AZOOR with unilateral disc edema: An atypical case report

Acute zonal occult outer retinopathy (AZOOR) diagnosis is challenging and frequently delayed. Atypical findings were described, nevertheless optic disc edema has not been consistently reported. In this study we pretend to describe a challenging diagnosis of AZOOR. In our case, a 19-year-old female presented painless vision loss in her right eye for 2 weeks. Fundus examination revealed optic disc hyperaemic edema and the visual field (VF) an enlarged blind spot. Non-infectious optic neuritis was assumed and intravenous corticotherapy administered. Four months later, VA had improved, but a VF defect persisted. Funduscopic examination showed mild peripapillary atrophy and autofluorescence zonal hyperautofluorescence around optic disc. Optical coherence tomography demonstrated diffuse loss of outer retinal layers and electroretinogram weakened signal at the corresponding region. In conclusion, unilateral optic disc edema, generally not associated with AZOOR typical presentation, hamper an early diagnosis and expresses this case relevance.

Insights into the antiviral activity of phospholipases A2 (PLA2s) from snake venoms

Viruses are associated with several human diseases that infect a large number of individuals, hence directly affecting global health and economy. Owing to the lack of efficient vaccines, antiviral therapy and emerging resistance strains, many viruses are considered as a potential threat to public health. Therefore, researches have been developed to identify new drug candidates for future treatments. Among them, antiviral research based on natural molecules is a promising approach. Phospholipases A₂ (PLA₂s) isolated from snake venom have shown significant antiviral activity against some viruses such as Dengue virus, Human Immunodeficiency virus, Hepatitis C virus and Yellow fever virus, and have emerged as an attractive alternative strategy for the development of novel antiviral therapy. Thus, this review provides an overview of remarkable findings involving PLA₂s from snake venom that possess antiviral activity, and discusses the mechanisms of action mediated by PLA₂s against different stages of virus replication cycle. Additionally, molecular docking simulations were performed by interacting between phospholipids from Dengue virus envelope and PLA₂s from Bothrops asper snake venom. Studies on snake venom PLA₂s highlight the potential use of these proteins for the development of broad-spectrum antiviral drugs.

Monitoring tumor response to neoadjuvant chemotherapy using MRI and 18F-FDG PET/CT in breast cancer subtypes

Purpose

To explore guidelines on the use of MRI and PET/CT monitoring primary tumor response to neoadjuvant chemotherapy (NAC), taking breast cancer subtype into account.

Materials and methods

In this prospective cohort study, 188 women were included with stages II and III breast cancer. MRI and ¹⁸F-FDG-PET/CT were acquired before and during NAC. Baseline pathology was assessed from tumor biopsy. Tumors were stratified into HER2-positive, ER-positive/HER2-negative (ER-positive), and ER-negative/PR-negative/HER2-negative (triple-negative) subtypes, and treated according to subtype. Primary endpoint was pathological complete response (pCRmic) defined as no or only small numbers of scattered invasive tumor cells. We evaluated imaging scenarios using MRI only, PET/CT only, and combinations.

Results

pCRmic was found in 35/46 (76.1%) of HER2-positive, 11/87 (12.6%) of ER-positive, and 31/55 (56.4%) of triple-negative tumors. For HER2-positive tumors, MRI yielded the strongest predictor (AUC: 0.735; sensitivity 36.2%), outperforming PET/CT (AUC: 0.543; p = 0.04), and with comparable results to combined imaging (AUC: 0.708; p = 0.213). In ER-positive tumors, the combination of MRI and PET/CT was slightly superior (AUC: 0.818; sensitivity 55.8%) over MRI alone (AUC: 0.742; p = 0.117) and PET/CT alone (AUC: 0.791). However, even though relatively large numbers of ER-positive tumor patients were included, no significant differences were yet found. For triple-negative tumors, MRI (AUC: 0.855; sensitivity 45.4%), PET/CT (AUC: 0.844; p = 0.220) and combined imaging (AUC: 0.868; p = 0.213) yielded comparable results.

Conclusions

For HER2-positive tumors, MRI shows significant advantage over PET/CT. For triple-negative tumors, comparable results were seen for MRI, PET/CT and combined imaging. For ER-positive tumors, combining MRI with PET/CT may result in optimal response monitoring, although not yet significantly.

PET/CT with 18F-FDG predicts short-term outcome in stage II/III breast cancer patients upstaged to N2/3 nodal disease

INTRODUCTION

¹⁸F-FDG PET/CT has high positive predictive value for the detection of avid lymph node metastases in breast cancer patients. We analysed the effect of upstaging lymph nodes by PET/CT on short-term outcome in stage II/III breast cancer patients.

