Shin Ahn

Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy

OBJECTIVES The purpose of this study was to determine the relative accuracies of mammography, sonography, MRI and clinical examination in predicting residual tumour size and pathological response after neoadjuvant chemotherapy for locally advanced or inflammatory breast cancer. Each prediction method was compared with the gold standard of surgical pathology. METHODS 43 patients (age range, 25-62 years; mean age, 42.7 years) with locally advanced or inflammatory breast cancer who had been treated by neoadjuvant chemotherapy were enrolled prospectively. We compared the predicted residual tumour size and the predicted response on imaging and clinical examination with residual tumour size and response on pathology. Statistical analysis was performed using weighted kappa statistics and intraclass correlation coefficients (ICC). RESULTS The ICC values between predicted tumour size and pathologically determined tumour size were 0.65 for clinical examination, 0.69 for mammography, 0.78 for sonography and 0.97 for MRI. Agreement between the response predictions at mid-treatment and the responses measured by pathology had kappa values of 0.28 for clinical examination, 0.32 for mammography, 0.46 for sonography and 0.68 for MRI. Agreement between the final response predictions and the responses measured by pathology had kappa values of 0.43 for clinical examination, 0.44 for mammography, 0.50 for sonography and 0.82 for MRI. CONCLUSION Predictions of response and residual tumour size made on MRI were better correlated with the assessments of response and residual tumour size made upon pathology than were predictions made on the basis of clinical examination, mammography or sonography. Thus, the evaluation of predicted response using MRI could provide a relatively sensitive early assessment of chemotherapy efficacy.

The usefulness of procalcitonin and C-reactive protein as early diagnostic markers of bacteremia in cancer patients with febrile neutropenia.

Purpose Procalcitonin (PCT) and C-reactive protein (CRP) are well known inflammatory markers. This study was designed to determine whether PCT and CRP are useful as early diagnostic markers for bacteremia in cancer patients with febrile neutropenia (FN) in the emergency department (ED). Materials and Methods In this retrospective study, 286 episodes of FN in the ED were consecutively included between June 2009 and August 2010. From medical records, clinical characteristics including PCT and CRP were extracted and analyzed. Results Bacteremia was identified in 38 (13.3%) of the 286 episodes. The median values of PCT (2.8 ng/mL vs. 0.0 ng/mL, p=0.000) and CRP (15.9 mg/dL vs. 5.6 mg/dL, p=0.002) were significantly higher in the group with bacteremia compared to the group without bacteremia. In univariate analysis, elevated PCT (>0.5 ng/mL) and CRP (>10 mg/dL) as well as older age, hypotension, tachycardia, tachypnea, and high body temperature were significantly associated with bacteremia. On multivariate analysis, elevated PCT (>0.5 ng/mL) (odds ratio [OR], 3.6; 95% confidence interval [CI], 1.4 to 9.2; p<0.01) and tachypnea (OR, 3.4; 95% CI, 1.4 to 8.5; p<0.01) were independent early diagnostic markers for bacteremia in FN patients. The area under the curve of PCT was 74.8% (95% CI, 65.1 to 84.6%) and that of CRP was 65.5% (95% CI, 54.8 to 76.1%). With a PCT cut-off value of 0.5 ng/mL, sensitivity and specificity were 60.5% and 82.3%, respectively, while the sensitivity and specificity were 57.6% and 67.3%, respectively, with a CRP cutoff of 10 mg/dL. Conclusion These findings suggest that PCT is a useful early diagnostic marker for the detection of bacteremia in FN at the ED and has better diagnostic value than CRP.

Correlation between mammographic and sonographic findings and prognostic factors in patients with node-negative invasive breast cancer

OBJECTIVES The purpose of this study was to correlate sonographic and mammographic findings with prognostic factors in patients with node-negative invasive breast cancer. METHODS Sonographic and mammographic findings in 710 consecutive patients (age range 21-81 years; mean age 49 years) with 715 node-negative invasive breast cancers were retrospectively evaluated. Pathology reports relating to tumour size, histological grade, lymphovascular invasion (LVI), extensive intraductal component (EIC), oestrogen receptor (ER) status and HER-2/neu status were reviewed and correlated with the imaging findings. Statistical analysis was performed using logistic regression analysis and intraclass correlation coefficient (ICC). RESULTS On mammography, non-spiculated masses with calcifications were associated with all poor prognostic factors: high histological grade, positive LVI, EIC, HER-2/neu status and negative ER. Other lesions were associated with none of these poor prognostic factors. Hyperdense masses on mammography, the presence of mixed echogenicity, posterior enhancement, calcifications in-or-out of masses and diffusely increased vascularity on sonography were associated with high histological grade and negative ER. Associated calcifications on both mammograms and sonograms were correlated with EIC and HER-2/neu overexpression. The ICC value for the disease extent was 0.60 on mammography and 0.70 on sonography. CONCLUSION Several sonographic and mammographic features can have a prognostic value in the subsequent treatment of patients with node-negative invasive breast cancer. Radiologists should pay more attention to masses that are associated with calcifications because on both mammography and sonography associated calcifications were predictors of positive EIC and HER-2/neu overexpression.

