Age-related Changes of the Prostate on Magnetic Resonance Imaging: Quantitative and Qualitative Evaluation in a Screening Cohort of BRCA Mutation Carriers

BACKGROUND

Age-related changes in multiparametric magnetic resonance imaging (mpMRI) of the prostate have been reported in the general population but not in screening cohorts.

OBJECTIVES

To evaluate age-related changes on prostatic mpMRI in a screening cohort of BRCA1/2 mutation carriers.

METHODS

Asymptomatic BRCA1/2 mutation carriers underwent mpMRI as part of a screening program. All included patients were followed for 3 years with no evidence of prostate cancer. mpMRIs were retrospectively evaluated by two abdominal radiologists for peripheral zone (PZ) patterns on T2 (homogenous hyperintensity, wedge-shaped hypointensities, patchy hypointensities, or diffuse hypointensity), and transition zone (TZ) pattern on T2 (homogenous, heterogeneous, nodular). Apparent diffusion coefficient (ADC) values of PZ and TZ were measured. Statistical analysis was performed using a predefined age cutoff of 50 years old.

RESULTS

Overall, 92 patients were included: 38 in the younger age group (40-49 years) and 54 in the older age group (50-69 years). PZ homogenous hyperintensity and wedge-shaped hypointensities were more common in the older patients, whereas diffuse hypointensity was more common in younger patients (P < 0.001 for both readers) with substantial inter-reader agreement between the readers (kappa=0.643). ADC values were lower in young patients in the PZ (P < 0.001) and TZ (P = 0.003).

CONCLUSIONS

Age-related differences in mpMRI were validated in BRCA mutation carriers. As some features overlap with prostatic carcinoma, awareness is crucial, specifically to diffuse T2 hypointensities of the PZ and lower ADC values in the PZ and TZ, which are more common in younger patients.

MRI background parenchymal enhancement in patients with invasive lobular carcinoma: Endocrine hormonal treatment effect

OBJECTIVES

High background parenchymal enhancement (BPE) levels and asymmetric distribution could cause diagnostic uncertainty due to morphological similarity to breast cancer, especially invasive lobular carcinoma (ILC). We investigated BPE in ILC patients, its association with the tumor hormonal profile, and the effect of endocrine treatment (ET).

METHODS

The analysis included all MRI examinations performed at our institution between 2010 and 2019 for ILC-diagnosed patients. Baseline study and the first follow-up study were reviewed. Digital medical records were reviewed to retrieve demographics/pathology results/treatment information. BPE and fibroglandular tissue were assessed qualitatively on the contralateral breast according to the criteria of the Breast Imaging Reporting and Data System (BI-RADS).

RESULTS

The study included 129 patients. Most (91%) had pure ILC. All received ET; 12% also received chemotherapy; 90% had surgery first; 70% by breast conservation. On the baseline MRI, 70% had mild or moderate BPE; whereas, on the follow-up study, the majority (59%) had minimal BPE. Most BPE reductions were by 2 degrees. In the baseline study, additional biopsies were required in 59% of cases, and in 17%, a short-term follow-up was recommended. In the follow-up study, biopsies were recommended in 10%, and a short-term follow-up was requested in 16%. A correlation between progesterone receptor intensity index and baseline BPE level was observed (r = 0.3, p = 0.004).

CONCLUSION

ILC patients usually exhibit high BPE. ET decreases BPE, and therefore may decrease false-positive interpretations. Additional research is needed to explore whether study can be performed on ET without compromising sensitivity.

KEY POINTS

∙ High background parenchymal enhancement levels reduces breast MRI sensitivity, yielding high false positive rates especially when reporting cases of invasive lobular carcinoma [ILC].∙Treatment of ILC with endocrine therapy reduces background parenchymal enhancement and thus could decrease these false-positive interpretations.

Rate of breast biopsy referrals in female BRCA mutation carriers aged 50 years or more: a retrospective comparative study and matched analysis

Purpose

To evaluate the total biopsy and positive biopsy rates in women at high risk of breast cancer compared to the general population.

Methods

The study group consisted of 330 women with pathogenic variants (PVs) in BRCA1/2 attending the dedicated multidisciplinary breast cancer clinic of a tertiary medical center in Israel. Clinical, genetic, and biopsy data were retrieved from the central healthcare database and the medical files. Patients aged 50 years or older during follow-up were matched 1:10 to women in the general population referred for routine breast cancer screening at the same age, as recommended by international guidelines. The groups were compared for rate of biopsy studies performed and percentage of positive biopsy results. Matched analysis was performed to correct for confounders.