PATIENTS AND METHODS

A total of 278 stage II/III primary breast cancer patients (mean age 48.9 years, range 19-75 years) were re-staged with ¹⁸F-FDG PET/CT before start of pre-operative systemic treatment (PST). Patients were divided in three groups based on risk for local recurrence: a low - (T2N0), intermediate - (T0-2N1 and T3N0) and a high-risk group (T0-3N2-3, T3N1 and T4). Within these groups we looked at local recurrence-free survival (LRFS), recurrence-free survival (RFS) and overall survival (OS) within the first 3 years of follow-up.

RESULTS

With a median follow-up (FU) of 50 months the RFS, LRFS and OS were 87%, 88% and 92% respectively for the whole group. PET/CT upstaged 43 patients from the low- and intermediate risk group to the high-risk group, based on detection of ≥4 avid axillary nodes or occult N2/3-disease. Patients upstaged with PET/CT had more events for all three analyses compared to the original risk groups, which resulted in a significantly worse RFS (69.8%; p = 0.03) a nearly significantly worse LRFS (p = 0.052) and no effect in OS (p = 0.433).

DISCUSSION

Additional PET/CT staging allows breast cancer patients to be treated according to the true stage, still stage II/III breast cancer patients upstaged to N2/3 by PET/CT have worse short-term outcome, despite adjustment of treatment, than patients staged high-risk with conventional imaging.

Contribution of SPECT/CT for sentinel node localization in patients with ipsilateral breast cancer relapse

Background

In recent years repeat sentinel node (SN) biopsy has been proven to be feasible in local breast cancer recurrence (LBCR). However, in these patients SNs outside the ipsilateral axilla are frequently observed. This study evaluates the contribution of SPECT/CT for SN localization and surgical adjustment in LBCR patients.

Methods

SN biopsy was performed in 122 LBCR patients (median age 60.5 years, range 24–87), enrolled from August 2006 to July 2015. Median disease-free time lapse was 109.5 months (range 9–365). Axillary lymph node dissection (ALND) had previously been performed in 55 patients, SN biopsy in 44, both techniques in 13 and fine-needle aspiration in 10. Primary breast cancer treatment included radiotherapy in 104 patients (85.3 %) and chemotherapy in 40 (32.8 %). Preoperative lymphatic mapping, using planar scintigraphy (PS) and SPECT/CT included report of SN location according to lymph node territory. In case of a territorial PS-SPECT/CT mismatch, surgery was adjusted according to SPECT/CT findings.

Results

SPECT/CT SN visualization rate was higher than PS (53.3 % vs. 43.4 %, p n.s.) with, in total, 19 additional SN (118 vs. 99, p n.s.). PS-SPECT/CT territory mismatch, found in 60 % (39/65) of patients with SN visualization, led to surgical adjustment in 21.3 % (26/122) of patients. The SN procedure was finally performed in 104 patients resulting in a 65.7 % surgical retrieval rate with a total of 132 removed SNs (1.86/patient). SN metastases were found in 17/71 patients (23.9 %), in 16 of them (94 %) in ipsilateral basins outside the axilla or in the contralateral axilla.

Conclusion

Using SPECT/CT there is a trend to visualize more SNs in LBCR, providing at the same time important anatomical information to adjust intraoperative SN procedures. The addition of SPECT/CT to the standard imaging protocol may lead to better staging mainly in patients presenting drainage outside the ipsilateral axilla.

Abstract P1-02-03: The effect on short–term progression free survival of the detection of ≥4 FDG-avid nodes or occult N3–disease in breast cancer patients with PET/CT

Aim: The risk for locoregional recurrence (LRR), after neoadjuvant chemotherapy (NAC), is based on staging before NAC as well as the final pathology after NAC. Especially the number of tumour–positive axillary nodes, which is also an important selection factor for postoperative radiotherapy, is not adequately assessed by ultrasound before NAC or axillary lymph node dissection after NAC. PET/CT has a high positive predictive value for the detection of lymph node metastases. Newly found lymph node metastasis on PET/CT incentivized us to change the radiotherapy plan for patients with primary breast cancer scheduled for NAC in our institute.

Koolen et al. reported an upstaging of 23% stage II–III breast cancer patients to the radiotherapy requiring high–risk group (≥4 FDG–avid axillary nodes or detection of occult N3–disease) due to new lymph node metastasis detected with FDG PET/CT imaging. In this study, we report the effect of this upstaging with PET/CT short–term progression free survival (PFS).

