Abstract OT1-02-05: A single arm phase II study of adjuvant anti-PD1 (pembrolizumab) in combination with hormonal therapy in patients with hormone receptor (HR)-positive localized inflammatory breast cancer (IBC) who did not achieve a pathological complete response (pCR) to neoadjuvant chemotherapy

Background: The pCR rate to conventional chemotherapy in hormone receptor positive IBC has historically been low (7.4% for HR+ HER2-, and 30% for HR+ HER2+), and despite the use of adjuvant endocrine therapy, the recurrence rate is still as high as 40%. To date, no targeted agent is proven to improve the efficacy of adjuvant endocrine therapy within the IBC population to improve this poor disease free survival (DFS). One plausible reason for the poor efficacy of endocrine therapy is a suppressed immune system, which allows tumor cells to avoid detection despite expression of potential immunogenic surface antigens.

Trial Design: This is a single arm trial that will enroll stage III HR+ IBC patients who have completed neoadjuvant therapy but had residual disease at mastectomy. Enrollment should be before or within 2 months of beginning endocrine therapy. Monitoring of DFS will be done with radiological imaging every 3 cycles (starting at cycle 4) as clinically indicated, per standard of care. Pembrolizumab is given on day 1 of each 21 day cycle for up to 2 years if the disease is controlled, and hormonal therapy will be administered per standard of care.

Eligibility Criteria: Clinical stage 3 IBC ER+/PR+ and HER2 negative patients who completed neoadjuvant chemotherapy and surgery with evidence of residual cancer in the breast or lymph nodes, but be clinically disease-free with good performance status at the start of study. Patients also must have adequate hematologic and organ function, and have recovered from the acute effects from prior treatments.

Specific Aims: The primary objective is to determine the disease free survival (DFS) at 2 years of patients with adjuvant therapy using Pembrolizumab in combination with standard adjuvant hormonal therapy. The secondary objective is to determine the safety and toxicity profile of this combination.

Statistical Methods: With a sample size of 37 patients, assuming that 80% are alive (20% increase from historical data) and disease-free at 2 years, and all patients are followed for >2 years after enrollment with no dropout, a 95% confidence interval around the 2-year estimate of DFS will be generated. DFS will then be compared with the historical control rate of 60% by year 2 using a one-sided exponential MLE test.

Accrual: To date we have enrolled 3 patients since activation in January 2017, and the target enrollment is 37 patients.

Contact information: For more information or to refer a patient, please contact study coordinator, Angela Alexander - aalexand@mdanderson.org

Citation Format: Alexander A, Willey J, Sun H, Parker CA, Marx AN, Wood AL, Reddy SM, Reuben JM, Bassett RL, Le-Petross HT, Krishnamurthy S, Gong Y, Woodward WA, Valero V, Ueno NT, Lim B. A single arm phase II study of adjuvant anti-PD1 (pembrolizumab) in combination with hormonal therapy in patients with hormone receptor (HR)-positive localized inflammatory breast cancer (IBC) who did not achieve a pathological complete response (pCR) to neoadjuvant chemotherapy [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 OT1-02-05.

Is MRI helpful in assessing the distance of the tumour from the internal os in patients with cervical cancer below FIGO Stage IB2?

AIM

To determine the ability of magnetic resonance imaging (MRI) in detecting tumour-free margins from the internal os (IO).

MATERIALS AND METHODS

A database search yielded 79 women with early-stage cervical cancer who underwent radical hysterectomy and preoperative MRI. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI in assessment of ≤5 and >5 mm IO involvement were calculated with histopathological surgical specimen findings considered to be the reference standard. A main and subset analysis was performed. The subset analysis included only those patients who would have been considered for radical trachelectomy.

RESULTS

For predicting a distance between the tumour and the IO of ≤5 mm, MRI had a sensitivity of 73%, a specificity of 98.3%, a PPV of 95%, a NPV of 88.1%, and an accuracy of 89.8% for the main analysis, and sensitivity of 81.8%, a specificity of 93.2% a PPV of 69.2% a NPV of 96.5% and an accuracy of 91.4% for the subset analysis.

CONCLUSION

MRI has high specificity, NPV, and accuracy in detecting tumour from the IO, making MRI suitable for treatment planning in patients desiring trachelectomy to preserve fertility.

