiscence 1/7. After therapy, 20/26 pts underwent mastectomy: 6 pts had a pathologic complete response (no invasive disease), 12 had a pathologic partial response (scattered microscopic disease), and 2 pts had no response. Overall pathologic response rate was 90% for pts undergoing mastectomy; only 3 of the 20 resectable pts are alive without relapse a mean of 19.5 months after mastectomy. Conclusions: Neoadjuvant P 80 mg/m2 with full dose XRT in a WO/WO schedule is tolerable and effective allowing 20/26 unresectable pts to undergo successful mastectomy. Pts do not require routine GCSF support. Although most pts eventually relapse distantly, this regimen does render some pts not responding to initial doxorubicin-based therapy resectable.

[Table: see text]

No significant financial relationships to disclose.

Selective gene expression using a DF3/MUC1 promoter in a human esophageal adenocarcinoma model

The efficacy of replication-deficient adenoviral vectors in gene therapy is confined to the number of tumor cells the vector infects. To focus and enhance the therapeutic efficacy, we employed a conditionally replication-competent adenoviral vector with a tissue-specific promoter, DF3/MUC1, in a human esophageal adenocarcinoma model. Our results demonstrate that Ad.DF3.E1A.CMV.TNF (Ad.DF3.TNF) specifically replicates in Bic-1 (DF3-producing cells) and mediates an enhanced biologic effect due to increased TNF-alpha in the same DF3-producing cells. We also show that the increased TNF-alpha interacts with ionizing radiation to produce greater tumor regression and a greater delay in tumor regrowth in Bic-1 (DF3-producing cells) compared to Seg-1 (DF3 non-producers). Tumor cell targeting using conditionally replication-competent adenoviral vectors with tumor-specific promoters to drive viral replication and deliver TNF-alpha provides a novel approach to enhancing tumor radiosensitivity.

Adenocarcinoma at a strictureplasty site in Crohn's disease: report of a case

Strictureplasties have proven useful and safe in Crohn's disease. Concerns have been raised, however, about the potential of carcinoma arising at the strictureplasty site. Here the authors report a case of a small-bowel adenocarcinoma developing at the site of a prior strictureplasty in a middle-aged male patient seven years postoperatively in the absence of any other preneoplastic disease of the small bowel. Presenting symptoms were of progressive obstruction after a long period of quiescent disease. With this report comes stronger evidence that adenocarcinoma does occur at strictureplasty sites, raising questions of its long-term safety.

NM-3, an isocoumarin, increases the antitumor effects of radiotherapy without toxicity

We examined the effects of a new antiangiogenic isocoumarin, NM-3, as a radiation modifier in vitro and in vivo. The present studies demonstrate that NM-3 is cytotoxic to human umbilical vein endothelial cells (HUVECs) but not to Lewis lung carcinoma (LLC) cells nor Seg-1, esophageal adenocarcinoma cells, in clonogenic survival assays. When HUVEC cultures are treated with NM-3 combined with ionizing radiation (IR), additive cytotoxicity is observed. In addition, the combination of NM-3 and IR inhibits HUVEC migration to a greater extent than either treatment alone. The effects of treatment with NM-3 and IR were also evaluated in tumor model systems. C57BL/6 female mice bearing LLC tumors were given injections for 4 consecutive days with NM-3 (25 mg/kg/day) and treated with IR (20 Gy) for 2 consecutive days. Combined treatment with NM-3 and IR significantly reduced mean tumor volume compared with either treatment alone. An increase in local tumor control was also observed in LLC tumors in mice receiving NM-3/IR therapy. When athymic nude mice bearing Seg-1 tumor xenografts were treated with NM-3 (100 mg/kg/day for 4 days) and 20 Gy (four 5 Gy fractions), significant tumor regression was observed after combined treatment (NM-3 and IR) compared with IR alone. Importantly, no increase in systemic or local tissue toxicity was observed after combined treatment (NM-3 and IR) when compared with IR alone. The bioavailability and nontoxic profile of NM-3 suggests that the efficacy of this agent should be tested in clinical radiotherapy.

Antitumor interaction of short-course endostatin and ionizing radiation

PURPOSE

The purpose of this study was to evaluate whether endostatin, an antiangiogenic cleavage fragment of collagen XVIII, enhances the antitumor effects of ionizing radiation (IR). Endostatin was injected to coincide with fractionated radiotherapy.