Comparative Efficacy of Sunitinib versus Sorafenib as First-Line Treatment for Patients with Metastatic Renal Cell Carcinoma

Background: This study investigated the efficacy and toxicity of sorafenib and sunitinib as primary treatment for patients with metastatic renal cell carcinoma (mRCC). Methods: We identified 49 and 220 patients treated with sorafenib and sunitinib, respectively, as first-line therapy in the Asan Medical Centre from April 2005 to March 2011. Results: Disease control rates of 71 and 74% were achieved with sorafenib and sunitinib, respectively (p = 0.687). After a median follow-up of 27.6 months, progression-free survival (PFS) and overall survival (OS) were not significantly different between the sorafenib and the sunitinib group (PFS 8.6 vs. 9.9 months, respectively, p = 0.948, and OS 25.7 vs. 22.6 months, p = 0.774). Patients treated with sorafenib required dose reduction due to toxicities less frequently than those treated with sunitinib (37 vs. 54%, p = 0.034). Haematological toxicity of grade 3 or 4 was more common in the sunitinib group than in the sorafenib group (45 vs. 4%, p < 0.001). Multivariate analysis showed old age, Hengs risk group, and bone and liver metastases, but not the type of vascular endothelial growth factor tyrosine kinase inhibitor, were independent prognostic factors affecting OS. Conclusion: The results of this study indicate that sorafenib has comparable efficacy to sunitinib in the treatment of mRCC patients and fewer and less severe toxicities, but the number of patients included in the study was small.

Role of procalcitonin and C‐reactive protein in differentiation of mixed bacterial infection from 2009 H1N1 viral pneumonia

Please cite this paper as: Ahn et al. (2011) Role of procalcitonin and C‐reactive protein in differentiation of mixed bacterial infection from 2009 H1N1 viral pneumonia. Influenza and Other Respiratory Viruses 5(6), 398–403.

Tissue microarray-based study of patients with lymph node-negative breast cancer shows that HER2/neu overexpression is an important predictive marker of poor prognosis

BACKGROUND Despite good prognosis in most cases of lymph node (LN)-negative breast cancer, individual patients may have markedly different clinical outcomes. Here, we investigated the prognostic significance of HER2/neu overexpression in these tumors. MATERIALS AND METHODS We employed a tissue microarray to examine HER2/neu overexpression by immunohistochemical staining in 359 consecutive patients diagnosed with LN-negative breast cancer, who underwent surgery from January 1993 to December 1998. RESULTS HER2/neu overexpression was detected in 81 of 359 (23.1%) patients. The 10-year disease-free survival (DFS) values (81.2% versus 61.8%, P value 0.000) and overall survival (OS) rates (85.7% versus 63.9%, P value 0.000) were significantly different between cases with HER2/neu-negative or HER2/neu-positive tumors. After multivariate analysis, HER2/neu status and tumor size were identified as independent prognostic factors for 10-year OS. Moreover, HER2/neu overexpression was significantly associated with poorer clinical outcomes in an intermediate-risk group identified by the St Gallen classification (10-year DFS, 79.6% versus 61.8%, P value 0.000; 10-year OS, 84.7% versus 63.9%, P value 0.000). CONCLUSIONS Our results show that HER2/neu overexpression is an important independent prognostic factor for LN-negative breast cancer cases and support the theory that more intensive adjuvant chemotherapy is required in the population with HER2/neu overexpression.

Transient global amnesia: seven years of experience with diffusion-weighted imaging in an emergency department.

Background/Aims: Hippocampal lesions on diffusion-weighted imaging (DWI) are commonly described in transient global amnesia (TGA). We evaluated the utility of DWI and the presence of hippocampal lesions in the diagnosis of TGA. Methods: A total of 203 TGA episodes were diagnosed at our emergency department from January 2003 to May 2010. DWI (5-mm slice thickness) was performed using a 1.5 T scanner. Patients were divided into 2 groups based on the presence of hippocampal lesions on DWI: DWI– and DWI+. The clinical characteristics and the time interval from development of amnesia to magnetic resonance imaging (MRI) were compared. Results: 16 patients had hippocampal lesions on DWI. The DWI– and DWI+ groups had similar clinical characteristics. The overall median time interval from amnesia to MRI was 6 h, and this interval was significantly longer for the DWI+ group than the DWI– group [9 h (IQR 6.5–25) vs. 5 h (IQR 4–9), p = 0.002]. Conclusion: DWI has a low diagnostic yield when performed early in the course of TGA. Positive findings can confirm the diagnosis, but in negative results, careful interpretation is required, including the time interval from amnesia to MRI.

Long-term neurological outcomes in patients after out-of-hospital cardiac arrest.

