Sherry Boschert

SAN FRANCISCO — Repairing skin barrier dysfunction due to environmental exposures and endogenous factors is essential for the optimal management of hand dermatitis.

The dysfunction also may be iatrogenic, which adds to morbidity by making the underlying eczema much harder to treat, Dr. Joseph F. Fowler Jr. explained at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Age, stress, ultraviolet radiation, low humidity, skin disease, and genetic factors can all lead to epidermal injury and inflammation, which may result in development of damage to the stratum corneum and dermis, causing a vicious cycle of further injury, noted Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum to block transepidermal water loss and to let the epidermis heal itself, he noted.

Second-generation moisturizers add emollients and humectants to bind water and lipids for temporary barrier improvement. Today's “regular” moisturizers offer occlusive and humectant activity, he explained. They are useful in situations of mild xerosis or transient subcutaneous damage in which normal healing processes are able to cope with the damage. They are not so effective for patients with prolonged subcutaneous damage, inflammation, or poor inherent repair ability (such as those with atopy).

The newest products, third-generation moisturizers, have occlusive and humectant properties but also add ingredients to provide the raw materials for stimulating barrier repair and for anti-inflammatory effects. Colloidal oatmeal is a third-generation moisturizer. Colloidal oatmeal products contain lipids such as linoleic acid, have an anti-inflammatory effect, and generally are free of common allergens such as preservatives.

Ceramide-containing moisturizers (CeraVe and EpiCeram) also are third-generation products, and with these it is important to get a balanced mixture of ceramides 1, 3 and 6, he advised.

MimyX, a cream containing palmitamide monoethanolamine (PEA), restores the skin barrier by mimicking the composition of skin barrier lipids such as PEA, triglycerides, phospholipids, and squalene, according to data from Stiefel Laboratories, which markets MimyX.

He has been a consultant, speaker, and investigator for Coria Laboratories (now Valeant), which markets CeraVe cream and for Stiefel.

Dr. Fowler recommended starting treatment for hand dermatitis with a class I or II topical steroid, plus adjunctive therapy with MimyX cream applied at least three times daily, or adjunctive therapy with high-strength (30%-40%) urea foam or lotion for hyperkeratotic hand eczema.

Dr. Fowler has no association with the companies that market Eletone, Atopiclair, or EpiCeram creams. He has been a consultant, speaker, or investigators for multiple other companies that make skin care products and treatments, including Allerderm, Galderma, Hyland's, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Triax, UCB, Medicis, Novartis, Abbott, Allergan, Amgen, Astellas, Centocor, Dow, Genentech, Taro, and 3M.

SDEF and this news organization are owned by Elsevier.

Age, stress, radiation, low humidity, skin disease, and genetic factors can lead to epidermal injury.

Source ©CDC

SAN FRANCISCO — Repairing skin barrier dysfunction due to environmental exposures and endogenous factors is essential for the optimal management of hand dermatitis.

The dysfunction also may be iatrogenic, which adds to morbidity by making the underlying eczema much harder to treat, Dr. Joseph F. Fowler Jr. explained at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Age, stress, ultraviolet radiation, low humidity, skin disease, and genetic factors can all lead to epidermal injury and inflammation, which may result in development of damage to the stratum corneum and dermis, causing a vicious cycle of further injury, noted Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum to block transepidermal water loss and to let the epidermis heal itself, he noted.

Second-generation moisturizers add emollients and humectants to bind water and lipids for temporary barrier improvement. Today's “regular” moisturizers offer occlusive and humectant activity, he explained. They are useful in situations of mild xerosis or transient subcutaneous damage in which normal healing processes are able to cope with the damage. They are not so effective for patients with prolonged subcutaneous damage, inflammation, or poor inherent repair ability (such as those with atopy).

The newest products, third-generation moisturizers, have occlusive and humectant properties but also add ingredients to provide the raw materials for stimulating barrier repair and for anti-inflammatory effects. Colloidal oatmeal is a third-generation moisturizer. Colloidal oatmeal products contain lipids such as linoleic acid, have an anti-inflammatory effect, and generally are free of common allergens such as preservatives.

Ceramide-containing moisturizers (CeraVe and EpiCeram) also are third-generation products, and with these it is important to get a balanced mixture of ceramides 1, 3 and 6, he advised.

MimyX, a cream containing palmitamide monoethanolamine (PEA), restores the skin barrier by mimicking the composition of skin barrier lipids such as PEA, triglycerides, phospholipids, and squalene, according to data from Stiefel Laboratories, which markets MimyX.

He has been a consultant, speaker, and investigator for Coria Laboratories (now Valeant), which markets CeraVe cream and for Stiefel.

Dr. Fowler recommended starting treatment for hand dermatitis with a class I or II topical steroid, plus adjunctive therapy with MimyX cream applied at least three times daily, or adjunctive therapy with high-strength (30%-40%) urea foam or lotion for hyperkeratotic hand eczema.

Dr. Fowler has no association with the companies that market Eletone, Atopiclair, or EpiCeram creams. He has been a consultant, speaker, or investigators for multiple other companies that make skin care products and treatments, including Allerderm, Galderma, Hyland's, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Triax, UCB, Medicis, Novartis, Abbott, Allergan, Amgen, Astellas, Centocor, Dow, Genentech, Taro, and 3M.

SDEF and this news organization are owned by Elsevier.

Age, stress, radiation, low humidity, skin disease, and genetic factors can lead to epidermal injury.

Source ©CDC

SAN FRANCISCO — Repairing skin barrier dysfunction due to environmental exposures and endogenous factors is essential for the optimal management of hand dermatitis.

The dysfunction also may be iatrogenic, which adds to morbidity by making the underlying eczema much harder to treat, Dr. Joseph F. Fowler Jr. explained at the women's and pediatric dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Age, stress, ultraviolet radiation, low humidity, skin disease, and genetic factors can all lead to epidermal injury and inflammation, which may result in development of damage to the stratum corneum and dermis, causing a vicious cycle of further injury, noted Dr. Fowler of the University of Louisville (Ky.) and president of the North American Contact Dermatitis Group.

Strategies for repairing the skin barrier start with first-generation occlusive moisturizers such as petrolatum to block transepidermal water loss and to let the epidermis heal itself, he noted.

Second-generation moisturizers add emollients and humectants to bind water and lipids for temporary barrier improvement. Today's “regular” moisturizers offer occlusive and humectant activity, he explained. They are useful in situations of mild xerosis or transient subcutaneous damage in which normal healing processes are able to cope with the damage. They are not so effective for patients with prolonged subcutaneous damage, inflammation, or poor inherent repair ability (such as those with atopy).

The newest products, third-generation moisturizers, have occlusive and humectant properties but also add ingredients to provide the raw materials for stimulating barrier repair and for anti-inflammatory effects. Colloidal oatmeal is a third-generation moisturizer. Colloidal oatmeal products contain lipids such as linoleic acid, have an anti-inflammatory effect, and generally are free of common allergens such as preservatives.

Ceramide-containing moisturizers (CeraVe and EpiCeram) also are third-generation products, and with these it is important to get a balanced mixture of ceramides 1, 3 and 6, he advised.

MimyX, a cream containing palmitamide monoethanolamine (PEA), restores the skin barrier by mimicking the composition of skin barrier lipids such as PEA, triglycerides, phospholipids, and squalene, according to data from Stiefel Laboratories, which markets MimyX.

He has been a consultant, speaker, and investigator for Coria Laboratories (now Valeant), which markets CeraVe cream and for Stiefel.

Dr. Fowler recommended starting treatment for hand dermatitis with a class I or II topical steroid, plus adjunctive therapy with MimyX cream applied at least three times daily, or adjunctive therapy with high-strength (30%-40%) urea foam or lotion for hyperkeratotic hand eczema.

Dr. Fowler has no association with the companies that market Eletone, Atopiclair, or EpiCeram creams. He has been a consultant, speaker, or investigators for multiple other companies that make skin care products and treatments, including Allerderm, Galderma, Hyland's, Johnson & Johnson, Quinnova, Ranbaxy, Shire, Triax, UCB, Medicis, Novartis, Abbott, Allergan, Amgen, Astellas, Centocor, Dow, Genentech, Taro, and 3M.

SDEF and this news organization are owned by Elsevier.

Age, stress, radiation, low humidity, skin disease, and genetic factors can lead to epidermal injury.

Source ©CDC

SAN DIEGO — Colonoscopists are finding more polyps thanks to advances in technology, but it's not yet clear that detection of these additional lesions will change patient outcomes.

The initial impact of new techniques—such as high-definition colonoscopy, narrow-band imaging, chromocolonoscopy, and adjunctive viewing with the Third Eye Retroscope—may be felt mainly as rising health care costs and increasing numbers of patients who are advised to get their next screening colonoscopy in 5 years instead of 10.

A panel of expert endoscopists at the annual meeting of the American College of Gastroenterology agreed that although there's no hard evidence on the benefit of removing polyps smaller than 6 mm, they take them out if they see them.

“We haven't shown yet that finding small 4-mm and 5-mm polyps makes a difference in preventing colon cancer,” said Dr. Walter J. Coyle of the Scripps Clinic, La Jolla, Calif., who comoderated the session. But with increased detection, “we're going to be screening these people more frequently.”

Smaller lesions predict larger ones, and the “adenoma to cancer” sequence suggests that getting any adenoma out is a good thing, Dr. Kenneth R. DeVault suggested. Although no randomized trials have shown that removing smaller lesions reduces mortality, “we believe it does, and it makes sense that it does, but it's not been unequivocally proven that finding a 3-mm adenoma changes things.”

And it may never be proven, because people are unlikely to tolerate randomization to watch-and-wait management of a 5-mm polyp, said Dr. DeVault of the Mayo Clinic, Jacksonville, Fla. However, studies of virtual colonoscopy may yield useful information on the natural history of small polyps.

High-Def Detection Rates

Dr. DeVault and his associates reported on a study showing that high-definition white light colonoscopy increased adenoma detection, compared with standard-definition white light colonoscopy.

Unexpectedly, increased detection of some adenomas using high-definition white light colonoscopy did not produce a “learning effect” leading to increased detection using standard-definition white light colonoscopy, as suggested by at least one previous study (Gut 2008;57:59-64).

In the current comparison, the adenoma detection rate for standard-definition white light colonoscopy did not increases over the course of the study and remained significantly lower than detection with high-definition equipment, Dr. Anna M. Buchner reported at the meeting.

They investigators conducted a “natural experiment” from October 2006 to March 2007 at their institution, the Mayo Clinic in Jacksonville, when the clinic wanted to upgrade to high-definition equipment but lacked the funds to replace all their colonoscopes at once, Dr. DeVault said. They randomized patients and physicians to one of three rooms with high-definition white light colonoscopes or one of three rooms with standard equipment.

High-definition white light colonoscopy used for 1,204 patients showed significantly better detection rates for all polyps (42%), hyperplastic polyps (20%), and adenomas (29%), compared with detection rates using standard-definition white light colonoscopy in 1,226 patients (38% for all polyps, 17% for hyperplastic polyps, and 24% for adenomas), reported Dr. Buchner, who is now with the University of Pennsylvania, Radnor.

Small or moderate-sized adenomas were significantly more likely to be detected by high-definition colonoscopy than with standard-definition imaging: Detection rates for adenomas sized 0-5 mm were about 21% with high-definition colonoscopy and 17% with standard-definition equipment. Detection rates for adenomas sized 6-9 mm were about 8% with high-definition colonoscopy and 6% with standard-definition technology. High-definition colonoscopy also was more likely to detect polyps on the left side of the colon, she added.

For adenomas larger than 10 mm, detection rates were similar with the two techniques. Over the course of the study, detection of polyps overall increased, but adenoma detection did not.

Detecting Polyps and Adenomas

Dr. Lianne K. Cavell and her associates reported in a poster presentation that high-definition colonoscopy significantly increased detection of all polyps, compared with standard-definition colonoscopy, but did not improve detection of adenomas.

Her study compared charts for 345 patients who underwent standard-definition colonoscopy with data on 375 patients examined after the introduction of high-resolution colonoscopy. Polyps were detected in 36% of patients with high-definition colonoscopy and 29% of patients with standard-definition colonoscopy. Adenomas were detected in 53% and 47%, respectively, but that difference was not statistically significant, said Dr. Cavell of New York–Presbyterian Hospital.

The potential downside of new imaging technology is that resection of potentially insignificant polyps may increase pathology costs, procedure times, and risks related to colonoscopy, she noted.

In a study presented by panelist Dr. Charles J. Kahi, high-definition chromocolonoscopy did not significantly increase detection of adenomas, compared with high-definition white light colonoscopy. Chromocolonoscopy did, however, significantly increase detection of flat lesions, reported Dr. Kahi of Indiana University, Bloomington.

Flat lesions seem to present earlier and develop more aggressively, Dr. DeVault noted, and the new technologies have helped him find such lesions.

In a randomized, multicenter study of 660 average-risk patients aged 50 years or older undergoing first-time screening colonoscopy, Dr. Kahi and his associates detected at least one adenoma in 55.5% of 321 patients using chromocolonoscopy and in 48.4% of 339 patients using white light colonoscopy. The 7.1 percentage point increase in the detection rate did not reach statistical significance, he reported.

Chromocolonoscopy detected an average of 1.3 adenomas per patient, and white light colonoscopy detected an average of 1.1 adenomas per patient, a difference that again was not significant.