Results

The total biopsy rate per 1000 follow-up years was 61.7 in the study group and 22.7 in the control group (p < 0.001). The corresponding positive biopsy rates per 1000 follow-up years were 26.4 and 2.0 (p < 0.001), and the positive biopsy percentages, 42.9% and 8.7% (p < 0.0001).

Conclusion

Women aged 50 + years with PVs in BRCA1/2 attending a dedicated clinic have a 2.7 times higher biopsy rate per 1000 follow-up years, a 13.2 times higher positive biopsy rate per 1000 follow-up years, and a 4.9 times higher positive biopsy percentage than same-aged women in the general population.

Abstract P2-11-16: Rate of breast biopsy referrals in BRCA mutation carriers: A retrospective comparative study and matched analysis

Purpose: To evaluate the total biopsy and positive biopsy rates in women at high risk of breast cancer compared to the general population. Methods: The study group consisted of 330 BRCA mutation carriers attending the dedicated multidisciplinary breast cancer clinic of a tertiary medical center in Israel. Clinical, genetic, and biopsy data were retrieved from the central healthcare database and the medical files. Patients who were at age 50 years or older during follow-up were matched 1:10 to women in the general population referred for routine breast cancer screening at the same age, as recommended in the international guidelines. The groups were compared for rate of biopsy studies performed and percentage of positive biopsy results. Matched analysis was performed to correct for confounders. Results: The matched analysis revealed that the total biopsy rate per 1000 follow-up-years was 61.7 in the study group and 22.7 in the control group (p &lt;0.001). The positive biopsy rates per 1000 follow-up-years were 26.4 and 2.0, correspondingly (p &lt;0.001), and the positive biopsy percentages were 42.9% and 8.7% correspondingly (p &lt;0.0001).Conclusions: BRCA mutation carriers who attend a dedicated clinic, have a 2.7 times higher biopsy rate per 1000 follow-up-years, a 13.2 times higher positive biopsy rate per 1000 follow-up-years, and a 4.9 times higher positive biopsy percentage compared with women in the general population. Keywords: Biopsy, BRCA, breast cancer, screening, high risk

Citation Format: Adi Pomerantz, Daliah Tsoref, Ahuva Grubstein, Sonya Wadhawker, Yael Rapson, Itay Gadiel, Hadar Goldvaser, Ariel Hammerman, Tzipora Shochat, Eran Sharon, Rinat Yerushalmi. Rate of breast biopsy referrals in BRCA mutation carriers: A retrospective comparative study and matched analysis [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P2-11-16.

[DIFFERENT APPROACHES TO MAMMOGRAPHY AS A SCREENING TOOL FOR BREAST CANCER]

Mammography as a screening tool can reduce mortality from breast cancer. Nevertheless, it has disadvantages such as false positive results, false negative, impaired sensitivity in women with dense breast over-diagnosis and radiation. Due to the different weight given to the advantages versus the disadvantages of mammography, different approaches to screening have developed. These range from annual screening starting at the age of 40 years, to biannual screening starting at the age of 50. The official screening program in Israel is biannual screening between the ages of 50 and 74.

3,3-Diindolylmethane (DIM): a nutritional intervention and its impact on breast density in healthy BRCA carriers. A prospective clinical trial

Women who carry the BRCA mutation are at high lifetime risk of breast cancer, but there is no consensus regarding an effective and safe chemoprevention strategy. A large body of evidence suggests that 3,3-diindolylmethane (DIM), a dimer of indole-3-carbinol found in cruciferous vegetables, can potentially prevent carcinogenesis and tumor development. The primary aim of this prospective single-arm study was to investigate the effect of DIM supplementation on breast density, a recognized predictive factor of breast cancer risk. Participants were 23 healthy female BRCA carriers (median age 47 years; 78% postmenopausal) who were treated with oral DIM 100 mg × 1/day for 1 year. The amount of fibroglandular tissue (FGT) and background parenchymal enhancement (BPE) on magnetic resonance imaging (MRI) performed before and after the intervention was scored by two independent expert radiologists using the Breast Imaging and Reporting Data System. The results showed a decrease in the average score for FGT amount from 2.8 ± 0.8 at the onset to 2.65 ± 0.84 after 1 year (P = 0.031), with no significant change in BPE (P = 0.429). A group of DIM-untreated age- and menopausal-status-matched women from the BRCA clinic did not show a significant change in FGT amount (P = 0.33) or BPE (P = 0.814) in a parallel year. Mean estradiol level decreased from 159 to 102 pmol/l (P = 0.01), and mean testosterone level decreased from 0.42 to 0.31 pmol/l (P = 0.007). Side effects were grade 1. In conclusion, 1 year’s supplementation with DIM 100 mg × 1/day in BRCA carriers was associated with a significant decline in FGT amount on MRI. Larger randomized studies are warranted to corroborate these findings.