A phase I study of decitabine with pegylated interferon α-2b in advanced melanoma: impact on DNA methylation and lymphocyte populations

BACKGROUND

Melanoma cell lines treated with decitabine show upregulation of cancer antigens, and interferon-α upregulates MHC Class I antigens in cancer cells, leading to enhanced T-cell recognition and T-cell mediated tumor apoptosis. We evaluated the synergy between the hypomethylating effects of decitabine and the immunomodulatory effects of interferon in a combination regimen administered to advanced melanoma patients in a phase 1 trial.

METHODS

Patients with one prior systemic therapy were eligible. Using a modified 3 + 3 design, patients received escalating doses of decitabine and pegylated interferon α-2b (PEG-IFN) during every 28-day treatment cycle. Global DNA methylation was measured on days 1 and 5 of cycles 1 and 3. Cytokine profiling and quantification of T-cell subpopulations by FACS were performed at baseline and cycle 3.

RESULTS

Seventeen patients were assigned to one of four dose levels. Decitabine 15 mg/m2/d + PEG-IFN 3 μg/kg was the maximum tolerated dose (MTD). Grade 3/4 cytopenias were seen across all dose levels: anemia (1), neutropenia (7), and thrombocytopenia (2). One patient remained progression-free for 37 weeks. The other 16 patients progressed at or before 12 weeks. Median overall survival was 39 weeks. Hypomethylation was seen at all dose levels. Due to treatment-induced lymphocytopenia, absolute changes in T-cell populations post-treatment were too small to be meaningfully interpreted.

CONCLUSIONS

The response to this combination regimen was characterized by significant myelosuppression, particularly neutropenia. Although disappointing efficacy and slow accrual led to early closure of the trial, hypomethylation showed pharmacodynamic evidence of a therapeutic effect of decitabine at all dose levels.

Thickness of superficial basal cell carcinoma (sBCC) predicts imiquimod efficacy: a proposal for a thickness-based definition of sBCC

BACKGROUND

Basal cell carcinoma (BCC) is the most common malignancy in the white population. It is an important driver of healthcare costs and causes significant morbidity. Topical imiquimod is a good noninvasive treatment alternative for surgical excision in superficial BCC (sBCC). However, there are currently no uniform histological definitions of sBCC. A definition based on tumour thickness might be a good alternative.

OBJECTIVES

To determine whether tumour thickness in sBCC is a predictor of treatment failure.

METHODS

We retrospectively examined 127 histological biopsy specimens of sBCC treated primarily with imiquimod five times a week for 6 weeks. Mean follow-up was 34 months (range 3-91). Recurrence was evaluated clinically with histological verification.

RESULTS

Among nonrecurrent cases the median tumour thickness was 0·26 mm (range 0·09-0·61), while for recurrent cases the median tumour thickness was 0·57 mm (range 0·41-1·41, P < 0·0001). Among lesions ≤ 0·40 mm in thickness, none recurred, whereas for lesions > 0·40 mm the recurrence rate was 58% (P < 0·0001).

CONCLUSIONS

We recommend the use of tumour thickness to define the superficial pattern in pathology reports for BCC as this can help to determine treatment response of sBCC to imiquimod.

Metaplastic sarcomatoid carcinoma of the breast appears more aggressive than other triple receptor-negative breast cancers

Metaplastic sarcomatoid carcinoma (MSC) of the breast is usually triple receptor (ER, PR, and HER2) negative and is not currently recognized as being more aggressive than other triple receptor-negative breast cancers. We reviewed archival tissue sections from surgical resection specimens of 47 patients with MSC of the breast and evaluated the association between various clinicopathologic features and patient survival. We also evaluated the clinical outcome of MSC patients compared to a control group of patients with triple receptor-negative invasive breast carcinoma matched for patient age, clinical stage, tumor grade, treatment with chemotherapy, and treatment with radiation therapy. Factors independently associated with decreased disease-free survival among patients with stage I-III MSC of the breast were patient age > 50 years (P = 0.029) and the presence of nodal macrometastases (P = 0.003). In early-stage (stage I-II) MSC, decreased disease-free survival was observed for patients with a sarcomatoid component comprising ≥ 95% of the tumor (P = 0.032), but tumor size was the only independent adverse prognostic factor in early-stage patients (P = 0.043). Compared to a control group of triple receptor-negative patients, patients with stage I-III MSC had decreased disease-free survival (two-sided log rank, P = 0.018). Five-year disease-free survival was 44 ± 8% versus 74 ± 7% for patients with MSC versus triple receptor-negative breast cancer, respectively. We conclude that MSC of the breast appears more aggressive than other triple receptor-negative breast cancers.

