Real-world first-line treatment of patients with BRAFV600E-mutant metastatic colorectal cancer: the CAPSTAN CRC study

BACKGROUND

BRAFV600E mutations occur in 8%-12% of metastatic colorectal cancer (mCRC) cases and are associated with poor survival. European guidelines recommend combination (doublet or triplet) chemotherapy plus bevacizumab in first line. However, an unmet need remains for more effective treatments for these patients.

PATIENTS AND METHODS

CAPSTAN CRC is a European, retrospective, multicenter, observational study evaluating real-world treatment practices for patients with BRAFV600E-mutant mCRC treated between 1 January 2016 and 31 January 2020. The primary objective was to describe first-line treatment patterns. Secondary objectives included describing baseline demographics, mutational testing procedures, treatment effectiveness, and safety.

RESULTS

In total, 255 patients (median age 66.0 years; 58.4% female) with BRAFV600E-mutant unresectable mCRC from seven countries were included. Most had right-sided tumors (52.5%) and presented with synchronous disease at diagnosis (66.4%). Chemotherapy plus targeted therapy (68.7%) was preferred at first line over chemotherapy alone (31.3%). The main first-line treatments were FOLFOX plus bevacizumab (27.1%) and FOLFOXIRI (folinic acid, 5-fluorouracil, oxaliplatin, irinotecan) with/without bevacizumab (27.1%/19.2%). Median duration of first-line treatment was 4.9 months. Overall, 52.5% received second-line treatment. Across all first-line regimens, progression-free survival (PFS) and overall survival were 6.0 [95% confidence interval (CI) 5.3-6.7] months and 12.9 (95% CI 11.6-14.1) months, respectively. Triplet plus targeted therapy was associated with more adverse events (75.0%) compared with triplet chemotherapy alone (50.0%) and doublet chemotherapy alone (36.1%). Multivariate analysis identified low body mass index and presence of three or more metastatic sites as significant prognostic factors for PFS.

CONCLUSIONS

This study is, to date, the largest real-world analysis of patients with BRAFV600E-mutant mCRC, providing valuable insights into routine first-line treatment practices for these patients. The data highlight the intrinsic aggressiveness of this disease subgroup, confirming results from previous real-world studies and clinical trials, and stressing the urgent need for more effective treatment options in this setting.

Neoadjuvant chemotherapy with or without radiotherapy versus upfront surgery for resectable pancreatic adenocarcinoma: a meta-analysis of randomized clinical trials

BACKGROUND

The role of neoadjuvant chemotherapy (NC) in resectable pancreatic cancer (RPC) has yet to be defined. This review aims to analyze the benefit of NC in RPC compared with upfront surgery (US) in terms of overall survival (OS) and disease-free survival (DFS).

PATIENTS AND METHODS

PubMed, CENTRAL (The Cochrane Library), and Embase were systematically reviewed until 3 November 2021. Abstract proceedings and virtual meeting presentations from the American Society of Clinical Oncology and the European Society of Medical Oncology conferences, reference articles of published clinical trials, and review articles were considered. Only randomized clinical trials (RCTs) comparing NC administration with or without radiotherapy previous with surgery (experimental arm) versus US followed by adjuvant chemotherapy with or without radiotherapy (control arm) for RPC were included.

RESULTS

A total of 1135 studies were screened. Of these, 1117 studies were primarily excluded. Of the remaining 18 studies, 5 were excluded because of no adequate trial design for this work and 7 others had no available results. Finally, 6 trials with 469 patients with pancreatic cancer randomized to NC (n = 212) or US (n = 257) were selected. Compared with US, NC significantly improved OS [hazard ratio (HR) 0.75; 95% confidence interval (CI) 0.58-0.98; P = 0.033] and DFS (HR 0.73; 95% CI 0.59-0.89; P = 0.002). While the NC approach was not significantly associated with lower resection rate [relative risk (RR) 0.92; 95% CI 0.84-1.01; P = 0.069], the R0 resection rate was significantly higher for NC than for US (RR 1.31; 95% CI 1.13-1.52; P = 0.0004).

CONCLUSION

This is the first meta-analysis of RCTs showing that NC improves OS for RPC compared with US followed by adjuvant therapy. Ongoing RCTs should confirm these findings with FOLFIRINOX to generalize the indication of NC.

Prognostic factors in advanced pancreatic ductal adenocarcinoma patients-receiving second-line treatment: a single institution experience

BACKGROUND

Second-line (2L) treatments for advanced pancreatic ductal adenocarcinoma (PDAC) achieve a modest benefit at the expense of potential toxicity. In the absence of predictive factors of response, the identification of prognostic factors could help in the therapeutic decisions-making. The purpose of this study was to assess the prognostic factors associated with shorter survival in patients with advanced PDAC who received 2L treatment.

