Patient Preference for Surgical Methods for Ipsilateral Breast Tumor Recurrence

BACKGROUND

Mastectomy has been the standard surgical treatment for ipsilateral breast tumor recurrence (IBTR). Recently, there has been growing interest in repeat breast-conserving surgery (rBCS) for IBTR among breast surgeons; however, there is currently little information regarding patient preferences for surgical procedure for IBTR. The purpose of this study was to evaluate preference for surgical procedure (mastectomy vs. rBCS) among breast cancer patients who had undergone salvage surgery for IBTR.

METHODS

Overall, 100 breast cancer patients who had undergone salvage surgery for IBTR were asked about their preferred surgical methods for IBTR and the reason. The association of patient preference and the reasons related to various clinical and pathological factors were assessed.

RESULTS

Of the 100 respondents, only 11 patients (11%) preferred rBCS. Patients who had undergone rBCS and radiotherapy for IBTR were significantly more likely to prefer to undergo rBCS than other groups (p = 0.030). The most frequent reason for choosing rBCS was the patient's desire to minimize breast deformity and surgical wounds.

CONCLUSIONS

Our study revealed that there is a low rate of patients who opt to undergo rBCS among patients who had undergone salvage surgery for IBTR. Discrepancies in perceptions regarding the surgical procedure for IBTR between patients and their surgeons may exist.

Ultrasonography-Based Quantitative Evaluation of Second Metatarsophalangeal Joint Instability in Female Patients With Hallux Valgus

BACKGROUND

Patients with moderate to severe hallux valgus (HV) sometimes exhibit second metatarsophalangeal (MTP) joint dislocation. Second MTP joint instability due to plantar plate (PP) injury has been suggested as one of the causes. However, there have been no reports that quantitatively evaluate this instability. This study aimed to evaluate second MTP joint instability in patients with HV without dislocation via ultrasonography and investigate its relationship with the presence of PP injury or foot form.

METHODS

Between May 2018 and July 2023, symptomatic female patients with HV without any lesser toe deformity were included in this study. Second MTP joint instability was defined as the dorsal displacement ratio (DDR) of the passively subluxated proximal phalangeal articular surface on the metatarsal head articular surface. The presence of PP injury was assessed using ultrasonography. Foot "form" was determined by measuring standard foot bony angles on weight-bearing foot-ankle radiographs. The relationship between DDR or PP injury and radiographic measurements was investigated.

RESULTS

Sixty-four patients (100 feet) were included. The average DDR of the second MTP joint in patients with HV without dislocation was 35.7%. There was an increase in the probability of PP injury, above a cutoff DDR value r of 35.4% (area under the curve = 0.712). The sensitivity, specificity, positive predictive value, and negative predictive value for the presence of PP injury based on this cutoff level were 63.9%, 74.4%, 79.6%, and 56.9%, respectively. Metatarsalgia was reported in 21 feet (21.0%), of which 15 feet (71.4%) showed PP injury. An increase in DDR was weakly associated with increased metatarsus adductus angle and decreased second metatarsal height.

CONCLUSION

In female patients with HV without second MTP dislocation, we found ultrasonographic evidence of second MTP plantar plate injury and joint instability to be a relatively common finding with a high prevalence in those with localized metatarsalgia.

LEVEL OF EVIDENCE

Level II, development of diagnostic criteria based on consecutive patients.

Proximal Supination Osteotomy for Hallux Valgus: Comparison of Clinical and Radiologic Outcomes for the Most Severe Deformities

BACKGROUND

There is little available information regarding the difference in outcomes between severe hallux valgus (S-HV), defined as 40 degrees ≤ hallux valgus angle (HVA) < 50 degrees, and what we consider to be "super-severe HV" (SS-HV), defined as >50 degrees, following a proximal metatarsal osteotomy. We aimed to retrospectively compare the outcomes of a proximal metatarsal osteotomy in S- and SS-HV.

METHODS

The series consisted of 57 female patients (57 feet) treated with a proximal supination osteotomy for symptomatic S- and SS-HV (33 and 24 feet, respectively). The outcome measures included radiographic parameters and for 45 patients included the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) score, and a visual analog scale pain score (VAS-PS) preoperatively and at a minimum follow-up of 12 months with a median of 26 months. No significant differences were found in age, body mass index, and the duration of follow-up between patients with S-HV and SS-HV (P > .10 for all comparisons) with the numbers available.

RESULTS

Preoperative HVA in patients with S- and SS-HV was significantly improved at the final follow-up (P < .0001 for both comparisons). No significant differences in postoperative HVA and IMA were observed between patients with S- and SS-HV (P = .51 and .50, respectively). All 5 preoperative subscale scores of SAFE-Q in patients with S- and SS-HV significantly improved postoperatively (P < .01 for all comparisons). Preoperative VAS-PS in patients with S- and SS-HV significantly improved postoperatively (P < .0001 and <.009, respectively). There were no significant differences in preoperative and postoperative scores of all the SAFE-Q subscales and VAS-PS between patients with S-HV and SS-HV (P > .10 for all) with the numbers available.

CONCLUSION

We found for this patient group that a proximal supination osteotomy can achieve a large correction for SS-HV as well as S-HV and significantly improve radiologic and clinical outcomes in SS-HV. The outcomes between patients with S- and SS-HV were not different in this series.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Operative outcomes of hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joints

BACKGROUND

Hallux valgus is sometimes accompanied by osteoarthritis of the lesser tarsometatarsal joint. However, information on the operative procedures and outcomes for the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint simultaneously is limited. We aimed to describe this operative procedure and evaluate the outcomes of the treatment of hallux valgus with osteoarthritis of the lesser tarsometatarsal joint.

METHODS

Fifteen patients (17 feet; average age, 66.9 years; average follow-up, 59.4 months; and minimum follow-up, 24 months) with symptomatic hallux valgus accompanied by painful osteoarthritis of the lesser tarsometatarsal joint were enrolled. All feet showed osteoarthritis of the second and/or third tarsometatarsal joint on dorsoplantar weight-bearing radiograph. The operative procedure included a proximal osteotomy of the first metatarsal and arthrodesis of the lesser tarsometatarsal joint with an autologous bone graft.

RESULTS

The mean Japanese Society for Surgery of the Foot hallux metatarsophalangeal-interphalangeal score significantly improved from 54.8 points preoperatively to 91.7 points postoperatively (P <0.001). The mean postoperative visual analog score (15 feet) was 1.0 (0-3.9). Preoperative midtarsal pain disappeared in 14 feet and decreased in one foot postoperatively. Preoperative metatarsalgia was found in five feet, of which, it disappeared in two feet, decreased in two feet, and transferred to another region in one foot at the latest follow-up. The mean hallux valgus and intermetatarsal angles were 42.4° and 18.4° preoperatively, which decreased significantly to 12.5° and 6.9° postoperatively, respectively (P <0.001, all). Recurrence of hallux valgus (hallux valgus angle ≥20°) was observed in two feet (11.8%). Nonunion of the third tarsometatarsal joint was observed in one foot (3.1% among 32 joints).

CONCLUSIONS

The clinical and radiographic results indicated that operative treatment for hallux valgus with painful osteoarthritis of the lesser tarsometatarsal joint significantly improves forefoot and midfoot pain and function and has low complication rates.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Eribulin is an immune potentiator in breast cancer that upregulates human leukocyte antigen class I expression via the induction of NOD-like receptor family CARD domain-containing 5

Eribulin inhibits microtubule polymerization and improves the overall survival of patients with recurrent metastatic breast cancer. A subgroup analysis revealed a low neutrophil to lymphocyte ratio (NLR) (<3) to be a prognostic factor of eribulin treatment. We thus hypothesized that eribulin might be related to the immune response for breast cancer cells and we analyzed the effects of eribulin on the immune system. Immunohistochemical staining revealed that human leukocyte antigen (HLA) class I expression was increased in clinical samples after eribulin treatment. In vitro assays revealed that eribulin treatment increased HLA class I expression in breast cancer line cells. RNA-sequencing demonstrated that eribulin treatment increased the expression of the NOD-like family CARD domain-containing 5 (NLRC5), a master regulator of HLA class I expression. Eribulin treatment increased the NY-ESO-1-specific T-cell receptor (TCR) transduced T (TCR-T) cell response for New York oesophageal squamous cell carcinoma 1 (NY-ESO-1) overexpressed breast cancer cells. The eribulin and TCR-T combined therapy model revealed that eribulin and immunotherapy using TCR-T cells has a synergistic effect. In summary, eribulin increases the expression of HLA class 1 via HLA class 1 transactivatior NLRC5 and eribulin combination with immunotherapy can be effective for the treatment of breast cancer.