P3-07-05: Nomogram Incorporating SLN Metastasis Size Provides the Most Accurate Prediction of Non-SLN Involvement in Breast Cancer Patients

Introduction: The finding of metastatic disease in the axillary nodes remains an important factor that guides adjuvant therapy decisions in breast cancer. The value of completion axillary lymph node dissection (ALND) may not be the same in all patients and determining the risk of non-SLN involvement can be a guide in surgical decision making. We recently developed a nomogram that incorporates the maximum SLN metastasis size to predict non-SLN axillary involvement (Mittendorf et al., Ann Surgery 2011,in press). The purpose of this study was to compare the accuracy of this nomogram to another widely used nomogram that does not include SLN metastasis size.

Methods: We queried a prospective breast cancer database for patients with clinically negative nodes undergoing sentinel node biopsy who did not receive neoadjuvant therapy. We identified 431 patients with invasive breast cancer treated from 1996 to 2007 who had a positive SLN and underwent completion ALND. We evaluated clinicopathologic data including histology, multifocality, nuclear grade, pathologic tumor size, number of SLNs recovered, number of positive SLNs, maximum SLN metastasis size, presence of extranodal extension, hormone receptor status, and presence of lymphovascular invasion. Data were entered into our nomogram and the nomogram that does not include SLN metastasis size. The accuracy of the 2 nomograms in predicting non-SLN axillary metastasis was compared in all patients and in subgroups of patients based on burden of disease in the SLN.

Results: For the entire cohort of 431 women with positive SLNs, our SLN size nomogram was more accurate in the detection of non-SLN disease (area under the receiver operating characteristic curve [AUC] 78.3% vs. 72.4%, p=0.01). Whether or not SLNs were subjected to frozen section did not influence the relative accuracies of the 2 nomograms. When patients were analyzed by burden of disease in the SLNs, our SLN size nomogram was more accurate in predicting non-SLN disease in patients with macrometastases in the SLN (AUC 77.3% vs. 70.3%, p=0.008). There was no significant difference in the accuracy of the 2 nomograms for patients with isolated tumor cells or micrometastases in the SLNs.

Conclusions: Our nomogram incorporating SLN metastasis size with other clinicopathologic factors is the most accurate predictor of the risk of non-SLN metastasis in patients with a positive SLN. The SLN size nomogram is highly accurate in women with macrometastases, who may benefit the most from completion ALND. Using a nomogram with SLN metastasis size can provide the most accurate information for patient counseling and surgical decision making.

Mechanistic evaluation of the combination effect of paclitaxel (Pac) and bevacizumab (Bev) in breast cancer xenografts

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Background: Chemosensitization is the ability to augment the effects of standard chemotherapy. One of the possible mechanisms for chemosensitization is improving intratumoral chemotherapy concentrations by increasing total or regional delivery of chemotherapy to the tumor. This mechanism potentially leads to a decreased tumor interstitial fluid pressure (IFP). This study evaluates the interaction between tumor IFP, intra-tumor drug accumulation and blood vessel perfusion. Methods: GILM2 human breast cancer (triple negative phenotype) cells were injected into the mammary fat pad of female nude mice. Mice were randomized to 4 arms: Control, Pac 24 mg/Kg, Bev 10 mg/Kg, and the same dose for the combination Pac + Bev, twice a week for 3 weeks. Tumor IFP was assessed using an ultraminiature catheter-tip technique (Ozerdem 2005). Concentration of Pac in tumor tissue was measured using liquid chromatography mass spectrometry (LC/MS) and blood vessel perfusion was assessed by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). Ultrastructural morphology changes were assessed by electron microscopy (EM). Results: Treatment started 35 days after implantation; tumor tissue concentration of Pac was significantly increased when combined with Bev (P = 0.03). In mice treated with the combination of Pac + Bev, IFP values decreased more gradually, with sustained and significant reduction at the end of the treatment (P = 0.0068; mean SEM day 0: 28,44 ± 6,1; mean SEM day 21: 7,41 ± 2,0). The IFP changes in the other 3 experimental arms did not reach statistical significance. The combination of Pac and Bev produced substantial changes to the proportions of endothelial cell/pericytes and increased apoptosis in tumor cells by 75% (detected by immunostaining for cleaved-caspase 3). Conclusions: The combination of Pac and Bev produces significant tumor reduction and increases three-fold the concentration of Pac in the tumor. This intra-tumor augmentation of Pac was correlated with the decrease of tumor IFP, which was independent of the action of Bev alone. Results of DCE-MRI and EM analyses of the treated tumors will also be presented.