There was a modest and significant increase in detection of small (less than 5 mm) or flat adenomas and detection of non-neoplastic lesions using chromocolonoscopy. High-definition chromocolonoscopy detected an average of 0.6 flat adenomas per patient, 0.8 small adenomas per patient, and 1.8 non-neoplastic lesions per patient, compared with 0.4 flat adenomas, 0.7 small adenomas, and 1.0 non-neoplastic lesions per patient with high-definition white light colonoscopy.

The two techniques did not differ significantly in detection of advanced adenomas or detection of advanced adenomas smaller than 10 mm in size.

Overall, the findings do not support routine use of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients, Dr. Kahi said.

In general, flat and depressed colon neoplasms are easy to miss on colonoscopy, he noted, but awareness is increasing that they are precursors for colorectal cancer. Flat or depressed lesions are more difficult to visualize than polypoid lesions with conventional colonoscopy and are more likely to contain high-grade dysplasia or invasive carcinoma.

Looking Back to the Future

The panelists agreed that one of the new technologies that could improve detection of larger lesions is the Third Eye Retroscope, which helps colonoscopists see lesions hidden behind folds.

Preliminary data from two studies presented at the meeting suggest that the Third Eye Retroscope may improve polyp detection during colonoscopy by 15%-20%. The Third Eye Retroscope is a disposable device inserted through the instrument channel of a conventional colonoscope after intubation to the cecum. The tip of the Retroscope bends 180 degrees so that the camera and an integrated light source can be directed back toward the tip of the colonoscope.

During the withdrawal phase of colonoscopy, a split-screen display provides both a conventional camera view and a continuous retrograde view from the Retroscope camera. The device can help find lesions located on the proximal aspect of flexures or haustral folds, panelist Dr. Daniel C. DeMarco said.

In a nonrandomized, subjective study of 340 colonoscopies, 17 endoscopists estimated that use of the Third Eye Retroscope increased detection of adenomas by 16%, reported Dr. DeMarco of Baylor University Medical Center, Dallas.

“We're finding lesions between 6 and 10 mm,” he noted. “Polyps that size that are adenomas are clinically significant.”

Of the 209 polyps found, the researchers estimated that 182 could have been detected with a conventional colonoscope, and the Third Eye yielded an additional 27—a 15% increase. Of the 116 adenomas found, an estimated 100 would have been seen by conventional colonoscopy and 16 (16%) only by the Third Eye, Dr. DeMarco said.

In a poster, A.M. Leufkens, Ph.D., and associates reported preliminary data from an ongoing prospective study that randomizes patients to get two exams by the same colonoscopist during tne period of sedation—either a standard colonoscopy followed by one with the Third Eye, or an exam with the Third Eye first, followed by regular colonoscopy.

Data on 126 of a planned 410 subjects show that endoscopists missed 2.6 times more polyps using the colonoscope alone than they did with the Third Eye as an adjunct to the colonoscope, reported Dr. Leufkens of University Medical Center, Utrecht, the Netherlands.

In 63 patients who had regular colonoscopy first, 55 polyps were found on the first exam; the second exam with the Third Eye yielded 18 more polyps for an “additional detection rate” of 32.7%. In 63 patients who were examined first with the Third Eye, 56 polyps were found initially; the second exam by colonoscopy alone yielded 7 more polyps for an additional detection rate of 12.5%.

Comoderator Dr. Samuel A. Giday of Johns Hopkins Bayview Medical Center, Baltimore, commented that “it's important that the differences we're seeing are small between the Third Eye, chromocolonoscopy, and narrow-band imaging.” More data are needed, he cautioned.

Guidelines from the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy state that high-quality screening colonoscopies are the result of four factors: an experienced colonoscopist, excellent bowel preparation, slow scope withdrawal time, and monitoring how often adenomas are being detected in screening colonoscopies, he said.

“A good gastroenterologist can use a regular scope, high definition or not, and do a very good screening test,” Dr. Giday said.

Dr. DeMarco's study was funded by the company that makes the Third Eye Retroscope, Avantis Medical Systems. Dr. Leufkens' study was also funded by Avantis, and one of Dr. Leufkens' associates is on the company's advisory board. The other physicians said they had no conflicts of interest related to these topics.

The findings do not support routine use of high-definition chromocolonoscopy for screening.

Source DR. KAHI

SAN DIEGO — Colonoscopists are finding more polyps thanks to advances in technology, but it's not yet clear that detection of these additional lesions will change patient outcomes.

The initial impact of new techniques—such as high-definition colonoscopy, narrow-band imaging, chromocolonoscopy, and adjunctive viewing with the Third Eye Retroscope—may be felt mainly as rising health care costs and increasing numbers of patients who are advised to get their next screening colonoscopy in 5 years instead of 10.

A panel of expert endoscopists at the annual meeting of the American College of Gastroenterology agreed that although there's no hard evidence on the benefit of removing polyps smaller than 6 mm, they take them out if they see them.

“We haven't shown yet that finding small 4-mm and 5-mm polyps makes a difference in preventing colon cancer,” said Dr. Walter J. Coyle of the Scripps Clinic, La Jolla, Calif., who comoderated the session. But with increased detection, “we're going to be screening these people more frequently.”

Smaller lesions predict larger ones, and the “adenoma to cancer” sequence suggests that getting any adenoma out is a good thing, Dr. Kenneth R. DeVault suggested. Although no randomized trials have shown that removing smaller lesions reduces mortality, “we believe it does, and it makes sense that it does, but it's not been unequivocally proven that finding a 3-mm adenoma changes things.”

And it may never be proven, because people are unlikely to tolerate randomization to watch-and-wait management of a 5-mm polyp, said Dr. DeVault of the Mayo Clinic, Jacksonville, Fla. However, studies of virtual colonoscopy may yield useful information on the natural history of small polyps.

High-Def Detection Rates

Dr. DeVault and his associates reported on a study showing that high-definition white light colonoscopy increased adenoma detection, compared with standard-definition white light colonoscopy.

Unexpectedly, increased detection of some adenomas using high-definition white light colonoscopy did not produce a “learning effect” leading to increased detection using standard-definition white light colonoscopy, as suggested by at least one previous study (Gut 2008;57:59-64).

In the current comparison, the adenoma detection rate for standard-definition white light colonoscopy did not increases over the course of the study and remained significantly lower than detection with high-definition equipment, Dr. Anna M. Buchner reported at the meeting.

They investigators conducted a “natural experiment” from October 2006 to March 2007 at their institution, the Mayo Clinic in Jacksonville, when the clinic wanted to upgrade to high-definition equipment but lacked the funds to replace all their colonoscopes at once, Dr. DeVault said. They randomized patients and physicians to one of three rooms with high-definition white light colonoscopes or one of three rooms with standard equipment.

High-definition white light colonoscopy used for 1,204 patients showed significantly better detection rates for all polyps (42%), hyperplastic polyps (20%), and adenomas (29%), compared with detection rates using standard-definition white light colonoscopy in 1,226 patients (38% for all polyps, 17% for hyperplastic polyps, and 24% for adenomas), reported Dr. Buchner, who is now with the University of Pennsylvania, Radnor.

Small or moderate-sized adenomas were significantly more likely to be detected by high-definition colonoscopy than with standard-definition imaging: Detection rates for adenomas sized 0-5 mm were about 21% with high-definition colonoscopy and 17% with standard-definition equipment. Detection rates for adenomas sized 6-9 mm were about 8% with high-definition colonoscopy and 6% with standard-definition technology. High-definition colonoscopy also was more likely to detect polyps on the left side of the colon, she added.

For adenomas larger than 10 mm, detection rates were similar with the two techniques. Over the course of the study, detection of polyps overall increased, but adenoma detection did not.

Detecting Polyps and Adenomas

Dr. Lianne K. Cavell and her associates reported in a poster presentation that high-definition colonoscopy significantly increased detection of all polyps, compared with standard-definition colonoscopy, but did not improve detection of adenomas.

Her study compared charts for 345 patients who underwent standard-definition colonoscopy with data on 375 patients examined after the introduction of high-resolution colonoscopy. Polyps were detected in 36% of patients with high-definition colonoscopy and 29% of patients with standard-definition colonoscopy. Adenomas were detected in 53% and 47%, respectively, but that difference was not statistically significant, said Dr. Cavell of New York–Presbyterian Hospital.

The potential downside of new imaging technology is that resection of potentially insignificant polyps may increase pathology costs, procedure times, and risks related to colonoscopy, she noted.

In a study presented by panelist Dr. Charles J. Kahi, high-definition chromocolonoscopy did not significantly increase detection of adenomas, compared with high-definition white light colonoscopy. Chromocolonoscopy did, however, significantly increase detection of flat lesions, reported Dr. Kahi of Indiana University, Bloomington.

Flat lesions seem to present earlier and develop more aggressively, Dr. DeVault noted, and the new technologies have helped him find such lesions.

In a randomized, multicenter study of 660 average-risk patients aged 50 years or older undergoing first-time screening colonoscopy, Dr. Kahi and his associates detected at least one adenoma in 55.5% of 321 patients using chromocolonoscopy and in 48.4% of 339 patients using white light colonoscopy. The 7.1 percentage point increase in the detection rate did not reach statistical significance, he reported.

Chromocolonoscopy detected an average of 1.3 adenomas per patient, and white light colonoscopy detected an average of 1.1 adenomas per patient, a difference that again was not significant.

There was a modest and significant increase in detection of small (less than 5 mm) or flat adenomas and detection of non-neoplastic lesions using chromocolonoscopy. High-definition chromocolonoscopy detected an average of 0.6 flat adenomas per patient, 0.8 small adenomas per patient, and 1.8 non-neoplastic lesions per patient, compared with 0.4 flat adenomas, 0.7 small adenomas, and 1.0 non-neoplastic lesions per patient with high-definition white light colonoscopy.

The two techniques did not differ significantly in detection of advanced adenomas or detection of advanced adenomas smaller than 10 mm in size.

Overall, the findings do not support routine use of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients, Dr. Kahi said.

In general, flat and depressed colon neoplasms are easy to miss on colonoscopy, he noted, but awareness is increasing that they are precursors for colorectal cancer. Flat or depressed lesions are more difficult to visualize than polypoid lesions with conventional colonoscopy and are more likely to contain high-grade dysplasia or invasive carcinoma.

Looking Back to the Future

The panelists agreed that one of the new technologies that could improve detection of larger lesions is the Third Eye Retroscope, which helps colonoscopists see lesions hidden behind folds.

Preliminary data from two studies presented at the meeting suggest that the Third Eye Retroscope may improve polyp detection during colonoscopy by 15%-20%. The Third Eye Retroscope is a disposable device inserted through the instrument channel of a conventional colonoscope after intubation to the cecum. The tip of the Retroscope bends 180 degrees so that the camera and an integrated light source can be directed back toward the tip of the colonoscope.

During the withdrawal phase of colonoscopy, a split-screen display provides both a conventional camera view and a continuous retrograde view from the Retroscope camera. The device can help find lesions located on the proximal aspect of flexures or haustral folds, panelist Dr. Daniel C. DeMarco said.

In a nonrandomized, subjective study of 340 colonoscopies, 17 endoscopists estimated that use of the Third Eye Retroscope increased detection of adenomas by 16%, reported Dr. DeMarco of Baylor University Medical Center, Dallas.

“We're finding lesions between 6 and 10 mm,” he noted. “Polyps that size that are adenomas are clinically significant.”

Of the 209 polyps found, the researchers estimated that 182 could have been detected with a conventional colonoscope, and the Third Eye yielded an additional 27—a 15% increase. Of the 116 adenomas found, an estimated 100 would have been seen by conventional colonoscopy and 16 (16%) only by the Third Eye, Dr. DeMarco said.

In a poster, A.M. Leufkens, Ph.D., and associates reported preliminary data from an ongoing prospective study that randomizes patients to get two exams by the same colonoscopist during tne period of sedation—either a standard colonoscopy followed by one with the Third Eye, or an exam with the Third Eye first, followed by regular colonoscopy.

Data on 126 of a planned 410 subjects show that endoscopists missed 2.6 times more polyps using the colonoscope alone than they did with the Third Eye as an adjunct to the colonoscope, reported Dr. Leufkens of University Medical Center, Utrecht, the Netherlands.

In 63 patients who had regular colonoscopy first, 55 polyps were found on the first exam; the second exam with the Third Eye yielded 18 more polyps for an “additional detection rate” of 32.7%. In 63 patients who were examined first with the Third Eye, 56 polyps were found initially; the second exam by colonoscopy alone yielded 7 more polyps for an additional detection rate of 12.5%.

Comoderator Dr. Samuel A. Giday of Johns Hopkins Bayview Medical Center, Baltimore, commented that “it's important that the differences we're seeing are small between the Third Eye, chromocolonoscopy, and narrow-band imaging.” More data are needed, he cautioned.

Guidelines from the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy state that high-quality screening colonoscopies are the result of four factors: an experienced colonoscopist, excellent bowel preparation, slow scope withdrawal time, and monitoring how often adenomas are being detected in screening colonoscopies, he said.

“A good gastroenterologist can use a regular scope, high definition or not, and do a very good screening test,” Dr. Giday said.

Dr. DeMarco's study was funded by the company that makes the Third Eye Retroscope, Avantis Medical Systems. Dr. Leufkens' study was also funded by Avantis, and one of Dr. Leufkens' associates is on the company's advisory board. The other physicians said they had no conflicts of interest related to these topics.