Plantar Pressure Distribution Before and After Surgery for Lesser Metatarsophalangeal Joint Dislocation With Hallux Valgus

Hallux valgus surgery and open reduction of the lesser metatarsophalangeal joints with metatarsal shortening osteotomy help treat severe hallux valgus concomitant with the lesser metatarsophalangeal joint dislocation; however, pre- and postoperative plantar pressure distribution and its effect on the foot remain unclear. The pre- and postoperative groups comprised 16 patients with moderate-to-severe symptomatic hallux valgus with lesser metatarsophalangeal joint dislocation. All feet underwent open reduction and collateral ligament reconstruction of the second metatarsophalangeal joint and proximal metatarsal shortening osteotomy under the second metatarsal with proximal osteotomy of the first metatarsal. Twenty healthy participants (20 feet) were included in the control group. The plantar pressure distribution was determined by measuring the peak pressure, maximum force, contact area, and force-time integral for 12 regions. Under the second toe, all measurements in the preoperative group were significantly lower than those of the control group. The peak pressure, maximum force, and contact area of the postoperative group were significantly greater than those of the preoperative group. However, no differences were observed between the postoperative and control groups. Under the second metatarsal head, the peak pressure of the preoperative group was significantly higher than that of the control group. The peak pressure of the postoperative group was significantly lower than that of the preoperative group and showed no differences from the control group. Open reduction and collateral ligament reconstruction of the lesser metatarsophalangeal joints and proximal metatarsal shortening osteotomy with proximal osteotomy of the first metatarsal in hallux valgus with lesser metatarsophalangeal joints dislocation cases may improve operative outcomes, including favorable foot function.

Radiological characteristics of hallux valgus with metatarsus adductus: A matched case-control study

BACKGROUND

No evidence has been found to support the hypothesis that there is a correlation between hallux valgus (HV) and intermetatarsal (IM) angles in HV with metatarsus adductus (MA) and that IM angle in HV with MA is lower than that in HV without MA. The present study aimed to analyze the radiographic characteristics of HV with MA compared to matched controls and to clarify the differences between HV with MA and without MA.

METHODS

Preoperative radiographs of 126 female patients (164 feet) who underwent hallux valgus surgery were reviewed. The HV, IM, and MA angles were measured. The MA was defined as MA angle of 20° or greater. Of all the feet, 37 (22.6%) had HV with MA (MA group). Control A (111 feet) having HV without MA was matched by age, gender, and BMI to MA group; Control B (79 feet) having HV without MA was matched by age, gender, BMI, and HV angle to the sub-MA group (31 feet) having HV with MA.

RESULTS

The correlation coefficient between the HV and IM angles in the MA group was considered negligible (r = 0.08, p = 0.63), whereas the correlation coefficient in Control A was considered moderate (r = 0.57, p < 0.00001). The correlation coefficient in the MA group was significantly smaller than in Control A (p < 0.01). There was no significant difference in the HV angle between the sub-MA group and Control B (p = 0.23), but the IM angle was significantly smaller than in Control B (p = 0.002).

CONCLUSION

There is no significant correlation between the HV and IM angles in HV with MA, as there is in HV without MA. HV with MA has a significantly smaller IM angle for the HV angle compared to HV without MA.

Low-Intensity Pulsed Ultrasound for Symptomatic Pseudarthrosis After Toe Fracture with Symphalangism: A Report of 2 Cases

CASE

Distal phalangeal fractures are often treated conservatively. However, some patients experience residual pain. We report 2 cases of patients who underwent low-intensity pulsed ultrasound (LIPUS) therapy for pseudarthrosis after fracture of the distal phalanx of the fifth toe with symphalangism. Both patients (female, 63 and 33-year-old, respectively) underwent conservative treatment with buddy-taping fixation; however, bone union failed, and LIPUS therapy was initiated. In both cases, bone union was achieved and pain resolved after 3 months.

CONCLUSION

Bone union occasionally fails after conservative treatment of distal phalangeal fractures. LIPUS is a useful treatment of symptomatic pseudarthrosis after such fractures.

Positional advantages of supine MRI for diagnosis prior to breast‑conserving surgery

The present study aimed to evaluate the rate of positive surgical margins for magnetic resonance imaging (MRI) performed in the supine position prior to breast-conserving surgery (BCS). The rate of positive surgical margins and the clinicopathological factors were examined in consecutive patients with BCS who underwent preoperative MRI performed in the supine position at Sapporo Medical University Hospital (Sapporo, Japan) and related hospitals and clinics between January 2012 and December 2013. Of 1,175 eligible patients, 1,150 were included after excluding 25 patients with either bilateral breast cancer or stage IV disease. Positive margin was defined as no cancer seen on the resected margin. The primary endpoint was the rate of positive surgical margins when preoperative MRI was performed in the supine position and the secondary endpoint was identification of the factors that predict positive margins. Of the 1,150 female patients (median age, 55 years; range, 29-97 years) who underwent BCS for breast cancer following MRI performed in the supine position, 215 (18.8%) had positive margins, which is similar to the rate with MRI in the prone position, and 930 (81.2%) had negative margins. The rate of positive surgical margins in patients of the human epidermal growth factor receptor 2 (HER2) type was significantly higher than that in the non-HER2 type group (6.5 and 2.9%; χ² P=0.0103). There was no increase in the rate of positive margins in breast cancers with a diameter of >T2. The rate of positive surgical margins following MRI performed in the supine position was 18.8%. Supine MRI appears to be suitable for informing on the extent of resection of breast cancer.

Preferences Regarding Breast Surgery Omission Among Patients With Breast Cancer Who Receive Neoadjuvant Chemotherapy

BACKGROUND/AIM

Currently, several ongoing prospective studies are investigating the safety of breast surgery omission in patients with breast cancer who are exceptional responders to neoadjuvant chemotherapy. However, there is little information about the preferences of these patients regarding omission of breast surgery.

PATIENTS AND METHODS

We conducted a questionnaire survey to assess preferences regarding omission of breast surgery among patients with breast cancer who had human epidermal growth factor receptor 2-positive or estrogen receptor-negative tumors and good clinical response after neoadjuvant chemotherapy. Patients' estimation of the risk of ipsilateral breast tumor recurrence (IBTR) after definitive surgery or breast surgery omission was also assessed.

RESULTS

Of 93 patients, only 22 (23.7%) said they would omit breast surgery. Under the scenario of omitting breast surgery, the 5-year IBTR rate estimated by patients who said they would omit breast surgery was significantly lower (median, 10%) than the rate estimated by patients who preferred undergoing definitive surgery (median, 30%) (p=0.017).

CONCLUSION

The proportion of our surveyed patients who were willing to omit breast surgery was low. Patients who said they preferred to omit breast surgery overestimated the 5-year IBTR risk.

Abstract P2-20-17: Eribulin is an immune potentiator in breast cancer by up-regulation of human leukocyte antigen class I

Background: Eribulin, an anticancer drug that increases the overall survival (OS) of patients with metastatic recurrent breast cancer, inhibits microtubule polymerization, although the mechanism is different from that of other microtubule inhibitors (taxanes). A subgroup analysis revealed a low neutrophil-to-lymphocyte ratio (NLR) (&lt; 3) to be a prognostic factor of eribulin treatment. NLR has also been reported to be a predictive marker for cancer immunotherapy. Checkpoint inhibitor-based cancer immunotherapy is currently available for breast cancer. We hypothesized that eribulin improves breast cancer cell immune response. Immunological effector cytotoxic T lymphocytes (CTLs) recognize antigenic peptides presented by human leukocyte antigen (HLA) class I; HLA class I downregulation is frequently observed in breast cancer. Here, we evaluated the CTL response in eribulin-treated breast cancer cells. Materials and Methods: HLA class I expression before and after eribulin treatment was evaluated using immunohistochemistry in tumors from patients, and by immunofluorescence, flow cytometry, western blotting, and quantitative RT-PCR (qRT-PCR) in breast cancer cells (MDA-MB231 and MCF7). Factors that upregulate HLA class I were screened using RNA-seq. To evaluate T cell recognition, we generated cancer testis antigen (NY-ESO-1)-specific T cell receptor transduced-T cells (TCR-T cells). NY-ESO-1 cDNA was stably transduced into MCF7 and MDA-MB-231 cells. TCR-T cell reactivity with MCF7/NY-ESO-1 cells was analyzed using an ELISPOT assay. A combinatorial therapy model was established using eribulin and TCR-T. Results: HLA class I was upregulated after eribulin treatment in clinical samples. To confirm this, we treated breast cancer cells with eribulin and evaluated HLA class I expression. Eribulin increased HLA class I expression, as evidenced by immunofluorescence, flow cytometry, western blotting, and qRT-PCR. RNA-seq results on eribulin-treated cells showed that eribulin upregulated NLRC5, a master regulator of HLA class I. IFNγ ELISPOT assay revealed that eribulin increased IFNγ secretion by TCR-T cells (p&lt; 0.01), indicating that eribulin enhanced the immune response. These results suggest that eribulin and immunotherapy had a synergistic effect. Therefore, we established an eribulin and NY-ESO-1 combinatorial therapy model and showed that the combination group had a significantly lower number of viable cancer cells than the eribulin- and TCR-T-only groups (p&lt; 0.01). Conclusions: Eribulin increased the expression of HLA class I, probably by upregulating NLRC5 in breast cancer cells. It also enhanced TCR-T recognition in breast cancer cells. The combinatorial therapy model revealed the synergistic effect of eribulin and TCR-T. These results indicate that eribulin might be an immune potentiator and that combination therapy with immunotherapy can be effective for the treatment of breast cancer.

