Oral Presentation
Excellent Long-Term Breast Preservation Rate Following
Accelerated Partial Breast Irradiation Using a Balloon Device
J.M. Mann, M.D., A.D. Osian, M.S., A. Brandmaier, M.D., W. Yan, M.D.,
K. Sung, M.D., B. Siegel, M.D., S. Fink, M.D., B. Kaplan, M.D., M. Fulman, M.D.,
G. Wu M.S., P. Christos Dr.P.H., D. Nori, M.D., A. Ravi, M.D.
Background and objectives: Accelerated partial breast irradiation (APBI)
using a balloon device is well tolerated. A recent retrospective population-based
study showed that there was an increase in the rate of subsequent mastectomy
for patients who receive APBI, as compared to whole-breast radiation therapy.
Our aim was to analyze the long-term results of patients treated with APBI at our
institution, to determine salvage mastectomy rate, locoregional recurrence and
cosmesis outcomes.
Materials and methods: Following IRB approval, we conducted a retro-
spective review of 111 patients treated from June 2003 to October 2014 at our
institution for early breast cancer, using a balloon device. After lumpectomy and
nodal staging, patients received APBI via high-dose-rate (HDR) Ir192 brachytherapy. A CT-based 3D plan was performed and a dose of 34 Gy in 10 fractions was
given twice daily 6 hours apart, over 5 days. Follow-up was 2-3 times per year
either by a surgeon and/or radiation oncologist. Yearly mammograms were obtained. Patients included postmenopausal women with node-negative early stage
invasive ductal carcinoma with tumor size < 3 cm (n = 93) or ductal carcinoma in
situ (n = 18). Cosmesis was evaluated using Harvard criteria as excellent, good,
fair or poor.
Results: At a median follow-up time of 66 months after completing treatment
(range 1-139 months) and with a minimum of 5 years follow-up data for 55.9%
(n = 62) of patients, the incidence of ipsilateral breast tumor recurrence elsewhere (IBTRE) was 2.7% (n = 3) and the incidence of ipsilateral axilla nodal
recurrence was 1.8% (n = 2). The ipsilateral breast preservation rate was 97.3%.
Salvage mastectomy rate was 2.7% (n = 3), and 5-year salvage mastectomy
free rate was 98.7% (91.0%, 99.8%). There were no incidences of distant failure.
There were no breast cancer-related deaths. The 5-year overall survival rate was
91.7% (83.2%, 96.0%) and the 10-year breast cancer specific survival was 100%.
Of the 3 cases of IBTRE, two were ER negative (p = 0.076). Mean time to IBTRE
was 78.7 ± 27.5 months from treatment completion. A significant association was
noted between African-American ethnicity and IBTRE (p = 0.0398). Excellent to
good cosmesis was observed in 98.1% of patients. The maximum skin dose
(mean value) for patients with excellent, good, and fair cosmesis was 302.2 Gy,
315.4 Gy, and 372.5 Gy (88.9%, 92.7%, and 109.5% of the prescription dose),
respectively. The maximum skin dose was below 340 Gy (100% of prescribed
dose) in 69.9% of patients with excellent to good cosmesis.
Conclusion: Long-term follow-up of patients receiving APBI with a balloon
device showed low salvage mastectomy rate with durable long-term breast
preservation. Excellent local control with good cosmesis was noted in these
postmenopausal patients treated with accelerated partial breast irradiation.
11
Oral Presentation
Parental Knowledge of Child Development
S. Munoz-Blanco, M.D.,*† L. Gerber, Ph.D.,† G. Wu, M.S.,† S. Kopple, M.D.*
Background: The American Academy of Pediatrics (AAP) recommends
developmental surveillance at every well-child visit between birth and 5 years.
