Outcome Analysis of Dual Plating in Management of Unstable Bicondylar Tibial Plateau Fracture - A Prospective Study

Introduction:

Bicondylar tibial plateau fractures account for 10-30% of tibial plateau fractures. Despite recent advancements in the management of unstable bicondylar tibial plateau fractures, the outcomes are often poor. The present study aimed to evaluate the functional outcomes and complications of internal fixation of bicondylar tibial plateau fractures with the dual plating using two incisions.

Materials and methods:

The present study included 30 patients (26 males; 4 females, mean age 35.6 years; range, 19 to 65 years) with bicondylar tibial plateau fractures who were treated with dual plating between January 2017 to August 2019. Out of 30 patients, 5 patients had Schatzker type (V) and 25 patients had Schatzker type (VI) bicondylar tibial plateau fracture. All patients were treated with dual plating using two incisions. In all patient’s similar standard physical rehabilitation therapy was followed. All complications including intra and post-operative were assessed and recorded. The patients were followed-up for over 24 months. Functional outcomes were assessed with Rasmussen’s functional grading system, Oxford knee score, and range of motion of knee joint. Radiological outcomes were evaluated using Rasmussen’s radiological scoring system.

Result:

All fractures united with a mean time of 18 weeks. The average knee range of motion was 1.5° - 130° (range: 0° - 10° for extension lag, range: 100° -135° for flexion). Mean Rasmussen's functional grading score at the final follow-up was 26.75. All patients showed excellent or good radiographic results according to Rasmussen’s radiological scoring with a mean score of 8.5 (range 6-10). The post-operative radiographs showed mean MPTA was 84.3° and the mean PPTA was 6.2°. In the present study, complications were encountered in five patients. However, there were no cases of secondary loss of reduction, failure of the implant, malunion, or non-union.

Conclusion:

The surgical treatment of bicondylar tibial plateau fractures with dual locking represents a significant treatment option and provides rigid fixation in these fractures with good functional and radiological outcomes.

Acute Rejection of a Kidney Transplant in a Patient With Common Variable Immunodeficiency: A Case Report

Common variable immunodeficiency is a primary immunodeficiency characterized by hypogammaglobulinemia and recurrent bacterial infections. We report a case of a 44-year-old male patient with end-stage renal disease and an established diagnosis of common variable immunodeficiency who underwent a living unrelated kidney transplant. He remained nearly infection free on maintenance immunoglobulin replacement. However, his posttransplant course was complicated by acute rejection that ultimately led to allograft loss. This case illustrates the challenge of transplantation in this patient population because of the delicate balance that must be achieved between maintaining adequate immunosuppression and minimizing the risk of infection.

Successful autotransplantation of a mature mesiodens to replace a traumatized maxillary central incisor

AIM

This case describes the successful transplantation of a mature mesiodens tooth to replace a traumatized maxillary central incisor.

SUMMARY

A 17-year-old male attended 1 week after a traumatic injury to his left maxillary central incisor (tooth 21). Radiographs revealed a horizontal root fracture and a poor prognosis. The tooth was atraumatically removed and replaced with a mesiodens lying in the same region. After stabilization, root canal treatment was performed and aesthetics were restored with a tooth coloured restoration. A 2-year follow-up revealed the tooth had good aesthetics and function.

KEY LEARNING POINTS

A supernumerary nonfunctional tooth such as a mesiodens can be successfully used to replace a missing permanent tooth by autotransplantation. Autotransplantation has a high success rate if case selection is good, appropriate surgery is carried out and excellent hygiene is maintained. Autotransplantation should be considered as one of the most biologic techniques for replacing a missing tooth with minimal cost. Autotransplantation can be carried out even after complete root formation in the donor tooth.

Identification of FUS p.R377W in essential tremor

BACKGROUND AND PURPOSE

Exome sequencing analysis has recently identified a nonsense mutation in fused in sarcoma (FUS) segregating with essential tremor (ET) within a large French-Canadian family. Further characterization of FUS resulted in the identification of additional mutations in ET patients; however, their pathogenicity still remains to be confirmed. The role of FUS in an independent cohort of ET patients from Canada was evaluated.

METHODS

The entire coding sequence of FUS in 217 patients diagnosed with ET was analyzed and two missense variants in 219 healthy controls were genotyped by Sanger sequencing.