Citation Format: Asaka Wada, Goro Kutomi, Yoshihiko Hirohashi, Daisuke Kyuno, Hiroaki Shima, Yoko Kuga, Toshihiko Torigoe, Ichiro Takemasa. Eribulin is an immune potentiator in breast cancer by up-regulation of human leukocyte antigen class I [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-20-17.

Morphology of the asymptomatic Αchilles tendon: Measurement of tendon length and shape using magnetic resonance imaging, and investigation of related factors

BACKGROUND

One of the severe complications of Achilles tendon (AT) rupture is muscle weakness due to tendon lengthening. It is very important to prevent tendon lengthening during treatment; however, data on the length, thickness, and width of normal ATs are scarce. Furthermore, no studies have investigated the factors related to the AT length and shape. We aimed to determine the normal AT length and shape and to investigate any correlating factors.

METHODS

We measured the AT length, thickness, and width of 100 asymptomatic patients using magnetic resonance imaging. We also investigated the correlation between the AT length, thickness, and width and factors including age, sex, height, body weight, body mass index, history of sports activities, and the area of Kager's fat pad.

RESULTS

The mean AT length was 42.1 ± 12.9 mm. The AT length in 73% of the patients was within the range of 30-55 mm. Individual differences in the tendon length were large, but there was no correlation between the tendon length and patient height (P = 0.505). There was a strong correlation between the AT length and area of Kager's fat pad on magnetic resonance imaging (r = 0.734, P < 0.001). Furthermore, the correlation coefficient between the area of Kager's fat pad on magnetic resonance imaging and the area of Kager's triangle on radiography was extremely high (r = 0.851, P < 0.001).

CONCLUSIONS

The AT length can be predicted based on the area of Kager's triangle of the unaffected ankle on radiography. If the AT length is > 55 mm or longer than the length measured directly or calculated from the estimated area of Kager's triangle, tendon lengthening should be suspected. Our findings could provide an important indicator for the evaluation of AT lengthening not only in daily clinical situations but also in clinical studies.

Additional effect of anthracycline in preoperative chemotherapy with a sequential anthracycline‑containing regimen preceded by pertuzumab, trastuzumab and docetaxel combination therapy

The proper use of anthracycline-containing regimens in combination with anti-HER2-targeted therapy in a neoadjuvant setting for patients with HER2-positive breast cancer has not been resolved. Regimens preceded by anthracyclines have become the standard of care, and although the order has no significant impact on HER2-negative breast cancer, it is inconclusive as to whether a taxane-first sequence would have a similar effect on HER2-positive breast cancer. The present study aimed to investigate the benefit of a taxane-first sequence and of adriamycin and cyclophosphamide (AC) in patients with non-clinical complete response (non-cCR) to pertuzumab, trastuzumab and docetaxel (PTD). The present single-center prospective observational study was performed to investigate PTD followed by AC, and aimed to clarify the cCR rate after PTD alone and the pathological clinical response (pCR) rate after subsequent AC in patients without cCR after PTD alone. A total 24 patients were analyzed; of these, 14 achieved pCR (pCR rate, 58.3%). While four of 14 patients (28.6%) in the intention-to-treat population achieved pCR, nine of 14 patients (64.3%) achieved pCR with AC but not cCR after PTD. The median tumor reduction rate after four cycles of PTD was 58.9% (range, 20.8-100%) in all 24 patients, whereas the reduction rate after PTD-AC was 76.9% (range, 31.1-100%). Cardiac serious adverse events occurred in three patients (12.5%). In conclusion, a high pCR rate was observed for the taxane-first sequence. Patients were highly responsive to PTD, but some cases achieved additional antitumor effects after AC, which resulted in pCR without cCR after PTD alone. Since cardiotoxicity remains a significant problem, a higher risk-benefit treatment strategy is required to aim for AC omission. Trial registration number: UMIN000046338, name of registry: UMIN-CTR, date of registration: December 10, 2021.

The Relationship Between Duration of General Anesthesia and Postoperative Fall Risk During Hospital Stay in Orthopedic Patients

OBJECTIVES

We performed a retrospective observational study to investigate the relationship between general anesthesia duration and postoperative falls of hospitalized patients who underwent orthopedic surgery.

METHODS

We used electronic medical record data and incident report data from the Osaka Medical and Pharmaceutical University Hospital. The study included 4,042 patients admitted to the Department of Orthopedic Surgery from 2014 to 2018, and the following exclusion criteria were applied: no surgery, less than 18 years of age, and fall between admission and surgery. This study only considered falls that occurred within 21 days of surgery. The multivariate logistic regression model adjusted for patient background was used to determine the risk of falling according to the duration of general anesthesia.

RESULTS

After exclusions, 3,398 patients were included in the analysis. Among them, 45 patients (1.32%) had fallen, of whom 7 (15.6%) were injured and 2 (4.4%) experienced fractures. Multivariate logistic regression analysis to determine the adjusted odds ratio showed that longer general anesthesia duration was an independent risk factor for postoperative falls. In addition, cardiovascular disease had significantly higher associations with postoperative falls.

CONCLUSIONS

In the postoperative care of orthopedic patients, the risk of falling should be assessed by considering the duration of general anesthesia in addition to the traditional fall risk factors. Furthermore, falls could be prevented by educating patients and their caregivers about the risk and mobilizing staff to support postoperative patients at a higher risk of falls when they walk in the hospital.

Prevalence and radiological characteristics of the dislocation of the second metatarsophalangeal joint in patients undergoing hallux valgus surgery; a matched control study

BACKGROUND

Hallux valgus (HV) is occasionally associated with chronic subluxation or dislocation (CS/D) of the second metatarsophalangeal joint (2MTPj). The present study aimed to radiographically investigate the prevalence and characteristics of HV with CS/D of the 2MTPj compared with matched controls.

METHODS

Dorsoplantar and lateral weight-bearing radiographs of 79 female patients (79 feet) who had HV with an age of 50 years or more were reviewed. All feet were treated with a proximal supination osteotomy for correction of HV. CS/D of the 2MTPj was evaluated on preoperative dorsoplantar and lateral radiographs. HV and intermetatarsal (IM) angles were measured. Seventy-nine feet were divided into two groups: Group CD (16 feet) had HV with CS/D of the 2MTPj, and Group non-CD had HV without the CS/D of the 2MTPj (63 feet). The severity of HV was divided into two grades according to the HV angle: moderate deformity (Group M, 36 feet, HV angle of less than 40°) and severe deformity (Group S, 43 feet, HV angle of 40° or greater). Group CD and non-CD, and Group M and S were matched by age, gender, and BMI.

RESULTS

The prevalence of CS/D of the 2MTPj was 20.3%. Group CD had a significantly higher HV angle (p = 0.0001) and a significantly higher IM angle (p = 0.042) than Group non-CD. The prevalence of CS/D of the 2MTPj in Group S (34.9%) were significantly higher than that in Group M (2.8%) (p < 0.001).

CONCLUSIONS

CS/D of the 2MTPj was significantly associated with greater HV and IM angles compared with matched controls. The prevalence of CS/D of the 2MTPj (34.9%) in Group S was significantly higher than that in Group M. Severe HV can be at higher risk of acquiring CS/D of the 2MTPj in middle-aged and older females.

Dislocations of the second and third metatarsophalangeal joints after local steroid injection in patients with refractory metatarsalgia: A case report

Local steroid injections are frequently administered to patients with refractory metatarsalgia. No reports have described dislocation of the second and third metatarsophalangeal joints after local steroid injections. A 46-year-old woman had suffered from metatarsalgia and received multiple local steroid injections for over 2 years. The second and third metatarsophalangeal joints revealed dorsal dislocations on the lateral radiograph. Therefore, collateral ligament reconstruction of the metatarsophalangeal joints was performed. Intraoperative findings suggested that the rupture of the plantar plate may have caused dorsal dislocation of both joints. Thus, unnecessary multiple steroid injections around the lesser metatarsophalangeal joint should be avoided.

Plantar pressure distribution in hallux valgus feet after a first metatarsal proximal crescentic osteotomy with a lesser metatarsal proximal shortening osteotomy

BACKGROUND

Plantar pressure distribution after the first metatarsal proximal crescentic osteotomy (FMPCO) with lesser metatarsal proximal shortening osteotomy (LMPSO) for hallux valgus with metatarsalgia has not been previously described.