METHODS

We conducted a single institution retrospective study, which included all patients with advanced PDAC who received 2L treatment between September 2006 and February 2020 at La Paz University Hospital, Madrid (Spain). Significant variables in the logistic regression model were used to create a prognostic score.

RESULTS

We included 108 patients. The median overall survival (OS) was 5.10 months (95%CI 4.02-6.17). In the multivariate analysis, time to progression (TTP) shorter than 4 months after first-line treatment (OR 4.53 [95%CI 1.28-16.00] p = 0.01), neutrophil-to-lymphocyte ratio (NLR) greater than 3 at the beginning of 2L (OR 9.07 [95%CI 1.82-45.16] p = 0.01) and CA-19.9 level higher than the upper limit of normal at the beginning of 2L (OR 7.83 [95%CI 1.30-49.97] p = 0.02) were independently associated with OS shorter than 3 months. The prognostic score classified patients into three prognostic groups (good, intermediate and poor) with significant differences in OS (p < 0.001).

CONCLUSIONS

TTP shorter than 4 months after first-line treatment, NLR greater than 3 and CA-19.9 level higher than the upper limit of normal at the beginning of 2L were associated with shorter overall survival. We developed a prognostic score that classifies patients with advanced PDAC into three prognostic groups after progression to the first-line. This score could help in the decision-making for 2L treatment.

Social support, coping strategies and sociodemographic factors in women with breast cancer

INTRODUCTION

The aim of this study was to analyze the associations between perceived social support and sociodemographic variables on coping strategies.

METHODS

A prospective, cross-sectional, multicenter study was conducted in 404 women with resected, non-metastatic breast cancer. Participants completed questionnaires: perceived social support (MSPSS), coping strategies (Mini-MAC), and psychological distress (BSI-18).

RESULTS

Sociodemographic factors as age, education, and partnership status were associated with coping strategies. As for maladaptive strategies, hopelessness was more frequent in older people and lower educational level; fatalism in older and single people, and cognitive avoidance was associated with lower educational level. Suppor t from family, friends, and partners was associated with a greater fighting spirit. In contrast, high psychological distress (anxiety and depression) was associated with greater use of maladaptive strategies.

CONCLUSION

Young people, a high level of education, having a partner, low psychological distress, and seeking social support were associated with the use of adaptive cancer coping strategies.

Effect of prone position without volume expansion on pulse pressure variation in spinal surgery : a prospective observational study

Background : Pulse pressure variation (PPV) is a predictor of fluid responsiveness in supine patients under mechanical ventilation. Its use has also been validated in the prone position. The aim of this study was to assess changes in PPV induced by prone position in patients undergoing spinal surgery. Methods : Ninety-six patients aged 12 to 75 years, scheduled for elective spinal surgery were included. Patients were excluded if they had clinical signs related to any organ failure, or if they required vasoactive drugs and/or volume expansion during the early stages of anesthesia. Patients received a standardized anesthesia protocol. Fluid expansion was not allowed from induction until 10 minutes after positioning. Hemodynamic measurements recorded before the induction of anesthesia (T0) included : arterial pressure (systolic (SAP) diastolic (DAP) and mean (MAP)) and heart rate (HR). Radial artery was cannulated after intubation and measurements, as well as PPV, were noted in supine position (T1). Patients were then placed in prone position hemodynamics and PPV measurements were repeated (T2). Results : Forty-eight patients completed the study. Anesthesia induction induced a significant decrease in SAP, DAP, and MAP with no effect on HR. Prone position did not induce any significant changes in SAP, MAP, DAP, and HR. A significant difference was found between PPV values in supine (Mean=10.5, SD=4.5) and prone positions (Mean=15.2, SD=7.1) ; t=-4.15 (p<0.001). The mean increase in PPV was 4.7%. Conclusion : Prone position without prior volume expansion induces a significant increase in PPV prior to any modification in arterial blood pressure and heart rate.

Analysis of DDT Residues in Soil by ELISA: An International Interlaboratory Study

An international interlaboratory study was conducted to determine the performance of a group of laboratories from developing and developed countries. The study used a commercial microwell ELISA on unknown samples spiked with different levels of DDT. The study design was based on Youden pairs and balanced replicates. Two soils, differing in particle size distributions, organic matter content, and cation-exchange capacities and thought to be DDT-free, were spiked at 5 DDT levels between 0.025 and 2 mg/kg. Nineteen laboratories in 17 countries took part in the collaborative trial; of these, the majority were modestly equipped laboratories in developing countries. Samples were analyzed without filtration or cleanup and using standards of pure DDT in methanol. Data were analyzed for repeatability and reproducibility, and average recoveries at the spike levels were calculated. Mean real recoveries for both soils were similar (103% for soil A and 100% for soil B), with values between 0.1 and 2 mg/kg DDT. Precision estimates were best in the linear working range of the assay (0.1–0.5 mg/kg DDT), with reproducibility relative standard deviations (RSDR) typically averaging about 38 and 46% near the upper and lower detection limits, respectively. Corresponding repeatability relative standard deviation (RSDr) values were 20–36% and 36–57%. Thus, even though much of the trial was performed under developing country conditions, performance statistics were similar to other reported results obtained with ELISAs on small molecules of agricultural importance, such as mycotoxins and pesticide and antibiotic residues.