RESULTS

Sequencing of FUS identified a previously reported non-pathogenic mutation p.G174_G175del in one ET patient and two healthy controls, and a novel p.R377W in one patient with family history of disease. This mutation is highly conserved and strongly predicted to be damaging by in silico analysis.

CONCLUSION

This study has identified a novel FUS p.R377W substitution in ET patients. Additional genotyping studies in a large number of ET patients and controls are necessary to conclusively define its pathogenicity.

Abstract P3-03-01: 3D mapping of total choline in human breast cancer using high-speed MR spectroscopic imaging at 3T: initial experience during neoadjuvant therapy

OBJECTIVE: To assess the feasibility of quantitative high-speed MR spectroscopic imaging (MRSI) of total Choline (tCho) as an adjunct to dynamic-contrast enhanced MRI to improve lesion characterization and monitor treatment response in patients undergoing neoadjuvant chemotherapy (NAC).

METHODS: Twelve patients with infiltrating ductal carcinoma (Table 1) were studied using a clinical 3T MR scanner (Siemens, Erlangen, Germany) equipped with 8- and 16-channel breast array (Hologic Inc., Bedford, MA). Four patients were studied before NAC. Four patients were studied once during NAC. Two patients were studied before and within 2–7 days of treatment initiation. One of these patients participated in an additional scan after 5 months of treatment. Two additional patients were studied at 3 time points during NAC. Measurements were performed using PRESS prelocalized 3D Proton-Echo-Planar-Spectroscopic-Imaging (PEPSI) using TR/TE=2000ms/135ms, matrix size up to 32×16×8, voxel size = 1cc, and total acquisition time of 10 minutes (including water reference scan). Additional data were collected at TE 60 ms to enhance sensitivity for detecting tCho and J-coupled resonances. TE-averaging (8 steps, DTE: 2.5 ms) was employed to minimize gradient sideband artifacts. Quantification of tCho in reference to tissue water was performed using spectral fitting and relaxation correction.

RESULTS: Strongly elevated tCho with maximum concentration up to 5.3 mmol/kg was measured in 9 patients with enhancing lesions larger than 2 cc volume (Table 2). Decreases in tCho were measured in all four patients who were followed during neoadjuvant chemotherapy. Decreases in tCho were measurable during the first week of neoadjuvant treatment in responders, consistent with previous studies. Our preliminary data also indicate that the combination of concentration and spatial extent of detectable tCho may be the most sensitive marker of treatment response.

Gamma-aminobutyric acid (GABA)-B receptor 1 in cerebellar cortex of essential tremor

Some reports suggest cerebellar dysfunction as the basis of essential tremor (ET). Several drugs with the action of gamma-aminobutyric acid (GABA) are known to improve ET. Autopsy studies were performed on brains from nine former patients followed at the Movement Disorders Clinic Saskatchewan, Canada, and compared with five normal control brains. We aimed to measure the concentration of GABA B receptor 1 (GBR1) in the brains of patients who had had ET and to compare them to the GABA concentration in brains of controls. Western blot was used to determine the expression of GBR1 in cerebellar cortex tissue. We found that compared to the controls, the ET brains had three different patterns of GBR1 protein concentration--two with high, four comparable, and three with marginally low levels. There was no association between the age of onset, severity or duration of tremor, the response to alcohol or other drugs and GBR1 level. Thus, we conclude that our study does not support that GBR1 is involved in ET. Further studies are needed to verify these results.

P2-10-04: 3D Mapping of Total Choline in Human Breast Cancer Using High-Speed MR Spectroscopic Imaging at 3T: A Feasibility Study

PURPOSE: To assess the feasibility of quantitative high-speed MR spectroscopic imaging (MRSI) of total Choline (tCho) as an adjunct to dynamic-contrast enhanced (DCE) MRI to improve lesion characterization and monitor treatment response in patients undergoing neoadjuvant chemotherapy.

METHOD AND MATERIALS: Seven patients with biopsy-confirmed, infiltrating ductal carcinoma were studied using a clinical 3T MR scanner (Siemens Medical Solutions, Erlangen, Germany) equipped with 8- and 16-channel breast array (Hologic Inc., Bedford, MA). Measurements were performed using PRESS prelocalized 3D Proton-Echo-Planar-Spectroscopic-Imaging (PEPSI) using TR/TE=2000ms/135ms, matrix size up to 32×16x8, voxel size=1cc, and total acquisition time of 10 minutes (including water reference scan). Additional data were collected at TE 60 ms to enhance sensitivity for detecting tCho and J-coupled resonances. TE-averaging (8 steps, ΔTE: 2.5 ms) was employed to minimize gradient sideband artifacts. Quantification of tCho in reference to tissue water was performed using spectral fitting and relaxation correction.