METHODS

The pre- (Pre) and postoperative (Post) groups comprised of 18 patients who underwent unilateral FMPCO with LMPSO; fifteen healthy volunteers constituted the control (C) group. For each of the 10 regions, peak pressure (Peak-P), maximum force (Max-F), contact time (Con-T), contact area (Con-A), and force-time integral (FTI) were measured.

RESULTS

The mean Peak-P of the second metatarsal head was significantly lower in the Post group than the Pre group. The mean Peak-P, Max-F, Con-T, and FTI were not significantly different between the Post and C groups. The mean Con-A was significantly lower in the Post group than the C group.

CONCLUSION

FMPCO with LMPSO may improve the plantar pressure of the central forefoot comparable to healthy subjects.

An Optimal Timing for Removing a Drain After Breast Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

In clinical practice, drains had been routinely used for reducing seroma formation after breast surgery. However, an optimal timing to remove drains does not identify yet.

METHODS

This study aimed to compare the clinical outcome, such as seroma formation, surgical site infection (SSI), and a length of hospital stay between early removal and late removal. A systematic review was performed using PubMed, MEDLINE, and the Cochrane Library. Breast cancer patients who received surgery using drains were eligible. Those parameters were compared between early vs late removal.

RESULTS

Eleven studies included in this meta-analysis. Seroma formation in the early removal group was significantly higher than the one in the late removal group (RR = 1.58: 95%CI [1.25-2.01], P = 0.0001), meanwhile no significant difference was found among the groups for SSI (RR = 0.82: 95%CI [0.51-1.31], P= 0.40). A length of hospital stay in the early removal group was also significantly shorter than late removal (RR -3.31: 95%CI [-5.13-1.49], P = 0.0004).

CONCLUSIONS

Seroma formation was significantly higher in patients who had early drain removal. Conversely, SSI incidence was low, and early removal did not increase SSI incidence. In conclusion, early drain removal has no proved clinical benefit in these settings besides reduction of hospital stays.

Extensor hallucis longus muscle contracture after distal tibial physeal injury: A report of two cases

Few studies have reported about isolated contracture in the extensor hallucis longus (EHL) muscle, but none of the EHL muscle contracture after distal tibial physeal injury. Two such cases in 16- and 14-year-old boys who underwent surgeries for distal physeal injury of the tibia at a previous hospital are presented. Extension contracture of the hallux appeared 1-2 months post-surgery. Physical examinations revealed that the extension contracture of the first metatarsophalangeal joint was aggravated in plantar flexion of the ankle due to a tenodesis effect, and magnetic resonance imaging showed atrophy and signal changes in the anterior compartment muscles. This was diagnosed as EHL muscle contracture due to anterior compartment syndrome (ACS) after distal tibial physeal injury. The EHL tendon transfers were performed in both cases, with favorable short-term results. Therefore, the EHL tendon transfer might be preferable in case of the EHL muscle contracture due to partial ACS.

Postural stability impairment in patients with bilateral hallux valgus: A case-control study using a stabilometer

BACKGROUND

Hallux valgus (HV) is an important risk factor for falls (in older people); however, the detailed relationship is less understood. We aimed to evaluate postural stability in bilateral HV patients.

METHODS

Two groups of 20 female patients-an HV group and a C (i.e., non-HV) group-participated in this study. Evaluations were made using the Timed Up and Go (TUG) test, the Berg Balance Scale (BBS), the Falls Efficacy Scale (FES), track length (LNG), velocity (VEL), enveloped area (ENV), and root mean square area (RMS).

RESULTS

TUG and FES scores were significantly higher and BBS scores were lower in the HV group than in the C group. LNG was significantly longer, VEL was higher, and ENV and RMS were wider in the HV group than in the C group.

CONCLUSIONS

The HV group exhibited impaired walking mobility, balance, and postural stability.

Corrugation of an unpaved road surface under vehicle weight

Road corrugation refers to the formation of periodic, transverse ripples on unpaved road surfaces. It forms spontaneously on an initially flat surface under heavy traffic and can be considered to be a type of unstable growth phenomenon, possibly caused by the local volume contraction of the underlying soil due to a moving vehicle's weight. In the present work, we demonstrate a possible mechanism for road corrugation using experimental data of soil consolidation and numerical simulations. The results indicate that the vertical oscillation of moving vehicles, which is excited by the initial irregularities of the surface, plays a key role in the development of corrugation.

Erector spinae plane block versus retrolaminar block for postoperative analgesia after breast surgery: a randomized controlled trial

PURPOSE

The newly introduced erector spinae plane block (ESPB) has given anesthesiologists an alternative regional anesthetic technique for thoracic analgesia. Although ESPB and retrolaminar block (RLB) have similar puncture sites, no clinical study comparing ESPB and RLB has been reported. The aim of this study was to compare ESPB and RLB in terms of analgesic efficacy in the context of multimodal analgesia following breast surgery.

METHODS

Fifty female patients undergoing breast surgery under general anesthesia were randomly allocated to receive either ultrasound-guided ESPB or RLB with 20 mL of 0.375% levobupivacaine for postoperative analgesia. The primary outcome was analgesic efficacy in terms of time to first postoperative rescue analgesic after the block procedure. The secondary outcomes were consumption of remifentanil during anesthesia, pain intensity at rest for 24 h postoperatively, and occurrence of postoperative nausea and vomiting (PONV).

RESULTS

After excluding five patients, 45 patients (22 and 23 patients in the ESPB and RLB group, respectively) were analyzed. Median time until the first postoperative rescue analgesic after the block procedure in the ESPB group was not significantly longer than that in the RLB group (8.6 [range 2.7-24] vs. 4.8 [3.0-24] h; P = 0.83). There was no significant difference in the consumption of remifentanil during anesthesia, pain intensity at rest for 24 h postoperatively, and occurrence of PONV between the two groups.

CONCLUSION

ESPB is equivalent, and not superior, to RLB for postoperative analgesia after breast surgery when 20 mL of 0.375% levobupivacaine is injected at the fourth thoracic vertebra.

The Unique Mental Impacts of Breast-Conserving Surgery and Mastectomy According to a Multi-Centered Cross Sectional Survey Conducted in Japan

Background: Improving health-related quality of life (HRQOL) has become a fundamental goal of breast cancer management. This study aimed to examine the differences between the QOL outcomes of breast-conserving surgery (BCS) and mastectomy. We also established structural equation models for BCS and mastectomy to elucidate their unique effects on QOL.Methods: Between July 2019 and November 2019, 254 patients, who were scheduled to visit one of four clinics, were recruited for this study. We evaluated HRQOL using various questionnaires, such as the BREAST-Q, EQ-5D-5L, and Hospital Anxiety and Depression Scale (HADS). The relationships among the examined clinical indicators were evaluated using structural equation modeling (SEM). Results: The QOL scores of the BCS group were better than those of the mastectomy group (0.85±0.129 vs. 0.81±0.12, P=0.020). Also, anxiety (2.94±2.95 vs. 3.81±3.08, P=0.025) and depression (2.55±2.77 vs. 3.74±3.19, P=0.002) were less severe in the BCS group than in the mastectomy group. Furthermore, the relationships among QOL status and mental health status were more complex in the BCS group than in the mastectomy group (Chi-square minimization p-value: 0.231 vs. 0.469, respectively). Also, depression directly affected QOL in the mastectomy group (R=-0.47), but not in the BCS group.Conclusions: There were differences in QOL and mental health between the BCS and mastectomy groups. SEM is useful for identifying such differences, which can be used to develop strategies for improving QOL.

Ultrasound-assisted near nerve method in nerve conduction study for the diagnosis of tarsal tunnel syndrome. A case report

Objectives

The sensitivity of nerve conduction studies (NCSs) of the medial and lateral plantar nerves for the diagnosis of tarsal tunnel syndrome (TTS) is not high enough. The near nerve method (NNM) is a recording technique for NCSs that allows the recording of large, clear potentials. The NNM was reported to improve the sensitivity of diagnoses of TTS. However, the NNM requires special skill using electrical motor threshold in positioning a needle electrode correctly. Thus, we performed the NNM with the aid of ultrasound imaging (ultrasound-assisted). The aim of this case report is to show the utility of ultrasound-assisted NNM in the electrodiagnosis of TTS.

Case report

A 69-year-old woman presented with paresthesia on the lateral sole of her right foot. Ultrasound imaging showed a space occupying lesion (SOL) posterior to the medial malleolus, caused by tenosynovitis, as discovered after surgery. We performed an NCS of the medial and lateral plantar nerves with ultrasound-assisted NNM. Ultrasound-assisted NNM allowed us to easily determine the needle insertion site just proximal to the SOL and to avoid penetrating the SOL and the vessels, and, furthermore, simplified moving the needle electrode toward the target nerve. The results of the NCS revealed that there was severe injury to the lateral plantar nerve and no injury to the medial plantar nerve.

Conclusions

In the NCS of the medial and lateral plantar nerves with NNM to diagnose TTS, ultrasound-assisted NNM can be useful for simplicity and safety.

