Thoracic Surgery News (Archived)

CHICAGO - A novel technique utilizing stapled lung debris could help determine adequate and inadequate surgical margins in resected non-small cell lung cancer, results of a prospective study suggest.

Researchers at Albany (N.Y.) Medical College and the Hospital of St. Raphael in New Haven, Conn., are using cytology to analyze lung tissue taken from spent staple cartridges used during sublobar resection. The staple cartridge is simply mixed with 30 cc of normal saline and serves as the cytologic margin, Dr. Thomas Fabian explained at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

"People have [observed] that certain staples used through cancers can potentially contaminate new tissue planes, so that is how the idea was born," he said in an interview.

Dr. Fabian and his colleagues prospectively compared staple-line cytology with traditional histopathologic evaluation of surgical specimens taken from 97 patients undergoing diagnostic sublobar wedge resection between November 2007 and September 2009. Of the 98 specimens retrieved, 30 were benign and 68 were malignant.
Staple-line cytology was 100% accurate in the evaluation of benign lesions when compared with histology, he said.

In the 68 malignant nodules, initial blinded cytologic evaluation was positive in 7, surgical pathology was positive in 6, and both were positive in 4.

Subsequent unblinded review of both specimens changed the final pathologic interpretation in 4 (6%) of the 68 cases, said Dr. Fabian, chief of thoracic surgery at the Albany Medical Center. The interpretation changed from a negative margin to a positive margin in 3 surgical specimens (7%) and in 1 staple-line cytology specimen (2%).

According to analysis of the unblinded data, staple-line cytology demonstrated an overall accuracy of 96%, with 88% sensitivity, 97% specificity, 70% positive-predictive value, and 99% negative-predictive value.

Dr. Fabian described staple-line cytology as a simple technique that could serve as an adjunct to the gold standard of histopathology, which he said is prone to inaccuracies including both false positives and false negatives.

"We need to reevaluate the techniques that allow us to accurately assess surgical margins - particularly in the setting of sublobar resections, given the growing interest in this technique," according to Dr. Fabian.

"The cytologic technique appears to be sensitive, specific, and accurate, but it does need to be validated at other institutions and with additional studies," he added.

Dr. Fabian acknowledged that by design the study lacked clinical outcome data and said further evaluation is ongoing. The next step is to evaluate the technique in patients undergoing sublobar resection with curative intent.

Of the 68 malignant samples, 43 were diagnosed as adenocarcinoma, 7 as squamous cell carcinoma, 3 as large cell, 1 as small cell, 5 as carcinoid, and 9 as other histologies.

Dr. Fabian disclosed serving as a speaker for, and receiving research funding and honoraria from, Covidien. His coauthors reported no conflicts.

CHICAGO - A novel technique utilizing stapled lung debris could help determine adequate and inadequate surgical margins in resected non-small cell lung cancer, results of a prospective study suggest.

Researchers at Albany (N.Y.) Medical College and the Hospital of St. Raphael in New Haven, Conn., are using cytology to analyze lung tissue taken from spent staple cartridges used during sublobar resection. The staple cartridge is simply mixed with 30 cc of normal saline and serves as the cytologic margin, Dr. Thomas Fabian explained at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

"People have [observed] that certain staples used through cancers can potentially contaminate new tissue planes, so that is how the idea was born," he said in an interview.

Dr. Fabian and his colleagues prospectively compared staple-line cytology with traditional histopathologic evaluation of surgical specimens taken from 97 patients undergoing diagnostic sublobar wedge resection between November 2007 and September 2009. Of the 98 specimens retrieved, 30 were benign and 68 were malignant.
Staple-line cytology was 100% accurate in the evaluation of benign lesions when compared with histology, he said.

In the 68 malignant nodules, initial blinded cytologic evaluation was positive in 7, surgical pathology was positive in 6, and both were positive in 4.

Subsequent unblinded review of both specimens changed the final pathologic interpretation in 4 (6%) of the 68 cases, said Dr. Fabian, chief of thoracic surgery at the Albany Medical Center. The interpretation changed from a negative margin to a positive margin in 3 surgical specimens (7%) and in 1 staple-line cytology specimen (2%).

According to analysis of the unblinded data, staple-line cytology demonstrated an overall accuracy of 96%, with 88% sensitivity, 97% specificity, 70% positive-predictive value, and 99% negative-predictive value.

Dr. Fabian described staple-line cytology as a simple technique that could serve as an adjunct to the gold standard of histopathology, which he said is prone to inaccuracies including both false positives and false negatives.

"We need to reevaluate the techniques that allow us to accurately assess surgical margins - particularly in the setting of sublobar resections, given the growing interest in this technique," according to Dr. Fabian.

"The cytologic technique appears to be sensitive, specific, and accurate, but it does need to be validated at other institutions and with additional studies," he added.

Dr. Fabian acknowledged that by design the study lacked clinical outcome data and said further evaluation is ongoing. The next step is to evaluate the technique in patients undergoing sublobar resection with curative intent.

Of the 68 malignant samples, 43 were diagnosed as adenocarcinoma, 7 as squamous cell carcinoma, 3 as large cell, 1 as small cell, 5 as carcinoid, and 9 as other histologies.

Dr. Fabian disclosed serving as a speaker for, and receiving research funding and honoraria from, Covidien. His coauthors reported no conflicts.