COVID-19 classification of X-ray images using deep neural networks

Objectives

In the midst of the coronavirus disease 2019 (COVID-19) outbreak, chest X-ray (CXR) imaging is playing an important role in diagnosis and monitoring of patients with COVID-19. We propose a deep learning model for detection of COVID-19 from CXRs, as well as a tool for retrieving similar patients according to the model’s results on their CXRs. For training and evaluating our model, we collected CXRs from inpatients hospitalized in four different hospitals.

Methods

In this retrospective study, 1384 frontal CXRs, of COVID-19 confirmed patients imaged between March and August 2020, and 1024 matching CXRs of non-COVID patients imaged before the pandemic, were collected and used to build a deep learning classifier for detecting patients positive for COVID-19. The classifier consists of an ensemble of pre-trained deep neural networks (DNNS), specifically, ReNet34, ReNet50¸ ReNet152, and vgg16, and is enhanced by data augmentation and lung segmentation. We further implemented a nearest-neighbors algorithm that uses DNN-based image embeddings to retrieve the images most similar to a given image.

Results

Our model achieved accuracy of 90.3%, (95% CI: 86.3–93.7%) specificity of 90% (95% CI: 84.3–94%), and sensitivity of 90.5% (95% CI: 85–94%) on a test dataset comprising 15% (350/2326) of the original images. The AUC of the ROC curve is 0.96 (95% CI: 0.93–0.97).

Conclusion

We provide deep learning models, trained and evaluated on CXRs that can assist medical efforts and reduce medical staff workload in handling COVID-19.

Key Points

• A machine learning model was able to detect chest X-ray (CXR) images of patients tested positive for COVID-19 with accuracy and detection rate above 90%.

• A tool was created for finding existing CXR images with imaging characteristics most similar to a given CXR, according to the model’s image embeddings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08050-1.

Timing to imaging and surgery after neoadjuvant therapy for breast cancer

Neoadjuvant therapy (NAT) is increasingly used in breast cancer (BC), yet, the recommended time interval between NAT completion, preoperative imaging assessment, and breast surgery is not clearly defined. This single-center retrospective study investigated tumor growth between NAT completion and surgery. The analysis included 106 BC patients who received NAT (69% chemotherapy alone, 31% chemotherapy plus anti-HER2 therapy), had post-NAT breast MRI, and definitive surgery between 2012 and 2019. The median time interval between end-of-treatment and surgery was 6 weeks; 90% had surgery within 8 weeks of NAT completion, and 10% had surgery 8-12 weeks after NAT completion. No significant correlation was found between any of the time intervals (i.e., NAT completion-to-surgery, NAT completion-to-MRI, post-NAT MRI to surgery) and the tumor size as captured in the pathology report. The only parameter that was significantly correlated with pathological tumor size was tumor size as measured on the post NAT MRI (P < .0001). The difference in tumor size between post NAT MRI and surgical pathology did not correlate with the time interval between end-of-treatment and surgery. The ratio between residual tumor size on post-NAT MRI and the time interval from the end-of-treatment to surgery, significantly correlated with the tumor size on surgical pathology (P < .0001) suggesting that NAT has a beneficial effect weeks after end-of-treatment. In conclusion, our results suggest that for patients undergoing neoadjuvant chemotherapy, surgery within 4-8 weeks of completing NAT is reasonable, and is unlikely to result in a clinically significant change in residual tumor size.