Effect of Toe Type on Static Balance in Ballet Dancers

OBJECTIVES

Some forefoot shapes are ideal for pointe work in ballet. Egyptian-type, with the hallux being longest and the remaining toes decreasing in size, and Greek-type, with the second toe longer than the hallux, are considered less optimal for pointe work. Square-type, with the second toe the same length as the hallux, is considered optimal. This study compared postural stability in the bipedal stance, demi pointe, and en pointe between ballet dancers with the two toe types using a stabilometer.

METHODS

This study included 25 Japanese ballet academy dancers who had received ballet lessons for at least 6 years. Toes were categorized into Egyptian-type (n=14) and square-type (n=11). Bipedal stance, demi pointe, and en pointe were tested. Center of pressure (COP) parameters were calculated from ground-reaction forces using two force plates: total trajectory length (LNG), velocities of anterior-posterior (VAP) and medial-lateral directions (VML), and maximum range displacement in the anterior-posterior (MAXAP) and medial-lateral directions (MAXML). Mann-Whitney U-tests were used to examine differences in COP parameters.

RESULTS

There were no differences in parameters during bipedal stance or demi pointe. However, dancers with Egyptian-type toes had significantly greater LNG (p<0.01), VML (p=0.01), MAXML (p<0.01), and MAXAP (p=0.03) during en pointe.

CONCLUSIONS

Ballet dancers with Egyptian-type toes demonstrated greater displacement in the medial-lateral and anterior-posterior directions during en pointe. Ballet dancers should be aware of toe types and sway character to optimize ballet training and balance.

Abstract P1-02-11: The difference between tumor width on a contrast-enhanced ultrasound and the extent of pathological breast cancer

Background: Contrast-enhanced ultrasound (CEUS) is a modality capable of visualizing the blood vessels through the use of the microbubble agent “Perflubutane”. It can also allow for an improved visualization of breast tumors. Currently, CEUS is being used on a daily practice for breast cancer screening and treatment planning in many medical centers. This technique was approved in Japan following evidence gleaned through Phase-2 and Phase-3 clinical studies and has advanced over the past seven years. Regarding the extent of malignant breast tumor, it has been revealed that contrast-enhanced lesions observed using CEUS might be longer than those same lesions visible on B-mode. However, what contrast-enhanced images on CEUS reflect pathologically remains unclear. To resolve this issue, more complete evidence of the detailed imagery of lesions obtained by CEUS seemed to be needed. In the present study, we investigated the maximum tumor width on B-mode/CEUS images compared with the maximum pathological extent of the cancer. (Evergreen study, UMIN: 000028995).

Methods: In this retrospective multi-center study, 153 operable breast cancer patients who had undergone B-mode and CEUS prior to breast surgery between August 2012 and January 2017 were registered. The maximum tumor width was measured on B-mode and CEUS, and the tumor diameter width was determined at a postoperative histopathological examination (P) by investigators. With five blind readers as independent reviewers, the lesion width of 303 images was read (B-mode and CEUS). We analyzed the difference between the lesion width on CEUS or B-mode and the pathological width using paired t-tests and the Pearson product-moment correlation coefficient.

Results: The mean tumor widths (±standard deviation) measured by investigators were 15±7 mm (B-mode), 19±8 mm (CEUS) and 17±9 mm (P). The difference calculated by P from B-mode was -3±7 mm (p&lt;0.0001, r=0.6142), while that from CEUS was 1±6 mm (p=0.0163, r=0.7372). CEUS showed a significantly positive high correlation (p&lt;0.0001, r=0.8548) with B-mode. The mean (±standard deviation) widths measured by blind readers were 16±7 mm (B-mode) and 18±8 mm (CEUS). The difference calculated by

P from B-mode was -2±8 mm (p=0.0005, r=0.5067), while that from CEUS was 1±8 mm (p=0.1256 r=0.5354). CEUS and B-mode also showed a significantly positive high correlation (p&lt;0.0001, r=0.7909).

Discussion: Our data suggested that the maximum lesion width might increase, in order, from B-mode to P and CEUS. Furthermore, the difference in the lesion width determined by B-mode and P appeared to be significant, although not that between P and CEUS. Moreover, a positive high correlation was detected between B-mode and CEUS. Therefore, the width on CEUS might tend to be larger than that on B-mode, regardless of the tumor size. Additional information may be determined through an analysis of the design and extent of dissection when partial mastectomy is to be performed. These findings may also provide clues as to what can be anticipated pathologically when a lesion is enhanced with CEUS.

Citation Format: Aya Noro, Hiroaki Shima, Toshiko Hirai, Midori Noma, Takashi Nakamura, Emi Sato, Terumi Kaga, Yukio Mitsuzuka, Keitaro Kamei, Yumi Imayoshi, Toshikazu Ito, Shinsaku Kanazawa, Kumiko Kato, Ryuzo Sekiguchi, Goro Kutomi, Mitsuru Mori, Tadashi Hasegawa, Ichiro Takemasa, Toshitaka Okuno. The difference between tumor width on a contrast-enhanced ultrasound and the extent of pathological breast cancer [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 P1-02-11.

Randomized phase II trial of survivin 2B peptide vaccination for patients with HLA-A24-positive pancreatic adenocarcinoma

The prognosis of advanced pancreatic adenocarcinoma is still extremely poor. This study sought to determine the efficacy of, and immunological response to, peptide vaccination therapy in patients with this disease. In this multicenter randomized phase II study, patients with advanced pancreatic adenocarcinoma after gemcitabine and/or tegafur/gimeracil/oteracil were randomly assigned to 3 groups that each received a 2-step treatment course. In Step 1, the groups received treatments of: (i) survivin 2B peptide (SVN-2B) plus interferon-β (IFNβ); (ii) SVN-2B only; or (iii) placebo until the patients show progression. In Step 2, all patients who consented to participate received 4 treatments with SVN-2B plus IFNβ. The primary endpoint was progression-free survival (PFS) after initiation of Step 1 treatment. Secondary endpoints included immunological effects assessed by analysis of PBMCs after Step 1. Eighty-three patients were randomly assigned to receive SVN-2B plus IFNβ (n = 30), SVN-2B (n = 34), or placebo (n = 19). No significant improvement in PFS was observed. Survivin 2B-specific CTLs were found to be increased in the SVN-2B plus IFNβ group by tetramer assay. Among patients who participated in Step 2, those who had received SVN-2B plus IFNβ in Step 1 showed better overall survival compared with those who had received placebo in Step 1. Patients vaccinated with SVN-2B plus IFNβ did not have improved PFS, but showed significant immunological reaction after vaccination. Subgroup analysis suggested that a longer SVN-2B plus IFNβ vaccination protocol might confer survival benefit. (Clinical trial registration number: UMIN 000012146).

Immunohistological analysis of pancreatic carcinoma after vaccination with survivin 2B peptide: Analysis of an autopsy series

Immune checkpoint inhibitors (ICIs) have revolutionized the treatment of cancer by providing new options in addition to existing therapies. However, peptide vaccination therapies still represent an attractive approach, because of the antigen specificity. We identified survivin 2B peptide (SVN-2B), a 9-mer antigenic peptide encoded by survivin, and an SVN-2B peptide vaccine-based phase II randomized clinical trial targeting unresectable and refractory pancreatic carcinoma was undertaken. The SVN-2B peptide vaccine did not have any statistically significant clinical benefits in that study. Therefore, we undertook an autopsy study to analyze the immune status of the pancreatic cancer lesions at the histological level. Autopsies were carried out in 13 patients who had died of pancreatic cancer, including 7 who had received SVN-2B peptide vaccination and 6 who had not, as negative controls. The expression of immune-related molecules was analyzed by immunohistochemical staining. Cytotoxic T lymphocytes were analyzed by tetramer staining and enzyme-linked immunospot assay. Histological analysis revealed dense infiltration of CD8+ T cells in some lesions in patients who had received the SVN-2B peptide vaccine. A high rate of programmed cell death ligand 1 expression in cancer cells was observed in these cases, indicating that CTLs were induced by SVN-2B peptide vaccination and had infiltrated the lesions. The lack of a significant antitumor effect was most likely attributable to the expression of immune checkpoint molecules. These findings suggest that the combination of a tumor-specific peptide vaccine and an ICI might be a promising approach to the treatment of pancreatic carcinoma in the future.

Operative Treatment for Hallux Valgus With Moderate to Severe Metatarsus Adductus

BACKGROUND

Operative treatment is indicated for patients who have symptomatic hallux valgus (HV) with moderate to severe metatarsus adductus (MA). However, there is limited information available on the operative procedures and outcomes for the treatment of HV with MA. We aimed to investigate the average 10-year follow-up clinical and radiologic outcomes.