RESULTS: Strongly elevated tCho with maximum concentration ranging from 0.3 to 4.1 mmol/kg was measured in five patients with single and multi-centric enhancing lesions larger than 2 cc volume (Table 1). The measured tCho concentration in Grade 3 tumors was higher than in lower grade untreated and treated tumors. Strong decreases in tCho concentration were measured in 2 patients undergoing neoadjuvant therapy in a follow-up scan. At short TE an additional resonance was detected that was elevated in enhancing lesions and tentatively assigned to Taurine. Two patients had lesions smaller than 2 cc with surgical clips in which tCho was not detectable due to line broadening. MRSI data sets were preferentially collected before contrast injection, since it increased spectral line width by up to 50%.

CONCLUSION: This study demonstrates feasibility of quantitatively mapping tCho in invasive breast carcinoma using high-speed MRSI. The long-term goals are to utilize high-speed MRSI as an early predictor of treatment failure in women undergoing neoadjuvant therapy (i.e. chemotherapy, endocrine therapy or biologic therapy) for breast cancer and to develop an improved screening protocol for high-risk patients. Grant support: 1RC1EB010617-01

Abstract P2-06-11: Ramifications of HER2/ER/PR Guidelines from ASCO/CAP for Translational Cancer Research Using a Cohort from a Tertiary Care Centre in Ontario

Background: A transdisciplinary team from basic science, pathology, clinical and biostatistics was assembled to establish a framework with which to take novel laboratory biomarkers and targets to clinical validation. Human epidermal growth factor receptor (HER2), estrogen (ER) and progesterone (PR) receptor are of important prognostic and predictive value and drivers of systemic therapy for breast cancer (BC). As a first step, the current ASCO/CAP guidelines were used to re-assign centrally reviewed tumour specimens and compare to the clinically assigned scores for ER/PR and HER2.

Methods: With REB approval, a cohort of 62 cases of non-metastatic invasive BC with banked tumour specimens was assembled between 2005 and 2007. Clinico-pathological information for each case was retrospectively obtained from the medical file and entered into an anonymized database. Full section slides were originally stained by routine immunohistochemistry (IHC). Categorical clinical scores for ER/PR (negative-neg/weak/positive-pos) were compared to the continuous scores assigned in a blinded fashion using ASCO/CAP criteria (% pos/H-score). Categorical clinical scores obtained with duplicate IHC antibody staining of full sections for HER2 (neg/equivocal-eq/pos) were compared to those obtained from IHC assessments of triplicate 6mm cores in a tissue microarray (TMA) that were assigned to be neg/eq/pos using ASCO/CAP criteria. A senior breast pathologist adjudicated discordant specimens. Exact Fisher tests were used to compare the two sets of categorical assessments.

Results: Mean age was 43.5 years, (range 29-49). The majority of the cohort (59.7%) had N0 disease and received adjuvant chemotherapy (74.2%); 72.6% of the cohort was alive at the time of this analysis. Score means and ranges of ER/PR are displayed below. Two of 16 clinically ER neg cases (12.5%) were rescored as pos and 0/43 clinically ER pos cases were rescored as neg, P<0.0001. Two of 13 clinically PR neg cases (15.4%) were rescored as pos and 4/46 clinically PR pos cases (8.7%) were rescored as neg, (P<0.0001). HER2 status was reassessed for 51 cases, 41 of which (80%) had concordant scores (P<0.0001). Thirty-nine (76%) cases were classified as HER2 neg on TMA, 7 of which (18%) were eq on routine IHC and neg by fluorescence in situ hybridization. In routine IHC, 15.7% of tumours were eq. Four TMA cases were eq (7.8%%); with routine IHC, one of these was neg, one eq, and two were pos. Eight patients were HER2 pos in both assessments.

ER/PR scores

Conclusions: Systemic therapy recommendations could be impacted in a small but substantive number of cases by the methodology used for biomarker assessment and scoring, particularly near threshold values. This study illustrates that the scoring criteria used may be an important contributor to variability in correlative biomarker studies. Consideration should be given to routine systematic reassessment with continuous scoring for biomarker data proposed for use in correlative science studies.