CHICAGO - A novel technique utilizing stapled lung debris could help determine adequate and inadequate surgical margins in resected non-small cell lung cancer, results of a prospective study suggest.

Researchers at Albany (N.Y.) Medical College and the Hospital of St. Raphael in New Haven, Conn., are using cytology to analyze lung tissue taken from spent staple cartridges used during sublobar resection. The staple cartridge is simply mixed with 30 cc of normal saline and serves as the cytologic margin, Dr. Thomas Fabian explained at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

"People have [observed] that certain staples used through cancers can potentially contaminate new tissue planes, so that is how the idea was born," he said in an interview.

Dr. Fabian and his colleagues prospectively compared staple-line cytology with traditional histopathologic evaluation of surgical specimens taken from 97 patients undergoing diagnostic sublobar wedge resection between November 2007 and September 2009. Of the 98 specimens retrieved, 30 were benign and 68 were malignant.
Staple-line cytology was 100% accurate in the evaluation of benign lesions when compared with histology, he said.

In the 68 malignant nodules, initial blinded cytologic evaluation was positive in 7, surgical pathology was positive in 6, and both were positive in 4.

Subsequent unblinded review of both specimens changed the final pathologic interpretation in 4 (6%) of the 68 cases, said Dr. Fabian, chief of thoracic surgery at the Albany Medical Center. The interpretation changed from a negative margin to a positive margin in 3 surgical specimens (7%) and in 1 staple-line cytology specimen (2%).

According to analysis of the unblinded data, staple-line cytology demonstrated an overall accuracy of 96%, with 88% sensitivity, 97% specificity, 70% positive-predictive value, and 99% negative-predictive value.

Dr. Fabian described staple-line cytology as a simple technique that could serve as an adjunct to the gold standard of histopathology, which he said is prone to inaccuracies including both false positives and false negatives.

"We need to reevaluate the techniques that allow us to accurately assess surgical margins - particularly in the setting of sublobar resections, given the growing interest in this technique," according to Dr. Fabian.

"The cytologic technique appears to be sensitive, specific, and accurate, but it does need to be validated at other institutions and with additional studies," he added.

Dr. Fabian acknowledged that by design the study lacked clinical outcome data and said further evaluation is ongoing. The next step is to evaluate the technique in patients undergoing sublobar resection with curative intent.

Of the 68 malignant samples, 43 were diagnosed as adenocarcinoma, 7 as squamous cell carcinoma, 3 as large cell, 1 as small cell, 5 as carcinoid, and 9 as other histologies.

Dr. Fabian disclosed serving as a speaker for, and receiving research funding and honoraria from, Covidien. His coauthors reported no conflicts.

CHICAGO - New data suggest that microscopic vascular invasion may be a more powerful prognosticator in early lung cancer than are the tumor size-based categories suggested in the new TNM staging system.

Italian researchers used histologic and immunohistochemical techniques to identify microscopic vascular invasion (MVI), or the presence of neoplastic structures inside the lumen of a vessel, in one-third (154) of 512 patients with resected, pathologically staged T1a to T3 node-negative non-small cell lung cancer (NSCLC). The 2009 edition of the tumor, node, metastasis (TNM) staging system for lung tumors was used.

MVI was significantly correlated with the presence of tumor-infiltrating lymphocytes (odds ratio 1.65, P value = .03), adenocarcinoma histology (OR 1.32, P = .003), and increased tumor size (OR 1.13, P = .009).

Five-year overall survival was significantly lower for patients with MVI at 50% vs. those without MVI at 66% (P = .001), Dr. Enrico Ruffini said at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

The difference in survival remained significant even in those with squamous cell carcinoma (45% vs. 61%, P = .05), although it was more pronounced in those with adenocarcinoma (56% vs. 70%, P = .03).

"Microscopic vascular invasion is a significant independent negative prognostic factor," he said.

When patients with pT1a-T2b tumors were stratified by T-size category, the presence of MVI resulted in a one-category upstaging for each T category, said Dr. Ruffini of the division of thoracic surgery at the University of Torino (Italy). For example, T1a patients with MVI had a prognosis similar to that of patients with T1b tumors without MVI. The number of T3 cases was too small to stratify.

T size was prognostic of survival in the MVI-negative patients (P = .03) but was not a statistically significant factor in MVI-positive patients (P = .9), indicating that MVI is indeed a more powerful prognosticator, he said.

The 2009 TNM stresses the importance of tumor size as a major prognostic factor, but no TNM edition has so far included MVI as a major determinant in the staging of NSCLC.

In a multivariate survival analysis that included age, sex, histology, grading, T-size determinant, MVI, perineural invasion, and tumor-infiltrating lymphocytes, MVI was a stronger prognostic indicator (hazard ratio 1.43, P = .02) than T-size determinant (HR 1.06, P = .06), Dr. Ruffini said.

"The use of adjuvant chemotherapy in NSCLC patients with MVI may be considered," he said.

Invited discussant Dr. Mark Socinski pointed out that 88% of patients in the analysis had 5 cm or smaller tumors, a category of patients in which the role of adjuvant therapy has been discouraged. He highlighted the recent LACE meta-analysis of 4,584 NSCLC patients in five cisplatin-based adjuvant chemotherapy trials that showed an overall significant survival benefit of 4% at 5 years, but also a potentially negative effect in resected stage 1A (Ann. Oncol. 2010 Oct;21 Suppl. 7:vii196-vii198).