METHODS

Seventeen patients (21 feet, average age: 60.1 years) with symptomatic HV with moderate to severe MA were operatively treated. Mean postoperative follow-up duration was 114.4 (24-246) months. All feet had metatarsus adductus angle ≥20 degrees on dorsoplantar weight-bearing radiograph. The procedure included a proximal crescentic osteotomy of the first metatarsal and abduction osteotomy of the proximal third of the second and third metatarsals.

RESULTS

The mean American Orthopaedic Foot & Ankle Society scale score improved significantly postoperatively ( P < .001). The mean postoperative visual analog scale score (17 feet) was 2.0 (0-6). Preoperative metatarsalgia was severe in 2 feet, moderate in 17, and mild in 2. At the most recent follow-up evaluation, 11 feet had no pain, 9 had mild pain, and 1 had moderate pain. The mean hallux valgus angle, intermetatarsal angle, and metatarsus adductus angle significantly decreased postoperatively ( P < .001 for all). Recurrence of HV (HV angle ≥ 20 degrees) was observed in 4 feet.

CONCLUSION

The clinical and radiologic results indicated that our novel operative treatment for HV with moderate to severe MA can achieve significant correction of HV with MA deformities and significant improvement in pain and function.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Comparison of Plantar Pressure Distribution Between Postoperative Hallux Valgus Feet and Healthy Feet

BACKGROUND

Proximal crescentic osteotomy (PCO) in patients with moderate-to-severe hallux valgus (HV) is a well-established and effective procedure for correcting the deformity. However, there are no published studies comparing plantar pressure in postoperative HV feet with healthy feet. This study aimed to compare the plantar pressure distribution in postoperative HV feet with healthy feet.

METHODS

Twenty-six patients were included in the HV group, and 24 healthy participants were included in the control (C) group. All patients in the HV group underwent unilateral PCO. After undergoing PCO, this group was defined as the OP group. All subjects were women with no significant differences in age, height, weight, and body mass index. There were no significant differences in demographic characteristics between patients in each group. We divided the subjects' feet into 8 regions and measured the peak pressure (Peak-P), maximum force (Max-F), contact time, contact area, and the force-time integral in each region.

RESULTS

All parameters of the great toe were significantly higher in the OP group than in the HV group. All forefoot parameters were not significantly different between the 2 groups. No parameter of the great toe was significantly different between the OP and C groups. However, mean Peak-P and Max-F of the central forefoot were significantly higher in the OP group than in the C group.

CONCLUSION

PCO can improve the plantar pressure of the great toe in patients with moderate-to-severe HV to a level similar to that in healthy subjects.

LEVEL OF EVIDENCE

Level III, comparative study.

A genome-wide association study identifies three novel genetic markers for response to tamoxifen: A prospective multicenter study

Purpose

Although association studies of genetic variations with the clinical outcomes of breast cancer patients treated with tamoxifen have been reported, genetic factors which could determine individual response to tamoxifen are not fully clarified. We performed a genome-wide association study (GWAS) to identify novel genetic markers for response to tamoxifen.

Experimental design

We prospectively collected 347 blood samples from patients with hormone receptor-positive and human epidermal growth factor receptor 2-negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 to 28 days. We used Ki-67 response in breast cancer tissues after preoperative short-term tamoxifen therapy as a surrogate marker for response to tamoxifen. We performed GWAS and genotype imputation using 275 patients, and an independent set of 72 patients was used for replication study.

Results

The combined result of GWAS and the replication study, and subsequent imputation analysis indicated possible association of three loci with Ki-67 response after tamoxifen therapy (rs17198973 on chromosome 4q34.3, rs4577773 on 6q12, and rs7087428 on 10p13, P_combined = 5.69 x 10⁻⁶, 1.64 x 10⁻⁵, and 9.77 x 10⁻⁶, respectively). When patients were classified into three groups by the scoring system based on the genotypes of the three SNPs, patients with higher scores showed significantly higher after/before ratio of Ki-67 compared to those with lower scores (P = 1.8 x 10⁻¹²), suggesting the cumulative effect of the three SNPs.

Conclusion

We identified three novel loci, which could be associated with clinical response to tamoxifen. These findings provide new insights into personalized hormonal therapy for the patients with breast cancer.

Isolation and Characterization of jararaca GPIb-BP, a Snake Venom Antagonist Specific to Platelet Glycoprotein lb

A platelet glycoprotein lb-binding protein (GPIb-BP) was isolated from the snake venom of Bothrops jararaca. Jararaca GPIb-BP showed a single band with Mr of 30,000, and two distinct bands with Mr. of 17,000/13,000 under non-reducing and reducing conditions, respectively, on SDS-polyacrylamide gel electrophoresis. Jararaca GPIb-BP itself induced neither platelet aggregation nor serotonin release from platelets, but specifically bound to GPIb (40,629 ± 2,521 molecules per normal platelet, with Kd 39.1 ± 2.4 nM at saturation). The purified venom protein completely inhibited ristocetin- or botrocetin-induccd von Willebrand factor (vWF) binding, and blocked the bovine vWF binding to GPIb, with IC50 values ranging from 28 to 42 nM, without affecting the platelet aggregation induced by ADP or α-thrombin. 1251-jararaca GPIb-BP binding to GPIb was not altered by the presence of human α-thrombin. Jararaca GPIb-BP at a final concentration of 104 nM totally abolished vWF-dependent shear- induced platelet aggregation (SIPA) at a high shear stress, but had no effect on SIPA at a low shear stress. Reduced and S-carboxyamidomethylated jararaca GPIb-BP lost its inhibitory activity on SIPA. The NH2-terminal amino acid sequences of the subunits revealed a high degree of homology with those of several Ca2+-dependent lectins, especially to those of two functionally opposite venom proteins, botrocetin (a vWF-modulator) and alboaggregin-B (a GPIb- modulator).

Comparison of surgical outcomes and complications between the Harmonic FOCUS and conventional surgery for open thyroidectomy

The aim of the present study was to evaluate the potential advantages of the ultrasonic scalpel compared with the conventional technique in thyroid surgery. Patients with resectable thyroid cancer and Basedow's disease were assigned to ultrasonic scalpel or conventional technique (knot-tying and electrocoagulation). The present study used the Harmonic FOCUS^® (HF) as an ultrasonic scalpel. Between February 2013 and May 2016, 45 patients were enrolled into the study. Duration of the surgery was significantly decreased in the HF group compared with the conventional surgery (CS) group (median 142 vs. 151 min; P=0.0406). Intraoperative blood loss and total volume of drainage fluid were significantly decreased in the HF group compared with the CS group (median 40 vs. 125 ml; P=0.0054, and median 120 vs. 175.5 ml; P=0.0490). Duration of drain placement and length of hospitalization stay were similar in the two groups. Furthermore, the overall incidence of postoperative complications did not differ between the two groups. Overall, the present study suggests that open thyroidectomy using the HF is safe and effective and not associated with any increase in complications.

Abstract P6-07-03: Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival

Background: Cancer stem cells (CSC) are good sources of tumor initiation, heterogeneity, progression, and metastasis because of their unique characteristics. Several potential markers for CSCs have been suggested for breast cancer, including CD44+/CD24−/low, aldehyde dehydrogenase 1 (ALDH1), and epithelial cell adhesion molecule/epithelial-specific antigen. We previously reported that ALDH1 gene expression is related to aggressive phenotypes and poor prognosis in breast cancers. In this study, we conducted differential analysis of mRNA expression in ALDH1-positive breast cancer to identify genes associated with CSC. Next, we performed basic and clinical studies of one gene.

Methods: Messenger RNA was isolated from ALDH1-positive cells and ALDH1-negative cells in 5 ALDH1-positive breast cancers. Microarray analysis revealed that several genes were significantly associated with the ALDH1 gene. Among them, we examined a long non-coding RNA of H19 in this study. We evaluated the effect of H19 on CSCs using RNA interference and a sphere formation assay using two cell lines, HCC1937 and iCSCL10A cells. We also investigated H19 expression in 192 surgical specimens by in situ hybridization and analyzed the relationship between H19 expression and clinic pathological findings in breast cancer patients.

Results: Through in vitro experiments, we confirmed that suppression of H19 reduced sphere formation in both HCC1937 and iCSCL10A cells. Among surgical specimens, 48 samples (25%) expressed H19. We verified thatH19 positivity was significantly higher in ALDH1-positive cases than in ALDH1-negative cases (68% vs 9.7%, p &lt; 0.001). H19 was significantly highly expressed in triple-negative breast cancer (TNBC) (46%) compared with other subtypes: luminal (33%), luminal-HER2 (6%), and HER2-enriched subtype (15%). H19-positive patients showed significantly worse prognosis (5-year disease-free survival 75.8% vs 91.5%, p = 0.001 and 5-year overall survival 88.7% vs 97.7%, p = 0.002). The effect of H19 expression on prognosis was the most significant in TNBC compared to in other subtypes (5-year disease-free survival 63.6% vs 88.9%, p = 0.038).