The findings do not support routine use of high-definition chromocolonoscopy for screening.

Source DR. KAHI

SAN DIEGO — Colonoscopists are finding more polyps thanks to advances in technology, but it's not yet clear that detection of these additional lesions will change patient outcomes.

The initial impact of new techniques—such as high-definition colonoscopy, narrow-band imaging, chromocolonoscopy, and adjunctive viewing with the Third Eye Retroscope—may be felt mainly as rising health care costs and increasing numbers of patients who are advised to get their next screening colonoscopy in 5 years instead of 10.

A panel of expert endoscopists at the annual meeting of the American College of Gastroenterology agreed that although there's no hard evidence on the benefit of removing polyps smaller than 6 mm, they take them out if they see them.

“We haven't shown yet that finding small 4-mm and 5-mm polyps makes a difference in preventing colon cancer,” said Dr. Walter J. Coyle of the Scripps Clinic, La Jolla, Calif., who comoderated the session. But with increased detection, “we're going to be screening these people more frequently.”

Smaller lesions predict larger ones, and the “adenoma to cancer” sequence suggests that getting any adenoma out is a good thing, Dr. Kenneth R. DeVault suggested. Although no randomized trials have shown that removing smaller lesions reduces mortality, “we believe it does, and it makes sense that it does, but it's not been unequivocally proven that finding a 3-mm adenoma changes things.”

And it may never be proven, because people are unlikely to tolerate randomization to watch-and-wait management of a 5-mm polyp, said Dr. DeVault of the Mayo Clinic, Jacksonville, Fla. However, studies of virtual colonoscopy may yield useful information on the natural history of small polyps.

High-Def Detection Rates

Dr. DeVault and his associates reported on a study showing that high-definition white light colonoscopy increased adenoma detection, compared with standard-definition white light colonoscopy.

Unexpectedly, increased detection of some adenomas using high-definition white light colonoscopy did not produce a “learning effect” leading to increased detection using standard-definition white light colonoscopy, as suggested by at least one previous study (Gut 2008;57:59-64).

In the current comparison, the adenoma detection rate for standard-definition white light colonoscopy did not increases over the course of the study and remained significantly lower than detection with high-definition equipment, Dr. Anna M. Buchner reported at the meeting.

They investigators conducted a “natural experiment” from October 2006 to March 2007 at their institution, the Mayo Clinic in Jacksonville, when the clinic wanted to upgrade to high-definition equipment but lacked the funds to replace all their colonoscopes at once, Dr. DeVault said. They randomized patients and physicians to one of three rooms with high-definition white light colonoscopes or one of three rooms with standard equipment.

High-definition white light colonoscopy used for 1,204 patients showed significantly better detection rates for all polyps (42%), hyperplastic polyps (20%), and adenomas (29%), compared with detection rates using standard-definition white light colonoscopy in 1,226 patients (38% for all polyps, 17% for hyperplastic polyps, and 24% for adenomas), reported Dr. Buchner, who is now with the University of Pennsylvania, Radnor.

Small or moderate-sized adenomas were significantly more likely to be detected by high-definition colonoscopy than with standard-definition imaging: Detection rates for adenomas sized 0-5 mm were about 21% with high-definition colonoscopy and 17% with standard-definition equipment. Detection rates for adenomas sized 6-9 mm were about 8% with high-definition colonoscopy and 6% with standard-definition technology. High-definition colonoscopy also was more likely to detect polyps on the left side of the colon, she added.

For adenomas larger than 10 mm, detection rates were similar with the two techniques. Over the course of the study, detection of polyps overall increased, but adenoma detection did not.

Detecting Polyps and Adenomas

Dr. Lianne K. Cavell and her associates reported in a poster presentation that high-definition colonoscopy significantly increased detection of all polyps, compared with standard-definition colonoscopy, but did not improve detection of adenomas.

Her study compared charts for 345 patients who underwent standard-definition colonoscopy with data on 375 patients examined after the introduction of high-resolution colonoscopy. Polyps were detected in 36% of patients with high-definition colonoscopy and 29% of patients with standard-definition colonoscopy. Adenomas were detected in 53% and 47%, respectively, but that difference was not statistically significant, said Dr. Cavell of New York–Presbyterian Hospital.

The potential downside of new imaging technology is that resection of potentially insignificant polyps may increase pathology costs, procedure times, and risks related to colonoscopy, she noted.

In a study presented by panelist Dr. Charles J. Kahi, high-definition chromocolonoscopy did not significantly increase detection of adenomas, compared with high-definition white light colonoscopy. Chromocolonoscopy did, however, significantly increase detection of flat lesions, reported Dr. Kahi of Indiana University, Bloomington.

Flat lesions seem to present earlier and develop more aggressively, Dr. DeVault noted, and the new technologies have helped him find such lesions.

In a randomized, multicenter study of 660 average-risk patients aged 50 years or older undergoing first-time screening colonoscopy, Dr. Kahi and his associates detected at least one adenoma in 55.5% of 321 patients using chromocolonoscopy and in 48.4% of 339 patients using white light colonoscopy. The 7.1 percentage point increase in the detection rate did not reach statistical significance, he reported.

Chromocolonoscopy detected an average of 1.3 adenomas per patient, and white light colonoscopy detected an average of 1.1 adenomas per patient, a difference that again was not significant.

There was a modest and significant increase in detection of small (less than 5 mm) or flat adenomas and detection of non-neoplastic lesions using chromocolonoscopy. High-definition chromocolonoscopy detected an average of 0.6 flat adenomas per patient, 0.8 small adenomas per patient, and 1.8 non-neoplastic lesions per patient, compared with 0.4 flat adenomas, 0.7 small adenomas, and 1.0 non-neoplastic lesions per patient with high-definition white light colonoscopy.

The two techniques did not differ significantly in detection of advanced adenomas or detection of advanced adenomas smaller than 10 mm in size.

Overall, the findings do not support routine use of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients, Dr. Kahi said.

In general, flat and depressed colon neoplasms are easy to miss on colonoscopy, he noted, but awareness is increasing that they are precursors for colorectal cancer. Flat or depressed lesions are more difficult to visualize than polypoid lesions with conventional colonoscopy and are more likely to contain high-grade dysplasia or invasive carcinoma.

Looking Back to the Future

The panelists agreed that one of the new technologies that could improve detection of larger lesions is the Third Eye Retroscope, which helps colonoscopists see lesions hidden behind folds.

Preliminary data from two studies presented at the meeting suggest that the Third Eye Retroscope may improve polyp detection during colonoscopy by 15%-20%. The Third Eye Retroscope is a disposable device inserted through the instrument channel of a conventional colonoscope after intubation to the cecum. The tip of the Retroscope bends 180 degrees so that the camera and an integrated light source can be directed back toward the tip of the colonoscope.

During the withdrawal phase of colonoscopy, a split-screen display provides both a conventional camera view and a continuous retrograde view from the Retroscope camera. The device can help find lesions located on the proximal aspect of flexures or haustral folds, panelist Dr. Daniel C. DeMarco said.

In a nonrandomized, subjective study of 340 colonoscopies, 17 endoscopists estimated that use of the Third Eye Retroscope increased detection of adenomas by 16%, reported Dr. DeMarco of Baylor University Medical Center, Dallas.

“We're finding lesions between 6 and 10 mm,” he noted. “Polyps that size that are adenomas are clinically significant.”

Of the 209 polyps found, the researchers estimated that 182 could have been detected with a conventional colonoscope, and the Third Eye yielded an additional 27—a 15% increase. Of the 116 adenomas found, an estimated 100 would have been seen by conventional colonoscopy and 16 (16%) only by the Third Eye, Dr. DeMarco said.

In a poster, A.M. Leufkens, Ph.D., and associates reported preliminary data from an ongoing prospective study that randomizes patients to get two exams by the same colonoscopist during tne period of sedation—either a standard colonoscopy followed by one with the Third Eye, or an exam with the Third Eye first, followed by regular colonoscopy.

Data on 126 of a planned 410 subjects show that endoscopists missed 2.6 times more polyps using the colonoscope alone than they did with the Third Eye as an adjunct to the colonoscope, reported Dr. Leufkens of University Medical Center, Utrecht, the Netherlands.

In 63 patients who had regular colonoscopy first, 55 polyps were found on the first exam; the second exam with the Third Eye yielded 18 more polyps for an “additional detection rate” of 32.7%. In 63 patients who were examined first with the Third Eye, 56 polyps were found initially; the second exam by colonoscopy alone yielded 7 more polyps for an additional detection rate of 12.5%.

Comoderator Dr. Samuel A. Giday of Johns Hopkins Bayview Medical Center, Baltimore, commented that “it's important that the differences we're seeing are small between the Third Eye, chromocolonoscopy, and narrow-band imaging.” More data are needed, he cautioned.

Guidelines from the American College of Gastroenterology and the American Society of Gastrointestinal Endoscopy state that high-quality screening colonoscopies are the result of four factors: an experienced colonoscopist, excellent bowel preparation, slow scope withdrawal time, and monitoring how often adenomas are being detected in screening colonoscopies, he said.

“A good gastroenterologist can use a regular scope, high definition or not, and do a very good screening test,” Dr. Giday said.

Dr. DeMarco's study was funded by the company that makes the Third Eye Retroscope, Avantis Medical Systems. Dr. Leufkens' study was also funded by Avantis, and one of Dr. Leufkens' associates is on the company's advisory board. The other physicians said they had no conflicts of interest related to these topics.

The findings do not support routine use of high-definition chromocolonoscopy for screening.

Source DR. KAHI

SAN DIEGO — Preliminary data from two studies suggest that the Third Eye Retroscope may improve polyp detection during colonoscopy by 15%-20%.

The Third Eye Retroscope is a disposable device inserted through the instrument channel of a conventional colonoscope after intubation to the cecum. The tip of the Retroscope bends 180 degrees so that the camera and an integrated light source can be directed back toward the tip of the colonoscope.

During the withdrawal phase of colonoscopy, a split-screen display gives the colonoscopist both a conventional camera view and a continuous retrograde view from the Retroscope camera.

The device can help find lesions located on the proximal aspect of flexures or haustral folds, Dr. Daniel C. DeMarco said at the annual meeting of the American College of Gastroenterology.

In a nonrandomized study with no control group, 17 physicians at nine U.S. institutions each examined 20 patients (total of 340 patients) by colonoscopy plus the Third Eye Retroscope and were asked to judge whether each lesion they found could have been detected by the colonoscope alone or was only seen because they were using the Third Eye.

Of the 209 polyps found, the investigators estimated that 182 could have been detected with a conventional colonoscope and that the Third Eye yielded an additional 27—a 15% increase in the detection rate. Of the 116 adenomas found, they estimated that 100 would have been seen by conventional colonoscopy and 16 (16%) would have been seen only by the Third Eye, said Dr. DeMarco of Baylor University Medical Center, Dallas.

In a separate poster, A.M. Leufkens, Ph.D., and associates reported preliminary data from an ongoing prospective study that randomizes patients to get two exams by the same colonoscopist during the same period of sedation—either a standard colonoscopy followed by one with the Third Eye, or an exam with the Third Eye first, followed by regular colonoscopy.

Data on 126 of a planned 410 subjects show that endoscopists missed 2.6 times more polyps using the colonoscope alone than they did with the Third Eye as an adjunct to the colonoscope, reported Dr. Leufkens of University Medical Center, Utrecht, the Netherlands.

In 63 patients who had regular colonoscopy first, 55 polyps were found on the first exam; the second exam with the Third Eye yielded 18 additional polyps for an “additional detection rate” of 32.7%. In 63 patients who were examined first with the Third Eye, 56 polyps were found initially; the second exam by colonoscopy alone yielded 7 more polyps for an additional detection rate of 12.5%. Both studies were funded by the company that makes the Third Eye Retroscope, Avantis Medical Systems. One of Dr. Leufkens' associates is on the company's advisory board.

The device can help find lesions located on the proximal aspect of flexures or haustral folds.

Source DR. DEMARCO

SAN DIEGO — Preliminary data from two studies suggest that the Third Eye Retroscope may improve polyp detection during colonoscopy by 15%-20%.

The Third Eye Retroscope is a disposable device inserted through the instrument channel of a conventional colonoscope after intubation to the cecum. The tip of the Retroscope bends 180 degrees so that the camera and an integrated light source can be directed back toward the tip of the colonoscope.

During the withdrawal phase of colonoscopy, a split-screen display gives the colonoscopist both a conventional camera view and a continuous retrograde view from the Retroscope camera.

The device can help find lesions located on the proximal aspect of flexures or haustral folds, Dr. Daniel C. DeMarco said at the annual meeting of the American College of Gastroenterology.

In a nonrandomized study with no control group, 17 physicians at nine U.S. institutions each examined 20 patients (total of 340 patients) by colonoscopy plus the Third Eye Retroscope and were asked to judge whether each lesion they found could have been detected by the colonoscope alone or was only seen because they were using the Third Eye.

Of the 209 polyps found, the investigators estimated that 182 could have been detected with a conventional colonoscope and that the Third Eye yielded an additional 27—a 15% increase in the detection rate. Of the 116 adenomas found, they estimated that 100 would have been seen by conventional colonoscopy and 16 (16%) would have been seen only by the Third Eye, said Dr. DeMarco of Baylor University Medical Center, Dallas.