METHODS

Xenografts of radioresistant SQ-20B tumor cells were established in athymic nude mice. Lewis lung carcinoma cells were injected into C57BI/6 mice. Mice bearing SQ-20B xenografts were injected intraperitoneally with 2.5 mg/kg/day of murine recombinant endostatin 5 times per week for 2 weeks 3 hours before IR treatment (50 Gy total dose). Mice bearing Lewis lung carcinoma tumors were injected intraperitoneally with endostatin (2.5 mg/kg/day) four times; the first injection was given 24 hours before the first IR dose (15 Gy) and then 3 hours before IR (15 Gy/day) for 3 consecutive days. Microvascular density was assessed on tumor tissue sections by use of CD31 immunohistochemistry and light microscopy. Endothelial cell survival analyses were employed to evaluate endostatin effects on human aortic endothelial cells and human umbilical vein endothelial cells. Endothelial cell apoptosis was examined by use of FACS analysis and DAPI microscopy.

RESULTS

In SQ-20B xenografts, combined treatment with endostatin and IR produced tumor growth inhibition that was most pronounced at the nadir of regression (day 21). By day 35, tumors receiving combined treatment with endostatin and IR were 47% smaller than tumors treated with endostatin alone. Interactive cytotoxic treatment effects between endostatin and IR were also demonstrated in mice bearing Lewis lung carcinoma tumors. Significant tumor growth inhibition was observed in the endostatin/IR group at days 11 and 13 compared with IR alone. Histologic analyses demonstrated a reduction in microvascular density after combined treatment with endostatin and IR compared with endostatin treatment alone. Survival analyses confirmed interactive cytotoxicity between endostatin and IR in both human aortic endothelial cells and human umbilical vein endothelial cells but not in SQ-20B tumor cells. Combined treatment with endostatin and IR produced an increase in cow pulmonary artery endothelial apoptosis compared with either treatment alone.

DISCUSSION

The tumor regression observed after combined treatment with endostatin and IR suggests additive antitumor effects in both human and murine tumors. Importantly, the concentrations of endostatin employed produced little tumor regression when endostatin was employed as a single agent. The results from the clonogenic and apoptosis assays support the hypothesis that the endothelial compartment is the target for the endostatin/IR interaction.

Blockage of the vascular endothelial growth factor stress response increases the antitumor effects of ionizing radiation

The family of vascular endothelial growth factor (VEGF) proteins include potent and specific mitogens for vascular endothelial cells that function in the lation of angiogenesis Inhibition of VEGF-induced angiogenesis either by neutralizing antibodies or dominant-negative soluble receptor, blocks the growth of primary and metastatic experimental tumors Here we report that VEGF expression is induced in Lewis lung carcinomas (LLCs) both in vitro and vivo after exposure to ionizing radiation (IR) and in human tumor cell lines (Seg-1 esophageal adenocarcinoma, SQ20B squamous cell carcinoma, T98 and U87 glioblastomas, and U1 melanoma) in vitro. The biological significance of IR-induced VEGF production is supported by our finding that treatment of tumor-bearing mice (LLC, Seg-1, SQ20B, and U87) with a neutralizing antibody to VEGF-165 before irradiation is associated with a greater than additive antitumor effect. In vitro, the addition of VEGF decreases IR-induced killing of human umbilical vein endothelial cells, and the anti-VEGF treatment potentiates IR-induced lethality of human umbilical vein endothelial cells. Neither recombinant VEGF protein nor neutralizing antibody to VEGF affects the radiosensitivity of tumor cells These findings support a model in which induction of VEGF by IR contributes to the protection of tumor blood vessels from radiation-mediated cytotoxicity and thereby to tumor radioresistance.

Multiple cytokines and acute inflammation raise mouse leptin levels: potential role in inflammatory anorexia

Several inflammatory cytokines, most notably tumor necrosis factor (TNF) and IL-1, induce anorexia and loss of lean body mass, common manifestations of acute and chronic inflammatory conditions. In C57BL/6 female mice, the administration of TNF, IL-1, and, to a lesser extent, leukemia inhibitory factor (LIF), produced a prompt and dose-dependent increase in serum leptin levels and leptin mRNA expression in fat. IL-10, IL-4, ciliary neurotrophic factor, and IL-2, cytokines not known to induce anorexia or decrease food intake, had no effect on leptin gene expression or serum leptin levels. After administration of Escherichia coli lipopolysaccharide (LPS), leptin gene expression and leptin levels were increased. These findings suggest that leptin levels may be one mechanism by which anorexia is induced during acute inflammatory conditions.

Is reoperation for gastrinoma excision indicated in Zollinger-Ellison syndrome?