Materials and methods:

Between 2007 and 2011 a total of 278 breast cancer patients (mean age 48.9y, range 19–75y), with a tumour of at least 3 cm and without metastases, received a baseline PET/CT for staging purposes and subsequent response monitoring to NAC. The group was divided in three groups: a low– (T2N0), intermediate– (T0–2N1 and T3N0) and a high–risk group (T0–3N2–3, T3N1 and T4). We classified LRR, distant metastases and death as an "event"; including all patients in the PFS analysis of the first 3 years.

Results:

With a median follow–up (FU) of 37 months and the upstaging as depicted in table 1

Upstaging of breast cancer risk-group after PET/CTTotal group before PET/CTChanged After PET/CTComplete after PET/CT (FU-events)Low-risk: N=47N=5Low-risk (2) N= 42Intermediate-risk: N=144N=38Intermediate-risk N= 106 (14)High-risk: N=87xHigh-risk N= 130 (27)Total: N=278Total: N= 43Total N= 278Table 1: The group was divided in three groups: a low- (T2N0), intermediate- (T0-2N1 and T3N0) and a high-risk group (T0-3N2-3, T3N1 and T4). The table shows the upstaging of breast cancer patients from low- and intermediate- to the high-risk group, and thus, after PET/CT, requiring radiotherapy.

: The patients not upstaged by PET/CT showed no difference in PFS between the high–risk, intermediate–risk and low–risk groups (Logrank p=0.18). Due to the migration of the 43 patients from the low– and intermediate group to the high–risk group, based on PET/CT findings, the PFS differed significantly between the risk–groups (Logrank p=0.04). No difference in loco–regional recurrence was seen between the low–risk and the high–risk group (P=0.18).

Conclusion:

After upstaging with PET/CT, into the high–risk group requiring radiotherapy, a significant difference is seen between the three risk–groups. PET/CT restaging may more adequately predict progression free survival. The detection occult lymphatic metastasis with PET/CT leads to upstaging in clinically unsuspected patients with primary breast cancer, enabling adequate radiotherapy treatment.

Citation Format: Suzana C Teixeira, Bas B Koolen, Paula HM Elkhuizen, Vincent van der Noort, Marie-Jeanne Vrancken-Peeters, Marcel P Stokkel, Emiel J Th Rutgers, Renato A Valdés-Olmos. The effect on short–term progression free survival of the detection of ≥4 FDG-avid nodes or occult N3–disease in breast cancer patients with PET/CT [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-02-03.

Abstract P5-01-14: Visualisation of histologic proven breast cancer on the MAMMI-PET: A dedicated PET for hanging breast imaging

Aim: The MAMMI–PET, a high–resolution full–ring system for dedicated hanging breast imaging was originally developed in the context of a EU–founded project to improve the detection of breast cancer. The aim of the present study was to evaluate the performance of the MAMMI–PET device in patients with at least one histologic confirmed primary breast cancer lesion (or index lesion), scanned in two European centres. All patients were included in the study after being scheduled to receive pre–operative chemotherapy (NAC) or radiotherapy.

Material and methods:

From March 2011 to March 2014, we included 234 female patients (mean age 52 y, range 24–82y) with histologically confirmed breast cancer. All patients were scanned with the MAMMI–PET (Oncovision, Valencia, Spain) after giving informed consent. Scans were acquired 110 min after a dose of a mean dose of 197.12 MBq18F–FDG. In both centers the acquisitions, the reconstruction of the images and the data collection were performed using similar standardized methods. We tested the relation between visualization of the primary tumor and possible additional lesions on the MAMMI–PET as well as the influence of various variables; including age, weight, breast cancer subtypes and receptor status, breast length, maximal tumor diameter and affected breast quadrants.

Results: A total of 236 breasts were imaged and 211 (98.4%) of the index lesions (diameter 5–170 mm, mean 32 mm) were located within the MAMMI–PET scanning range. Of all index lesions within the scanning range 1.4% was not FDG avid on the MAMMI–PET images. Lesions that were FDG-avid were either clearly (86.3%) or moderately (12.3%) visible. The overall MAMMI–PET sensitivity increased from 88.6% to 98.6% after exclusion of lesions outside the scanning range. No significant differences in lesion visibility were found due to breast cancer subtypes or breast quadrant location. Of the 35 index lesions touching the pectoral muscle 62.9% reached into the scanning range. A total of 41 additional FDG-avid lesions were detected, not categorized as an index tumor.