Research shows that surveillance is underperformed. 12-16% of children have
developmental or behavioral disorders.1 Only 20-30% of children with developmental disability are identified before entering school.2 Children of lower socioeconomic status, on public insurance, and minorities are at higher risk for
developmental delay.3 Early identification and early intervention of children with
developmental delay are key steps to improving the child's chances of success
and school readiness. Effectively exploring surveillance relies not just on provider
knowledge, but parental knowledge of developmental milestones in order to
help identify more latent concerns. There has been little research on parental
knowledge of normal development, nor has the research assessed parental
knowledge in the context of parental health literacy.
Objectives:
1. Assess parental knowledge of normal child development.
2. Assess parental knowledge of normal child development as a
function of parental health literacy level and demographic factors.
3. Explore parental satisfaction with provider elicitation of
developmental concerns.
Method: We conducted a cross-sectional anonymous survey to a convenience
sample of parents of children 9 to 36 months of age seen for a well-child visit or
sick visit at Theresa Lang Children's Center. The survey assessed: a) parental
knowledge of child development; b) health literacy level; and c) parental
satisfaction with care related to development. Basic demographic information
was collected. Questions evaluating parents' knowledge of child development
were modified from the Denver Development Screening Test. There were a total
of 12 developmental questions. Parents could score a maximum of 12 and a
minimum of 0. Health literacy level was assessed using a validated tool that asks
the question: "How often do you need to have someone help you when you read
instructions, pamphlets, or other written material from your doctor or pharmacy?"4
Parental satisfaction was assessed via structured questions. Demographic data
included: parental age, race/ethnicity, education level, place of birth, number of
children, whether the child received early intervention services or attendance at
day care. Chi square analyses were used.
Results: 64 surveys were completed. Knowledge of developmental milestones
was based on a minimum of 0 and a maximum of 12 correct answers. The mean
score was 3.2 and the maximum score was 8. There was no statistical correlation
between parental knowledge and health literacy. There was no association
* New York Hospital Queens
† Weill Cornell Medical College
Continued...
31
between parental knowledge and the following factors: number of children, early
intervention services, day care, parental age, place of birth, and education level.
The only statistically significant finding was an association with race/ethnicity,
with non-Hispanic white parents performing higher; however, few respondents
were non-Hispanic white (p < .0008). 92% of parents were satisfied with care
related to developmental assessment of their child.
Conclusions: Our preliminary results suggest that parental knowledge of child
development is poor across all developmental domains, regardless of health
literacy level and various demographic factors. Therefore, parental education is
key. Our next step is to implement an education project on child development
for all parents in our clinic to improve developmental knowledge and facilitate
addressing developmental concerns in a timely fashion.
References
1. Incorporating Comprehensive Developmental Screening into Program and Services for
Young Children (Ounce of Prevention Fund, 2006)
2. Developmental Screening in Early Childhood Systems: Summary Report (American
Academy of Pediatrics/Health Child Care America, 2009)
3. Improving the Lives of Young Children, the Role of Developmental Screenings in Medicaid
and CHIP (Urban Institute 2010) National Survey of Children's Health, New York State 2007
4. The Single Item Literacy Screener: Evaluation of a brief instrument to identify limited reading
ability (BMC Family Practice 2006)
32
Oral Presentation
Accuracy of Cellular Phone Applications in Predicting
The Fertile Window
R. Setton, M.D.,1 C. Tierney, M.D.,1 T. Tsai, M.D.2
Objective: Cellular phone applications (APPs) as a tool for timing intercourse
are widely used by couples trying to conceive. There is no current literature
describing the effectiveness of this method. In this study, we sought to determine
the accuracy of commonly used APPs in predicting the fertile window of a standard 28-day cycle.
Materials and methods: The top resulting fifteen free APPs for Android and
iOS cellular phones that provided calendars for fertility and ovulation prediction
were downloaded. Cycles were standardized to 28 days in length, 4 days of
menses, and the last menstrual period was set to January 1, 2015. The predicted
date of ovulation and fertile window generated were compared to the accepted
standard, estimating a date of ovulation on cycle day (CD) 15, January 15, and a
fertile window consisting of CD10-CD15, the day of ovulation plus the preceding
five cycle days, January 10-15, as established by Wilcox, et al. (NEJM, 1995).