In a separate poster, A.M. Leufkens, Ph.D., and associates reported preliminary data from an ongoing prospective study that randomizes patients to get two exams by the same colonoscopist during the same period of sedation—either a standard colonoscopy followed by one with the Third Eye, or an exam with the Third Eye first, followed by regular colonoscopy.

Data on 126 of a planned 410 subjects show that endoscopists missed 2.6 times more polyps using the colonoscope alone than they did with the Third Eye as an adjunct to the colonoscope, reported Dr. Leufkens of University Medical Center, Utrecht, the Netherlands.

In 63 patients who had regular colonoscopy first, 55 polyps were found on the first exam; the second exam with the Third Eye yielded 18 additional polyps for an “additional detection rate” of 32.7%. In 63 patients who were examined first with the Third Eye, 56 polyps were found initially; the second exam by colonoscopy alone yielded 7 more polyps for an additional detection rate of 12.5%. Both studies were funded by the company that makes the Third Eye Retroscope, Avantis Medical Systems. One of Dr. Leufkens' associates is on the company's advisory board.

The device can help find lesions located on the proximal aspect of flexures or haustral folds.

Source DR. DEMARCO

SAN DIEGO — Preliminary data from two studies suggest that the Third Eye Retroscope may improve polyp detection during colonoscopy by 15%-20%.

The Third Eye Retroscope is a disposable device inserted through the instrument channel of a conventional colonoscope after intubation to the cecum. The tip of the Retroscope bends 180 degrees so that the camera and an integrated light source can be directed back toward the tip of the colonoscope.

During the withdrawal phase of colonoscopy, a split-screen display gives the colonoscopist both a conventional camera view and a continuous retrograde view from the Retroscope camera.

The device can help find lesions located on the proximal aspect of flexures or haustral folds, Dr. Daniel C. DeMarco said at the annual meeting of the American College of Gastroenterology.

In a nonrandomized study with no control group, 17 physicians at nine U.S. institutions each examined 20 patients (total of 340 patients) by colonoscopy plus the Third Eye Retroscope and were asked to judge whether each lesion they found could have been detected by the colonoscope alone or was only seen because they were using the Third Eye.

Of the 209 polyps found, the investigators estimated that 182 could have been detected with a conventional colonoscope and that the Third Eye yielded an additional 27—a 15% increase in the detection rate. Of the 116 adenomas found, they estimated that 100 would have been seen by conventional colonoscopy and 16 (16%) would have been seen only by the Third Eye, said Dr. DeMarco of Baylor University Medical Center, Dallas.

In a separate poster, A.M. Leufkens, Ph.D., and associates reported preliminary data from an ongoing prospective study that randomizes patients to get two exams by the same colonoscopist during the same period of sedation—either a standard colonoscopy followed by one with the Third Eye, or an exam with the Third Eye first, followed by regular colonoscopy.

Data on 126 of a planned 410 subjects show that endoscopists missed 2.6 times more polyps using the colonoscope alone than they did with the Third Eye as an adjunct to the colonoscope, reported Dr. Leufkens of University Medical Center, Utrecht, the Netherlands.

In 63 patients who had regular colonoscopy first, 55 polyps were found on the first exam; the second exam with the Third Eye yielded 18 additional polyps for an “additional detection rate” of 32.7%. In 63 patients who were examined first with the Third Eye, 56 polyps were found initially; the second exam by colonoscopy alone yielded 7 more polyps for an additional detection rate of 12.5%. Both studies were funded by the company that makes the Third Eye Retroscope, Avantis Medical Systems. One of Dr. Leufkens' associates is on the company's advisory board.

The device can help find lesions located on the proximal aspect of flexures or haustral folds.

Source DR. DEMARCO

SAN DIEGO — High-definition chromocolonoscopy did not significantly increase detection of adenomas, compared with high-definition white light colonoscopy, in a randomized, multicenter study of 660 patients.

In average-risk patients aged 50 years or older undergoing first-time screening colonoscopy, at least one adenoma was seen in 55.5% of 321 patients using chromocolonoscopy and in 48.4% of 339 patients using white light colonoscopy. The 7.1 percentage point increase in the detection rate did not reach statistical significance (P value, 0.07), Dr. Charles J. Kahi and his associates reported at the annual meeting of the American College of Gastroenterology.

Chromocolonoscopy detected an average of 1.3 adenomas per patient, and white light colonoscopy detected an average of 1.1 adenomas per patient, a difference that again was not statistically significant (P value, 0.07), said Dr. Kahi of Indiana University, Bloomington.

There was a modest, statistically significant increase in detection of small (less than 5 mm) or flat adenomas and detection of non-neoplastic lesions using chromocolonoscopy. High-definition chromocolonoscopy detected an average of 0.6 flat adenomas per patient, 0.8 small adenomas per patient, and 1.8 non-neoplastic lesions per patient, compared with 0.4 flat adenomas, 0.7 small adenomas, and 1.0 non-neoplastic lesions per patient with high-definition white light colonoscopy (P values, 0.01, 0.03, and less than 0.0001, respectively).

The two techniques did not differ significantly in detection of advanced adenomas (0.06 per patient with chromocolonoscopy and 0.04 per patient with white-light colonoscopy) or detection of advanced adenomas smaller than 10 mm in size (0.02 per patient with chromocolonoscopy and 0.01 per patient with white light colonoscopy).

Overall, these findings do not support the routine use of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients, Dr. Kahi said.

In general, flat and depressed colon neoplasms are easy to miss on colonoscopy, he noted, but awareness is increasing that they are precursors for colorectal cancer in Western populations. Flat or depressed lesions are more difficult to visualize than polypoid lesions with conventional colonoscopy and are more likely to contain high-grade dysplasia or invasive carcinoma.

The mean procedure time was significantly longer in the chromocolonoscopy group (31 minutes) compared with the white light colonoscopy group (22 minutes), and the mean dose of the sedative propofol was significantly higher in the chromocolonoscopy group (345 mg) than with white light (297 mg).

Dr. Kahi reported having no conflicts of interest related to this study.

Chromocolonoscopy detected an average of 1.3 adenomas per patient; white light colonoscopy detected 1.1.

Source DR. KAHI

SAN DIEGO — High-definition chromocolonoscopy did not significantly increase detection of adenomas, compared with high-definition white light colonoscopy, in a randomized, multicenter study of 660 patients.

In average-risk patients aged 50 years or older undergoing first-time screening colonoscopy, at least one adenoma was seen in 55.5% of 321 patients using chromocolonoscopy and in 48.4% of 339 patients using white light colonoscopy. The 7.1 percentage point increase in the detection rate did not reach statistical significance (P value, 0.07), Dr. Charles J. Kahi and his associates reported at the annual meeting of the American College of Gastroenterology.

Chromocolonoscopy detected an average of 1.3 adenomas per patient, and white light colonoscopy detected an average of 1.1 adenomas per patient, a difference that again was not statistically significant (P value, 0.07), said Dr. Kahi of Indiana University, Bloomington.

There was a modest, statistically significant increase in detection of small (less than 5 mm) or flat adenomas and detection of non-neoplastic lesions using chromocolonoscopy. High-definition chromocolonoscopy detected an average of 0.6 flat adenomas per patient, 0.8 small adenomas per patient, and 1.8 non-neoplastic lesions per patient, compared with 0.4 flat adenomas, 0.7 small adenomas, and 1.0 non-neoplastic lesions per patient with high-definition white light colonoscopy (P values, 0.01, 0.03, and less than 0.0001, respectively).

The two techniques did not differ significantly in detection of advanced adenomas (0.06 per patient with chromocolonoscopy and 0.04 per patient with white-light colonoscopy) or detection of advanced adenomas smaller than 10 mm in size (0.02 per patient with chromocolonoscopy and 0.01 per patient with white light colonoscopy).

Overall, these findings do not support the routine use of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients, Dr. Kahi said.

In general, flat and depressed colon neoplasms are easy to miss on colonoscopy, he noted, but awareness is increasing that they are precursors for colorectal cancer in Western populations. Flat or depressed lesions are more difficult to visualize than polypoid lesions with conventional colonoscopy and are more likely to contain high-grade dysplasia or invasive carcinoma.

The mean procedure time was significantly longer in the chromocolonoscopy group (31 minutes) compared with the white light colonoscopy group (22 minutes), and the mean dose of the sedative propofol was significantly higher in the chromocolonoscopy group (345 mg) than with white light (297 mg).

Dr. Kahi reported having no conflicts of interest related to this study.

Chromocolonoscopy detected an average of 1.3 adenomas per patient; white light colonoscopy detected 1.1.

Source DR. KAHI

SAN DIEGO — High-definition chromocolonoscopy did not significantly increase detection of adenomas, compared with high-definition white light colonoscopy, in a randomized, multicenter study of 660 patients.

In average-risk patients aged 50 years or older undergoing first-time screening colonoscopy, at least one adenoma was seen in 55.5% of 321 patients using chromocolonoscopy and in 48.4% of 339 patients using white light colonoscopy. The 7.1 percentage point increase in the detection rate did not reach statistical significance (P value, 0.07), Dr. Charles J. Kahi and his associates reported at the annual meeting of the American College of Gastroenterology.

Chromocolonoscopy detected an average of 1.3 adenomas per patient, and white light colonoscopy detected an average of 1.1 adenomas per patient, a difference that again was not statistically significant (P value, 0.07), said Dr. Kahi of Indiana University, Bloomington.

There was a modest, statistically significant increase in detection of small (less than 5 mm) or flat adenomas and detection of non-neoplastic lesions using chromocolonoscopy. High-definition chromocolonoscopy detected an average of 0.6 flat adenomas per patient, 0.8 small adenomas per patient, and 1.8 non-neoplastic lesions per patient, compared with 0.4 flat adenomas, 0.7 small adenomas, and 1.0 non-neoplastic lesions per patient with high-definition white light colonoscopy (P values, 0.01, 0.03, and less than 0.0001, respectively).

The two techniques did not differ significantly in detection of advanced adenomas (0.06 per patient with chromocolonoscopy and 0.04 per patient with white-light colonoscopy) or detection of advanced adenomas smaller than 10 mm in size (0.02 per patient with chromocolonoscopy and 0.01 per patient with white light colonoscopy).

Overall, these findings do not support the routine use of high-definition chromocolonoscopy for colorectal cancer screening in average-risk patients, Dr. Kahi said.

In general, flat and depressed colon neoplasms are easy to miss on colonoscopy, he noted, but awareness is increasing that they are precursors for colorectal cancer in Western populations. Flat or depressed lesions are more difficult to visualize than polypoid lesions with conventional colonoscopy and are more likely to contain high-grade dysplasia or invasive carcinoma.

The mean procedure time was significantly longer in the chromocolonoscopy group (31 minutes) compared with the white light colonoscopy group (22 minutes), and the mean dose of the sedative propofol was significantly higher in the chromocolonoscopy group (345 mg) than with white light (297 mg).

Dr. Kahi reported having no conflicts of interest related to this study.

Chromocolonoscopy detected an average of 1.3 adenomas per patient; white light colonoscopy detected 1.1.

Source DR. KAHI

SAN DIEGO — A year-long study surprised investigators when results showed that increased detection of some adenomas using high-definition white light colonoscopy did not produce a “learning effect” leading to increased detection using standard-definition white light colonoscopy.

At least one previous study has suggested that getting accustomed to using high-definition colonoscopy with or without narrow-band imaging to identify previously unseen adenomas produced a cross-over learning effect that helped endoscopists recognize similar lesions using standard-definition colonoscopy, thus increasing adenoma detection with both technologies (Gut 2008;57:59-64).

In the current comparison, however, the adenoma detection rate for standard-definition white light colonoscopy did not increase significantly over the course of the study and remained significantly lower than detection with high-definition equipment, Dr. Anna M. Buchner reported at the annual meeting of the American College of Gastroenterology.

“There wasn't as much learning effect as we thought,” Dr. Kenneth R. DeVault, a coinvestigator in the study, said at a press briefing.

They conducted a “natural experiment” from October 2006 to March 2007 at their institution, the Mayo Clinic in Jacksonville, Fla., when the clinic wanted to upgrade to high-definition equipment but lacked the funds to replace all their colonoscopes at once, Dr. DeVault said.

They put new high-definition white light colonoscopes in three rooms for routine colonoscopies and randomized patients and physicians to one of these rooms or one of three rooms with standard-definition equipment.

High-definition white light colonoscopy used for 1,204 patients showed significantly better detection rates for all polyps (42%), hyperplastic polyps (20%), and adenomas (29%), compared with detection rates using standard-definition white light colonoscopy in 1,226 patients (38% for all polyps, 17% for hyperplastic polyps, and 24% for adenomas), reported Dr. Buchner, who is now with the University of Pennsylvania, Radnor.

Small or moderate-sized adenomas were more likely to be detected by high-definition colonoscopy than with standard-definition imaging: Detection rates for adenomas sized 0-5 mm were approximately 21% with high-definition colonoscopy and 17% with standard-definition equipment. Detection rates for adenomas sized 6-9 mm were approximately 8% with high-definition colonoscopy and 6% with standard-definition technology. High-definition colonoscopy also was more likely to detect polyps on the left side of the colon, she added.

For adenomas larger than 10 mm, however, detection rates were similar with the two techniques. Over the course of the study, detection of polyps overall increased, but adenoma detection did not.

The general characteristics of the patients and of the procedures done using standard-definition colonoscopy did not change significantly between the 6 months prior to introduction of high-definition colonoscopy in some procedure rooms and the ensuing study period, Dr. Buchner noted.