"We need to make sure [MVI] is easily reproducible amongst pathologists, and we also clearly need to demonstrate that adjuvant therapy can overcome the biologic impact of this histopathologic finding," said Dr. Socinski of the Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill.

Dr. Ruffini acknowledged that bias could have been introduced into the study through its retrospective design, use of overall survival rather than disease-free survival as an outcome measure, and the long study period of January 1998 to August 2008. Prospective validation of MVI is underway using the prospective International Association for the Study of Lung Cancer database, he said.

The median tumor size among the 512 patients was 3.4 cm, with 164 classified as having T1a (less than 2 cm) tumors, 123 T1b (2-3 cm), 164 T2a (3-5 cm), 50 T2b (5-7 cm), and 11 T3 (greater than 7 cm) tumors.

The researchers and Dr. Socinski disclosed no relevant conflicts.

CHICAGO - New data suggest that microscopic vascular invasion may be a more powerful prognosticator in early lung cancer than are the tumor size-based categories suggested in the new TNM staging system.

Italian researchers used histologic and immunohistochemical techniques to identify microscopic vascular invasion (MVI), or the presence of neoplastic structures inside the lumen of a vessel, in one-third (154) of 512 patients with resected, pathologically staged T1a to T3 node-negative non-small cell lung cancer (NSCLC). The 2009 edition of the tumor, node, metastasis (TNM) staging system for lung tumors was used.

MVI was significantly correlated with the presence of tumor-infiltrating lymphocytes (odds ratio 1.65, P value = .03), adenocarcinoma histology (OR 1.32, P = .003), and increased tumor size (OR 1.13, P = .009).

Five-year overall survival was significantly lower for patients with MVI at 50% vs. those without MVI at 66% (P = .001), Dr. Enrico Ruffini said at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

The difference in survival remained significant even in those with squamous cell carcinoma (45% vs. 61%, P = .05), although it was more pronounced in those with adenocarcinoma (56% vs. 70%, P = .03).

"Microscopic vascular invasion is a significant independent negative prognostic factor," he said.

When patients with pT1a-T2b tumors were stratified by T-size category, the presence of MVI resulted in a one-category upstaging for each T category, said Dr. Ruffini of the division of thoracic surgery at the University of Torino (Italy). For example, T1a patients with MVI had a prognosis similar to that of patients with T1b tumors without MVI. The number of T3 cases was too small to stratify.

T size was prognostic of survival in the MVI-negative patients (P = .03) but was not a statistically significant factor in MVI-positive patients (P = .9), indicating that MVI is indeed a more powerful prognosticator, he said.

The 2009 TNM stresses the importance of tumor size as a major prognostic factor, but no TNM edition has so far included MVI as a major determinant in the staging of NSCLC.

In a multivariate survival analysis that included age, sex, histology, grading, T-size determinant, MVI, perineural invasion, and tumor-infiltrating lymphocytes, MVI was a stronger prognostic indicator (hazard ratio 1.43, P = .02) than T-size determinant (HR 1.06, P = .06), Dr. Ruffini said.

"The use of adjuvant chemotherapy in NSCLC patients with MVI may be considered," he said.

Invited discussant Dr. Mark Socinski pointed out that 88% of patients in the analysis had 5 cm or smaller tumors, a category of patients in which the role of adjuvant therapy has been discouraged. He highlighted the recent LACE meta-analysis of 4,584 NSCLC patients in five cisplatin-based adjuvant chemotherapy trials that showed an overall significant survival benefit of 4% at 5 years, but also a potentially negative effect in resected stage 1A (Ann. Oncol. 2010 Oct;21 Suppl. 7:vii196-vii198).

"We need to make sure [MVI] is easily reproducible amongst pathologists, and we also clearly need to demonstrate that adjuvant therapy can overcome the biologic impact of this histopathologic finding," said Dr. Socinski of the Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill.

Dr. Ruffini acknowledged that bias could have been introduced into the study through its retrospective design, use of overall survival rather than disease-free survival as an outcome measure, and the long study period of January 1998 to August 2008. Prospective validation of MVI is underway using the prospective International Association for the Study of Lung Cancer database, he said.

The median tumor size among the 512 patients was 3.4 cm, with 164 classified as having T1a (less than 2 cm) tumors, 123 T1b (2-3 cm), 164 T2a (3-5 cm), 50 T2b (5-7 cm), and 11 T3 (greater than 7 cm) tumors.

The researchers and Dr. Socinski disclosed no relevant conflicts.

CHICAGO - New data suggest that microscopic vascular invasion may be a more powerful prognosticator in early lung cancer than are the tumor size-based categories suggested in the new TNM staging system.

Italian researchers used histologic and immunohistochemical techniques to identify microscopic vascular invasion (MVI), or the presence of neoplastic structures inside the lumen of a vessel, in one-third (154) of 512 patients with resected, pathologically staged T1a to T3 node-negative non-small cell lung cancer (NSCLC). The 2009 edition of the tumor, node, metastasis (TNM) staging system for lung tumors was used.