Results: Data from twenty-seven APPs were collected. Of all the APPs downloaded, only two (7.4%) predicted the precise fertile window of January 10-15.
Three of the APPs (11.1%) generated a window that consisted only of days within
the actual fertile window, but did not include all fertile cycle days. Twenty-three
out of twenty-seven APPs (85.1%) generated fertility windows that contained
days after ovulation. The range of dates generated for a fertility window were as
early as CD5 and as late as CD18. Cycle day 14 was the only cycle day that was
universally included as part of the fertile window in all APPs analyzed.
Conclusions: The most commonly downloaded cellular phone APPs used by
the general public to predict fertile windows are generally inaccurate, though the
clinical impact of this inaccuracy remains unclear. Patients trying to conceive with
the assistance of calendars generated from APPs should be counseled to use
this modality with caution.
1. Weill Cornell Medical College, New York, NY
2. New York Hospital Queens, Flushing, NY
Continued...
33
Table 1. Examples of Predicted Fertility Window
and Date of Ovulation of APPs
Device
Predicted
Fertile
Window
Predicted
Date of
Ovulation
# of Days
Outside
Fertile
Window
# of Fertile
Days Not
Included
Android
1/12-1/16
1/15
1
2
1/11-1/14
1/14
iOS
1/10-1/15
1/15
Ladytimer
iOS
1/12-1/15
1/15
Period Diary
iOS
1/5-1/15
N/A
APP
Fertile Days
Calculator
Fertility
Fertility
Calendar
Fertility Friend
Mobile
Woman Log
Calendar
iPeriod
Android
Android
Android
Android
Kindara
iOS
Fertility Tracker
Life Period
Tracker
34
iOS
1/13-1/17
1/10-1/17
1/11-1/18
1/12-1/16
1/10-1/16
N/A
N/A
1/15
N/A
1/15
2
2
0
3
0
1
0
1
5
3
0
2
1
0
2
2
0
0
Poster Presentation
Radial Artery Access Approach Is Associated With the Use of
Decreased Amount of Contrast in Staged Percutaneous Coronary
Intervention During Index Hospitalization in Patients Presenting
With Acute ST-Segment Elevation Myocardial Infarction
Nelson Chavarria, M.D., Hafiz Hussain, M.D., Jyoti Gupta, M.D.,
Emmanuel Moustakakis, M.D., Gregory Gustafson, M.D., Chong Park, M.D.
Introduction: Transitioning an organization from primarily femoral access to
radial artery-based access for the treatment of staged percutaneous interventions can be challenging. However, trans-radial access can provide multiple
benefits from clinical, operational, facility, and outcomes perspectives. We
conducted a retrospective analysis, comparing femoral approach versus radial
approach for staged percutaneous coronary interventions after initial revascularization for STEMI.
Methods: Medical records of patients who presented (between August 2010
and January 2015) with STEMI and had subsequent staged PCI during the same
hospitalization were included in this retrospective study. Baseline characteristics,
angiographic data and hospitalization course were reviewed. T test and Chi
Square tests were used to analyze the data.
Results: 102 procedures in 51 patients with the mean age of 59.1 ± 9.8 were
performed and 145 coronary stents were placed. 37.2% patients were diabetic.
65.4% patients had left ventricular ejection fraction ≤ 50%. 22 (43.2%) patients
had their staged PCI performed via radial approach. There was statistically
significant increase in the amount (ml) of contrast in formal approach compared
with radial approach (114.83 ± 79.3 vs. 79.3 ± 43.6; p = 0.038). There was no
statistically significant difference regarding fluoroscopy time (13.3 ± 11 vs. 10.8
± 6.8; p = 0.3) and total procedure duration (51.4 ± 28.1 vs. 48.8 ± 25.5; p = 0.7).