Death-associated protein kinase 1 variation and Parkinson's disease

BACKGROUND AND PURPOSE

  Mutations of the LRRK2 gene are now recognized as major risk factors for Parkinson's disease. The Lrrk2 protein is a member of the ROCO family, which also includes Lrrk1 and Dapk1. Functional genetic variants of the DAPK1 gene (rs4877365 and rs4878104) have been previously associated with Alzheimer's disease.

METHODS

  Herein, we assessed the role of DAPK1 variants (rs4877365 and rs4878104) in risk of Parkinson's disease with Sequenom iPLEX genotyping, employing one Taiwanese series (391 patients with Parkinson's disease, 344 controls) and five separate Caucasian series' (combined sample size 1962 Parkinson's disease patients, 1900 controls).

RESULTS

  We observed no evidence of association for rs4877365 and rs4878104 and risk of Parkinson's disease in any of the individual series or in the combined Caucasian series under either an additive or recessive model.

CONCLUSION

  These specific DAPK1 intronic variants do not increase the risk of Parkinson's disease. However, further functional studies are required to elucidate the potential therapeutic implications with the dimerization of the Dapk1 and Lrrk2 proteins.

Meeting the 12 lymph node (LN) benchmark in colon cancer

BACKGROUND

Examining >or=12 LN in colon cancer has been suggested as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN centers compared to a US population-based sample.

METHODS

Patients with stage I-III disease resected at NCCN centers were identified from a prospective database (n = 718) and were compared to 12,845 stage I-III patients diagnosed in a SEER region. Age, gender, location, stage, number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Multivariate logistic regression models were developed to identify factors associated with evaluating 12 LNs.

RESULTS

92% of NCCN and 58% of SEER patients had >or=12 LN evaluated. For patients treated at NCCN centers, factors associated with not meeting the 12 LN target were left-sided tumors, stage I disease and BMI >30.

CONCLUSIONS

>or=12 LN are almost always evaluated in NCCN patients. In contrast, this target is achieved in 58% of SEER patients. With longer follow-up of the NCCN cohort we will be able to link this quality metric to patterns of recurrence and survival and thereby better understand whether increasing the number of nodes evaluated is a priority for cancer control.

Effect of lymph node retrieval rates on the utilization of adjuvant chemotherapy in stage II colon cancer

BACKGROUND

Failing to meet the benchmark of 12 lymph nodes in resection specimens is an indication for adjuvant chemotherapy in stage II colon cancer.

METHODS

Among consecutive eligible patients with pathologic stage II colon cancer treated at eight NCI-designated comprehensive cancer centers between September 1, 2005 and February 19, 2008, we analyzed receipt of adjuvant chemotherapy, with less than 12 versus 12+ lymph nodes removed and examined the primary explanatory variable of interest.

RESULTS

Among 258 patients, 46% received adjuvant chemotherapy. An oxaliplatin-containing regimen was used 67% of the time. Younger age (<50 years, P < 0.001), presence of lymphovascular invasion (P = 0.007), and higher T stage (P = 0.007) were independently associated with adjuvant chemotherapy use. There was significant inter-institutional variability in practice with the proportion receiving treatment ranging from 17% to 64% (P < 0.05). Notably, presence of less than 12 lymph nodes in the surgical specimen was a strong predictor of treatment (P = 0.008).

CONCLUSIONS

Adjuvant chemotherapy use after resection of stage II colon cancer is common, but by no means standard practice at National Comprehensive Cancer Network (NCCN) institutions. More attention to achieving the recommended benchmark for lymph node dissection has the potential to decrease exposure to the toxicity of adjuvant treatment.

Course in Parkinson disease subtypes: A 39-year clinicopathologic study

BACKGROUND

Individual variations in the course of Lewy body Parkinson disease (PD) are well known. Patients have been classified into different clinical subtypes to identify differences in the course among the subgroups. Several studies indicate that the outcome is more favorable in tremor dominant (TD) cases but others report no difference. A majority of progression studies are based on cross-sectional single point data or short-term clinical observations. The lack of longitudinally followed autopsy-confirmed PD cohort remains a major weakness in the literature. Biochemical studies of brain indicate most pronounced abnormalities in akinetic/rigid (AR) and the least in TD cases. We postulate that PD course in these subtypes is concordant with the biochemical findings.

OBJECTIVE

To compare the course in TD, mixed (MX), and AR subtypes of PD.