No significant financial relationships to disclose.

Forensic isotope analysis to refine a hydrologic conceptual model

Water resources in the arid southwestern United States are frequently the subject of conflict from competing private and public interests. Legal remedies may remove impasses, but the technical analysis of the problem often determines the future success of legal solutions. In Owens Valley, California, the source of water for the Los Angeles Aqueduct (LAA) is flow diverted from the Owens River and its tributaries and ground water from valley aquifers. Future management of ground water delivered to the LAA needs technical support regarding quantity available, interconnection of shallow and confined aquifers, impact on local springs, and rate of recharge. Ground water flow models and ground water composition are tools already in use, but these have large uncertainty for local interpretations. This study conducted targeted sampling of springs and wells to evaluate the hydrologic system to corroborate conceptual and numerical models. The effort included measurement of intrinsic isotopic composition at key locations in the aquifers. The stable isotopic data of boron (delta(11)B), sulfur (delta(34)S), oxygen (delta(18)O), hydrogen (delta D), and tritium ((3)H) supported by basic chemical data provided rules for characterizing the upper and the lower aquifer system, confirmed the interpretation of ground water flow near faults and flow barriers, and detected hydraulic connections between the LAA and the perennial springs at key locations along the unlined reach of the LAA. This study exemplifies the use of forensic isotopic approaches as independent checks on the consistency of interpretations of conceptual models of a ground water system and the numerical hydrologic simulations.

Geochemical tracers to evaluate hydrogeologic controls on river salinization

The salinization of rivers, as indicated by salinity increases in the downstream direction, is characteristic of arid and semiarid regions throughout the world. Historically, salinity increases have been attributed to various mechanisms, including (1) evaporation and concentration during reservoir storage, irrigation, and subsequent reuse; (2) displacement of shallow saline ground water during irrigation; (3) erosion and dissolution of natural deposits; and/or (4) inflow of deep saline and/or geothermal ground water (ground water with elevated water temperature). In this study, investigation of salinity issues focused on identification of relative salinity contributions from anthropogenic and natural sources in the Lower Rio Grande in the New Mexico-Texas border region. Based on the conceptual model of the system, the various sources of water and, therefore, salinity to the Lower Rio Grande were identified, and a sampling plan was designed to characterize these sources. Analysis results for boron (delta(11)B), sulfur (delta(34)S), oxygen (delta(18)O), hydrogen (delta(2)H), and strontium ((87)Sr/(86)Sr) isotopes, as well as basic chemical data, confirmed the hypothesis that the dominant salinity contributions are from deep ground water inflow to the Rio Grande. The stable isotopic ratios identified the deep ground water inflow as distinctive, with characteristic isotopic signatures. These analyses indicate that it is not possible to reproduce the observed salinization by evapotranspiration and agricultural processes alone. This investigation further confirms that proper application of multiple isotopic and geochemical tracers can be used to identify and constrain multiple sources of solutes in complex river systems.

Loss of phosphatase and tensin homologue deleted on chromosome 10 and phosphorylation of mammalian target of rapamycin are associated with progesterone refractory endometrial hyperplasia

The objective of our study was to evaluate the phosphatase and tensin homologue deleted on chromosome 10 (PTEN), p27, and mammalian target of rapamycin (mTOR) expressions in women with progesterone-responsive and refractory endometrial hyperplasia (EH) samples and to determine if these markers could be associated with response or used as potential targets for treatment. Thirty-eight matched pre- and posttreatment pairs of paraffin-embedded endometrial biopsies were obtained from patients with EH. Immunohistochemical analysis for PTEN, p27, and phospho-mTOR were performed on all samples. Median age at diagnosis was 49 years (20-79 years). Median treatment interval was 3 months (1-12 months). Sixteen patients (42.1%) had complete resolution of their hyperplasia (responders), and 22 (57.9%) had persistent hyperplasia (nonresponders) after treatment with progesterone. In the pretreatment samples, no markers were found to predict nonresponders. In posttreatment samples, loss of PTEN expression with phospho-mTOR expression was observed in more nonresponders than responders (40.9% vs 6.3%; P= 0.03). Phospho-mTOR overexpression was found in 63.6% of nonresponders. We found that persistent hyperplasia refractory to progesterone therapy was associated both with the loss of PTEN and with the loss of phosphorylation of mTOR. In select cases of non-responsive progesterone refractory EH, a rational target for treatment may involve the mTOR pathway.