Neither approach caused any stroke, bleeding requiring transfusions, major
adverse cardiac events defined by death, q wave MI and stroke at 30 days.
Conclusion: A radial based approach for staged percutaneous coronary inter-
ventions after initial revascularization for STEMI is associated with the use of
decreased amount of contrast with comparable outcomes to a femoral approach.
Further studies are required to confirm these findings.
29
Poster Presentation
The Use of Epogen® Via Intravenous and Subcutaneous
Routes
Farhanah Yousaf, M.B.B.S., Opeyemi Oladele, M.D., Saw Hnin Mu, M.D.,
Chaim Charytan, M.D., Bruce S. Spinowitz, M.D.
Background: In the new era of payment bundling, dialysis centers are incentivized to be more efficient in the delivery of health services, including ESA
administration. We retrospectively compared 3-month total IV and SC Epogen
dose administered to chronic maintenance hemodialysis patients.
Methods: Two study periods were selected, keeping in mind the change in
hemoglobin targets effective June 2011, which was implemented at our unit in
September 2011, possible seasonal effect, if any, and sufficient time (2-4 months)
to achieve stable doses post-switch from IV to SC. Thus, May to July 2010 period
(IV Period) was selected for IV Epogen and May to July 2011 period (SC Period)
was selected for SC Epogen.
Medical records of all hemodialysis (HD) patients who received Epogen
during the study periods were reviewed, following hospital IRB approval. Patients
who received SC Epogen during April to July 2010 or IV Epogen during April to
July 2011, patients who continued to receive IV Epogen beyond March 2011,
patients who received darbepoetin within 6 months of either study period, hospitalization for > 1 day during April to July 2010 or April to July 2011, not registered
for HD for at least 3 months prior to and during both study periods (new patients,
transplants, transfers, expiries), positive Guaiac test during April to July 2010 or
April to July 2011, were excluded. Monthly Epogen dose as well as hemoglobin,
TSAT, and ferritin levels from selected study periods were tabulated for each
patient. Mean and standard deviations were calculated and paired t-test was
performed for comparison between IV and SC Epogen use. Epogen dose was
expressed as the average weekly dose per patient.
Results: Mean age of patients was 67 ± 14; that included 23 females and 33
males with estimated dry weight of 71 ± 22 Kg. Our investigation demonstrated
a 20% mean reduction in total 3-month use of SC Epogen in 2011 compared to
the total 3-month use of IV Epogen in 2010, in spite of increased iron supplementation in IV period.
Conclusions: Our results support that smaller doses of SC Epogen are required
to maintain comparable hemoglobin levels versus IV Epogen. Our study also
demonstrates that the dose reduction in SC Epogen is progressive and evident,
in spite of increased iron supplementation during IV period. Therefore, the
rHuEPO related costs can be reduced with SC route of administration without
compromising quality of care. Further studies are warranted to investigate the
potential of greater hemoglobin cycling with SC administration of rHuEPO.
Continued...
Table 1. Anemia Management During IV and SC Periods
IV Period
Weekly Dose of Epogen®
Administered (IU)/Patient
TSAT (%)
Ferritin (ng/mL)
Hemoglobin (g/dL)
Iron Supplementation (mg)
(Iron Sucrose/Ferumoxytol)
(May-July 2011)
n = 56
Mean ± SD
27 ± 8
29 ± 11
8206 ± 8718*
457 ± 243†
6556 ± 6414*
650 ± 321†
11.0 ± 1.0
11.1 ± 1.0
739 ± 798‡
445 ± 506‡
* p < 0.05 IV Epogen versus SC Epogen
† p < 0.001 IV period ferritin levels versus SC period
‡ p < 0.05 IV period iron supplementation versus SC period
62
SC Period
(May-July 2010)