The investigators reported having no conflicts related to this study.

Detection of adenomas remained significantly lower with the standard-definition equipment.

Source DR. BUCHNER

SAN DIEGO — A year-long study surprised investigators when results showed that increased detection of some adenomas using high-definition white light colonoscopy did not produce a “learning effect” leading to increased detection using standard-definition white light colonoscopy.

At least one previous study has suggested that getting accustomed to using high-definition colonoscopy with or without narrow-band imaging to identify previously unseen adenomas produced a cross-over learning effect that helped endoscopists recognize similar lesions using standard-definition colonoscopy, thus increasing adenoma detection with both technologies (Gut 2008;57:59-64).

In the current comparison, however, the adenoma detection rate for standard-definition white light colonoscopy did not increase significantly over the course of the study and remained significantly lower than detection with high-definition equipment, Dr. Anna M. Buchner reported at the annual meeting of the American College of Gastroenterology.

“There wasn't as much learning effect as we thought,” Dr. Kenneth R. DeVault, a coinvestigator in the study, said at a press briefing.

They conducted a “natural experiment” from October 2006 to March 2007 at their institution, the Mayo Clinic in Jacksonville, Fla., when the clinic wanted to upgrade to high-definition equipment but lacked the funds to replace all their colonoscopes at once, Dr. DeVault said.

They put new high-definition white light colonoscopes in three rooms for routine colonoscopies and randomized patients and physicians to one of these rooms or one of three rooms with standard-definition equipment.

High-definition white light colonoscopy used for 1,204 patients showed significantly better detection rates for all polyps (42%), hyperplastic polyps (20%), and adenomas (29%), compared with detection rates using standard-definition white light colonoscopy in 1,226 patients (38% for all polyps, 17% for hyperplastic polyps, and 24% for adenomas), reported Dr. Buchner, who is now with the University of Pennsylvania, Radnor.

Small or moderate-sized adenomas were more likely to be detected by high-definition colonoscopy than with standard-definition imaging: Detection rates for adenomas sized 0-5 mm were approximately 21% with high-definition colonoscopy and 17% with standard-definition equipment. Detection rates for adenomas sized 6-9 mm were approximately 8% with high-definition colonoscopy and 6% with standard-definition technology. High-definition colonoscopy also was more likely to detect polyps on the left side of the colon, she added.

For adenomas larger than 10 mm, however, detection rates were similar with the two techniques. Over the course of the study, detection of polyps overall increased, but adenoma detection did not.

The general characteristics of the patients and of the procedures done using standard-definition colonoscopy did not change significantly between the 6 months prior to introduction of high-definition colonoscopy in some procedure rooms and the ensuing study period, Dr. Buchner noted.

The investigators reported having no conflicts related to this study.

Detection of adenomas remained significantly lower with the standard-definition equipment.

Source DR. BUCHNER

SAN DIEGO — A year-long study surprised investigators when results showed that increased detection of some adenomas using high-definition white light colonoscopy did not produce a “learning effect” leading to increased detection using standard-definition white light colonoscopy.

At least one previous study has suggested that getting accustomed to using high-definition colonoscopy with or without narrow-band imaging to identify previously unseen adenomas produced a cross-over learning effect that helped endoscopists recognize similar lesions using standard-definition colonoscopy, thus increasing adenoma detection with both technologies (Gut 2008;57:59-64).

In the current comparison, however, the adenoma detection rate for standard-definition white light colonoscopy did not increase significantly over the course of the study and remained significantly lower than detection with high-definition equipment, Dr. Anna M. Buchner reported at the annual meeting of the American College of Gastroenterology.

“There wasn't as much learning effect as we thought,” Dr. Kenneth R. DeVault, a coinvestigator in the study, said at a press briefing.

They conducted a “natural experiment” from October 2006 to March 2007 at their institution, the Mayo Clinic in Jacksonville, Fla., when the clinic wanted to upgrade to high-definition equipment but lacked the funds to replace all their colonoscopes at once, Dr. DeVault said.

They put new high-definition white light colonoscopes in three rooms for routine colonoscopies and randomized patients and physicians to one of these rooms or one of three rooms with standard-definition equipment.

High-definition white light colonoscopy used for 1,204 patients showed significantly better detection rates for all polyps (42%), hyperplastic polyps (20%), and adenomas (29%), compared with detection rates using standard-definition white light colonoscopy in 1,226 patients (38% for all polyps, 17% for hyperplastic polyps, and 24% for adenomas), reported Dr. Buchner, who is now with the University of Pennsylvania, Radnor.

Small or moderate-sized adenomas were more likely to be detected by high-definition colonoscopy than with standard-definition imaging: Detection rates for adenomas sized 0-5 mm were approximately 21% with high-definition colonoscopy and 17% with standard-definition equipment. Detection rates for adenomas sized 6-9 mm were approximately 8% with high-definition colonoscopy and 6% with standard-definition technology. High-definition colonoscopy also was more likely to detect polyps on the left side of the colon, she added.

For adenomas larger than 10 mm, however, detection rates were similar with the two techniques. Over the course of the study, detection of polyps overall increased, but adenoma detection did not.

The general characteristics of the patients and of the procedures done using standard-definition colonoscopy did not change significantly between the 6 months prior to introduction of high-definition colonoscopy in some procedure rooms and the ensuing study period, Dr. Buchner noted.

The investigators reported having no conflicts related to this study.

Detection of adenomas remained significantly lower with the standard-definition equipment.

Source DR. BUCHNER

SAN FRANCISCO — The estimated 10-year risk for developing cardiovascular disease was at least as great as the risk of having a breast cancer recurrence in 78% of 242 postmenopausal women who were treated with an aromatase inhibitor for early-stage, hormone receptor–positive breast cancer.

Clinicians should consider the effects of various breast cancer therapies on other potential health problems, such as cardiovascular disease, when choosing cancer treatment, Dr. Aditya Bardia said at a breast cancer symposium sponsored by the American Society of Clinical Oncology, where he presented the finding.

With more women surviving breast cancer, these considerations take on growing importance, said Dr. Bardia of Johns Hopkins University, Baltimore. In 2009, an estimated 182,460 U.S. women will be diagnosed with breast cancers, with 42% of new breast cancers in women older than 65 years.

Cardiovascular disease is the leading cause of death in U.S. women. One previous study found an association between aromatase inhibitor therapy and cardiovascular risk, but other studies have reported no such association, he noted.

Dr. Bardia and his associates analyzed data on a subset of women from a randomized study that was designed primarily to compare two aromatase inhibitors—exemestane (Aromasin) and letrozole (Femara)—in 2 years of treatment either as first-line breast cancer therapy or after 2-5 years of tamoxifen therapy. All women were postmenopausal and had stage 0-III HR-positive breast cancer.

The investigators used the modified Framingham score at study enrollment to estimate the risk of developing a serious cardiovascular disease event over the next 10 years. The scoring tool also was used to calculate each woman's “heart age” at baseline, a composite end point representing multiple risk factors in addition to biological age.

The cardiovascular disease risk was equal to the cancer recurrence risk in 43% of patients and higher than the cancer risk in 35%, with the other 22% having lower risk for cardiovascular disease than for cancer.

Several factors identified women who were more likely to be at greater risk for cardiovascular disease than for breast cancer recurrence, Dr. Bardia said. The likelihood of greater cardiovascular risk was 16 times higher in women with a “heart age” greater than 65 years, compared with “younger” hearts. It was six times higher in those with breast tumors sized less than 2 cm, compared with larger tumors, and five times higher in patients with stage I breast disease, compared with those at stage II or III.

Two factors—having grade 1 or 2 breast disease instead of grade 3, and having lymph node–negative cancer instead of positive nodes—each tripled the likelihood that cardiovascular risk would be greater than cancer recurrence risk.

The study was funded by the National Institutes of Health, Pfizer Inc. (which markets exemestane), and Novartis (which markets letrozole). Dr. Bardia also has received research funding from AstraZeneca and Eli Lilly & Co.

Elsevier Global Medical News

SAN FRANCISCO — The estimated 10-year risk for developing cardiovascular disease was at least as great as the risk of having a breast cancer recurrence in 78% of 242 postmenopausal women who were treated with an aromatase inhibitor for early-stage, hormone receptor–positive breast cancer.

Clinicians should consider the effects of various breast cancer therapies on other potential health problems, such as cardiovascular disease, when choosing cancer treatment, Dr. Aditya Bardia said at a breast cancer symposium sponsored by the American Society of Clinical Oncology, where he presented the finding.

With more women surviving breast cancer, these considerations take on growing importance, said Dr. Bardia of Johns Hopkins University, Baltimore. In 2009, an estimated 182,460 U.S. women will be diagnosed with breast cancers, with 42% of new breast cancers in women older than 65 years.

Cardiovascular disease is the leading cause of death in U.S. women. One previous study found an association between aromatase inhibitor therapy and cardiovascular risk, but other studies have reported no such association, he noted.

Dr. Bardia and his associates analyzed data on a subset of women from a randomized study that was designed primarily to compare two aromatase inhibitors—exemestane (Aromasin) and letrozole (Femara)—in 2 years of treatment either as first-line breast cancer therapy or after 2-5 years of tamoxifen therapy. All women were postmenopausal and had stage 0-III HR-positive breast cancer.

The investigators used the modified Framingham score at study enrollment to estimate the risk of developing a serious cardiovascular disease event over the next 10 years. The scoring tool also was used to calculate each woman's “heart age” at baseline, a composite end point representing multiple risk factors in addition to biological age.

The cardiovascular disease risk was equal to the cancer recurrence risk in 43% of patients and higher than the cancer risk in 35%, with the other 22% having lower risk for cardiovascular disease than for cancer.

Several factors identified women who were more likely to be at greater risk for cardiovascular disease than for breast cancer recurrence, Dr. Bardia said. The likelihood of greater cardiovascular risk was 16 times higher in women with a “heart age” greater than 65 years, compared with “younger” hearts. It was six times higher in those with breast tumors sized less than 2 cm, compared with larger tumors, and five times higher in patients with stage I breast disease, compared with those at stage II or III.

Two factors—having grade 1 or 2 breast disease instead of grade 3, and having lymph node–negative cancer instead of positive nodes—each tripled the likelihood that cardiovascular risk would be greater than cancer recurrence risk.

The study was funded by the National Institutes of Health, Pfizer Inc. (which markets exemestane), and Novartis (which markets letrozole). Dr. Bardia also has received research funding from AstraZeneca and Eli Lilly & Co.

Elsevier Global Medical News

SAN FRANCISCO — The estimated 10-year risk for developing cardiovascular disease was at least as great as the risk of having a breast cancer recurrence in 78% of 242 postmenopausal women who were treated with an aromatase inhibitor for early-stage, hormone receptor–positive breast cancer.

Clinicians should consider the effects of various breast cancer therapies on other potential health problems, such as cardiovascular disease, when choosing cancer treatment, Dr. Aditya Bardia said at a breast cancer symposium sponsored by the American Society of Clinical Oncology, where he presented the finding.

With more women surviving breast cancer, these considerations take on growing importance, said Dr. Bardia of Johns Hopkins University, Baltimore. In 2009, an estimated 182,460 U.S. women will be diagnosed with breast cancers, with 42% of new breast cancers in women older than 65 years.

Cardiovascular disease is the leading cause of death in U.S. women. One previous study found an association between aromatase inhibitor therapy and cardiovascular risk, but other studies have reported no such association, he noted.

Dr. Bardia and his associates analyzed data on a subset of women from a randomized study that was designed primarily to compare two aromatase inhibitors—exemestane (Aromasin) and letrozole (Femara)—in 2 years of treatment either as first-line breast cancer therapy or after 2-5 years of tamoxifen therapy. All women were postmenopausal and had stage 0-III HR-positive breast cancer.

The investigators used the modified Framingham score at study enrollment to estimate the risk of developing a serious cardiovascular disease event over the next 10 years. The scoring tool also was used to calculate each woman's “heart age” at baseline, a composite end point representing multiple risk factors in addition to biological age.

The cardiovascular disease risk was equal to the cancer recurrence risk in 43% of patients and higher than the cancer risk in 35%, with the other 22% having lower risk for cardiovascular disease than for cancer.

Several factors identified women who were more likely to be at greater risk for cardiovascular disease than for breast cancer recurrence, Dr. Bardia said. The likelihood of greater cardiovascular risk was 16 times higher in women with a “heart age” greater than 65 years, compared with “younger” hearts. It was six times higher in those with breast tumors sized less than 2 cm, compared with larger tumors, and five times higher in patients with stage I breast disease, compared with those at stage II or III.

Two factors—having grade 1 or 2 breast disease instead of grade 3, and having lymph node–negative cancer instead of positive nodes—each tripled the likelihood that cardiovascular risk would be greater than cancer recurrence risk.

The study was funded by the National Institutes of Health, Pfizer Inc. (which markets exemestane), and Novartis (which markets letrozole). Dr. Bardia also has received research funding from AstraZeneca and Eli Lilly & Co.

Elsevier Global Medical News

Adding ultrasound examination of axillary nodes and fine-needle aspiration of suspicious nodes prior to lumpectomy in women with early-stage breast cancer spared 17 (30%) of 57 women the need for sentinel node biopsy and a second surgery, a study of 274 patients found.

The 17 patients with cancerous lymph cells on axillary ultrasound and fine-needle aspiration cytology (AUS-FNAC) underwent axillary clearance at the same time as lumpectomy, Dr. Bedanta Baruah reported Oct. 6 in a press briefing sponsored by the American Society of Clinical Oncology.