Continued lamivudine versus delavirdine in combination with indinavir and zidovudine or stavudine in lamivudine-experienced patients: results of Adult AIDS Clinical Trials Group protocol 370

OBJECTIVE

To compare the virologic activity of continued lamivudine (3TC) versus a switch to delavirdine (DLV) when initiating protease inhibitor therapy in nucleoside-experienced patients.

DESIGN

Randomized, open-label, multi-center study.

SETTING

Adult AIDS clinical trials units.

PATIENTS

Protease and non-nucleoside reverse transcriptase inhibitor-naive patients who had received 3TC plus zidovudine (ZDV), stavudine (d4T), or didanosine (ddl) for at least 24 weeks.

INTERVENTIONS

Patients with plasma HIV-1 RNA levels > 500 copies/ml who previously received d4T + 3TC or ddI + 3TC were randomized to ZDV + 3TC + indinavir (IDV) or ZDV + DLV + IDV.

MAIN OUTCOME MEASURES

Primary endpoints were the proportion of patients with plasma HIV-1 RNA levels < or = 200 copies/ml at 24 weeks, and occurrence of serious adverse events. The proportion of patients with plasma HIV-1 RNA levels < or = 200 copies/ml at week 48 was a secondary endpoint.

RESULTS

At week 24, 58% of subjects in the ZDV + 3TC + IDV arm and 73% in the ZDV + DLV + IDV arm had plasma HIV-1 RNA levels < or = 200 copies/ml (P = 0.29). At week 48, plasma HIV-1 RNA levels were < or = 200 copies/ml in 48% and 83%, respectively (P = 0.007). Rash and hyperbilirubinemia occurred more frequently in the DLV arm than in the 3TC arm. Steady-state plasma IDV levels were higher among patients in the DLV arm as compared with the 3TC arm.

CONCLUSIONS

Substituting DLV for 3TC when adding IDV improved virologic outcome in nucleoside-experienced patients. This result might be explained, in part, by the positive effect of DLV on IDV pharmacokinetics.

Maintenance antiretroviral therapies in HIV-infected subjects with undetectable plasma HIV RNA after triple-drug therapy. AIDS Clinical Trials Group Study 343 Team

BACKGROUND

Combination antiretroviral therapy with indinavir, zidovudine, and lamivudine can suppress the level of human immunodeficiency virus (HIV) RNA in plasma below the threshold of detection for two years or more. We investigated whether a less intensive maintenance regimen could sustain viral suppression after an initial response to combination therapy.

METHODS

HIV-infected subjects who had CD4 cell counts greater than 200 per cubic millimeter, who had been treated with indinavir, lamivudine, and zidovudine, and who had less than 200 copies of HIV RNA per milliliter of plasma after 16, 20, and 24 weeks of induction therapy were randomly assigned to receive either continued triple-drug therapy (106 subjects), indinavir alone (103 subjects), or a combination of zidovudine and lamivudine (107 subjects). The primary end point was loss of viral suppression, which was defined as a plasma level of at least 200 copies of HIV RNA per milliliter on two consecutive measurements during maintenance therapy.

RESULTS

During maintenance treatment, 23 percent of the subjects receiving indinavir and 23 percent of those receiving zidovudine and lamivudine, but only 4 percent of those receiving all three drugs, had loss of viral suppression (P<0.001 for the comparison between triple-drug therapy and the other two maintenance regimens). Subjects with greater increases in CD4 cell counts during induction therapy, higher viral loads at base line (i.e., at the beginning of induction therapy), and slower rates of viral clearance were at greater risk for loss of viral suppression. The presence of zidovudine-resistance mutations in HIV RNA at base line was strongly predictive of the loss of viral suppression in subjects treated with zidovudine and lamivudine.

CONCLUSIONS

The suppression of plasma HIV RNA after six months of treatment with indinavir, zidovudine, and lamivudine is better sustained by the continuation of these three drugs than by maintenance therapy with either indinavir alone or zidovudine and lamivudine.