Conclusions: H19 is clearly associated with CSCs and correlated with poor prognosis in breast cancer patients, particularly TNBC. Our future studies will investigate the role of H19 in maintaining the nature of CSCs and protein-coding genes associated with H19.

Citation Format: Shima H, Kida K, Yamada A, Sugae S, Narui K, Miyagi Y, Ryo A, Ichikawa Y, Ishikawa T, Endo I. Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival [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 P6-07-03.

Responsiveness of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) in patients with hallux valgus

BACKGROUND

In this study, we investigated the responsiveness of the Self-Administered Foot Evaluation Questionnaire (SAFE-Q) for patient's assessment before and after hallux valgus surgery.

METHODS

Patient-reported answers on the SAFE-Q and Short Form-36 (SF-36) before and at a mean of 3-4 and 9-12 months after hallux valgus surgery were analyzed. Data of 100 patients (92 women, eight men) from 36 institutions throughout Japan were used for analysis.

RESULTS

In all subscales of the SAFE-Q, the trend of increased scores after surgery was statistically significant (P < 0.001). Among the patients with available scores both before and at 9-12 months after surgery (n = 66), the largest effect sizes (ESs) were observed for shoe-related (1.60), pain and pain-related (1.05), and general health and well-being (0.84) scales. In the SF-36 (n = 64), the largest ES was observed for the bodily pain scale (0.86). Less notable changes were observed for the remaining SF-36 domains.

CONCLUSION

The SAFE-Q is the first patient-reported outcome measure which includes a quality of life assessment of shoes. In our cohort, the most remarkable responsiveness was observed for the shoe-related subscale. Based on its responsiveness, the SAFE-Q appears to be sufficient for evaluation of foot-related quality of life before and after surgery.

Simultaneous Reconstruction of the Medial and Lateral Collateral Ligaments for Chronic Combined Ligament Injuries of the Ankle

BACKGROUND

Objective data on chronic injuries of the medial collateral ligament (MCL) of the ankle are scarce. Chronic MCL injuries are frequently associated with lateral collateral ligament (LCL) injuries. For patients with chronic combined MCL and LCL injuries, the authors have performed simultaneous surgery of the 2 ligaments.

HYPOTHESIS

Simultaneous surgery of the 2 ligaments may be effectively used to treat chronic combined MCL and LCL injuries.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). Preoperative and postoperative clinical outcomes were measured with the Karlsson score and the Japanese Society for Surgery of the Foot (JSSF) ankle-hindfoot scale score. The patients underwent preoperative and postoperative functional measurements and a radiological examination. In addition, preoperative magnetic resonance imaging (MRI) results, arthroscopic findings, and histology of the MCL were evaluated.

RESULTS

Preoperatively, the deep fibers of the MCL did not appear striated in 29 ankles, and high-intensity signal changes were observed in 23 ankles on T2-weighted or gradient echo MRI. MCL ruptures were confirmed with arthroscopic surgery. Medial impingement lesions and focal chondral lesions were confirmed in 10 and 21 ankles, respectively. Histology of the reconstructed MCL showed dense collagen fibers with vessels. The mean postoperative follow-up period was 30 months (range, 24-52 months). There was a significant change between preoperative and postoperative Karlsson scores (69.0 vs 96.1 points, respectively; P < .0001) and JSSF scores (69.8 vs 94.5 points, respectively; P < .0001). On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. Postoperatively, all 23 athletes returned to their preinjury level of sports participation.

CONCLUSION

MCL insufficiency resulted from medial ankle instability and medial impingement lesions. Outcomes in the patients indicated that MCL reconstruction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.

Catastrophic cellular events leading to complex chromosomal rearrangements in the germline

Although complex chromosomal rearrangements were thought to reflect the accumulation of DNA damage over time, recent studies have shown that such rearrangements frequently arise from 'all-at-once' catastrophic cellular events. These events, designated chromothripsis, chromoanasynthesis, and chromoanagenesis, were first documented in the cancer genome and subsequently observed in the germline. These events likely result from micronucleus-mediated chromosomal shattering and subsequent random reassembly of DNA fragments, although several other mechanisms have also been proposed. Typically, only one or a few chromosomes of paternal origin are affected per event. These events can produce intrachromosomal deletions, duplications, inversions, and translocations, as well as interchromosomal translocations. Germline complex rearrangements of autosomes often result in developmental delay and dysmorphic features, whereas X chromosomal rearrangements are usually associated with relatively mild clinical manifestations. The concept of these catastrophic events provides novel insights into the etiology of human genomic disorders. This review introduces the molecular characteristics and phenotypic outcomes of catastrophic cellular events in the germline.

Current status of the prognostic molecular biomarkers in breast cancer: A systematic review

Biomarkers that facilitate the prediction of breast cancer prognosis can improve the quality of life in patients during the long period of illness and treatment. Particularly in recent years, with the advent of a more exhaustive analysis of genetic information and gene products, the molecular mechanisms at play during breast cancer have gradually become clearer. In the present study, a systematic review of the literature between 2009 and 2014 was conducted by searching for the keywords 'breast cancer', 'biomarkers', 'diagnosis', 'prognosis' and 'drug response' to clarify the present state of knowledge regarding biomarkers. In the final analysis, 16 studies on biomarkers for the breast cancer prognosis were retrieved. From these, 7 biomarkers in 9 studies were found to be strongly reliable predictors of prognosis and a further 7 biomarkers in 7 studies were poorly reliable. The use of these prognostic biomarkers should increase the options available for treatment algorithms.

The effect of platelet-rich plasma on Achilles tendon healing in a rabbit model

OBJECTIVE

The aim of the present study was to evaluate the effects of PRP on Achilles tendon healing in rabbits during the inflammatory, proliferative, and remodeling phases by histological examination and quantitative assessments.

METHODS

Fifty mature male Japanese albino rabbits with severed Achilles tendons were divided into two equal groups and treated with platelet-rich plasma (PRP) or left untreated. Tendon tissue was harvested at 1, 2, 3, 4, and 6 weeks after treatment, and sections were stained with hematoxylin-eosin and monoclonal antibodies against CD31 and type I collagen.

RESULTS

Collagen fibers proliferated more densely early after severance, and subsequent remodeling of the collagen fibers and approximation of normal tendinous tissue occurred earlier in the PRP group than in the control group. The fibroblast number was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Similarly, the area ratio of CD31-positive cells was significantly higher in the PRP group than in the control group at 1 and 2 weeks. Positive staining for type I collagen was more intense in the PRP group than in the control group after 3 weeks, indicating tendon maturation.

CONCLUSION

Administration of PRP shortened the inflammatory phase and promoted tendon healing during the proliferative phase.

Clinicopathological characteristics of thyroid cancer misdiagnosed by fine needle aspiration

Fine-needle aspiration (FNA) is commonly used as a preoperative assessment to diagnose thyroid cancer. However, misdiagnosis of malignancy by FNA is not rare, even if image examination suggests the possibility of thyroid cancer. In the present study, the clinicopathological factors of patients whose preoperative FNA examination had not led to a diagnosis of thyroid cancer were examined. In total, 125 patients with thyroid cancer who underwent FNA and surgery (total thyroidectomy, subtotal thyroidectomy or hemithyroidectomy) at the Department of Surgery, Surgical Oncology and Science of the Sapporo Medical University Hospital between 2006 and 2013 were retrospectively analyzed. The patients were divided into two groups: Group A, malignancy determined by FNA, and group B, no malignancy. The groups were then compared by gender, age, tumor size, stage, tumor stage, lymph node metastasis, histology, surgical procedure methods, presence or absence of calcification and thyroglobulin levels. The mean age of the patients in group A (5 males and 59 females) was 53.0 years. The mean age in group B (11 males and 49 females) was 54.2 years. The mean tumor size in both groups was 1.6 cm. The mean thyroglobulin levels were 82.7 ng/ml in Group A and 525.5 ng/ml in group B. There were also significant differences between the groups for tumor stage (P=0.046), histological type (P=0.024) and thyroglobulin levels (P=0.035). The results of the present study suggested that it may be difficult to diagnose thyroid cancer by FNA in cases with non-papillary carcinoma and higher thyroglobulin levels.

Direct Repair of Chronic Achilles Tendon Ruptures Using Scar Tissue Located Between the Tendon Stumps

BACKGROUND

Several surgical procedures for chronically ruptured Achilles tendons have been reported. Resection of the interposed scar tissue located between the tendon stumps and reconstruction using normal autologous tissue have been well described. We developed a direct repair procedure that uses scar tissue, which obviates the need to use normal autologous tissue.

METHODS

Thirty consecutive patients with Achilles tendon ruptures with a delay in diagnosis of >4 weeks underwent removal of a section of scar and healing tissue with direct primary suture of the ends of the tendon without the use of allograft or autograft. Patients were followed for a mean time of 33 months. Preoperative and postoperative clinical outcomes were measured with the Achilles Tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score. In addition, the patients underwent preoperative and postoperative functional measurements and magnetic resonance imaging. Lastly, we evaluated the histology of the interposed healing tissue.