3,3'-Diindolylmethane (DIM): A nutritional intervention and its impact on breast density in healthy BRCA carriers compared to non-treated carriers—A prospective clinical trial

1556

Background: Women who carry the BRCA mutation are at high lifetime risk of breast cancer, but there is no consensus regarding an effective and safe chemoprevention strategy. A large body of evidence suggests that 3,3-diindolylmethane (DIM), a dimer of indole-3-carbinol (I3C) found in cruciferous vegetables, can potentially prevent carcinogenesis and tumor development. The primary aim of this prospective study was to investigate the effect of DIM supplementation on breast density, a recognized predictive factor of breast-cancer risk. Methods: Participants were 23 healthy female BRCA carriers (median age 47 years; 78% postmenopausal) who were treated with oral DIM 100 mgx1/d for one year. The amount of fibroglandular tissue (FGT) and background parenchymal enhancement (BPE) on magnetic resonance imaging (MRI) performed before and after the intervention were scored by two independent expert radiologists using the Breast Imaging and Reporting Data System (BI-RADS). Each woman in the cohort was matched by age (within 3 years) and menopausal status to a woman attending the clinic who was not participating in the study and who underwent breast MRI in parallel year. Results: A decrease in the average score for FGT amount from 2.8±0.8 at onset to 2.65±0.842.8 after one year (p = 0.031), with no significant change in BPE (p = 0.429). A group of DIM-untreated age- and menopausal-status-matched clinic patients did not show a significant change in FGT amount (p = 0.33) or BPE (p = 0.814) in a parallel year. Mean estradiol level decreased from 159 to 102 pmol/L (p = 0.01), and mean testosterone level, from 0.42 to 0.31 pmol/L (p = 0.007). Side effects were grade 1. Conclusions: One year’s supplementation with DIM 100 mgX1/d in BRCA carriers was associated with a significant decline in FGT amount on MRI. Larger randomized studies are warranted to corroborate these findings. Clinical trial information: NCT02197000.

Abstract OT3-04-01: Feasibility of incorporating miniaturized, flexible radiofrequency (RF) sensors in a breast biopsy needle for accurate real-time characterization of benign and malignant tissue

Background: With approximately 1.6 million annual procedures in the United States and 3 million world-wide, needle biopsy is considered the Gold Standard for breast cancer diagnosis and treatment planning. Overdiagnosis can result in unnecessary treatment, cost, and anxiety, while underdiagnosis can delay treatment and diminish outcomes. A 2015 study published in JAMA1 found nearly 25% discordance between pathology diagnosis and expert review, most pronounced in cases of DCIS, Atypia and in patients with dense breasts.

It has been well established that physiologic differences between benign and malignant tissues are reflected in their electrical properties.2,3,4 Access to real-time tissue properties during the biopsy procedure has the potential for increasing accuracy by enabling the most suspicious tissue to be sampled, and by providing the tissue characterization to pathology for comparison with histologic findings.

Through research made possible by the European Union’s Horizon 2020 research award, this feasibility study sought to determine if five 0.8mm miniaturized, flexible RF sensors (Dune Medical Devices, Alpharetta, GA) mounted within the sample cavity of a 14-gauge biopsy needle can accurately measure and map the electrical properties of multiple breast tissue types.

Methods: Between March, 2018 and March, 2019, 44 patients undergoing mastectomy or lumpectomy at three medical centers in Israel were enrolled in the study. The biopsy needle was applied to freshly excised specimens, with continuous readings by the sensors. An average of 8.1 cores (ranging from 2-10) were obtained from each specimen. Cores were oriented and analyzed by standard histopathology. Based on histology, the dielectric properties of the various tissue types were derived, and the ability of the device to differentiate between malignant and non-malignant tissue was assessed.

Results: A total of 357 cores from 44 specimens were analyzed. Ease of use and quality of tissue samples were equivalent to that of a standard biopsy needle. The dielectric properties of three tissue groups: Fat, Healthy non-Fat, and Malignant, in the low radiofrequency range were measured, showing distinct differences between the various types. Feature sizes larger than 0.8 mm were analyzed. The differentiation ability between tissue types was characterized using sensitivity and specificity of 85% and 99% respectively.

Conclusions: Miniature, flexible RF sensors can be incorporated onto a biopsy needle. Although this study utilized a 14-gauge core needle, the 0.8mm sensor size allows for configuration within both vacuum-assisted and core biopsy needles of various gauges.

The dielectric properties of breast tissue can be assessed in real-time during the biopsy procedure. These results show promise in differentiating between breast tissue types, specifically cancerous and benign, enabling more accurate tissue sampling and subsequent diagnosis.