METHODS

Longitudinal clinical follow-up and autopsy studies were performed on 166 patients with PD over 39 years (1968-2006). Patients were classified into TD, AR, and MX based on the entire clinical course. Only the pathologically confirmed PD cases were included.

RESULTS

Sixty-six percent of cases had MX, 26% AR, and 8% TD profile. The age at onset was younger (p < 0.001) and progression to Hoehn & Yahr stage 4 was slower (p = 0.016) in the TD cases. Dementia was most common in AR (p = 0.039) and the least common in TD. In general, the course was most favorable in TD, followed by MX and AR subgroups.

CONCLUSION

The three subtypes of Parkinson disease have different courses which are concordant with the differences in brain biochemical abnormalities.

Development of satranidazole mucoadhesive gel for the treatment of periodontitis

The aim of the paper was to develop satranidazole-containing mucoadhesive gel for the treatment of periodontitis. Different mucoadhesive gels were prepared, using various gelling agents like sodium carboxymethylcellulose (SCMC), poloxamer 407, hydroxyethylcellulose, hydroxypropylcellulose, hydroxypropylmethylcellulose, and the mucoadhesive polymer carbopol 934P. The selected formulations (based on the mucoadhesive force) were studied for different mechanical properties, such as mucoadhesive strength, hardness, compressibility, adhesiveness, and cohesiveness through Texture Profile Analyzer. In vitro satranidazole release from the prepared formulations was also determined and compared with marketed preparation of metronidazole (Metrogyl gel). The formulation SC30 (containing SCMC 3% w/v) showed maximum mucoadhesive strength (167.72 +/- 3.76 g) and adhesiveness (-46.23 +/- 0.34 N mm), with low hardness (9.81 +/- 0.04 N) and compressibility (40.05 +/- 0.48 N mm) and moderate cohesiveness (0.87 +/- 0.01). SC30 formulation exhibited long-term release. Thus, SC30 gel was evaluated for its clinical effectiveness along with marketed metronidazole gel. At the end of the study (42 days of clinical studies), both formulations were found to significantly reduce the probing depth, plaque index, gingival index, calculus criteria, and bleeding index. However, the SC30 gel was more effective in reducing the above parameters than marketed metronidazole gel. This study confirmed the acceptability and effectiveness of satranidazole gel for treatment of periodontitis.

How often is adjuvant FOLFOX (Adj FOLFOX) discontinued for toxicity among colon cancer patients in the routine care setting?

9530

Background: Although 12 cycles of Adj FOLFOX are recommended for stage III and high risk stage II colon cancer, toxicity may preclude completion of treatment. We used the NCCN Colorectal Cancer Outcomes Database to identify how frequently Adj FOLFOX is discontinued prematurely for toxicity in a non-clinical trial population. Methods: Newly diagnosed stage II-III colon cancer pts treated with Adj FOLFOX at 7 NCI-designated comprehensive cancer centers between 9/05–12/07 were identified. We assessed completion of the prescribed adjuvant chemotherapy (AC) course, including Adj FOLFOX and 5FU-based adjuvant treatment alone subsequent to discontinuation of oxaliplatin (oxal). Dose limiting toxicity (DLT) of Adj FOLFOX was defined as premature discontinuation of Adj FOLFOX due to toxicity. We evaluated potential predictors of Adj FOLFOX DLT, including older age and history of diabetes in a multivariable logistic model controlling for stage and center. We measured the duration of Adj FOLFOX use in weeks, from first to last dose. Results: 293 pts began Adj FOLFOX. Pts who experienced DLT (40%) had a shorter duration of Adj FOLFOX and were less likely to complete AC, even after oxal was discontinued. The only significant predictor of experiencing a DLT was a history of diabetes. Conclusions: Our analysis of patients treated outside of a clinical trial demonstrated a notably high rate of discontinuation of Adj FOLFOX due to DLT, particularly in pts with diabetes. The results underscore the need for systematic assessment of toxicity especially among diabetics.

[Table: see text]

[Table: see text]

Vascular Pathology in Male Lewis Rats following Short-Term, Low-Dose Rotenone Administration

The long-term administration of low doses of rotenone has been used to produce a model of Parkinson disease (PD) in rats. However, only about 50% of similarly treated rats develop the PD-like syndrome, with many dying during the first few days of treatment. The lesions in male Lewis rats that became moribund or died after short-term, low-dose rotenone administration are described. Dosed rats had fibrinoid change and acute hemorrhage involving small arteries and arterioles of the brain and lungs. The thalamus, hypothalamus, and medulla oblongata were most frequently and severely affected. Blood vessels in the brain of some male Lewis rats appeared acutely susceptible to the effects of rotenone. Understanding the selective nature of the fibrinoid change and hemorrhage might explain how rotenone produces PD-like signs and lesions in rats, and it might also provide the basis for a model of intraparenchymal hemorrhagic cerebrovascular disease (i.e., hemorrhagic strokes) in humans.