RESULTS

The mean AOFAS scores were 82.8 points preoperatively and 98.1 points postoperatively. The mean postoperative ATRS was 92.0 points. At the time of the latest follow-up, none of the patients had experienced tendon reruptures or difficulties in walking or climbing stairs, and all except 2 patients could perform a single-limb heel rise. All athletes had returned to their pre-injury level of sports participation. Preoperative T2-weighted magnetic resonance imaging showed that 22 Achilles tendons were thickened with diffuse intratendinous high-signal alterations, and 8 Achilles tendons were thinned. Postoperative T2-weighted magnetic resonance imaging findings included fusiform-shaped tendon thickening and homogeneous low-signal alterations of the tendons in all patients. Histologically, the interposed scar tissue consisted of dense collagen fibers.

CONCLUSIONS

Shortening of the tissue between the 2 tendon ends that included healing scar and direct repair of healing tendon without allograft or autograft can be effective for treatment-delayed or neglected Achilles tendon rupture.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Abstract 2031: Association between CYP2D6 genotype and response to tamoxifen in a prospective multicenter study in Japan

Purpose:

CYP2D6 is key enzyme responsible for the generation of the potent active metabolite of tamoxifen, “endoxifen”. We previously reported that reduced- or null-function alleles of CYP2D6 were significantly associated with poor clinical outcome of breast cancer patients treated with tamoxifen. However, there are still discrepant reports questioning the association between CYP2D6 genotype and tamoxifen efficacy. Hence, we carried out prospective multicenter studies to evaluate the value of CYP2D6 genotyping in tamoxifen therapy.

Patients and Methods:

We studied 279 patients with hormone receptor-positive and Her-2 negative, invasive breast cancer receiving preoperative tamoxifen monotherapy for 14 - 28 days. Ki-67 response in breast cancer tissues after tamoxifen therapy was used as a surrogate marker of response to tamoxifen. We investigated the effects of allelic variants of CYP2D6 on Ki-67 change in breast cancer tissues, histological response, breast conservative operation and hot flash.

Results:

Ki-67 labeling index in breast cancer tissues significantly decreased after preoperative tamoxifen monotherapy for 14-28 days (P = 0.00000000024). Moreover, proportion of estrogen receptor positive cells in breast cancer tissues were significantly associated with Ki-67 change after tamoxifen therapy (P = 0.0099). CYP2D6 variants were not significantly associated with histological response, breast conservative operation and hot flash (P = 0.25, P = 0.28 and P = 0.34, respectively). However, CYP2D6 variants were significantly associated with Ki-67 decrease after the preoperative tamoxifen therapy (P = 0.000014; in patients with two variant alleles v patients carrying one or two wild-type alleles).

Conclusion:

Our result suggest that genetic variation in CYP2D6 is a key predictor for the prognosis of patients with breast cancer treated with tamoxifen.

Citation Format: Hitoshi Zembutsu, Seigo Nakamura, Sadako Akashi-Tanaka, Takashi Kuwayama, Chie Watanabe, Tomoko Takamaru, Hiroyuki Takei, Kana Miyahara, Hiroshi Matsumoto, Yoshie Hasegawa, Goro Kutomi, Hiroaki Shima, Fukino Satomi, Hideki Maeda, Minoru Okazaki, Hisamitsu Zaha, Mai Onomura, Ayami Matsukata, Yasuaki Sagara, Shinichi Baba, Akimitsu Yamada, Kazuhiro Shimada, Daisuke Shimizu, Koichiro Tsugawa, Arata Shimo, Tan Ern Yu, Mikael Hartman, Chan Ching Wang, Soo Chin Lee, Yusuke Nakamura. Association between CYP2D6 genotype and response to tamoxifen in a prospective multicenter study in Japan. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2031.

Flap revascularization in patients following immediate reconstruction using an autologous free dermal fat graft for breast cancer: a report of two cases

It has been reported that use of the free dermal fat graft (FDFG) technique produces a good cosmetic outcome for breast cancer. An FDFG is harvested from the lower abdomen as a columnar-shaped specimen and implanted into the defect of the breast after a partial mastectomy as a volume replacement technique. In this report, two patients who underwent breast-conserving surgery with immediate reconstruction using an autologous FDFG are described in order to show the difference in status between one case with and one without blood flow in the graft. To assess the benefit of this technique using FDFGs, their cosmetic satisfaction was evaluated using a questionnaire, graft shrinkage was measured by CT, and blood flow was assessed using contrast-enhanced ultrasound (CEUS). Both patients scored 10 of 12 points on the questionnaire. After 2 years, shrinkage of the grafts was 21.6 and 25.2 %, respectively. Although one patient had no blood flow in the center of the graft, the other had blood flow from the pectoralis major muscle to the center of the graft. While satisfaction and graft shrinkage were similar in the two patients, one case showed blood flow and had a somewhat softer graft than the other. The graft status was maintained with a good cosmetic outcome for 3 years after breast-conserving surgery with immediate reconstruction using an autologous FDFG, despite mild shrinkage and hardness of the graft. It is notable that blood flow was observed into the graft on CEUS, and more distinct perfusion was seen in the softer graft case after more than 3 years.

SOX2 and ALDH1 as Predictors of Operable Breast Cancer

AIM

Sex-determining region Y-box binding protein-2 (SOX2) and aldehyde dehydrogenase-1 (ALDH1) are known cancer stem-cell markers, and represent candidate predictors for breast cancer prognosis. In this study we investigated the relationships between SOX2/ALDH1 expression and prognosis.

MATERIALS AND METHODS

One hunred and two breast cancer surgical specimens were immunohistochemically analyzed for SOX2 and ALDH1 expression.

RESULTS

Disease-free survival (DFS) and overall survival (OS) were significantly poorer for SOX2-positive patients than SOX2-negative (p=0.0024 and p=0.0021, respectively), and for ALDH1-positive patients than ALDH1-negative (p=0.0049 and p=0.0083). DFS and OS were worse for SOX2- or ALDH1-positive patients than double-negative (p=0.0053 and p=0.0166). While an obvious tendency toward worse DFS was seen for estrogen receptor (ER)-negative patients, and attenuated for ER-positive, only SOX2/ALDH1 any-positive patients showed significantly poorer DFS (p=0.0258).

CONCLUSION

SOX2 and ALDH1 can be considered markers of poor prognosis, particularly in ER-negative patients. SOX2/ALDH1 any-positivity might also offer a reliable predictor of poor prognosis.

Novel synthesis process for solar-light-active porous carbon-doped CuO nanoribbon and its photocatalytic application for the degradation of an organic dye

A simple, one-step novel solution process was developed for the synthesis of carbon-doped CuO (C-CuO) nanoribbons without the use of a catalyst, template, substrate, or costly instrumentation at room temperature.

Simple synthesis process for ZnO sphere-decorated CNT fiber and its electrical, optical, thermal, and mechanical properties

An easy process to produce ZnO sphere-decorated CNT (ZSDC) fibers was established.

Proximal supination osteotomy of the first metatarsal for hallux valgus

BACKGROUND

Risk factors for hallux valgus recurrence include postoperative round-shaped lateral edge of the first metatarsal head and postoperative incomplete reduction of the sesamoids. To prevent the occurrence of such conditions, we developed a proximal supination osteotomy of the first metatarsal. Our aim was to describe this novel technique and report the outcomes in this report.

METHODS

Sixty-six patients (83 feet) underwent a distal soft tissue procedure combined with a proximal supination osteotomy. After the proximal crescentic osteotomy, the proximal fragment was pushed medially, and the distal fragment was abducted, and then the distal fragment of the first metatarsal was manually supinated. Outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) score and radiographic examinations. The average follow-up duration was 34 (range, 25 to 52) months.

RESULTS

The mean AOFAS score improved significantly from 58.0 points preoperatively to 93.8 points postoperatively (P < .0001). The mean hallux valgus and intermetatarsal angle decreased significantly from 38.6 and 18.0 degrees preoperatively to 11.0 and 7.9 degrees postoperatively, respectively (both, P < .0001). Sixty-nine feet (69/83, 83%) had a positive round sign preoperatively, and 66 feet (66/83, 80%) had a negative round sign postoperatively. According to the Hardy's classification of position of the sesamoids, all feet were classified as grade V or greater preoperatively, and 49 feet (49/83, 59%) were classified as grade IV or less postoperatively. Three feet (3/83, 4%) had recurrence of hallux valgus, defined as a hallux valgus angle ≥ 25 degrees.

CONCLUSION

The rates of occurrence of a positive round sign and incomplete reduction of the sesamoids significantly decreased postoperatively, which may have contributed to the low hallux valgus recurrence rates. We conclude that a proximal supination osteotomy was an effective procedure for correction of hallux valgus and can achieve a low rate of hallux valgus recurrence.

LEVEL OF EVIDENCE

Level IV, retrospective case series.