AIM The main treatment goal in survivors of out-of-hospital cardiac arrest (OHCA) is a favorable neurologic outcome. Little is known, however, about long-term trends of neurologic status in OHCA survivors. This study was designed to assess the rates of long-term neurologic recovery and survival according to neurologic status at one month. METHODS This retrospective observational study assessed all adult OHCA survivors (≥18 years) admitted to a tertiary hospital in an urban area who achieved return of spontaneous circulation (ROSC) between July 2005 and August 2013. Neurologic outcomes were measured by Cerebral Performance Category (CPC) score and patients were categorized according to CPC score at 1 month. Their neurologic status was re-evaluated 6, 12, and 24 months after cardiac arrest. RESULTS Of 778 OHCA cases, 282 patients (36.2%) were admitted to our hospital, and 279 were included in this study. At one month, 84 (30.1%) survivors were assessed with the CPC with 42.8% (n=36) having good neurologic outcome and 57.1% (n=48) poor neurologic outcome. Only two patients with poor neurologic outcome (4.1%) showed improved neurologic status from CPC 3 to CPC 2, during the first 6 months and none showed neurologic improvement after 6 months. The estimated 3-year survival was much higher for CPC 1 (96.4%) than for CPC 4 (24.2%) survivors. CONCLUSIONS Neurologic recovery of OHCA survivors with poor neurologic outcomes at one month was rare and did not occur more than 6 months after cardiac arrest.

Predictive factors for poor prognosis febrile neutropenia.

Purpose of review Most patients with chemotherapy-induced febrile neutropenia recover rapidly without serious complications. However, it still remains a life-threatening treatment-related toxicity, and is associated with dose reductions and delays of chemotherapeutic agents that may compromise treatment outcomes. Recent developments of risk stratification enabled early discharge with oral antibiotics for low-risk patients. However, even in low-risk patients, medical complications including bacteremia could happen. The authors reviewed recent literature to provide an update on research regarding predictive factors for poor prognosis in patients with febrile neutropenia. Recent findings Various prognostic factors have been suggested with controversies. Hematological parameters, prophylactic measurements and patient-specific risk factors showed inconsistent results. MASCC risk-index score, which was originally developed to identify low-risk patients, in turn showed that the lower the MASCC score, the poorer the prognosis of febrile neutropenia, with very low levels (<15), the rate of complications was high. Patients with severe sepsis and septic shock commonly had procalcitonin concentration above 2.0 ng/ml, and this level should be considered at high risk of poor prognosis. Summary Lower MASCC score and higher procalcitonin concentration can predict poor outcomes in febrile neutropenia. More research is required with regard to the other factors showing controversies.

Predicting Outcome With Diffusion-Weighted Imaging in Cardiac Arrest Patients Receiving Hypothermia Therapy: Multicenter Retrospective Cohort Study.

Objectives: Many comatose patients following cardiac arrest have ischemic brain injury. Diffusion-weighted imaging is a sensitive tool to identify hypoxic-ischemic brain injury. The accurate prediction of the prognosis for comatose cardiac arrest survivors has been challenging, and thus, a multimodal approach, combining diffusion-weighted image findings, could be feasible. The aim of this study was to assess regional brain injury on diffusion-weighted imaging and to test the potential association with its neurologic outcome in patients treated with target temperature management after out-of-hospital cardiac arrest. Design and Setting: A multicenter, registry-based, retrospective cohort study was conducted using cases from 24 hospitals across South Korea. Of the 930 adult (≥ 18 yr) nontraumatic out-of-hospital cardiac arrest patients treated with target temperature management between January 2007 and December 2012 at these hospitals, we included the patients who underwent brain diffusion-weighted imaging in the first week after cardiac arrest. The brain regions examined included the four cerebral lobes, basal ganglia-thalamus, brain stem, and cerebellum. Imaging results were compared between a good neurologic outcome, defined as a cerebral performance category score of 1 or 2, and a poor neurologic outcome (cerebral performance category score ≥ 3). Measurement and Main Results: Poor neurologic outcome occurred in 118 of the 172 patients analyzed (68.6%). Positive diffusion-weighted image findings, defined as any regional brain injury lesion in diffusion-weighted imaging, were present in 106 patients. Positive diffusion-weighted image findings had 93% sensitivity, 86% specificity, 76% positive predictive value, and 96% negative predictive value for a poor neurologic outcome. The poor outcome group had higher numbers of affected brain lesions than the good outcome group (3.8 ± 1.9 vs 0.1 ± 0.6; p < 0.01). By multivariate analysis, positive diffusion-weighted image findings (odds ratio, 58.2; 95% CI, 13.29–254.91) and lack of a shockable rhythm (odds ratio, 0.13; 95% CI, 0.03–0.57) were associated with a poor neurologic outcome. Conclusions: Diffusion-weighted imaging allows reliable prediction of poor neurologic outcome in comatose patients treated with target temperature management after out-of-hospital cardiac arrest. Further prospective validation study will be required to generalize this result.