Meeting the 12 lymph nodes (LN) benchmark in colorectal cancer surgery: A comparison of NCCN and SEER data

4015

Background: The American College of Pathology has suggested that 12 or more LN be examined from colorectal cancer surgical specimen. Both ASCO and NCCN have considered adopting the 12 LN threshold as a quality metric. The purpose of this study was to determine whether the 12 LN benchmark is achieved at NCCN specialty centers. Methods: Patients with newly diagnosed stage I-III colon or rectal cancer, who had primary surgery at NCCN centers in 2005–6 were selected (n=345). Similarly, data from 14,019 stage I-III colorectal patients diagnosed in 2002 in a SEER region were obtained to determine the extent to which this goal was met in a population-based sample. Patient characteristics of age, gender, location, stage and number of positive nodes were compared for NCCN and SEER data in regards to number of nodes evaluated. Univariate logistic regression models were developed to identify factors associated with the 12 LN target at the NCCN. Factors evaluated were number of positive nodes, age, gender, comorbidity score, ECOG performance status, insurance, location, stage, surgery technique, and NCCN center. Results: As detailed in the Table , 89% of the 2005–6 NCCN sample and 45% of the SEER sample had at least 12 LN evaluated. For patients treated at NCCN centers, stage I compared to stage III (OR=0.20; 95% CI=0.08 to 0.48, p<0.0001) and rectal cancer (OR=0.44; 95% CI=0.22 to 0.88, p=0.02) were each less likely to achieve the 12 LN target. Conclusions: For patients operated on at NCCN centers, at least 12 LN are almost always removed and examined as part of an oncologic resection. In population based samples, this target is achieved in less than half of cases. With longer follow-up we will be able to link this potential quality metric directly to outcomes and thereby better inform whether increasing the number of nodes evaluated is an important priority for cancer control. Table 1 . Characteristics of CRC patients who did and did not have 12 or more LN evaluated at primary resection.

[Table: see text]

No significant financial relationships to disclose.

Incidence of minimally invasive colorectal cancer (CRC) surgery in patients treated at NCCN institutions

6575

Background: In May 2004 the Clinical Outcomes of Surgical Therapy Study Group published the results of the North American randomized trial demonstrating that oncologic outcome is similar for laparoscopic assisted and open surgery for CRC. This and other studies have shown quicker recovery with laparoscopic CRC surgery including earlier resolution of postoperative ileus, less discomfort, and earlier discharge from the hospital. The extent to which surgeons have adopted the minimally invasive surgical (MIS) approach in CRC is unknown. Methods: Using the NCCN Colon/Rectal Cancer Outcomes Project Database, 715 patients were identified who underwent CRC resection in 2005–6. The distribution of lesions included right colon (39%), left colon (31%), and rectum (30%). The incidence of MIS for CRC and clinicopathologic features associated with this approach were analyzed by logistic regression; results are reported as odd ratio (OR) with 95% confidence intervals (CI), and significance defined at p<0.05 level. Results: A total of 167 (23%) patients underwent MIS colorectal surgery (laparoscopy in 98% and robotic in 2%). Conversion to open surgery was noted in 33 cases (20%). Surgery was performed in outside institutions in 21% of cases prior to patients presenting to NCCN institutions for further treatment. The MIS approach was more common in colon than rectal cancer (30% vs.12%, OR 2.96, CI 1.94–4.51, p<0.0001). Within the colon cancer cohort, right sided lesions were more likely to be approached with MIS techniques rather than left sided lesions (32% vs. 25%; OR 1.42, CI 1.96–2.21, p<0.0001). Stage I tumors were also more likely to be managed with the less invasive approach: Stage I-41%; II-20%; III-21%; IV-19% (Stage I vs. IV, OR=3.00, CI 1.74–5.16 p<0.0001). No differences in surgical approach were noted based on age, gender, race, Charlson comorbidity score, insurance type, or location of surgery (NCCN vs outside facility). Conclusion: The majority of CRC surgery for patients presenting to NCCN institutions is performed by open techniques. Right sided and early stage CRCs were more likely treated with MIS, possibly related to the less demanding nature of the procedure. The adoption of MIS is expected to rise as surgeons become trained in MIS techniques for CRC.