Traditionally, women with a suspicious breast lump undergo FNAC or core needle biopsy to determine malignancy. Those with malignancies usually undergo sentinel lymph node biopsy at the time of lumpectomy and, in many parts of the world, results of the sentinel node biopsy are not available for several days, necessitating a second surgery for those with positive lymph nodes. At Dr. Baruah's institution, Cardiff (Wales) University, sentinel node biopsy results are available 3 days after surgery.

“Even in the [United States] and other centers where results of the sentinel biopsy are usually available at the time of initial surgery, using this technique would still prevent a very high number of unnecessary sentinel node biopsies,” he said. “We therefore recommend that all patients who are due for a lumpectomy should have this procedure before the formal surgery.”

Dr. Baruah reported having no conflicts of interest related to this study.

Dr. Lori Pierce, moderator of the press briefing and professor of radiation oncology at the University of Michigan, Ann Arbor, commented, “Patients diagnosed with early-stage breast cancer should discuss with their doctors the best method of determining whether cancer cells have gone to their lymph nodes under the arm.”

All patients who were scheduled to undergo breast conservation surgery in the Cardiff breast unit in 2007 and 2008 underwent AUS-FNAC at the time of initial diagnostic breast biopsy. Those with positive axillary nodes underwent axillary clearance at the time of lumpectomy, and those with negative nodes on AUS-FNAC underwent sentinel lymph node biopsy during lumpectomy.

In all, 57 patients (21%) had nodal macrometastases on final histology. The 17 identified by AUS-FNAC gave the procedure a sensitivity of 30%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84%, with an overall accuracy of 84%,.

Previous studies used ultrasound alone to try and detect axillary metastases, which resulted in many false positives; the addition of FNAC eliminated false positives, he noted. Micrometastases in seven patients went undetected by AUS-FNAC, however, so any patient with normal results on AUS-FNAC still should undergo sentinel node biopsy, Dr. Baruah suggested. The importance of detecting micrometastases is not clear, Dr. Baruah said, but his unit offers patients with micrometastases axillary clearance, to be safe.

Adding ultrasound examination of axillary nodes and fine-needle aspiration of suspicious nodes prior to lumpectomy in women with early-stage breast cancer spared 17 (30%) of 57 women the need for sentinel node biopsy and a second surgery, a study of 274 patients found.

The 17 patients with cancerous lymph cells on axillary ultrasound and fine-needle aspiration cytology (AUS-FNAC) underwent axillary clearance at the same time as lumpectomy, Dr. Bedanta Baruah reported Oct. 6 in a press briefing sponsored by the American Society of Clinical Oncology.

Traditionally, women with a suspicious breast lump undergo FNAC or core needle biopsy to determine malignancy. Those with malignancies usually undergo sentinel lymph node biopsy at the time of lumpectomy and, in many parts of the world, results of the sentinel node biopsy are not available for several days, necessitating a second surgery for those with positive lymph nodes. At Dr. Baruah's institution, Cardiff (Wales) University, sentinel node biopsy results are available 3 days after surgery.

“Even in the [United States] and other centers where results of the sentinel biopsy are usually available at the time of initial surgery, using this technique would still prevent a very high number of unnecessary sentinel node biopsies,” he said. “We therefore recommend that all patients who are due for a lumpectomy should have this procedure before the formal surgery.”

Dr. Baruah reported having no conflicts of interest related to this study.

Dr. Lori Pierce, moderator of the press briefing and professor of radiation oncology at the University of Michigan, Ann Arbor, commented, “Patients diagnosed with early-stage breast cancer should discuss with their doctors the best method of determining whether cancer cells have gone to their lymph nodes under the arm.”

All patients who were scheduled to undergo breast conservation surgery in the Cardiff breast unit in 2007 and 2008 underwent AUS-FNAC at the time of initial diagnostic breast biopsy. Those with positive axillary nodes underwent axillary clearance at the time of lumpectomy, and those with negative nodes on AUS-FNAC underwent sentinel lymph node biopsy during lumpectomy.

In all, 57 patients (21%) had nodal macrometastases on final histology. The 17 identified by AUS-FNAC gave the procedure a sensitivity of 30%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84%, with an overall accuracy of 84%,.

Previous studies used ultrasound alone to try and detect axillary metastases, which resulted in many false positives; the addition of FNAC eliminated false positives, he noted. Micrometastases in seven patients went undetected by AUS-FNAC, however, so any patient with normal results on AUS-FNAC still should undergo sentinel node biopsy, Dr. Baruah suggested. The importance of detecting micrometastases is not clear, Dr. Baruah said, but his unit offers patients with micrometastases axillary clearance, to be safe.

Adding ultrasound examination of axillary nodes and fine-needle aspiration of suspicious nodes prior to lumpectomy in women with early-stage breast cancer spared 17 (30%) of 57 women the need for sentinel node biopsy and a second surgery, a study of 274 patients found.

The 17 patients with cancerous lymph cells on axillary ultrasound and fine-needle aspiration cytology (AUS-FNAC) underwent axillary clearance at the same time as lumpectomy, Dr. Bedanta Baruah reported Oct. 6 in a press briefing sponsored by the American Society of Clinical Oncology.

Traditionally, women with a suspicious breast lump undergo FNAC or core needle biopsy to determine malignancy. Those with malignancies usually undergo sentinel lymph node biopsy at the time of lumpectomy and, in many parts of the world, results of the sentinel node biopsy are not available for several days, necessitating a second surgery for those with positive lymph nodes. At Dr. Baruah's institution, Cardiff (Wales) University, sentinel node biopsy results are available 3 days after surgery.

“Even in the [United States] and other centers where results of the sentinel biopsy are usually available at the time of initial surgery, using this technique would still prevent a very high number of unnecessary sentinel node biopsies,” he said. “We therefore recommend that all patients who are due for a lumpectomy should have this procedure before the formal surgery.”

Dr. Baruah reported having no conflicts of interest related to this study.

Dr. Lori Pierce, moderator of the press briefing and professor of radiation oncology at the University of Michigan, Ann Arbor, commented, “Patients diagnosed with early-stage breast cancer should discuss with their doctors the best method of determining whether cancer cells have gone to their lymph nodes under the arm.”

All patients who were scheduled to undergo breast conservation surgery in the Cardiff breast unit in 2007 and 2008 underwent AUS-FNAC at the time of initial diagnostic breast biopsy. Those with positive axillary nodes underwent axillary clearance at the time of lumpectomy, and those with negative nodes on AUS-FNAC underwent sentinel lymph node biopsy during lumpectomy.

In all, 57 patients (21%) had nodal macrometastases on final histology. The 17 identified by AUS-FNAC gave the procedure a sensitivity of 30%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 84%, with an overall accuracy of 84%,.

Previous studies used ultrasound alone to try and detect axillary metastases, which resulted in many false positives; the addition of FNAC eliminated false positives, he noted. Micrometastases in seven patients went undetected by AUS-FNAC, however, so any patient with normal results on AUS-FNAC still should undergo sentinel node biopsy, Dr. Baruah suggested. The importance of detecting micrometastases is not clear, Dr. Baruah said, but his unit offers patients with micrometastases axillary clearance, to be safe.

SAN FRANCISCO — Survival rates for extremely preterm infants held steady from 2000 to 2002, compared with the 1990s, and neurologic outcomes may have improved in some places, preliminary data suggest.

These trends are illustrated in data on 1,478 infants with birth weights of 500–999 g born in the Case Western Reserve University system, Dr. Thomas K. Shimotake said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The likelihood of surviving to a corrected age of 20 months increased from 49% in 1982–1989 to 68% in 1990–1999, then stayed relatively flat with a nonsignificant increase in survival to 71% in 2000–2002 (Pediatrics 2005;115:997–1003).

Long-term follow-up of infants in the Case Western study suggest improved neurodevelopmental outcomes in the most recent years, added Dr. Shimotake, codirector of the neurointensive care nursery at the UCSF Children's Hospital.

The proportion of infants with “intact survival” (no impairments at 18- to 24-months of follow-up) increased from 12% in the 1980s to 21% in the 1990s, then dropped to 15% in 2000–2002. Rates for any neurosensory abnormality increased from 18% to 23% between the 1980s and 1990s, then decreased to 9% in 2000–2002. The proportion of infants with cerebral palsy increased from 8% in the 1980s to 13% in the 1990s, then fell to 5% in 2000–2002 (Pediatrics 2007;119:37–45).

“That's a pretty dramatic fall without any improvement in survival rates, which is good news for that population, but it may not be applicable to everybody. Other people have reported higher rates” of cerebral palsy, he said. The incidence of cerebral palsy in preterm infants still is much higher than the rate of 2–3/1,000 live births seen in the general population, and preterm infants are 20–30 times more likely than term infants to have cerebral palsy, he added.

Unpublished data released by the Vermont Oxford Network in 2006 showed severe disabilities in 29%-32% of extremely low-birth-weight infants at 18- to 24-month follow-up exams between 1999 and 2004, with severe disability seen in 25% of those whose follow-up exams occurred in 2005. “That's pretty close to the most recent information we have,” Dr. Shimotake said. “It will be interesting to see how this plays out over the next couple of years, to see if this is consistent with findings reported at Case Western and see if there are improvements in neurologic outcomes. Generally, people feel that there are.”

At UCSF, which sees a high-risk population, “our follow-up outcomes have not been as robust,” he noted. Although 60%-75% of infants born at 24–26 weeks' gestation survive, neurologic impairments affect 79% born at 24 weeks, 62% born at 25 weeks, and 60% born at 26 weeks.

Practice changes in the past 2 decades undoubtedly improved survival, Dr. Shimotake said. Prenatal steroid use increased from no use in the 1980s to 41% of extremely preterm infants in the 1990s to 78% in 2000–2002, and “it's probably higher than that now,” he said. Use of surfactants has increased to 80%-90% of these cases. The use of assisted ventilation increased initially between the 1980s and 1990s, then decreased because of awareness of the injurious effects of aggressive resuscitation and mechanical ventilation, he noted.

It's important to give the most up-to-date data on survival and outcomes when counseling parents of extremely preterm infants, Dr. Shimotake said. “It's nice that we can have babies survive at extremely low birth weights, but what's important is how these babies ultimately live,” he said.

Dr. Shimotake said he has no conflicts of interest related to these topics.

SAN FRANCISCO — Survival rates for extremely preterm infants held steady from 2000 to 2002, compared with the 1990s, and neurologic outcomes may have improved in some places, preliminary data suggest.

These trends are illustrated in data on 1,478 infants with birth weights of 500–999 g born in the Case Western Reserve University system, Dr. Thomas K. Shimotake said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The likelihood of surviving to a corrected age of 20 months increased from 49% in 1982–1989 to 68% in 1990–1999, then stayed relatively flat with a nonsignificant increase in survival to 71% in 2000–2002 (Pediatrics 2005;115:997–1003).

Long-term follow-up of infants in the Case Western study suggest improved neurodevelopmental outcomes in the most recent years, added Dr. Shimotake, codirector of the neurointensive care nursery at the UCSF Children's Hospital.

The proportion of infants with “intact survival” (no impairments at 18- to 24-months of follow-up) increased from 12% in the 1980s to 21% in the 1990s, then dropped to 15% in 2000–2002. Rates for any neurosensory abnormality increased from 18% to 23% between the 1980s and 1990s, then decreased to 9% in 2000–2002. The proportion of infants with cerebral palsy increased from 8% in the 1980s to 13% in the 1990s, then fell to 5% in 2000–2002 (Pediatrics 2007;119:37–45).

“That's a pretty dramatic fall without any improvement in survival rates, which is good news for that population, but it may not be applicable to everybody. Other people have reported higher rates” of cerebral palsy, he said. The incidence of cerebral palsy in preterm infants still is much higher than the rate of 2–3/1,000 live births seen in the general population, and preterm infants are 20–30 times more likely than term infants to have cerebral palsy, he added.

Unpublished data released by the Vermont Oxford Network in 2006 showed severe disabilities in 29%-32% of extremely low-birth-weight infants at 18- to 24-month follow-up exams between 1999 and 2004, with severe disability seen in 25% of those whose follow-up exams occurred in 2005. “That's pretty close to the most recent information we have,” Dr. Shimotake said. “It will be interesting to see how this plays out over the next couple of years, to see if this is consistent with findings reported at Case Western and see if there are improvements in neurologic outcomes. Generally, people feel that there are.”

At UCSF, which sees a high-risk population, “our follow-up outcomes have not been as robust,” he noted. Although 60%-75% of infants born at 24–26 weeks' gestation survive, neurologic impairments affect 79% born at 24 weeks, 62% born at 25 weeks, and 60% born at 26 weeks.

Practice changes in the past 2 decades undoubtedly improved survival, Dr. Shimotake said. Prenatal steroid use increased from no use in the 1980s to 41% of extremely preterm infants in the 1990s to 78% in 2000–2002, and “it's probably higher than that now,” he said. Use of surfactants has increased to 80%-90% of these cases. The use of assisted ventilation increased initially between the 1980s and 1990s, then decreased because of awareness of the injurious effects of aggressive resuscitation and mechanical ventilation, he noted.

It's important to give the most up-to-date data on survival and outcomes when counseling parents of extremely preterm infants, Dr. Shimotake said. “It's nice that we can have babies survive at extremely low birth weights, but what's important is how these babies ultimately live,” he said.