MVI was significantly correlated with the presence of tumor-infiltrating lymphocytes (odds ratio 1.65, P value = .03), adenocarcinoma histology (OR 1.32, P = .003), and increased tumor size (OR 1.13, P = .009).

Five-year overall survival was significantly lower for patients with MVI at 50% vs. those without MVI at 66% (P = .001), Dr. Enrico Ruffini said at the Chicago Multidisciplinary Symposium in Thoracic Oncology.

The difference in survival remained significant even in those with squamous cell carcinoma (45% vs. 61%, P = .05), although it was more pronounced in those with adenocarcinoma (56% vs. 70%, P = .03).

"Microscopic vascular invasion is a significant independent negative prognostic factor," he said.

When patients with pT1a-T2b tumors were stratified by T-size category, the presence of MVI resulted in a one-category upstaging for each T category, said Dr. Ruffini of the division of thoracic surgery at the University of Torino (Italy). For example, T1a patients with MVI had a prognosis similar to that of patients with T1b tumors without MVI. The number of T3 cases was too small to stratify.

T size was prognostic of survival in the MVI-negative patients (P = .03) but was not a statistically significant factor in MVI-positive patients (P = .9), indicating that MVI is indeed a more powerful prognosticator, he said.

The 2009 TNM stresses the importance of tumor size as a major prognostic factor, but no TNM edition has so far included MVI as a major determinant in the staging of NSCLC.

In a multivariate survival analysis that included age, sex, histology, grading, T-size determinant, MVI, perineural invasion, and tumor-infiltrating lymphocytes, MVI was a stronger prognostic indicator (hazard ratio 1.43, P = .02) than T-size determinant (HR 1.06, P = .06), Dr. Ruffini said.

"The use of adjuvant chemotherapy in NSCLC patients with MVI may be considered," he said.

Invited discussant Dr. Mark Socinski pointed out that 88% of patients in the analysis had 5 cm or smaller tumors, a category of patients in which the role of adjuvant therapy has been discouraged. He highlighted the recent LACE meta-analysis of 4,584 NSCLC patients in five cisplatin-based adjuvant chemotherapy trials that showed an overall significant survival benefit of 4% at 5 years, but also a potentially negative effect in resected stage 1A (Ann. Oncol. 2010 Oct;21 Suppl. 7:vii196-vii198).

"We need to make sure [MVI] is easily reproducible amongst pathologists, and we also clearly need to demonstrate that adjuvant therapy can overcome the biologic impact of this histopathologic finding," said Dr. Socinski of the Lineberger Comprehensive Cancer Center at the University of North Carolina, Chapel Hill.

Dr. Ruffini acknowledged that bias could have been introduced into the study through its retrospective design, use of overall survival rather than disease-free survival as an outcome measure, and the long study period of January 1998 to August 2008. Prospective validation of MVI is underway using the prospective International Association for the Study of Lung Cancer database, he said.

The median tumor size among the 512 patients was 3.4 cm, with 164 classified as having T1a (less than 2 cm) tumors, 123 T1b (2-3 cm), 164 T2a (3-5 cm), 50 T2b (5-7 cm), and 11 T3 (greater than 7 cm) tumors.

The researchers and Dr. Socinski disclosed no relevant conflicts.

LONDON - The daily, long-term use of low-dose aspirin cuts the risk of death from several types of cancer, according to a large meta-analysis.

In a meta-analysis of eight randomized clinical trials involving 25,570 patients, low-dose aspirin taken for 5 years or longer reduced mortality from esophageal, pancreatic, brain, stomach, colorectal, prostate, and even lung cancer, with doses as low as 75 mg/day having an effect.

This is the first time that low-dose aspirin has been linked to a reduction in cancer mortality other than colorectal cancer, said Dr. Peter M. Rothwell, who conceived and coordinated the research.

Dr. Rothwell of the John Radcliffe Hospital and the University of Oxford, United Kingdom, and his associates in October 2010 showed that low-dose aspirin reduced the 20-year risk of new colon cancer cases by approximately one-quarter and deaths by a third (Lancet 2010;376:1741-50).

The current study looked at all deaths from cancer that occurred during or after completion of eight randomized clinical trials that had been performed to look at the effects of daily aspirin vs. control for the primary or secondary prevention of vascular events (Lancet 2010 [doi:10.1016/S0140-6736(10)62110-1]).

Across all eight trials, 674 cancer deaths occurred in 25,570 patients, with aspirin treatment significantly reducing the risk of death, compared with no aspirin treatment (pooled odds ratio [OR] 0.79, 95% confidence interval [CI] 0.68-0.92, P = .003).

Using individual patient data available for seven of the trials and in which 657 cancer deaths occurred in 23,535 patients, the benefit of aspirin therapy was apparent only after 5 years or more of follow-up. The hazard ratio (HR) for death from all types of cancer was 0.66 (95% CI 0.50-0.87, P =.003), with a greater effect seen in patients with gastrointestinal tumors (HR 0.46, 95% CI 0.27-0.77, P =.003).

"We found that within the trials, while people were still on aspirin vs. no aspirin, the aspirin group had about a 30%-40% reduction in cancer deaths between year 5 and the end of the trial," Dr. Rothwell said at a press briefing.