Conclusions:

The MAMMI–PET missed only a small percentage of malignant lesions located within the scanning range of the device. Lesions near the pectoral muscle were the subgroup less often visualized. No significant influence on the visualization of the FDG avid lesions was seen due to tumor subgroups, hormone receptor status, and breast quadrant location or tumor size.

Citation Format: Suzana C Teixeira, José Ferrer Rebolleda, Bas B Koolen, Raúl Sánches Jurado, Marcel P Stokkel, María del Puig Cózar Santiago, Emiel J Th Rutgers, Renato A Valdés-Olmos. Visualisation of histologic proven breast cancer on the MAMMI-PET: A dedicated PET for hanging breast imaging [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-01-14.

Abstract P1-02-02: Locoregional assessment by FDG PET/CT in stage II/III breast cancer patients: A multivariate analysis

Aim : Previously we demonstrated the additional value of PET/CT in prone position for breast cancer detection. The purpose of the present study was to evaluate, with a multivariate analysis, the factors influencing detection and quantification of FDG–avid primary tumors (PT) and regional lymph node metastases (LN) detected with PET/CT in patients with stage II/III breast cancer.

Materials and methods : From August 2010 to April 2012 we included 198 patients (mean 51 yr, range 26–82), with stage II/III breast cancer. A dose of 18F–FDG between 180–240 MBq, was administered intravenously. After 60±10 minutes a PET/CT of the thorax in prone position was acquired, scanning 3.00 min per bed position and reconstructed in high–resolution using 2x2x2 mm voxels and 2 mm CT slice thickness. Subsequently, a standard PET/CT was performed in supine position from skull base to thighs, scanning 1.30 min per bed position and using a standard reconstruction with 4x4x4 mm voxels, a standard 5mm CT slice reconstruction and an extra 2 mm CT slice reconstruction. On all PET/CT images we quantitatively assessed the SUVmax of FDG–avid PTs and LNs. We qualitatively assessed tumor multifocality, PT visibility, LN detection in defined regions and the occurrence of anatomical mismatch between PET and CT. The obtained results were then evaluated with a multivariate analysis for scanning position, patient age, breast size, tumor volume, number of FDG–avid lesions, lymph node location and anatomical mismatch between PET and CT.

Results: Prone position imaging positively influenced the visualization of tumor multifocality (p<0.001), the total number of lymph nodes (p<0.001) and of axillary LNs (p<0.001). PT visibility was not significantly influenced by any of the parameters.

A higher SUVmax of the primary tumor was found solely with increased tumor volume (p=0.001) or breast size (p<0.001). The standard 5mm CT slice reconstruction of the supine PET/CT was the only factor causing an increase in anatomical mismatch between PET and CT for axillary lymph nodes (p=0.004).

Conclusion: Prone position for PET/CT influences the visualization of primary tumor multifocality and the number of FDG avid loco-regional lymph nodes. Tumor FDG-uptake appears to be most influenced by tumor volume and breast size. Both results can be important for adequate staging and subsequent breast cancer treatment.

Citation Format: Suzana C Teixeira, Bas B Koolen, Wouter V Vogel, Marcel P Stokkel, Marie-Jeanne Vrancken-Peeters, Vincent van der Noort, Emiel J Th Rutgers, Renato A Valdés-Olmos. Locoregional assessment by FDG PET/CT in stage II/III breast cancer patients: A multivariate analysis [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-02-02.

Substrate specificity and subsite mobility in T. aurantiacus xylanase 10A

The substrate specificity of Thermoascus aurantiacus xylanase 10A (TAX) has been investigated both biochemically and structurally. High resolution crystallographic analyses at 291 K and 100 K of TAX complexes with xylobiose show that the ligand is in its alpha anomeric conformation and provide a rationale for specificity on p-nitrophenyl glycosides at the -1 and -2 subsites. Trp 275, which is disordered in uncomplexed structures, is stabilised by its interaction with xylobiose. Two structural subsets in family 10 are identified, which differ by the presence or absence of a short helical stretch in the eighth betaalpha-loop of the TIM barrel, the loop bearing Trp 275. This structural difference is discussed in the context of Trp 275 mobility and xylanase function.

[Botulinum toxin the treatment of spasmodic torticollis: a meta-analysis]

The authors made a meta-analysis of the results of botulinum toxin injection for the treatment of spasmodic torticollis. They concluded that botulinum toxin is effective for the treatment of cervical dystonia.