Bone healing is achievable despite extensive wound dehiscence and wide plate and screws exposure in children

BACKGROUND

Extensive wound dehiscence and wide plate and screw exposure in the early weeks following orthopaedic surgery in children is usually managed either by extensive debridement, lavage and secondary closure or hardware removal and external fixation.

PATIENTS

Three children with LCP plate and screws exposure were managed by simple repetitive debridement and local wound care without any IV antibiotics, nor secondary closure or hardware removal. All three cases occurred in the tibia, one following tibial osteotomy in lateral hemimelia with a long history of previous surgeries, one following wide excision of a tibial Ewing sarcoma with chemo- and radiotherapy, and the third following wide excision of a 12cm necrotic tibial segment due to chronic osteomyelitis. Bone healing was uneventful in 2 cases and was in progress in the case with the Ewing sarcoma. Plate and screws were removed in all cases, following an obvious bone healing in 2 cases, and forced by the need for chemotherapy due to the presence of lung metastases in the third case. Spontaneous soft tissue healing occurred thereafter.

CONCLUSION

A stable fixation may lead to a good bone healing despite an extensive wound dehiscence and a wide plate and screws exposure with just a proper local wound care and without any major additional surgery.

LEVEL OF EVIDENCE

Level IV.

Understanding the foot's functional anatomy in physiological and pathological conditions: the calcaneopedal unit concept

BACKGROUND

A thorough review of the available orthopaedic literature shows significant controversies, inconsistencies and sparse data regarding the terminology used to describe foot deformities. This lack of consensus on terminology creates confusion in professional discussions of foot anatomy, pathoanatomy and treatment of deformities. The controversies apply to joint movements as well as static relationships between the bones.

DESCRIPTION

The calcaneopedal unit (CPU) is a specific anatomical and physiological entity, represented by the entire foot excepted the talus. The calcaneus, midfoot and forefoot are solidly bound by three strong ligaments that create a unit that articulates with the talus. The movement of the CPU is complex, as it rotates under the talus, around the axis of Henke that coincides with the talo-calcaneal ligament of Farabeuf.This calcaneopedal unit is deformable. It is compared with a twisted plate, able to adapt to many physiological situations in standing position, in order to acheive a plantigrade position.Moreover, the calcaneopedal unit and the talo-tibiofibular complex are interdependent; rotation of the latter produces morphologic modifications inside the former and vice versa.

PURPOSE

This paper is a review article of this concept and of its physiopathological applications.

Positional disappearance of motor evoked potentials is much more likely to occur in non-idiopathic scoliosis

PURPOSE

This study evaluates intraoperative disappearance of motor waveforms related to patient positioning in neurologically asymptomatic patients with spinal deformity.

METHODS

This is a retrospective review of 190 neurologically asymptomatic patients aged seven to 17 years planned for posterior instrumentation under neuromonitoring. There were 159 patients with adolescent idiopathic scoliosis and 31 patients with secondary scoliosis. Patients underwent surgery with transcranial electric stimulation motor evoked potentials (TES-MEPs). In case of abnormal findings, surgery was temporarily discontinued and necessary measures undertaken. In case of permanent signal disappearance surgery was definitively discontinued.

RESULTS

Six patients showed permanent loss of signal during early stages of surgery. These patients had a mean major curve of 64° Cobb angle and a mean thoracic kyphosis (D2 to D12) of 72°. The 184 remaining patients had a mean major curve of 50° Cobb angle and a thoracic kyphosis of 35°. A retrospective descriptive review of the patients' radiographs shows hyperkyphosis to be the common ground between the six secondary scoliosis cases. Gradual preoperative traction maintained during the surgery applied in two of these patients taken back to surgery six months later was associated with maintenance of TES-MEP signals throughout the surgery.

CONCLUSION

This study shows that positional permanent loss of neuromonitoring signals is more likely to occur in patients with secondary scoliosis and hyperkyphosis shown to have sharper spine deformity and suspected to have a more vulnerable spinal cord. Gradual skeletal traction performed in two of these patients and maintained during surgery showed promising results.

LEVEL OF EVIDENCE

IV.

Risk of malnutrition and emotional distress as factors affecting health-related quality of life in patients with resected cancer

INTRODUCTION

This study analyzes the prevalence of malnutrition, depression, anxiety, and somatization and which factor has the biggest effect on quality of life (QoL) in individuals with resected cancer.

METHODS

A prospective study was conducted among 747 participants. Participants completed the EORTC-QLQ30, MST, and BSI-18 questionnaires.