Dr. Shimotake said he has no conflicts of interest related to these topics.

SAN FRANCISCO — Survival rates for extremely preterm infants held steady from 2000 to 2002, compared with the 1990s, and neurologic outcomes may have improved in some places, preliminary data suggest.

These trends are illustrated in data on 1,478 infants with birth weights of 500–999 g born in the Case Western Reserve University system, Dr. Thomas K. Shimotake said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The likelihood of surviving to a corrected age of 20 months increased from 49% in 1982–1989 to 68% in 1990–1999, then stayed relatively flat with a nonsignificant increase in survival to 71% in 2000–2002 (Pediatrics 2005;115:997–1003).

Long-term follow-up of infants in the Case Western study suggest improved neurodevelopmental outcomes in the most recent years, added Dr. Shimotake, codirector of the neurointensive care nursery at the UCSF Children's Hospital.

The proportion of infants with “intact survival” (no impairments at 18- to 24-months of follow-up) increased from 12% in the 1980s to 21% in the 1990s, then dropped to 15% in 2000–2002. Rates for any neurosensory abnormality increased from 18% to 23% between the 1980s and 1990s, then decreased to 9% in 2000–2002. The proportion of infants with cerebral palsy increased from 8% in the 1980s to 13% in the 1990s, then fell to 5% in 2000–2002 (Pediatrics 2007;119:37–45).

“That's a pretty dramatic fall without any improvement in survival rates, which is good news for that population, but it may not be applicable to everybody. Other people have reported higher rates” of cerebral palsy, he said. The incidence of cerebral palsy in preterm infants still is much higher than the rate of 2–3/1,000 live births seen in the general population, and preterm infants are 20–30 times more likely than term infants to have cerebral palsy, he added.

Unpublished data released by the Vermont Oxford Network in 2006 showed severe disabilities in 29%-32% of extremely low-birth-weight infants at 18- to 24-month follow-up exams between 1999 and 2004, with severe disability seen in 25% of those whose follow-up exams occurred in 2005. “That's pretty close to the most recent information we have,” Dr. Shimotake said. “It will be interesting to see how this plays out over the next couple of years, to see if this is consistent with findings reported at Case Western and see if there are improvements in neurologic outcomes. Generally, people feel that there are.”

At UCSF, which sees a high-risk population, “our follow-up outcomes have not been as robust,” he noted. Although 60%-75% of infants born at 24–26 weeks' gestation survive, neurologic impairments affect 79% born at 24 weeks, 62% born at 25 weeks, and 60% born at 26 weeks.

Practice changes in the past 2 decades undoubtedly improved survival, Dr. Shimotake said. Prenatal steroid use increased from no use in the 1980s to 41% of extremely preterm infants in the 1990s to 78% in 2000–2002, and “it's probably higher than that now,” he said. Use of surfactants has increased to 80%-90% of these cases. The use of assisted ventilation increased initially between the 1980s and 1990s, then decreased because of awareness of the injurious effects of aggressive resuscitation and mechanical ventilation, he noted.

It's important to give the most up-to-date data on survival and outcomes when counseling parents of extremely preterm infants, Dr. Shimotake said. “It's nice that we can have babies survive at extremely low birth weights, but what's important is how these babies ultimately live,” he said.

Dr. Shimotake said he has no conflicts of interest related to these topics.

SAN FRANCISCO — Putting reassuring wording in a pregnant patient's chart may alleviate worry for the mother after a fetal ultrasound shows an isolated choroid plexus cyst or isolated echogenic intracardiac focus, Dr. Mary E. Norton said.

Neither of these findings is cause for ultrasound follow-up or amniocentesis if the mother has no other risk factors for chromosomal abnormalities, Dr. Norton explained at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They do, however, cause anxiety or fear in many patients, studies suggest. It's hard for mothers to get over the idea of a cyst in the fetal brain when they hear that it is marginally associated with chromosomal abnormalities, for example, despite physician counseling that isolated choroid plexus cysts are not associated with Down syndrome and resolve in essentially all cases, she said.

How can clinicians ensure an adequate assessment when a choroid plexus cyst is identified without instilling unnecessary anxiety for the mother? Scheduling multiple visits and ultrasounds and meetings with genetic counselors is not the way to go, said Dr. Norton, professor of obstetrics and gynecology and reproductive services at the university and regional director of perinatal genetic services for Kaiser Permanente, San Francisco.

At her institutions, when clinicians performing a fetal ultrasound identify a choroid plexus cyst, they get extra, careful images of the heart and hands at that time to check for abnormalities. If this is not done on the level I ultrasound, clinicians should consider getting a level II ultrasound for these patients, she suggested.

If no other abnormalities are seen and results of any other screening (such as a triple screen) suggest that the woman is at low risk for chromosomal abnormalities, the following wording goes in her chart: “An isolated choroid plexus cyst was identified. While this finding has been associated with fetal chromosome abnormalities, no other major or minor anomalies were identified in this fetus. In the absence of other risk factors, this finding most commonly represents a normal variant and no further evaluation is recommended.”

The same wording is used after a fetal ultrasound identifies isolated echogenic intracardiac focus, inserting this phrase in place of “choroid plexus cyst.”

“These patients don't need to have an echocardiogram to evaluate the fetal heart,” because this finding is not associated with congenital heart defects, she said. “They're not pathologic in and of themselves, but they do have a small association with an increased risk of chromosomal abnormalities.”

That can raise anxiety unnecessarily in a woman with no other risk factors for abnormalities, but putting the reassuring wording in the chart can help them reframe their risk, Dr. Norton said.

Closer management is needed for fetal ultrasound findings with borderline significance, such as renal pelviectasis, or findings that have the potential for significant abnormality (echogenic bowel or mild ventriculomegaly), she added.

In more than 90% of cases, fetal pelviectasis is a normal finding representing a physiological response to maternal progesterone. In a small percentage of cases, however, it can represent obstruction of the ureteropelvic junction or reflux that may have important implications after birth.

The risk for Down syndrome may be marginally increased with isolated pelviectasis, and amniocentesis is not warranted unless other risk factors are present, she noted.

Studies suggest that ultrasound follow-up is reasonably sensitive and specific if the pelviectasis measures less than 4 mm in pregnancies before 20 weeks' gestation, less than 7 mm between 20 and 30 weeks' gestation, or less than 10 mm from 30 weeks to term, Dr. Norton said.

There's no need for monthly ultrasounds, but schedule a repeat ultrasound in the middle of the third trimester to rule out progression of the pelviectasis and determine the need for postnatal follow-up, she said.

If the findings persist in the third trimester, wait at least 10 days after delivery for postnatal follow-up so the fetal volume status can adjust from prenatal to postnatal status. In the past, prophylactic antibiotics were given to the newborn during these 10 days in case the findings represented reflux, but it is unclear whether antibiotics are necessary. “That's a pediatric urologic decision,” she noted.

Of the two more concerning findings, echogenic bowel has been associated with trisomies, cystic fibrosis, viral infection, intrauterine growth restriction (IUGR), and fetal demise.

“Echogenic bowel is a tricky one because we see it in many cases that ultimately go on to have a completely normal outcome, and we never know why it was there,” she said.

Dr. Norton advised careful evaluation and follow-up. Get cystic fibrosis screening if it hasn't already been done, and do maternal or fetal testing for cytomegalovirus and possibly toxoplasmosis. “We do offer amniocentesis for karyotyping,” although it's unclear whether this is warranted in women who are otherwise low risk, she said. Get a follow-up ultrasound to evaluate the bowel and fetal growth in the third trimester. “The risk of IUGR is not inconsequential,” she warned.

Mild ventriculomegaly, in which fetal cerebral ventricles measure 10–15 mm, usually involves normal variants, especially when the ventricles are in the smaller end of that range. Rare cases may represent obstructive hydrocephalus or be markers for other underlying CNS pathology.

Order a level II ultrasound and get a fetal MRI, which can clearly show developments of the fetal brain and CNS findings not seen on ultrasound. “We do order MRI, although the precise utility of that, I would acknowledge, is still under investigation,” Dr. Norton said.

Because ventriculomegaly is associated with chromosomal abnormalities or infectious disease in a small number of cases, she offers amniocentesis for karyotyping and testing for cytomegalovirus and possibly toxoplasmosis.

Dr. Norton said that she has no conflicts of interest related to her presentation.

SAN FRANCISCO — Putting reassuring wording in a pregnant patient's chart may alleviate worry for the mother after a fetal ultrasound shows an isolated choroid plexus cyst or isolated echogenic intracardiac focus, Dr. Mary E. Norton said.

Neither of these findings is cause for ultrasound follow-up or amniocentesis if the mother has no other risk factors for chromosomal abnormalities, Dr. Norton explained at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They do, however, cause anxiety or fear in many patients, studies suggest. It's hard for mothers to get over the idea of a cyst in the fetal brain when they hear that it is marginally associated with chromosomal abnormalities, for example, despite physician counseling that isolated choroid plexus cysts are not associated with Down syndrome and resolve in essentially all cases, she said.

How can clinicians ensure an adequate assessment when a choroid plexus cyst is identified without instilling unnecessary anxiety for the mother? Scheduling multiple visits and ultrasounds and meetings with genetic counselors is not the way to go, said Dr. Norton, professor of obstetrics and gynecology and reproductive services at the university and regional director of perinatal genetic services for Kaiser Permanente, San Francisco.

At her institutions, when clinicians performing a fetal ultrasound identify a choroid plexus cyst, they get extra, careful images of the heart and hands at that time to check for abnormalities. If this is not done on the level I ultrasound, clinicians should consider getting a level II ultrasound for these patients, she suggested.

If no other abnormalities are seen and results of any other screening (such as a triple screen) suggest that the woman is at low risk for chromosomal abnormalities, the following wording goes in her chart: “An isolated choroid plexus cyst was identified. While this finding has been associated with fetal chromosome abnormalities, no other major or minor anomalies were identified in this fetus. In the absence of other risk factors, this finding most commonly represents a normal variant and no further evaluation is recommended.”

The same wording is used after a fetal ultrasound identifies isolated echogenic intracardiac focus, inserting this phrase in place of “choroid plexus cyst.”

“These patients don't need to have an echocardiogram to evaluate the fetal heart,” because this finding is not associated with congenital heart defects, she said. “They're not pathologic in and of themselves, but they do have a small association with an increased risk of chromosomal abnormalities.”

That can raise anxiety unnecessarily in a woman with no other risk factors for abnormalities, but putting the reassuring wording in the chart can help them reframe their risk, Dr. Norton said.

Closer management is needed for fetal ultrasound findings with borderline significance, such as renal pelviectasis, or findings that have the potential for significant abnormality (echogenic bowel or mild ventriculomegaly), she added.

In more than 90% of cases, fetal pelviectasis is a normal finding representing a physiological response to maternal progesterone. In a small percentage of cases, however, it can represent obstruction of the ureteropelvic junction or reflux that may have important implications after birth.

The risk for Down syndrome may be marginally increased with isolated pelviectasis, and amniocentesis is not warranted unless other risk factors are present, she noted.

Studies suggest that ultrasound follow-up is reasonably sensitive and specific if the pelviectasis measures less than 4 mm in pregnancies before 20 weeks' gestation, less than 7 mm between 20 and 30 weeks' gestation, or less than 10 mm from 30 weeks to term, Dr. Norton said.

There's no need for monthly ultrasounds, but schedule a repeat ultrasound in the middle of the third trimester to rule out progression of the pelviectasis and determine the need for postnatal follow-up, she said.

If the findings persist in the third trimester, wait at least 10 days after delivery for postnatal follow-up so the fetal volume status can adjust from prenatal to postnatal status. In the past, prophylactic antibiotics were given to the newborn during these 10 days in case the findings represented reflux, but it is unclear whether antibiotics are necessary. “That's a pediatric urologic decision,” she noted.

Of the two more concerning findings, echogenic bowel has been associated with trisomies, cystic fibrosis, viral infection, intrauterine growth restriction (IUGR), and fetal demise.

“Echogenic bowel is a tricky one because we see it in many cases that ultimately go on to have a completely normal outcome, and we never know why it was there,” she said.

Dr. Norton advised careful evaluation and follow-up. Get cystic fibrosis screening if it hasn't already been done, and do maternal or fetal testing for cytomegalovirus and possibly toxoplasmosis. “We do offer amniocentesis for karyotyping,” although it's unclear whether this is warranted in women who are otherwise low risk, she said. Get a follow-up ultrasound to evaluate the bowel and fetal growth in the third trimester. “The risk of IUGR is not inconsequential,” she warned.

Mild ventriculomegaly, in which fetal cerebral ventricles measure 10–15 mm, usually involves normal variants, especially when the ventricles are in the smaller end of that range. Rare cases may represent obstructive hydrocephalus or be markers for other underlying CNS pathology.

Order a level II ultrasound and get a fetal MRI, which can clearly show developments of the fetal brain and CNS findings not seen on ultrasound. “We do order MRI, although the precise utility of that, I would acknowledge, is still under investigation,” Dr. Norton said.

Because ventriculomegaly is associated with chromosomal abnormalities or infectious disease in a small number of cases, she offers amniocentesis for karyotyping and testing for cytomegalovirus and possibly toxoplasmosis.

Dr. Norton said that she has no conflicts of interest related to her presentation.

SAN FRANCISCO — Putting reassuring wording in a pregnant patient's chart may alleviate worry for the mother after a fetal ultrasound shows an isolated choroid plexus cyst or isolated echogenic intracardiac focus, Dr. Mary E. Norton said.