Treatment of human immunodeficiency virus infection with saquinavir, zidovudine, and zalcitabine. AIDS Clinical Trials Group

BACKGROUND

In patients with human immunodeficiency virus (HIV) infection, combined treatment with several agents may increase the effectiveness of antiviral therapy. We studied the safety and efficacy of saquinavir, an HIV-protease inhibitor, given with one or two nucleoside antiretroviral agents, as compared with the safety and efficacy of a combination of two nucleosides alone.

METHODS

In this double-blind trial, patients with HIV infection were randomly assigned to receive either saquinavir (1800 mg per day) plus both zidovudine (600 mg per day) and zalcitabine (2.25 mg per day) or zidovudine plus either saquinavir or zalcitabine. The 302 patients enrolled had CD4+ counts of 50 to 300 cells per cubic millimeter and had previously received zidovudine for a median of 27 months. The study lasted 24 weeks, with an optional double-blind extension period of an additional 12 to 32 weeks.

RESULTS

Ninety-six percent of the patients completed the 24-week study. In all three treatment groups, CD4+ cell counts rose at first and then fell gradually. The normalized area under the curve for the CD4+ count was greater with the three-drug combination than with either saquinavir and zidovudine (P=0.017) or zalcitabine and zidovudine (P<0.001). There were significantly greater reductions in plasma HIV with the three-drug combination than with the other regimens when peripheral-blood mononuclear cells were cultured for HIV and HIV RNA was assessed, and there were greater decreases in serum neopterin and beta2-microglobulin levels. There were no major differences in toxic effects among the three treatments.

CONCLUSIONS

Treatment with saquinavir, zalcitabine, and zidovudine was well tolerated. This drug combination reduced HIV-1 replication, increased CD4+ cell counts, and decreased levels of activation markers in serum more than did treatment with zidovudine and either saquinavir or zalcitabine. Studies are warranted to evaluate whether the three-drug combination will reduce morbidity and mortality.

Surgical findings in clenched-fist injuries

A total of 191 patients (representing 194 skin lacerations) hospitalized for clenched-fist injuries were evaluated for deep structure involvement. Tendon, joint, cartilage, and/or bone were damaged in 75%. Tendon involvement occurred in 28 of 138 (20.3%), joint capsule violation in 99 of 146 (67.8%), free articular cartilage fragments in 8 of 139 (5.8%) and articular-bone indentations in 23 of 139 (16.5%). All patients with clenched-fist lacerations or puncture wounds over joints should be treated by surgical debridement and exploration of the deep structures, including the joint, at the time they first seek medical care.

Displaced intraarticular fractures of the distal radius

The treatment of intraarticular fractures of the distal radius has been dramatically altered over the past decade. Investigations into the pathomechanics of these injuries highlight the problems of arthritis, pain, swelling, weakness, limited range of motion and instability associated with nonanatomic reduction of both intraarticular fragments and their associated ligaments. Factors affecting the prognosis for these injuries include degree and location of articular involvement and the energy of the precipitating force as well as the anatomy of reduction. Operative treatment is reserved for displaced intraarticular fractures. Those extremely comminuted fractures are best fixed with distraction and external fixation. The operative approach to these fractures is dependent on the anatomy. Ligamentous instability, in particular with radial styloid fractures, must be sought and treated. Kirschner wires can be used as "joy sticks" to control unstable carpal bones or fracture fragments prior to fixation. Plates and screws are useful in the stabilization of volar and dorsal rim fractures. The use of intraoperative radiographs is emphasized. Postoperative early range of motion, when possible, greatly improves the long-term results.

The isolated digital cord in Dupuytren's contracture: anatomy and clinical significance

This article describes the isolated occurrence of Dupuytren's pathologic fascial cords within digits of the hand. Thirty-seven cords were found in 32 patients with nearly half (45.6%) occurring in digits other than the small finger. Almost all patients (97.3%) had other clinical evidence of Dupuytren's disease. Cords were either single (83.8%) or double (16.2%) and originated from the periosteum at the base of the proximal phalanx in conjunction with adjacent ligaments and intrinsic tendons. They proceeded in an oblique direction to displace and then cross the neurovascular bundles before inserting on the bone and/or flexor tendon sheath of the middle phalanx. The average loss of extension of the proximal interphalangeal joint that resulted from these cords was 46 degrees, and surgical excision of the involved cords resulted in an average improvement of 24 degrees (53%).