RESULTS

Prevalence for risk of malnutrition, depression, anxiety, and somatization were 36.4%, 35.5%, 35.2%, and 48.8%, respectively. Hierarchical multiple regression analyses revealed that malnutrition risk, somatization, depression, and anxiety accounted for 50.8% of the variance in functional scale, 45.3% in symptom scale, and 52.2% in global health. Malnutrition, somatization, depression, and anxiety displayed high explanatory power on all health-related QoL (HRQoL) scales.

CONCLUSION

The risk of malnutrition and psychological symptoms is strongly associated with HRQoL in cancer patients; thus, medical oncologists should develop effective interventions that contribute to lowering the risk of malnutrition and psychological distress, thereby improving subjects' HRQoL before initiating adjuvant chemotherapy.

Validity and reliability of different techniques of neck-shaft angle measurement

AIM

To determine a valid and reliable neck-shaft angle (NSA) measurement method while rotating the pelvises in increments of 5° in order to simulate patient malpositioning.

MATERIALS AND METHODS

CT images of 17 patients were used to produce digitally reconstructed radiographs in frontal and lateral views and three-dimensional (3D)-reconstructions of the femurs, considered to be the reference standard. Malpositioning was simulated by axially rotating the frontal radiographs from 0° to 20°. Three operators measured in two-dimensions the NSA using four different methods, three times each, at each axial rotation (AR) position. Method 1 (femoral neck axis drawn by joining the centre of the femoral head (CFH) to the median of the femoral neck base; femoral diaphysis axis drawn by joining the median of two lines passing through the medial and lateral edges of the femoral axis below the lesser trochanter) and method 2 (femoral axis taken as the median of a triangle passing through base of femoral neck and medial and lateral head-neck junction; femoral diaphysis as previous) were described for the first time; method 3 was based on a previous study; method 4 was a free-hand technique. Reliability, validity, and global uncertainty were assessed.

RESULTS

Method 1 showed the best reliability and validity. The global uncertainty also showed minimal values for method 1, ranging from 7.4° to 14.3° across AR positions.

CONCLUSION

Method 1, based on locating the CFH, was the most reliable and valid method and should be considered as a standardised two-dimensional NSA measurement method for clinical application.

Lower-limb lengths and angles in children older than six years: Reliability and reference values by EOS® stereoradiography

BACKGROUND

Lower-limb alignment in children is classically assessed clinically or based on conventional radiography, which is associated with projection bias. Low-dose biplanar radiography was described recently as an alternative to conventional imaging. The primary objective of this study was to assess the reliability of length and angle values inferred from 3D reconstructions in children seen in everyday practice. The secondary objective was to obtain reference values for goniometry parameters in children.

HYPOTHESIS

3D reconstructions can be used to assess the lower limbs in children.

MATERIAL AND METHODS

The paediatric reliability study was done in 18 volunteers who were divided into three groups based on whether they were typically developing (TD) children, had skeletal development abnormalities, or had cerebral palsy. The reference data were obtained in 129 TD children. Each study participant underwent biplanar radiography with 3D reconstruction performed by experts and radiology technicians. Goniometry parameters were computed automatically. Reproducibility was assessed based on the intra-class coefficient (ICC) and the ISO 5725 standard (standard deviation of reproducibility, SDR).

RESULTS

For length parameters, the ICCs ranged from 0.94 to 1.00 and the SDR from 2.1 to 3.5mm. For angle parameters, the ICC and SDR ranges were 0.60-0.95 and 0.9°-4.6°, respectively. No significant differences were found across experts or radiology technicians. Age-specific reference data are reported.

DISCUSSION

These findings confirm the reliability of low-dose biplanar radiography for assessing lower-limb parameters in children seen in clinical practice. In addition, the study provides reference data for commonly measured parameters.

LEVEL OF EVIDENCE

IV.

Sclerotherapy using Surgiflo and alcohol: a new alternative for the treatment of aneurysmal bone cysts

PURPOSE

This study aims to review the results of sclerotherapy using Surgiflo in addition to alcohol in primary aneurysmal bone cysts (ABC).

METHODS

A total of 16 consecutive patients with histologically confirmed diagnosis of primary ABC were treated by percutaneous Surgiflo and alcohol injection at our institution. Clinical follow-up included the assessment of pain, swelling, limping and functional impairment. Radiological parameters included tumour volume, physis-cyst distance, thickness of cyst cortex, and presence of intracystic septations. Mean follow-up was 35,6 months (24-71 months). Treatment was considered successful when the cyst volume decreased by a minimum of 10%, the bone cortex became thicker, and the distance to physis increased.