To determine the longer-term effects of aspirin on cancer mortality, the team looked more closely at data from three of the trials. These had all been conducted in the United Kingdom and continued to collect information on cancer deaths via national death certification and cancer registration systems long after the trials had concluded.

In all, individual patient data were obtained on 1,634 cancer deaths that had occurred in 12,659 patients. Aspirin was found to reduce the 20-year risk of death from all solid cancers by 20% (HR 0.80, 95% CI 0.72-0.88, P less than .0001). Again, the effect on gastrointestinal cancer was greater (HR 0.65, 95% CI 0.54-0.78, P less than .0001), but there was no effect on hematologic malignancies.

At least 5 years of therapy were needed to reduce the risk of death from esophageal, pancreatic, brain, or lung cancer, with 10 years or more treatment required to see an effect on stomach and colorectal cancer death rates, and 15 years or more for prostate cancer. With regard to both lung and esophageal cancer, the effect of aspirin was limited to adenocarcinomas.

While the findings do not mean that everyone over the age of 40 years should now start taking daily aspirin to prevent cancer, given the increased risk of bleeding in some individuals, "We should probably stop taking people off aspirin unless they've got side effects," Dr. Rothwell said in an interview, adding "We probably shouldn't discourage those who want to take aspirin as actively as we have been doing."

"There is a fundamental difference between the treatment and the prevention of a disease," said Dr. Peter Elwood, professor of epidemiology at Cardiff University, Wales. Dr. Elwood suggested that deciding to take a daily dose of aspirin to prevent cancer could be another choice patients make once they have all the relevant facts, much as lifestyle changes are advised but not prescribed for cardiovascular disease prevention.

Dr. Rothwell has received honoraria from pharmaceutical companies with an interest in antiplatelet therapy, including AstraZeneca and Bayer.

LONDON - The daily, long-term use of low-dose aspirin cuts the risk of death from several types of cancer, according to a large meta-analysis.

In a meta-analysis of eight randomized clinical trials involving 25,570 patients, low-dose aspirin taken for 5 years or longer reduced mortality from esophageal, pancreatic, brain, stomach, colorectal, prostate, and even lung cancer, with doses as low as 75 mg/day having an effect.

This is the first time that low-dose aspirin has been linked to a reduction in cancer mortality other than colorectal cancer, said Dr. Peter M. Rothwell, who conceived and coordinated the research.

Dr. Rothwell of the John Radcliffe Hospital and the University of Oxford, United Kingdom, and his associates in October 2010 showed that low-dose aspirin reduced the 20-year risk of new colon cancer cases by approximately one-quarter and deaths by a third (Lancet 2010;376:1741-50).

The current study looked at all deaths from cancer that occurred during or after completion of eight randomized clinical trials that had been performed to look at the effects of daily aspirin vs. control for the primary or secondary prevention of vascular events (Lancet 2010 [doi:10.1016/S0140-6736(10)62110-1]).

Across all eight trials, 674 cancer deaths occurred in 25,570 patients, with aspirin treatment significantly reducing the risk of death, compared with no aspirin treatment (pooled odds ratio [OR] 0.79, 95% confidence interval [CI] 0.68-0.92, P = .003).

Using individual patient data available for seven of the trials and in which 657 cancer deaths occurred in 23,535 patients, the benefit of aspirin therapy was apparent only after 5 years or more of follow-up. The hazard ratio (HR) for death from all types of cancer was 0.66 (95% CI 0.50-0.87, P =.003), with a greater effect seen in patients with gastrointestinal tumors (HR 0.46, 95% CI 0.27-0.77, P =.003).

"We found that within the trials, while people were still on aspirin vs. no aspirin, the aspirin group had about a 30%-40% reduction in cancer deaths between year 5 and the end of the trial," Dr. Rothwell said at a press briefing.

To determine the longer-term effects of aspirin on cancer mortality, the team looked more closely at data from three of the trials. These had all been conducted in the United Kingdom and continued to collect information on cancer deaths via national death certification and cancer registration systems long after the trials had concluded.

In all, individual patient data were obtained on 1,634 cancer deaths that had occurred in 12,659 patients. Aspirin was found to reduce the 20-year risk of death from all solid cancers by 20% (HR 0.80, 95% CI 0.72-0.88, P less than .0001). Again, the effect on gastrointestinal cancer was greater (HR 0.65, 95% CI 0.54-0.78, P less than .0001), but there was no effect on hematologic malignancies.

At least 5 years of therapy were needed to reduce the risk of death from esophageal, pancreatic, brain, or lung cancer, with 10 years or more treatment required to see an effect on stomach and colorectal cancer death rates, and 15 years or more for prostate cancer. With regard to both lung and esophageal cancer, the effect of aspirin was limited to adenocarcinomas.

While the findings do not mean that everyone over the age of 40 years should now start taking daily aspirin to prevent cancer, given the increased risk of bleeding in some individuals, "We should probably stop taking people off aspirin unless they've got side effects," Dr. Rothwell said in an interview, adding "We probably shouldn't discourage those who want to take aspirin as actively as we have been doing."

"There is a fundamental difference between the treatment and the prevention of a disease," said Dr. Peter Elwood, professor of epidemiology at Cardiff University, Wales. Dr. Elwood suggested that deciding to take a daily dose of aspirin to prevent cancer could be another choice patients make once they have all the relevant facts, much as lifestyle changes are advised but not prescribed for cardiovascular disease prevention.