Neither of these findings is cause for ultrasound follow-up or amniocentesis if the mother has no other risk factors for chromosomal abnormalities, Dr. Norton explained at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They do, however, cause anxiety or fear in many patients, studies suggest. It's hard for mothers to get over the idea of a cyst in the fetal brain when they hear that it is marginally associated with chromosomal abnormalities, for example, despite physician counseling that isolated choroid plexus cysts are not associated with Down syndrome and resolve in essentially all cases, she said.

How can clinicians ensure an adequate assessment when a choroid plexus cyst is identified without instilling unnecessary anxiety for the mother? Scheduling multiple visits and ultrasounds and meetings with genetic counselors is not the way to go, said Dr. Norton, professor of obstetrics and gynecology and reproductive services at the university and regional director of perinatal genetic services for Kaiser Permanente, San Francisco.

At her institutions, when clinicians performing a fetal ultrasound identify a choroid plexus cyst, they get extra, careful images of the heart and hands at that time to check for abnormalities. If this is not done on the level I ultrasound, clinicians should consider getting a level II ultrasound for these patients, she suggested.

If no other abnormalities are seen and results of any other screening (such as a triple screen) suggest that the woman is at low risk for chromosomal abnormalities, the following wording goes in her chart: “An isolated choroid plexus cyst was identified. While this finding has been associated with fetal chromosome abnormalities, no other major or minor anomalies were identified in this fetus. In the absence of other risk factors, this finding most commonly represents a normal variant and no further evaluation is recommended.”

The same wording is used after a fetal ultrasound identifies isolated echogenic intracardiac focus, inserting this phrase in place of “choroid plexus cyst.”

“These patients don't need to have an echocardiogram to evaluate the fetal heart,” because this finding is not associated with congenital heart defects, she said. “They're not pathologic in and of themselves, but they do have a small association with an increased risk of chromosomal abnormalities.”

That can raise anxiety unnecessarily in a woman with no other risk factors for abnormalities, but putting the reassuring wording in the chart can help them reframe their risk, Dr. Norton said.

Closer management is needed for fetal ultrasound findings with borderline significance, such as renal pelviectasis, or findings that have the potential for significant abnormality (echogenic bowel or mild ventriculomegaly), she added.

In more than 90% of cases, fetal pelviectasis is a normal finding representing a physiological response to maternal progesterone. In a small percentage of cases, however, it can represent obstruction of the ureteropelvic junction or reflux that may have important implications after birth.

The risk for Down syndrome may be marginally increased with isolated pelviectasis, and amniocentesis is not warranted unless other risk factors are present, she noted.

Studies suggest that ultrasound follow-up is reasonably sensitive and specific if the pelviectasis measures less than 4 mm in pregnancies before 20 weeks' gestation, less than 7 mm between 20 and 30 weeks' gestation, or less than 10 mm from 30 weeks to term, Dr. Norton said.

There's no need for monthly ultrasounds, but schedule a repeat ultrasound in the middle of the third trimester to rule out progression of the pelviectasis and determine the need for postnatal follow-up, she said.

If the findings persist in the third trimester, wait at least 10 days after delivery for postnatal follow-up so the fetal volume status can adjust from prenatal to postnatal status. In the past, prophylactic antibiotics were given to the newborn during these 10 days in case the findings represented reflux, but it is unclear whether antibiotics are necessary. “That's a pediatric urologic decision,” she noted.

Of the two more concerning findings, echogenic bowel has been associated with trisomies, cystic fibrosis, viral infection, intrauterine growth restriction (IUGR), and fetal demise.

“Echogenic bowel is a tricky one because we see it in many cases that ultimately go on to have a completely normal outcome, and we never know why it was there,” she said.

Dr. Norton advised careful evaluation and follow-up. Get cystic fibrosis screening if it hasn't already been done, and do maternal or fetal testing for cytomegalovirus and possibly toxoplasmosis. “We do offer amniocentesis for karyotyping,” although it's unclear whether this is warranted in women who are otherwise low risk, she said. Get a follow-up ultrasound to evaluate the bowel and fetal growth in the third trimester. “The risk of IUGR is not inconsequential,” she warned.

Mild ventriculomegaly, in which fetal cerebral ventricles measure 10–15 mm, usually involves normal variants, especially when the ventricles are in the smaller end of that range. Rare cases may represent obstructive hydrocephalus or be markers for other underlying CNS pathology.

Order a level II ultrasound and get a fetal MRI, which can clearly show developments of the fetal brain and CNS findings not seen on ultrasound. “We do order MRI, although the precise utility of that, I would acknowledge, is still under investigation,” Dr. Norton said.

Because ventriculomegaly is associated with chromosomal abnormalities or infectious disease in a small number of cases, she offers amniocentesis for karyotyping and testing for cytomegalovirus and possibly toxoplasmosis.

Dr. Norton said that she has no conflicts of interest related to her presentation.

Women younger than age 45 years who were treated with lumpectomy and radiation for ductal carcinoma in situ were 68% more likely to have a local recurrence than were older women, a large population-based study found.

After a median follow-up of 8.5 years, women aged 44 and younger had a recurrence rate of 20%, compared with a 12% recurrence rate in those aged 45–50 years, the retrospective study showed. The 12% recurrence rate in the 45- to 50-year-old age group is similar to previously reported recurrence rates of 10%–15% in women older than age 50 in the 10 years after diagnosis, reported Dr. Iwa Kong of the University of Toronto.

She described the findings in a press briefing that preceded a breast cancer symposium sponsored by the American Society of Clinical Oncology. Dr. Kong reported having no conflicts of interest related to this study.

Previous studies have shown that treating ductal carcinoma in situ (DCIS) with lumpectomy and radiation results in a low overall recurrence rate of about 10% in the 10 years after diagnosis, but those studies included few women aged 50 or younger. Increasing concerns that younger women who are treated with lumpectomy and radiation may be at greater risk for recurrence inspired Dr. Kong and her associates to examine data on all women aged 50 and younger who were diagnosed with DCIS in Ontario, Canada, between 1994 and 2003.

Of the 583 who underwent breast conservation surgery and radiation therapy for DCIS, most received 50 Gy of radiation in 25 fractions, and 21% received a boost.

Local recurrences developed in 99 women (17%), and invasive local recurrences in 38 (7%). Recurrence rates were 23% in those aged 40 years or younger, 21% in those aged 40–44 years, and 14% in the 45- to 50-year-old women, for an unadjusted hazard ratio of 1.68.

These preliminary data do not imply that all young women with DCIS should undergo mastectomy, Dr. Kong cautioned. More research is needed to understand why young women had higher recurrence rates and to determine whether radiation boost, tamoxifen, or other treatments might be optimal for these patients. There may be a positive family history or genetic reasons for their DCIS, a correlation between breast density and higher recurrence rates, or other factors that deserve study, she said.

“I agree,” said Dr. Lori Pierce, moderator of the press briefing and professor of radiation oncology at the University of Michigan, Ann Arbor. “These are very important data, but we need to put them in context. When facing a young woman with DCIS, we need to make sure the margins are negative, and make sure the tumor is estrogen receptor positive if you discuss tamoxifen,” she explained. “Patients should be aware [of these data], but in the context of the limitations of a population-based study.”

The study design did not allow the capture of all treatment information that could have affected outcomes, such as the size of the DCIS, disease at margins, or the use of tamoxifen therapy, she said.

Overall, 88% of women remained free of local recurrence after 5 years, and 81% after 10 years. In addition, 95% of women at 5 years and 93% at 10 years were free of invasive local recurrence.

The investigators looked at follow-up data for a median of 8.5 years after diagnosis, and linked administrative databases to identify treatment and outcomes, followed by abstraction of primary charts for validation of the data.

Women younger than age 45 years who were treated with lumpectomy and radiation for ductal carcinoma in situ were 68% more likely to have a local recurrence than were older women, a large population-based study found.

After a median follow-up of 8.5 years, women aged 44 and younger had a recurrence rate of 20%, compared with a 12% recurrence rate in those aged 45–50 years, the retrospective study showed. The 12% recurrence rate in the 45- to 50-year-old age group is similar to previously reported recurrence rates of 10%–15% in women older than age 50 in the 10 years after diagnosis, reported Dr. Iwa Kong of the University of Toronto.

She described the findings in a press briefing that preceded a breast cancer symposium sponsored by the American Society of Clinical Oncology. Dr. Kong reported having no conflicts of interest related to this study.

Previous studies have shown that treating ductal carcinoma in situ (DCIS) with lumpectomy and radiation results in a low overall recurrence rate of about 10% in the 10 years after diagnosis, but those studies included few women aged 50 or younger. Increasing concerns that younger women who are treated with lumpectomy and radiation may be at greater risk for recurrence inspired Dr. Kong and her associates to examine data on all women aged 50 and younger who were diagnosed with DCIS in Ontario, Canada, between 1994 and 2003.

Of the 583 who underwent breast conservation surgery and radiation therapy for DCIS, most received 50 Gy of radiation in 25 fractions, and 21% received a boost.

Local recurrences developed in 99 women (17%), and invasive local recurrences in 38 (7%). Recurrence rates were 23% in those aged 40 years or younger, 21% in those aged 40–44 years, and 14% in the 45- to 50-year-old women, for an unadjusted hazard ratio of 1.68.

These preliminary data do not imply that all young women with DCIS should undergo mastectomy, Dr. Kong cautioned. More research is needed to understand why young women had higher recurrence rates and to determine whether radiation boost, tamoxifen, or other treatments might be optimal for these patients. There may be a positive family history or genetic reasons for their DCIS, a correlation between breast density and higher recurrence rates, or other factors that deserve study, she said.

“I agree,” said Dr. Lori Pierce, moderator of the press briefing and professor of radiation oncology at the University of Michigan, Ann Arbor. “These are very important data, but we need to put them in context. When facing a young woman with DCIS, we need to make sure the margins are negative, and make sure the tumor is estrogen receptor positive if you discuss tamoxifen,” she explained. “Patients should be aware [of these data], but in the context of the limitations of a population-based study.”

The study design did not allow the capture of all treatment information that could have affected outcomes, such as the size of the DCIS, disease at margins, or the use of tamoxifen therapy, she said.

Overall, 88% of women remained free of local recurrence after 5 years, and 81% after 10 years. In addition, 95% of women at 5 years and 93% at 10 years were free of invasive local recurrence.

The investigators looked at follow-up data for a median of 8.5 years after diagnosis, and linked administrative databases to identify treatment and outcomes, followed by abstraction of primary charts for validation of the data.

Women younger than age 45 years who were treated with lumpectomy and radiation for ductal carcinoma in situ were 68% more likely to have a local recurrence than were older women, a large population-based study found.

After a median follow-up of 8.5 years, women aged 44 and younger had a recurrence rate of 20%, compared with a 12% recurrence rate in those aged 45–50 years, the retrospective study showed. The 12% recurrence rate in the 45- to 50-year-old age group is similar to previously reported recurrence rates of 10%–15% in women older than age 50 in the 10 years after diagnosis, reported Dr. Iwa Kong of the University of Toronto.

She described the findings in a press briefing that preceded a breast cancer symposium sponsored by the American Society of Clinical Oncology. Dr. Kong reported having no conflicts of interest related to this study.

Previous studies have shown that treating ductal carcinoma in situ (DCIS) with lumpectomy and radiation results in a low overall recurrence rate of about 10% in the 10 years after diagnosis, but those studies included few women aged 50 or younger. Increasing concerns that younger women who are treated with lumpectomy and radiation may be at greater risk for recurrence inspired Dr. Kong and her associates to examine data on all women aged 50 and younger who were diagnosed with DCIS in Ontario, Canada, between 1994 and 2003.

Of the 583 who underwent breast conservation surgery and radiation therapy for DCIS, most received 50 Gy of radiation in 25 fractions, and 21% received a boost.

Local recurrences developed in 99 women (17%), and invasive local recurrences in 38 (7%). Recurrence rates were 23% in those aged 40 years or younger, 21% in those aged 40–44 years, and 14% in the 45- to 50-year-old women, for an unadjusted hazard ratio of 1.68.

These preliminary data do not imply that all young women with DCIS should undergo mastectomy, Dr. Kong cautioned. More research is needed to understand why young women had higher recurrence rates and to determine whether radiation boost, tamoxifen, or other treatments might be optimal for these patients. There may be a positive family history or genetic reasons for their DCIS, a correlation between breast density and higher recurrence rates, or other factors that deserve study, she said.

“I agree,” said Dr. Lori Pierce, moderator of the press briefing and professor of radiation oncology at the University of Michigan, Ann Arbor. “These are very important data, but we need to put them in context. When facing a young woman with DCIS, we need to make sure the margins are negative, and make sure the tumor is estrogen receptor positive if you discuss tamoxifen,” she explained. “Patients should be aware [of these data], but in the context of the limitations of a population-based study.”

The study design did not allow the capture of all treatment information that could have affected outcomes, such as the size of the DCIS, disease at margins, or the use of tamoxifen therapy, she said.

Overall, 88% of women remained free of local recurrence after 5 years, and 81% after 10 years. In addition, 95% of women at 5 years and 93% at 10 years were free of invasive local recurrence.

The investigators looked at follow-up data for a median of 8.5 years after diagnosis, and linked administrative databases to identify treatment and outcomes, followed by abstraction of primary charts for validation of the data.