RESULTS

Mean age at presentation was 9.5 years (5.16-13.84 years). All ABC's were primary and all patients underwent a single Surgiflo and alcohol session except for two (12.5%) who required a second session. All patients had a good clinical result at final follow-up. Satisfactory cyst healing was achieved in 11 cases according to radiological parameters. Tumour volume decreased from a mean of 122 cm³ (111 to 133) before injection to 86 cm³ (76 to 96) at last follow-up (p < 0.01). Physis-cyst distance increased from a mean of 1 cm (0.1 to 2) to 2.1 cm (0.5 to 4) at last follow-up (p < 0.01). Cortical thickness improved from 1 mm (0.5 to 1.5) to 2 mm (1 to 3.5) at last follow-up (p < 0.01).There were no treatment related complications. Surgery was performed in one patient having a C3 vertebra ABC after developing quadriparesis due to tumour progression.

CONCLUSION

Sclerotherapy using Surgiflo and alcohol may be used as an efficient, safe and minimally invasive alternative for the treatment of primary ABCs.

Influence of patient rotational malpositioning on pelvic parameters assessed on lateral radiographs

AIM

To estimate the effect of patients' axial rotation (AR) during pelvic radiograph acquisition, on the reliability and validity of sagittal pelvic parameters.

MATERIALS AND METHODS

Lateral digitally reconstructed radiographs (LDRRs) were obtained from the pelvic computed tomography (CT) scans of eight children and nine adults. Then, the AR of the pelvis was simulated and the corresponding LDRRs were reconstructed at 5°, 10°, 15°, and 20° of the AR. Pelvic parameters were measured digitally on each radiograph. Intra- and interobserver variability were evaluated at each AR position (three operators repeated the measurements three times each). The bias on each clinical parameter, in each AR position, was calculated relatively to the 0° position.

RESULTS

Interobserver variability increased similarly in children and adults with AR. It reached 4.4° for pelvic incidence and 4.7° for the sacral slope at 20° of AR. Biases on radiological parameters increased with AR and exceeded the acceptable threshold of errors when AR reached 10°. A linear regression was established (R²=0.834, p<0.0001) in order to estimate the AR of a patient on a lateral pelvic radiograph based on the measurement of the bifemoral distance normalized to the sagittal pelvic thickness.

CONCLUSIONS

AR of patients during radiograph acquisition can be estimated in clinical practice, which would allow physicians to discard any radiographs where the calculated AR exceeded 10°.

A podoscopic and descriptive study of foot deformities in patients with Down syndrome

INTRODUCTION

Subjects with Down syndrome (DS) are known to be affected by various foot deformities. Despite the fact that some of these deformities have been reported in the literature, a more comprehensive description would be of benefit. The aim of this study is to investigate the prevalence of known foot deformities in patients with DS and of other previously non-described foot anomalies in this population.

HYPOTHESIS

Subjects with DS have an increased prevalence of foot deformities compared to control subjects.

METHODS

Fifty-five subjects with DS (age: 14.6±7.4 years) had undergone podiatric clinical and podoscopic examinations to study their main foot deformities and their footprints, respectively. The results of these examinations were compared to those of an age-matched asymptomatic control group of fifty-three subjects (age: 13.4±11.2 years).

RESULTS

Significantly more prevalent foot deformities were found in the DS group: hallux valgus (36.4%), syndactyly between the 2nd and 3rd toes (9.1%), grade II pes planus (39.1%) and grade III pes planus (30%). Moreover, joint laxity (43.6%) was significantly more prevalent in the DS group. Furthermore, the presence of an increased space between the 1st and 2nd toes in patients with DS and its prevalence (73.6%) were described for the first time. A multivariate analysis revealed a significant relationship between the presence of joint laxity and flatfoot in only the control but not the DS group. Other foot deformities were found to be consistently more frequent in the DS population but not significantly higher than the control group.

DISCUSSION

Although subjects with DS had significantly greater joint laxity and BMI compared to the control group, neither of these factors was found to be related to the increased prevalence of flatfoot in DS patients.

LEVEL OF EVIDENCE

IV-retrospective study.

Is percutaneous medial hamstring myofascial lengthening as anatomically effective and safe as the open procedure?

BACKGROUND

Medial hamstring fractional lengthening is commonly performed in children with cerebral palsy (CP) to decrease contracture and/or to improve gait. Percutaneous procedures are gaining more and more popularity, even in the paediatric population, with equivocal results. The purpose of this paper was to determine the efficacy and safety of percutaneous medial hamstring myofascial lengthening (PHL).

METHODS

This is a prospective randomised controlled trial including 31 knees from 18 consecutive patients with CP scheduled for medial hamstring lengthening in the setting of multilevel tendon lengthening procedures in a university hospital. Other concomitant lower extremity surgeries were not exclusionary. A first paediatric orthopaedic surgeon executes the PHL at one level, as recently described in the literature. Another surgeon opens and extends the wound to explore what had been cut during the PHL and completes fractional lengthening (OHL) of both the semimembranosus (SM) and semitendinosus (ST) when possible. Popliteal angle (PA) was assessed by a third surgeon immediately before PHL, after PHL and then after OHL, using a goniometer in a standardised reproducible manner. All three surgeons were blinded to the others' findings. Primary endpoints included ease of performing PHL, the percentage of tendon-fascia/ muscle portion sectioned percutaneously and improvement of PA. Comparison between improvement of PA after PHL and OHL was done using a paired t-test with a 95% confidence interval.