Dr. Rothwell has received honoraria from pharmaceutical companies with an interest in antiplatelet therapy, including AstraZeneca and Bayer.

LONDON - The daily, long-term use of low-dose aspirin cuts the risk of death from several types of cancer, according to a large meta-analysis.

In a meta-analysis of eight randomized clinical trials involving 25,570 patients, low-dose aspirin taken for 5 years or longer reduced mortality from esophageal, pancreatic, brain, stomach, colorectal, prostate, and even lung cancer, with doses as low as 75 mg/day having an effect.

This is the first time that low-dose aspirin has been linked to a reduction in cancer mortality other than colorectal cancer, said Dr. Peter M. Rothwell, who conceived and coordinated the research.

Dr. Rothwell of the John Radcliffe Hospital and the University of Oxford, United Kingdom, and his associates in October 2010 showed that low-dose aspirin reduced the 20-year risk of new colon cancer cases by approximately one-quarter and deaths by a third (Lancet 2010;376:1741-50).

The current study looked at all deaths from cancer that occurred during or after completion of eight randomized clinical trials that had been performed to look at the effects of daily aspirin vs. control for the primary or secondary prevention of vascular events (Lancet 2010 [doi:10.1016/S0140-6736(10)62110-1]).

Across all eight trials, 674 cancer deaths occurred in 25,570 patients, with aspirin treatment significantly reducing the risk of death, compared with no aspirin treatment (pooled odds ratio [OR] 0.79, 95% confidence interval [CI] 0.68-0.92, P = .003).

Using individual patient data available for seven of the trials and in which 657 cancer deaths occurred in 23,535 patients, the benefit of aspirin therapy was apparent only after 5 years or more of follow-up. The hazard ratio (HR) for death from all types of cancer was 0.66 (95% CI 0.50-0.87, P =.003), with a greater effect seen in patients with gastrointestinal tumors (HR 0.46, 95% CI 0.27-0.77, P =.003).

"We found that within the trials, while people were still on aspirin vs. no aspirin, the aspirin group had about a 30%-40% reduction in cancer deaths between year 5 and the end of the trial," Dr. Rothwell said at a press briefing.

To determine the longer-term effects of aspirin on cancer mortality, the team looked more closely at data from three of the trials. These had all been conducted in the United Kingdom and continued to collect information on cancer deaths via national death certification and cancer registration systems long after the trials had concluded.

In all, individual patient data were obtained on 1,634 cancer deaths that had occurred in 12,659 patients. Aspirin was found to reduce the 20-year risk of death from all solid cancers by 20% (HR 0.80, 95% CI 0.72-0.88, P less than .0001). Again, the effect on gastrointestinal cancer was greater (HR 0.65, 95% CI 0.54-0.78, P less than .0001), but there was no effect on hematologic malignancies.

At least 5 years of therapy were needed to reduce the risk of death from esophageal, pancreatic, brain, or lung cancer, with 10 years or more treatment required to see an effect on stomach and colorectal cancer death rates, and 15 years or more for prostate cancer. With regard to both lung and esophageal cancer, the effect of aspirin was limited to adenocarcinomas.

While the findings do not mean that everyone over the age of 40 years should now start taking daily aspirin to prevent cancer, given the increased risk of bleeding in some individuals, "We should probably stop taking people off aspirin unless they've got side effects," Dr. Rothwell said in an interview, adding "We probably shouldn't discourage those who want to take aspirin as actively as we have been doing."

"There is a fundamental difference between the treatment and the prevention of a disease," said Dr. Peter Elwood, professor of epidemiology at Cardiff University, Wales. Dr. Elwood suggested that deciding to take a daily dose of aspirin to prevent cancer could be another choice patients make once they have all the relevant facts, much as lifestyle changes are advised but not prescribed for cardiovascular disease prevention.

Dr. Rothwell has received honoraria from pharmaceutical companies with an interest in antiplatelet therapy, including AstraZeneca and Bayer.

SAN DIEGO - Although the right internal thoracic artery is biologically identical to the left internal thoracic artery, it is rarely used in coronary artery bypass grafting.

In a study comparing the use of different graft sources for coronary artery bypass grafting (CABG), Dr. James Tatoulis and his colleagues found that the right internal thoracic artery (RITA) showed equivalent results to using the left internal thoracic artery (LITA).

Dr. Tatoulis of the Royal Melbourne Hospital and his colleagues evaluated consecutive RITA graft angiograms performed from 1986 to 2008. Patency was examined over time by coronary territory and by whether the RITA was in situ or free, and was compared with other coronary conduits, according to the study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 5,766 patients had a RITA graft, usually as part of bilateral internal thoracic artery CABG. The operative mortality was 1.1%, and the rate of deep sternal infection was 1.5%. Of the nearly 7,800 coronary conduits studied, 991 RITA conduits were examined at a mean of 100 months postoperatively.

The overall 10-year RITA patency was 90%. RITA graft patency to the left anterior descending artery (n = 149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal artery was 91% (n = 436), 85% (n = 199) to the right coronary artery (RCA), and 86% (n = 207) to the posterior descending artery (PDA). Ten-year patencies of RITA and LITA to the left anterior descending artery were identical.