No significant financial relationships to disclose.

Complications and effectiveness of combination chemotherapy in metastatic colorectal cancer (MCRC) with unresected primary (UP)

14537

Background: The outcome of patients (pts) with MCRC and unresected primary (UP) has not been studied systematically in the modern era of targeted and combination chemotherapy. We conducted a single institute retrospective study to determine the rate and nature of complications in this population. Methods: MCRC-UP pts treated at Roswell Park Cancer Institute between 2002 and 2006 were identified. Demographic, toxicity, efficacy, and palliative intervention data were collected. Primary tumor related complications including obstructive symptoms, bleeding, perforation, and fistulas were assessed. Results: 24 pts with colonic UP were identified. 14/24 were treated with bevacizumab-based chemotherapy (11 FOLFOX, 3 capecitabine), 7/24 with FOLFOX, 2 with capecitabine, and 1 with FOLFIRI. No perforations, hemorrhagic events, or arterial events were noted. None of the 24 pts required palliative surgical intervention secondary to the UP. Only 2 pts developed obstructive symptoms and 1 pt developed an entero-cutaneous fistula; all 3 events were attributed to peritoneal carcinomatosis. 10 pts with rectal UP were identified. 1 pt received upfront chemoradiation followed by 5-FU/bevacizumab. 9/10 pts were treated with upfront systemic chemotherapy (6 bevacizumab-based [5 FOLFOX, 1 capecitabine], 3 FOLFOX). Of these 9 pts, 4 required subsequent palliative radiation therapy for obstructive symptoms (3 pts) or pain (1pt) while 5 continue on systemic chemotherapy (median 1st line chemotherapy duration > 7 months). No perforations, bleeding requiring transfusion, or arterial events were noted among the rectal cancer population. 1 pt required a diverting colostomy for obstruction despite palliative CRT. Median time to progression on first line chemotherapy was 7.4 months for colon cancer and 8 months for rectal cancer. The median overall survival was 13.6 months for colon cancer and has not been reached for rectal cancer (exceeded 13 months). Conclusion: Treatment of MCRC with UP is feasible and is rarely associated with complications related to the primary tumor. Rectal cancer with UP can be managed with upfront chemotherapy. Subsequent palliative RT is needed in about 50% of these pts.

No significant financial relationships to disclose.

Randomized, blind, controlled trial of transdermal rotigotine in early Parkinson disease

OBJECTIVE

This multicenter, randomized, double-blind study was performed to compare the safety and efficacy of the once-daily dopamine agonist rotigotine, in a continuous-dosing transdermal-patch formulation, vs placebo in patients with early-stage Parkinson disease (PD).

METHODS

Patients were randomized to receive placebo (n = 96) or rotigotine (n = 181), starting at 2 mg/24 h (10-cm(2) patch size; 4.5-mg total drug content), titrated weekly up to 6 mg/24 h (30-cm(2) patch size; 13.5-mg total drug content), and then maintained for 6 months. The primary efficacy measures were 1) the change in the Unified Parkinson's Disease Rating Scale (UPDRS) scores (parts II and III) from baseline to end of treatment and 2) responder rates (patients with > or =20% improvement).

RESULTS

Patients receiving rotigotine had a mean absolute difference of 5.28 (+/-1.18) points lower in UPDRS subtotal scores compared with those receiving placebo (p < 0.0001). The mean change in part III motor scores was -3.50 (+/-7.26) (n = 177) and was the greatest contributor to UPDRS improvement. The rotigotine group had more responders (48 vs 19%; p < 0.0001). The most commonly reported adverse events were application site reactions (44% rotigotine vs 12% placebo), nausea (41 vs17%), somnolence (33 vs 20%), and dizziness (19 vs 13%), and most were mild or moderate in intensity.

CONCLUSIONS

Transdermal rotigotine, when titrated to a dosage of 6 mg/24 h, was effective for the treatment of early-stage Parkinson disease in this trial. Adverse events were similar to those found with other transdermal systems and dopamine agonists.