RESULTS

The first surgeon was at ease in palpating and identifying the semimembranosus tendon before PHL in ten knees only. PHL led to an undesirable cut of the semimembranosus muscle fibres to more than 50% of the muscle section area in eight cases (<50% in 23 cases, between 50% and 75% in eight cases), and of the semitendinosus muscle fibres to more than 50% in all cases (complete rupture in six cases, more than 75% in eight cases and approximately 50% in 17 cases). Mean PA measured 52° pre-operatively and decreased to 40° after PHL. After OHL, the PA averaged 22°. There was a significant difference between the PA value after PHL (M = 40, SD = 11.8) and the PA value after OHL (M = 22, SD = 8.7), p < 0.0001. The gain in PA did not correlate with the extent of semimembranosus muscle divided (p = 0.38) nor with the extent of semitendinosus muscle divided (p = 0.35). No major iatrogenic neurovascular injury was observed.

CONCLUSIONS

To the authors' knowledge, this is the first prospective study concerning the anatomic effects of PHL. Although it is a quick procedure, it is often associated with difficulty by the operating surgeon to identify and evaluate what should be cut percutaneously, leading to abusive injury of the muscle itself rather than the fascia alone. In addition, the gain in PA is statistically less following PHL than following OHL despite undesirable extensive muscle injury following PHL. This may be due to the multiple fascial cuts (fractional lengthening) usually performed in OHL.

Management of spinal infections in children with cerebral palsy

Cerebral palsy patients who undergo posterior spinal instrumentation for scoliosis are at a greater risk of surgical site infection compared to adolescents with idiopathic scoliosis. Many infecting organisms are reported. Risk factors include patients' specific factors, nutritional status as well as surgery related factors. Although surgical management is still controversial, it is always based on irrigation and debridement followed or not by implant removal. The purpose of this paper is to review the pathophysiology of surgical site infection in this patient population and to propose a treatment algorithm, based on a thorough review of the current literature and personal experience.

Performance of the clinical index of stable febrile neutropenia (CISNE) in different types of infections and tumors

PURPOSE

The clinical index of stable febrile neutropenia (CISNE) can contribute to patient safety without increasing the complexity of decision-making. However, febrile neutropenia (FN) is a diverse syndrome. The aim of this analysis is to assess the performance of CISNE according to the type of tumor and infection and to characterize these patients.

METHODS

We prospectively recruited 1383 FN episodes in situations of apparent clinical stability. Bonferroni-adjusted z tests of proportions were used to assess the association between the infections suspected at the time of onset and the type of tumor with the risk of serious complications and mortality. The performance of CISNE was appraised in each category using the Breslow-Day test for homogeneity of odds ratios and Forest Plots.

RESULTS

171 patients had a serious complication (12.3 %, 95 % confidence interval 10.7-14.2 %). The most common initial assumptive diagnoses were: fever without focus (34.5 %), upper respiratory infection (14.9 %), enteritis (12.7 %), stomatitis (11.8 %), and acute bronchitis (10.7 %). Lung and breast were the most common tumors, accounting for approximately 56 % of the series. The distribution of complications, mortality, and bacteremia varies for each of these categories. However, Breslow-Day tests indicate homogeneity of the odds ratio of the dichotomized CISNE score to predict complications in all infection and tumor subtypes.

CONCLUSION

Despite FN's clinical and microbiological heterogeneity, the CISNE score was seen to be consistent and robust in spite of these variations. Hence, it appears to be a safe tool in seemingly stable FN.

Long-term survival in patients with metastatic renal cell carcinoma (mRCC) in the era of new targeted therapies: Five-year follow-up in a single Spanish medical institution (Genito-Urinary Tumor Unit, University Hospital 12 de Octubre)

376

Background: Recently, new targeted therapies have proved the efficacy in patients with mRCC in terms of progression-free survival (PFS) and overall survival (OS). There is also growing evidence that successive targeted treatments has achieved objective responses and sustained time to progression. Here, we report data from our insitution analysing the OS benefit of continuing targeted therapy after disease progression.

Methods: We identified 58 metastatic clear cell RCC patients who started targeted therapy between September 2005 and December 2008. The data were collected from our clinical trials registry. The patients were evaluated for differences in baseline characteristics and known prognostic factors (PFs) in metastatic RCC. We assessed overall survival for all patients.