In situ RITA (n=451) and free RITA (n=540) had similar 10-year patencies, 89% vs. 91% respectively.

RITA patency was found to be significantly better than radial artery and saphenous vein grafts for the circumflex marginal artery, the RCA, and the PDA. The 10-year survival of patients with RITA and LITA for triple-vessel coronary disease were identical at 89%.

Dr. Tatoulis and his colleagues stated that late patencies of RITA are excellent, equivalent to the LITA for identical territories, and always better than radial artery and saphenous vein grafts.

“Unfortunately, less than 10% of all coronary artery surgery worldwide is performed with two internal thoracic arteries," Dr. Tatoulis said in an interview.
He added that the use of this technique could improve patient outcomes and could offer an even better revascularization alternative to stents, particularly for triple-vessel coronary disease.

Dr. Tatoulis and his colleagues reported that they had no relevant disclosures.

SAN DIEGO - Although the right internal thoracic artery is biologically identical to the left internal thoracic artery, it is rarely used in coronary artery bypass grafting.

In a study comparing the use of different graft sources for coronary artery bypass grafting (CABG), Dr. James Tatoulis and his colleagues found that the right internal thoracic artery (RITA) showed equivalent results to using the left internal thoracic artery (LITA).

Dr. Tatoulis of the Royal Melbourne Hospital and his colleagues evaluated consecutive RITA graft angiograms performed from 1986 to 2008. Patency was examined over time by coronary territory and by whether the RITA was in situ or free, and was compared with other coronary conduits, according to the study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 5,766 patients had a RITA graft, usually as part of bilateral internal thoracic artery CABG. The operative mortality was 1.1%, and the rate of deep sternal infection was 1.5%. Of the nearly 7,800 coronary conduits studied, 991 RITA conduits were examined at a mean of 100 months postoperatively.

The overall 10-year RITA patency was 90%. RITA graft patency to the left anterior descending artery (n = 149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal artery was 91% (n = 436), 85% (n = 199) to the right coronary artery (RCA), and 86% (n = 207) to the posterior descending artery (PDA). Ten-year patencies of RITA and LITA to the left anterior descending artery were identical.

In situ RITA (n=451) and free RITA (n=540) had similar 10-year patencies, 89% vs. 91% respectively.

RITA patency was found to be significantly better than radial artery and saphenous vein grafts for the circumflex marginal artery, the RCA, and the PDA. The 10-year survival of patients with RITA and LITA for triple-vessel coronary disease were identical at 89%.

Dr. Tatoulis and his colleagues stated that late patencies of RITA are excellent, equivalent to the LITA for identical territories, and always better than radial artery and saphenous vein grafts.

“Unfortunately, less than 10% of all coronary artery surgery worldwide is performed with two internal thoracic arteries," Dr. Tatoulis said in an interview.
He added that the use of this technique could improve patient outcomes and could offer an even better revascularization alternative to stents, particularly for triple-vessel coronary disease.

Dr. Tatoulis and his colleagues reported that they had no relevant disclosures.

SAN DIEGO - Although the right internal thoracic artery is biologically identical to the left internal thoracic artery, it is rarely used in coronary artery bypass grafting.

In a study comparing the use of different graft sources for coronary artery bypass grafting (CABG), Dr. James Tatoulis and his colleagues found that the right internal thoracic artery (RITA) showed equivalent results to using the left internal thoracic artery (LITA).

Dr. Tatoulis of the Royal Melbourne Hospital and his colleagues evaluated consecutive RITA graft angiograms performed from 1986 to 2008. Patency was examined over time by coronary territory and by whether the RITA was in situ or free, and was compared with other coronary conduits, according to the study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 5,766 patients had a RITA graft, usually as part of bilateral internal thoracic artery CABG. The operative mortality was 1.1%, and the rate of deep sternal infection was 1.5%. Of the nearly 7,800 coronary conduits studied, 991 RITA conduits were examined at a mean of 100 months postoperatively.

The overall 10-year RITA patency was 90%. RITA graft patency to the left anterior descending artery (n = 149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal artery was 91% (n = 436), 85% (n = 199) to the right coronary artery (RCA), and 86% (n = 207) to the posterior descending artery (PDA). Ten-year patencies of RITA and LITA to the left anterior descending artery were identical.

In situ RITA (n=451) and free RITA (n=540) had similar 10-year patencies, 89% vs. 91% respectively.

RITA patency was found to be significantly better than radial artery and saphenous vein grafts for the circumflex marginal artery, the RCA, and the PDA. The 10-year survival of patients with RITA and LITA for triple-vessel coronary disease were identical at 89%.

Dr. Tatoulis and his colleagues stated that late patencies of RITA are excellent, equivalent to the LITA for identical territories, and always better than radial artery and saphenous vein grafts.

“Unfortunately, less than 10% of all coronary artery surgery worldwide is performed with two internal thoracic arteries," Dr. Tatoulis said in an interview.
He added that the use of this technique could improve patient outcomes and could offer an even better revascularization alternative to stents, particularly for triple-vessel coronary disease.

Dr. Tatoulis and his colleagues reported that they had no relevant disclosures.

It should not come as a surprise that approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, as has been recently reported in the New England Journal of Medicine.