Improving the accuracy of breast biopsies should provide immediate clinical impact by reducing overstaging and subsequent unneeded treatment, procedures and cost, as well as reducing understaging of breast cancer which results in delayed diagnosis and missed cancer.

Forward-looking, real-time tissue characterization during biopsy could prove especially beneficial should newer protocols currently under trial, such as active surveillance for low risk DCIS5 and omission of surgery for exceptional responders of neoadjuvant chemotherapy,6 become treatment options. The ability to mount the sensors to minimally invasive treatment devices will lay the foundation for expanding the technology to other cancer types, with the potential for precision delivery of new targeted drugs, radiation and ablation therapies at the site of the cancer.

Citation Format: Noemi Weisenberg, Avihai Lachman, Lisa Cadena, Inbal Shimens, Olga Shmain, Ahuva Grubstein, Yael Rapson, Hana Cernik, Debora Kidron, Tania Zehavi, Evgeny Edelstein, Vladimir Kravtsov, Tatiana Kogan, Meirav Wolff Bar, Judith Diment, Ilana Haas, Patricia Malinger, Eran Sharon, Yehudit Birnbaum, Ada Magen, Yael Sobol, Osnat Givon Madhala, Sonya Wadhawker, Tanir M Allweis. Feasibility of incorporating miniaturized, flexible radiofrequency (RF) sensors in a breast biopsy needle for accurate real-time characterization of benign and malignant tissue [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 OT3-04-01.

Ultrasound guided tattooing of axillary lymph nodes in breast cancer patients prior to neoadjuvant therapy, and identification of tattooed nodes at the time of surgery

BACKGROUND

Breast cancer patients with lymph node (LN) metastases at diagnosis often undergo neoadjuvant therapy (NAT). Identification of a LN which regressed after NAT remains a challenge.

OBJECTIVE

To evaluate marking of involved nodes by tattooing with carbon suspension, and identifying these nodes during surgery.

METHODS

A small amount (0.2-0.5 ml) of carbon suspension was injected into one or two axillary LNs under ultrasound guidance at the time of LN biopsy or before or shortly after starting NAT for LN positive breast cancer. During surgery an attempt was made to identify and remove the tattooed LN as a separate specimen. All patients underwent sentinel LN mapping and biopsy and/or axillary LN dissection as mandated by their clinical status.

RESULTS

Sixty three patients underwent tattooing of axillary LNs with no complications or adverse events. At surgery a tattooed node was identified in 60 patients (95%; 95% CI 87, 98). Of 56 patients who underwent sentinel mapping with Tc99, in 51 (91%; 95% CI 81, 96) at least one radioactive LN was identified. Of 50 patients in whom both radioactivity and tattoo were identified in axillary LNs, in 40 (80%; 95% CI 67, 89) LNs were radioactive and tattooed, however in 10 patients (20%; 95% CI 11, 33), the tattooed LN was not radioactive.

CONCLUSIONS

Tattooing of axillary LNs is safe and easily performed. Tattooing was helpful in identifying the marked LN in the majority of cases. This technique helps to ensure that metastatic LNs are identified and removed at surgery after NAT.

Comparison of background parenchymal enhancement and fibroglandular density at breast magnetic resonance imaging between BRCA gene mutation carriers and non-carriers

OBJECTIVE

High background parenchymal enhancement and amount of fibroglandular tissue on breast magnetic resonance imaging are related to increased breast cancer risk. This study sought to compare these parameters between BRCA mutation carriers and non-carriers and to evaluate the potential implications of the findings for short term follow-up.

MATERIALS AND METHODS

Magnetic resonance imaging studies of known BRCA mutation carriers, were compared to age-matched non-carrier studies performed in the same center during the same period. The groups were compared for qualitative background parenchymal enhancement and amount of fibroglandular tissue using the Breast Imaging Reporting and Data System (BI-RADS).

RESULTS

Breast parenchymal enhancement was high in up to one-third of the cohort: 22% of carriers and 33% of controls (p = 0.013). These results were sustained on separate analysis of menstrual-cycle-timed examinations. Amount of fibroglandular tissue was high in most cases: 62% of carriers and 75% of controls (p = 0.004). A BI-RADS final assessment score of 3 was more common in patients with high parenchymal enhancement, especially controls.