Parkinsonism, Lrrk2 G2019S, and tau neuropathology

Lrrk2 G2019S is predominantly associated with alpha-synuclein-immunopositive Lewy body pathology. We have identified Family SK where Lrrk2 G2019S segregates with slowly progressive parkinsonism and the affected proband has tau-immunopositive neurofibrillary tangle pathology. Thus alpha-synucleinopathy and tauopathy, the predominant pathologies associated with parkinsonism, may be alternate outcomes of the same underlying genetic cause. Intriguingly, we observe no evidence of a direct interaction between either the tau or alpha-synuclein protein with Lrrk2.

Outcomes and toxicities among octogenarians and nonagenarians with colorectal cancer (crc) treated with chemotherapy or concurrent chemoradiation - a single institution study

13514

Background: Chemotherapy is associated with an improved overall survival with acceptable toxicities in patients ≥ 70 years. However, little to no data exists regarding feasibility and tolerability of chemotherapy and/or radiation in CRC patients ≥ 80 years. The purpose of this study was to identify the trends of increased toxicity in this subgroup of patients. Methods: A retrospective study on patients ≥ 80 yrs treated for CRC with either chemotherapy alone or chemoradiation during the period of 1996- 2005 at Roswell Park Cancer Institute was conducted. Survival analysis was performed using the Kaplan-Meier method. Results: 29 patients were identified. 8 patients were diagnosed as having rectal cancer and received combined chemoradiation. 21 patients had colon cancer and received chemotherapy alone either in the adjuvant or metastatic setting. The median age was 82 years (range: 80–93). The median survival for all stages receiving chemo and/or radiation therapy was 37 months (95% CI: 27–53). The median survival for patients with stage IV disease was 6 months (95% CI: 5–33). Grade III/IV GI toxicities were seen in 59% (95% CI: 37–72%) of patients. Grade III/IV hematologic toxicities were seen in 17% (95% CI: 8–37%) of patients. Empiric chemotherapy dose reductions were implemented, starting the first cycle, in 90% (95% CI: 72–96%)of patients. Therapy had to be withheld in 34% (95% CI: 19–52%) of patients by more than 1 week due to toxicities in the first 2 months of treatment. Conclusions: Our study, demonstrates a higher rate of toxicities than previously reported for patients ≥ 70 years. This has occurred despite an initial dose-reduction in the majority of the treated population (90%). Octogenarian and nonagenarian CRC patients experienced a higher rate of GI toxicities during treatment, some of which were life threatening. This data supports the urgent need to conduct prospective studies to identify treatment recommendations for patients ≥ 80. Data from larger elderly phase II studies with median ages < 80 should not be extrapolated to octogenarians and nonagenarians.

No significant financial relationships to disclose.

Derangement of p53 and MDM2 is involved in transformation of differentiated into anaplastic thyroid cancer

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Background: Anaplastic thyroid cancer arises as a consequence of tumor progression, or transformation, from pre-existing differentiated thyroid cancer. Mutation of the p53 tumor-suppressor gene represents a common event in thyroid tumor progression. MDM2 encodes a protein that complexes with p53, downregulates its function, and leads to its degradation via a ubiquitin-proteasome pathway. The objective of this study was to evaluate the change in p53 and MDM2 expression in the transformation of differentiated to anaplastic thyroid carcinoma. Methods: Of 94 cases of anaplastic thyroid cancer diagnosed and treated in British Columbia Canada over a 20 year period (1984–2004) 32 cases (34%) had adequate tissue available for evaluation and 12 of these cases had associated foci of differentiated thyroid carcinoma. A tissue microarray was constructed from these 12 anaplastic thyroid tumors and their associated differentiated foci. Immunohistochemistry was utilized to evaluate expression of p53 and MDM2 by these tumors. Results: There was decreased expression of p53 and MDM2 by the anaplastic tumors when compared to the differentiated thyroid tumors from which they evolved. The expression of p53 and MDM2 was 17% and 8%, respectively, by the differentiated thyroid carcinoma, and 83% and 25%, respectively, by the anaplastic tumors. Evaluating the anaplastic cancers and the differentiated foci from which they evolved, p53 overexpression developed in 8 (67%) of tumors and MDM2 overexpression developed in 3 (25%) of tumors. All the anaplastic tumors that developed MDM2 overexpression also concurrently developed p53 overexpression. Conclusions: This report is the first to demonstrate derangement of p53, and its regulator, MDM2, is involved in the transformation of a subset of differentiated into anaplastic thyroid tumors. Isolated MDM2 overexpression does not appear to play an important role in anaplastic transformation of thyroid cancer.

No significant financial relationships to disclose.