Results: We identified 58 pts, 24 are still alive (43%). Median age was 56 (range 31–78). ECOG PS 0/1/2: 33/24/1. 46% (27) had diagnosis to treatment intervals < 1 year. Sites of metastatic disease included: lung 46%(26), bone 32%(19), hepatic 29%(17) and retroperitoneal 24%(14). Nephrectomy was pesented in 90% of all pts. The number of metastases location was: 1/2/3: 32%/11%/7%. The drugs administered are listed in table. Median number of treatments: 3 (range 1–7). The median overall survival (OS) was 44 months and the 3- year OS was 60.4%. Pts by MSKCC risk-group were: favourable prognostic (FP) 19%, intermediate prognostic (IP) 63%, poor prognostic (PP) 18%. The overall survival for FP group was not reached, and 3-year OS was 81%; for IP group the median survival time was 44 months and 3-year OS was 59%; and for PP group the median survival time was 25 months.

Conclusions: The survival for patients with mRCC who receive multiple lines of targeted therapy has increased to close to 4 years. These results indicate a clear shift in the evolution of mRCC but lack a great deal about what the best sequence. Final analysis of the best sequence of treatment will be presented at the meeting.

[Table: see text]

P4-09-34: Luminal Infiltrating Lobular Carcinoma of the Breast: Clinical and Prognostic Features

Background

Infiltrating lobular carcinoma (ILC) and infiltrating ductal carcinoma (IDC) are the two most common histologic types of invasive breast cancer. Previous studies have demonstrated distinctive clinical and biologic characteristics, however some features of ILC are yet uncertain like the relationship with the particular subtypes according to the gene expression profile.

The purpose of our study is to analyze how the patients with ILC differ from IDC regarding of percentage of luminal subtype, the tumor factors, treatment and patterns of recurrence.

Patients and Methods

We assessed 1190 breast cancer patients treated at the Hospital Universitario 12 de Octubre between 1995 and 2006 categorized as having ILC or IDC pure types.

Results: One thousand one hundred ninety tumors were included, being ILC 223 patients (18, 7%), IDC 967 patients (81, 3%) and 200 patients (10%) were luminal HER2+. The current analysis is limited to the 990 patients classified as luminal HER2−.

Median age was 59, 2 years for ILC and 58, 8 for IDC, with no significant differences among the groups. Compared to IDC, ILC showed a larger tumor size (≥T3: 15, 2% vs. 4, 8%, ***p&lt;0.01), lesser nodal involvement (35% vs 42, 7% p 0.048) and lower Ki67 expression (62, 6% vs. 52, 2% p=0.01). The proportion of luminal A subtype was greater in ILC (56, 3% vs. 46, 7% p=0.01). Mastectomy was more frequently performed for ILC (61, 2 % vs. 47, 7%, p=0.01). Regarding systemic therapy, 127(62,4%) ILC patients and 450 (57, 2%) IDC patients received adjuvant chemotherapy (QT). That was anthracycline-based in most cases (47, 2% for ILC and 46,4% for IDC). Adjuvant hormonal treatment was prescribed equally among both groups (196, 96% ILC and 739, 94% IDC), being the most commonly used drug ***tamoxifen.

With a median follow-up of 94 months, 45 ILC patients (22%) and 159(20, 2%) IDC relapsed. No differences were observed in DFS (p=0, 81) or OS (p=0, 47).

The most frequent metastatic site was bone (33% for ILC and 40, 8% for IDC), followed by local relapses (17, 7% for ILC vs. 17% for IDC) and liver (15, 5% for ILC vs. 15, 7% for IDC). ILC was associated with an increased incidence of peritoneal/mesenteric metastases (8 pts 17, 7% vs. 1pts 0,6% ***p&lt;0.01) and a lower incidence of lung relapses (8, 8% vs. 19, 4 % pts p&lt;0.05).

Conclusion: Luminal HER2− Infiltrating lobular carcinoma carries distinct clinicopathological features. In our study, ILC had similar prognosis as IDC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-09-34.

P3-05-06: Progression of Breast Cancer Molecular Subtypes through Different Clinical Stages

Purpose : Molecular classification of breast cancer (BC) through immunohistochemistry classifies patients globally in 4 subtypes with similar features and prognosis. The present study was designed to compare features of BC subtypes in early versus locally advanced clinical stages. A secondary objective was compare molecular subtypes of the primary vs recurrences.

Methods : The study included 1621 patients with non-metastatic invasive BC that were consecutively diagnosed at Hospital Universitario 12 de Octubre, Madrid, between 1997 and 2007. Luminal A was defined as ER+ and PR+, HER2−negative and Ki67 &lt; 14%. Luminal B was defined as PR-negative, HER2−positive or ki67≥14%. HER2 was defined as ER and PR-negative, and HER2−positive.Triple negative (TN) were tumors with ER, PR and HER2 -negativity. Clinicopathological characteristics and outcomes were retrospectively reviewed. Variables were compared with the X2 test, and survival curves were evaluated with Kaplan-Meier method.