CONCLUSION

BRCA mutation carriers demonstrated lower levels of breast parenchymal enhancement and amount of fibroglandular tissue than age-matched non-carriers. These differences are probably influenced by hormonal status, as well as highlight different risks in distinctive subgroups of breast cancer (hormone-enriched, mutation-associated defective DNA damage repair), affecting considerations of preventive medical treatment. Differences in the indications for imaging between the carrier and non-carrier groups (screening for mutations and breast cancer evaluation, respectively) probably accounted for the higher rate of BI-RADS 3 in the control group.

Analysis of false-negative readings of automated breast ultrasound studies

BACKGROUND

To assess the reasons for false-negative readings of automated breast ultrasound (ABUS) studies.

METHODS

Between 2012 and 2015, 1,890 ABUS studies were performed at our tertiary medical center. Those for which false-negative results were documented in the initial ABUS report against the corresponding hand-held ultrasound (HHUS) scan were reviewed by three specialized breast radiologists. Key images of specific lesions were marked on the ABUS and HHUS scans and compared for quality (equal, better with HHUS, better with ABUS). Readers were also asked to identify the reasons for the differences in image quality between the scans: poor visibility, lesion location, or fibroglandular tissue shadowing.

RESULTS

Twenty-two ABUS studies met the study criteria. Two of the three readers found that most lesions were better demonstrated with HHUS. Overall agreement among the readers was moderate (kappa 0.36, SD 0.15, p = 0.002). Highest agreement was found for better image quality for HHUS than ABUS (kappa 0.4, SD 1.3, p = 0.0007). Of the four biopsy-proven carcinomas, three were found by all three readers to be better depicted with HHUS; two were located peripherally and were not seen by ABUS. For all readers, the most common reason for false-negative readings was poor visibility, followed by peripheral lesion location and shadowing obscuring the lesion.

CONCLUSIONS

Several factors may make reading ABUS images difficult. Resolution can be diminished by imperfect transducer-breast contact, and fibrotic breasts can cause artifacts such as marked shadowing. Peripheral lesions may be missed because of blind spots. Reader training and experience may play an important role in managing these issues. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:245-251, 2017.

Invasive Lobular Carcinoma of the Breast: Appearance on Digital Breast Tomosynthesis

BACKGROUND

The aim of this study was to characterize the signs of invasive lobular carcinoma of the breast on digital breast tomosynthesis (DBT) imaging.

PATIENTS AND METHODS

The study group included 23 women with pathologically proven invasive lobular carcinoma of the breast for whom both digital mammography (DM) and DBT images were available. The images were read jointly by 2 experienced breast radiologists. Findings were recorded according to the descriptors in the Breast Imaging and Reporting Data System lexicon and correlated with the detailed pathology results.

RESULTS

In 21 of the 23 patients, the combination of DM and DBT yielded pathologic findings (91%). Architectural distortions or spiculations were demonstrated in 87% of cases. The addition of DBT to DM improved lesion detection by more clearly depicting both the lesion margins and architectural distortions. Only 2 lesions were occult by both DM and DBT, including 1 lesion in a peripheral location that was not incorporated in the standard mediolateral oblique and craniocaudal views.

CONCLUSION

DBT improves the detection of invasive lobular carcinoma lesions by more clearly depicting architectural distortions and spiculations.

Abstract B32: The impact of PET-CT on staging, management, and prognostication of small cell lung cancer

Introduction: Although frequently used, there is no randomized data assessing the role of PET CT in the staging process of SCLC patients, or its impact on patients' management. We aimed to review retrospectively the utility of PET-CT in patients diagnosed with SCLC in a single tertiary medical center and to address these issues.