n = 56
Mean ± SD
Focal Fatty Infiltration of the Liver Mimicking Malignancy
In High-Risk Patients
V. Yalamanchi, D.O., W. Wang, M.D., M. Rubin, M.D., A.L. Bunim, M.D.
A 54-year-old male with a history of alcohol abuse was hospitalized for progressively worsening abdominal pain for five months. The patient noticed increased
abdominal girth without any weight changes. Blood tests revealed an elevation
of total bilirubin (9.1 mg/dL), alkaline phosphatase (243 U/L), aspartate aminotransferase (135 U/L) and alanine aminotransferase (34 U/L). Coagulation
studies revealed an elevated prothrombin time (22.7 s) and INR (2.00). An alphafeto protein level was normal at 5.4 ng/mL. Contrast-enhanced computed tomography (CT) of the abdomen and pelvis showed moderate ascites, a nodular liver
consistent with cirrhosis, and focal lesions (Figure 1). For further evaluation, contrast-enhanced magnetic resonance imaging (MRI) with contrast was performed
and a 5.7 cm mass with heterogenous contrast enhancement at the periphery of
segment 4A was seen (Figure 2). The differential for this lesion included a metastatic lesion, abscess, hemangioma or atypical hepatocellular carcinoma (HCC). A
biopsy of this lesion revealed hepatic steatosis with bridging fibrosis (Figure 3).
Immunochemistry staining was negative for any primary or secondary
malignancy (Figure 4).
Focal fatty infiltration can appear as nodular areas mimicking metastasis or
primary tumors in cirrhotics. Cirrhosis secondary to viral hepatitis or alcoholism
carries the highest risk for the development of HCC. Current guidelines state that
nodules greater than 1 cm for patients at risk for HCC require a 4-phase multidetector CT (MDCT) or dynamic contrast-enhanced MRI. During the arterial
phase, the HCC enhances more than the surrounding liver due to higher blood
flow by comparison. The delayed phase consists of the "washout period," in
which portal blood with contrast flows through the liver, making the HCC hypoechoic due to the lack of portal supply.1 Biopsy is the next step to diagnosis if
imaging studies are inconclusive; however, if negative, surveillance through
ultrasound (US) is performed at 3-6 month intervals until the lesion disappears,
increases in size, or is diagnostic for HCC. Early HCC may appear as regenerative (cirrhotic) nodules due to hypoechogenicity on imaging and a size less than
1 cm. 10-20% of HCC tumors do not enhance during contrast imaging due to
hypovascularity and are hard to distinguish between dysplastic nodules, also
further complicating the diagnosis.2
Non-cirrhotic patients with primary liver malignancies or metastasis
may also present with peritumoral sparing of fatty infiltration. Opposed-phase
gradient-echo MRI is the test of choice under these circumstances. The mechanism for areas of peritumoral sparing of fat appearing as hyperintense rims
involves arterioportal gradients. In the case of a patient with existing hepatic
hemangioma or HCC, the portal phase will create hyperechogenicity due to a
lack of portal flow through the tumors.2
This case posed a diagnostic dilemma because the patient had risk factors
for HCC such as alcohol-related cirrhosis, but he had a hepatic lesion with an
Continued...
atypical enhancement pattern. As a result, a biopsy was obtained, revealing a
benign condition. Subsequently, the patient stopped drinking, his ascites resolved
and this lesion disappeared on follow-up interval imaging.
Abstract and poster presentation at ACG Conference (Philadelphia, PA) 10/19/2014.
Manuscript accepted for publication in the Journal of Gastroenterology and Hepatology
(2015 in print).
Figure 1. CT Scan
CT scan demonstrated a heterogenous liver with new moderate ascites.
Figure 2. MRI
MRI showed relative enlargement, consistent with cirrhosis, in the lateral
segment of the left lobe of the liver, and a 5.7 cm mass in segment 4a.
86
Continued...
Figure 3. Liver Biopsy
Liver biopsy revealed benign steatotic liver with markedly
increased fibrosis bordering on cirrhosis.
Figure 4. Immunochemistry
Immunochemistry (CK7 and CK20) was negative for
metastatic disease and trichrome stain highlighted the
increased fibrosis.