Results : Most patients were diagnosed as T1 (48%) and T2 (39.7%) clinical stages, and classified as Luminal B (49%) and Luminal A (29%). GIII frequency increased from T1 to T3-4 in Luminal A (p=0.002), and Luminal B (p=0.051) subtypes, but not in HER2 (p=0.867) or TN (p=0.53).

Lumbar disc herniation in young children

AIM

This article explores lumbar disc herniation in young children through focusing on matters relevant to patient presentation, physical examination, differential diagnosis, imaging and treatment.

METHODS

Major databases were searched for studies that addressed lumbar disc herniation in young children.

RESULTS

Diagnosis of lumbar disc herniation in young children is usually delayed because of the rarity and lack of experience with this entity and the difficulty in extracting a reliable medical history. Nevertheless, lumbar disc herniation should be considered in the differential diagnosis of any young child presenting with a chief complaint of back pain and/or radiculopathy, especially in the setting of recent trauma. This should be coupled with a directed physical examination to elicit signs and narrow the differential diagnosis. Imaging studies, mainly magnetic resonance imaging, will help establish a diagnosis; yet radiographs are still required to exclude other spinal lesions. The initial management of lumbar disc herniation in children is the same as that in adults and consists of conservative treatment unless lumbar disc herniation affects the patient's motor and neurological functions in which case, early surgical treatment must be undertaken. Although the latter remains more difficult, current experience suggests a favourable outcome.

CONCLUSION

Awareness of lumbar disc herniation will help the paediatrician extract a relevant medical history, perform a directed physical examination, and order appropriate imaging studies. This will aid in initiating early intervention, be it conservative or operative, and achieving a favourable outcome.

The era of oral drugs in oncology: What do patients think about their efectiveness?

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Background: With the growing number of drugs available for the treatment of cancer, most of them of oral administration, some aspects of the everyday clinical practice are changing. Interesting is the opinion of the patients (pts) about oral therapy. Methods: We researched differences in preference, tolerance, effectiveness, and safety by means of the delivery of a survey to (pts) who had received oral and intravenous (IV) treatment. One hundred and ninety (pts) were enrolled from September to November 2008. Results: Seventy percent of the (pts) studied were women, the median age at diagnosis was 60 years (range, 28 - 91 years). Fifty percent had gynaecologic tumors; thirty percent digestive; eighteen percent lung cancer and two percent other tumors, with a median of 3 different lines of therapy (range, 1 to 9). Patients preferred the oral route over the IV (76% vs. 20% respectively; P<0.001) and four percent had no preference. Tolerance was better with oral therapy (64%) than with (IV) chemotherapy (CT) (36%; P<0.001). When the (pts) were asked for effectiveness, sixty percent of them considered the (IV) chemotherapy more effective, while eleven percent chose oral therapy and twenty-nine percent found both equally effective (p<0.001). Sixty one percent of the (pts) evaluated as more secure (IV) chemotherapy, while eight percent did so with oral therapy and thirty one percent did not think that differences existed with one or another route of administration (p< 0.001). Conclusions: The constant evolution in cancer therapy and the increasing participation of (pts) in therapeutic decisions makes it imperative to know the opinion of (pts) on these new treatments. When patients are asked for tolerance or preference, the majority of them choose the oral route. However, when asked about important issues such as effectiveness or safety that offers a treatment, most of them prefer the intravenous route.

No significant financial relationships to disclose.

Effect of gamma radiation on the inactivation of aflatoxin B1 in food and feed crops

Samples of food crops (peanut, peeled pistachio, unpeeled pistachio, rice, and corn) and feed (barley, bran, corn) were autoclave-sterilized, and inoculated with 10⁶ of spore suspension of an isolate of Aspergillus flavus fungus known to produce aflatoxin B1 (AFB1) . Following a 10-day period of incubation at 27 C to allow for fungal growth, food and feed samples were irradiated with gamma radiation at the doses 4, 6, and 10 kGy. Results indicated that degradation of AFB1 was positively correlated with the increase in the applied dose of gamma ray for each tested sample. At a dose of 10 kGy percentages of AFB1 degradation reached highest values at 58.6, 68.8, 84.6, 81.1 and 87.8% for peanuts, peeled pistachios, unpeeled pistachios, corn and rice samples, respectively. In feed samples percentages of AFB1 degradation were 45, 66, and 90% in barley, 47, 75, and 86% in bran, and 31, 72, and 84% in corn for the doses of 4, 6, and 10 kGy, respectively. AFB1 degradation in food samples correlated negatively with oil content in irradiated samples. Thus, in peanuts, which contained the highest oil content, percentage of AFB1 degradation at 10 kGy was not more than 56.6%, whereas, the corresponding value in corn, which contained the lowest oil content, reached as high as 80%. The above results indicate the possibility of using gamma radiation as a means of degradation of AFB1 in food and feed crops to levels lower than the maximum allowed levels.