Methods: We included all patients diagnosed with SCLC between January 2007 and December 2011 at Rabin Medical Center (Petach-Tikva, Israel), either staged by PET-CT or not. Data retrieved included: age, gender, Veteran's staging (LD or ED, as determined by the institute multidisciplinary team during thoracic tumor-board meeting), ECOG performance status, staging procedures done and their results (FDG-PET scan, CT scans, MRIs, Bone Scans, BMBs), pathology immunohistochemistry characteristics (Ki67, chromogranin, synaptophysin), serum markers levels (NSE, LDH, chromogranin, CEA), treatment modality (chemotherapy versus chemoradiation), Disease Free Survival (DFS), Progression Free Survival (PFS) and Overall Survival (OS). In the group of patients who underwent PET CT during the initial evaluation, we re-assessed staging, both according to the Veteran's Administration Lung Group's 2-stage classification (LD and ED) and according to the American Joint Committee on Cancer Staging manual, 7th edition (TNM). Staging was performed by two independent radiologists: one (HB), a nuclear medicine specialist, to decide on the stage according to PET-CT findings, and the other (YR), thoracic radiologist, to decide on the stage according to chest, abdomen and pelvic contrast-enhanced CT scan findings (with bone scan results if available) and blinded to the PET results. PET scans were also evaluated for SUVmax (maximal standardized uptake value) and TLG (total lesion glycolysis).

Results: 108 patients were diagnosed and treated for SCLC in the above mentioned period. 2 patients were excluded from the analysis for lack pathology or staging procedure data and 10 patients were excluded since their PET imaging was done elsewhere, not accessible for our assessment. Finally, out of 96 patients, 54 had a PET-CT done as part of their staging procedure.

PET-staged patients had significantly less staging procedures done than non-PET-staged patients (24% underwent 3-4 staging procedures versus 62%, p=0.04). PET altered management in 19 patients (35%), with 13 patients with suspected metastatic disease, who benefited from down-staging by PET.

It appears that treatment was significantly delayed in PET-staged patients with a mean of 30 days from diagnostic procedure to treatment versus 26 days (p=0.04).

TLG was found to correlate with OS and PFS, with high TLG level predicting poorer survival (HR=3.38, CI 1.385-8.259, p=0.007).

Conclusions: Although PET-CT adds to SCLC patients' management by reducing the amount of staging procedures and possibly down staging patients who otherwise would have been treated with palliative intent, in the setup of a public tertiary medical center, waiting for the PET to be done and reported could result in treatment delay. Randomized data is necessary to properly evaluate the sensitivity, specificity and influence on management of this modality. TLG appears to be a new promising prognostic biomarker in small cell lung tumors.

Citation Format: Alona Zer, Yael Rapson, Meital Nadam, Dov Flex, Aaron M. Allen, Salomon M. Stemmer, David Groshar, Hanna Bernstine. The impact of PET-CT on staging, management, and prognostication of small cell lung cancer. [abstract]. In: Proceedings of the AACR-IASLC Joint Conference on Molecular Origins of Lung Cancer; 2014 Jan 6-9; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2014;20(2Suppl):Abstract nr B32.

Clinical characteristics of eyes demonstrating atypical patterns in scanning laser polarimetry

PURPOSE

To characterize which clinical features are associated with the occurrence of atypical birefringence patterns (ABP) occasionally seen with scanning laser polarimetry (SLP).

METHODS

Sixty-one subjects, including glaucoma patients, glaucoma suspects, and normal subjects, underwent a full clinical examination, standard visual field (VF) test, and a GDx-VCC SLP examination. One eye was selected from each patient. The magnitude of ABP was determined in two independent ways: using a support vector machine analysis (typical scan score (TSS)) and by a masked experienced observer. We assessed whether the magnitude of ABP was correlated with age, gender, the refractive state of the eye, corneal polarization axis and magnitude, GDx global parameters (TSNIT and NFI), and the VF status, as evident from glaucoma hemifield test (GHT), mean deviation (MD), and the pattern standard deviation (PSD).

RESULTS

Of the 61 study eyes, 27 (44%) showed an ABP, based on a TSS cutoff (<82.5). A very high correlation was found between the TSS score and the masked experienced observer score (r(2)=0.80; P<0.001). The following clinical parameters were found, on bivariate analysis, to be significantly correlated with the presence of an ABP: age (r(2)=0.086; P=0.02); corneal polarization magnitude (r(2)=0.069; P=0.04); TSNIT (r(2)=0.16; P<0.001).

CONCLUSION

The presence and magnitude of ABP did not seem to be closely correlated with most clinical parameters. A low, but statistically significant, correlation was found for age and corneal polarization magnitude (r(2)=0.086 and 0.069, respectively). A low-medium correlation was found for TSNIT (r(2)=0.16); however, we speculate that this might represent a confounding effect, rather than an underlying association. We conclude that none of the clinical parameters investigated in this study appears to be strongly correlated with the presence of an ABP on SLP scans performed using the commercially available GDx-VCC.