Continued...
References
1. Kanematsu M, Hoshi H, Yamada T, et al. Overestimating the size of hepatic malignancy on
helical CT during arterial portography: equilibrium phase CT and pathology. J Comput Assist
Tomogr 1997; 21: 713-719.
2. Guillermo PS, Carlos HP, Mathieu N, Elisa C, Maureen GH. MDCT Imaging Findings of Liver
Cirrhosis: Spectrum of Hepatic and Extrahepatic Abdominal Complications. HPB Surgery
(2013), Article ID 129396, 12 pages http://dx.doi.org/10.1155/2013/129396.
88
Tell Me Where You Have Been So I Can Tell You What You Have
S. Tilak, M.D., R. Lazarescu, M.D.
Background: In today's society, with migration and tourism on a rise, a clinician
must carefully consider demographics and exposures in clinical decision-making,
to facilitate timely diagnosis and institute appropriate therapeutic measures.
Learning objectives: Raise awareness in the importance of demographics
and exposures in clinical decision-making.
Case presentation: 44-year-old male smoker with no past medical history,
who emigrated from Greece three months prior, was sent to the Emergency
Department for severe anemia. The patient reported several weeks of subjective
fevers, chills, night sweats, generalized malaise, unintentional weight loss and
worsening epigastric pain. He first noted severe left upper quadrant abdominal
pain four months prior while in Greece, which resolved. Routine blood tests were
within normal limits. He subsequently developed postprandial epigastric pain,
initially controlled with antacids.
Patient was febrile and tachycardic on presentation. Initial blood tests
showed significant pancytopenia with bandemia and reticulocytosis; however,
no evidence of hemolysis or disseminated intravascular coagulation. Fecal
occult blood test was negative. Patient was started on broad-spectrum antibiotics, however, failed to defervesce. Extensive infectious disease workup was
unrevealing for any bacterial, fungal or acute viral infections, including tuberculosis and HIV. Bone marrow biopsy showed no morphological or immunophenotypic evidence of EBV infection, carcinoma or lymphoma. An atypical
lymphoid population was detected on peripheral blood smear; however, T-cell
receptor gene rearrangement studies were negative. Serum protein electrophoresis showed hypergammaglobinemia. Rheumatologic workup was inconclusive
and the patient failed to respond to steroid therapy.
Throughout his hospitalization, the patient continued to be febrile and
subsequently developed transaminitis with significant splenomegaly. CT of the
abdomen and pelvis showed markedly enlarged spleen. CT-guided liver biopsy
showed benign liver parenchyma. Patient was planned for diagnostic and potentially therapeutic splenectomy, since he became blood transfusion-dependent.
Further discussion with an infectious disease specialist in Greece revealed a
recent outbreak of leishmaniasis in local communities. A bone marrow biopsy
was repeated, confirming the diagnosis of leishmaniasis by protein electrophoresis. Patient completed a course of liposomal amphotericin B with resolution
of fever, splenomegaly and pancytopenia.
Discussion: Our patient presented with fever of unknown origin and was subjected to extensive multi-organ system investigations with proposed splenectomy
for a condition commonly encountered and easily treated in his native country.
Leishmaniasis has been classified as a neglected tropical disease – a group of
parasitic and bacterial diseases that have been essentially eliminated in developed countries, but cause significant illness in more marginalized, developing
communities, affecting more than one billion people worldwide.1 However, the
literature demonstrates a rise in imported leishmaniasis in developed, nonendemic countries over the past decade, resulting from increased international
tourism, military operations, and immigration from endemic countries.2 Careful
consideration of demographics and exposures in clinical decision-making facilitates timely diagnosis and institution of appropriate therapeutic measures.
References:
1. CDC: http://www.cdc.gov/globalhealth/ntd/.
2. "Leishmaniasis, an emerging infection in travelers." International Journal of Infectious
Disease, Volume 14, Issue 12.
130