BACKGROUND

Surgical excision of gastrinomas in patients with Zollinger-Ellison syndrome (ZES) decreases the incidence of hepatic metastases, but long-term biochemical cures are achieved in fewer than 30% of cases. A growing number of patients have persistent or recurrent disease after initial operation. The effect of reoperation in these patients has not been previously reported.

METHODS

From December 1982 to August 1995, 120 patients with ZES underwent operation for gastrinoma resection. Seventy-eight patients had recurrent or persistent ZES after operation; 17 patients underwent 18 reoperations. After initial operation all patients underwent yearly functional and imaging studies. If a tumor was unequivocally imaged, reexploration was done.

RESULTS

Five patients, all with sporadic disease, were disease free after operation, with a median follow-up of 28 months. Tumor was found in all 18 reoperations and resected in 17. In patients with continuing disease-free intervals, locations of gastrinomas included pancreatic head lymph nodes (three), liver metastasis (one), and pancreatic tail lymph node (one). There were no deaths in the cured group; two patients in the group with persistent disease have died (median follow-up, 34 months).

CONCLUSIONS

Reoperation for gastrinoma excision resulted in elimination of disease in 30% of patients and should be considered for patients with imageable disease.

A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma

OBJECTIVES

The authors evaluate the results of preoperative imaging protocols and surgical re-exploration in a series of patients with missed parathyroid adenomas after failed procedures for primary hyperparathyroidism.

BACKGROUND

The success rate is lower and the complication rate is increased in patients undergoing reoperation for primary hyperparathyroidism compared with initial procedures. Scarring and distortion of tissue planes plus the potential for ectopic gland location leads to this worsened outcome.

METHODS

Two hundred eighty-eight consecutive patients with persistent/recurrent hyperparathyroidism were treated at a single institution after a failed procedure or procedures at outside institutions. Two hundred twenty-two of these patients (77%) were believed to have a missed single adenoma, and these patients underwent 228 operations and 227 preoperative work-ups. Preoperative evaluation consisted of a combination of four noninvasive imaging studies--neck ultrasound, nuclear medicine scan, neck and mediastinal computed tomography scan, and neck and mediastinal magnetic resonance imaging. Based on the noninvasive testing alone, 27% patients underwent surgery whereas the other patients underwent invasive studies, including selective angiography (58%), selective venous sampling for parathyroid hormone (43%), or percutaneous aspiration of suspicious lesions (15%).

RESULTS

Abnormal parathyroid adenomas were found in 209 of 222 initial procedures and 6 of 6 second procedures, with an overall success rate in terms of resolution of hypercalcemia in 97% (215/222) of patients. The single most common site of missed adenoma glands was in the tracheal-esophageal groove in the posterior superior mediastinum (27%). The most common ectopic sites for parathyroid adenomas are thymus (17%), intrathyroidal (10%), undescended glands (8.6%), carotid sheath (3.6%), and the retroesophageal space (3.2%). The most sensitive and specific noninvasive imaging test is the sestamibi subtraction scan, with 67% true-positive and no false-positive results. The rate of true-positive and false-positive results for ultrasound, computed tomography, magnetic resonance imaging, and technetium thallium scans were 48%/21%, 52%/16%, 48%/14% and 42%/8%, respectively. The incidence of injury to the recurrent laryngeal nerve was 1.3%.

CONCLUSIONS

A single missed parathyroid adenoma is the most common cause for a failed initial parathyroid operation. Appropriate use of preoperative imaging tests and knowledge of the potential location or parathyroid adenomas can lead to very high cure rates with minimal morbidity.

A high-performance liquid chromatographic procedure for the determination of disaturated phosphatidylcholine in human plasma

Plasma disaturated phosphatidylcholine (DSPC) concentration has been implicated as a risk factor for atherosclerosis. However, suitable methods for the estimation of these compounds in plasma are not available. In this paper, a method for the estimation of DSPC using argentation thin-layer chromatography and high-performance liquid chromatography is described. It is quantitative for the measurement of individual and total DSPC species and is not dependent on fatty acid chain length. The method employs hydrolysis of total plasma phosphatidyl choline by phospholipase C, followed by benzoylation of the diacylglycerols. The benzoates are then fractionated on silver nitrate-impregnated silica gel thin-layer chromatography plates, and the disaturated species separated and quantitated by high-performance liquid chromatography. The method is sensitive and reproducible and allows many samples to be done at once. With this method, the amounts of DSPC were found to be significantly higher in a group of normolipidemic diabetic subjects, compared to age-matched controls.