“Pathologic studies … have illustrated that plaques when ruptured were substantially bulky and associated with thin fibrous caps. These lesions at the time of diagnosis may not have been sizable but grow at a faster rate to become eligible for rupture,” Dr. Jagat Narula, who is chief of cardiology at the University of California in Irvine, said in an interview.

The bigger question concerns the potential role for newly available radiofrequency intravascular ultrasonography (RF IVUS) in early assessment of patients with ACS.

The study in question showed that the rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, reported Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.

The Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study was conducted at 37 medical centers in the United States and Europe.

Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available RF IVUS of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.

The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.

“We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions,” Dr. Stone and his colleagues said.

“Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common,” they noted.

“Despite [certain] caveats, PROSPECT study has contributed immensely to understanding plaque anatomy, plaque composition and the prognostic relevance of the atherosclerotic lesions,” said Dr. Narula.

RF IVUS at baseline revealed that most of the “nonculprit” coronary lesions - those that had been considered mild on the index angiography and were not treated at that time - were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.

“I think the major message is that the angiogram is a very poor discriminator of how much atherosclerosis is present and which type of atherosclerosis is going to go on and cause unexpected events,” Dr. Stone said in an interview. “Radiofrequency IVUS provides significantly more information than just regular gray-scale IVUS in helping differentiate the nature of these plaques and which ones are going to progress.”

Conventional gray-scale IVUS works by sending out ultrasound waves and the resulting reflection signal can reveal structural information. Gray-scale IVUS measures only the amplitude of the reflected waves. However, RF IVUS also interprets frequency information from the reflected waves.

“That radiofrequency signal has been mapped pixel by pixel to actual histology from human pathologic specimens.” So a four-color coded map with four different types of tissue can be created to map plaque composition.

“RF IVUS has a much higher signal-to-noise ratio because it's a catheter that is right next to the coronary plaque. So the resolution is much greater and you can see plaque composition the way that noninvasive modalities currently can't,” Dr. Stone said.

However, “there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention,” the investigators noted (N. Engl. J. Med. 2011:364:226-35).

First, this method lacks specificity at present. RF IVUS identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.

“Even when all three predictive variables were present, the event rate rose to only 18%,” they said.

Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 “nonculprit” lesions seen on angiography could be evaluated by RF IVUS.

Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.

While the ability of RF IVUS to assess luminal stenosis, plaque burden and positive remodeling is a useful tool, there are other diagnostic modalities to consider as well, said Dr. Narula. “Optical coherence tomography is the only technique that may accurately measure the cap thickness [and] CT angiography allows an assessment of both positive remodeling and the magnitude of necrotic cores.”

Intravascular optical coherence tomography (OCT) is similar to IVUS but light is used instead and resolution is greater. OCT uses a single fiberoptic wire that emits light and records the reflection as it is rotated and pulled back along the artery. OCT can be used to guide interventions, assess the lumen, visualize thrombi and dissections. It can also allow physicians to evaluate lesion cap thickness.

The advent of multislice CT - 264 slices and even greater - offers better and better resolution for non-invasive CT angiography. CTA can identify the presence of positive vessel remodeling and low-attenuation plaques, which along with a necrotic core, are thought to be associated with subsequent plaque rupture.

In the PROSPECT study, they also found that no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.

These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.

For now though, the early identification of such lesions needs to be validated in randomized trials and is limited by unclear therapeutical options.

“We need to answer two questions,” said Dr. Narula. “First, can we define the high-risk lesions especially when of intermediate angiographic severity? Second, even if it is possible, are we justified in recommending widespread imaging studies, especially when only a small fraction of nonculprit vessel plaques progress to acute events … plaques form, rupture, and heal all the time, and it would be difficult to precisely identify a high-risk plaque associated with a major event, let alone identify it in a treatable proximity to an event.”

Dr. Stone agreed. “We haven't yet done the randomized trials to say that if we find one of these lesions that the patients are better off if we then treat them. If so, what do we treat them with?”

“For now, statins remain the cornerstone of management of the non-obstructive disease. Whether new agents targeted at inflammation … or non-injurious stent implantation become worthy of clinical application, would depend upon the capability of imaging techniques to identify temporo-spatial proclivity of lesions for the occurrence of events, as also the demonstration of the virtue and benign nature of the intervention,” said Dr. Narula.

PROSPECT was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.

Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, and Boston Scientific. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.

It should not come as a surprise that approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, as has been recently reported in the New England Journal of Medicine.

“Pathologic studies … have illustrated that plaques when ruptured were substantially bulky and associated with thin fibrous caps. These lesions at the time of diagnosis may not have been sizable but grow at a faster rate to become eligible for rupture,” Dr. Jagat Narula, who is chief of cardiology at the University of California in Irvine, said in an interview.

The bigger question concerns the potential role for newly available radiofrequency intravascular ultrasonography (RF IVUS) in early assessment of patients with ACS.

The study in question showed that the rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, reported Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.

The Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study was conducted at 37 medical centers in the United States and Europe.

Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available RF IVUS of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.

The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.

“We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions,” Dr. Stone and his colleagues said.

“Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common,” they noted.

“Despite [certain] caveats, PROSPECT study has contributed immensely to understanding plaque anatomy, plaque composition and the prognostic relevance of the atherosclerotic lesions,” said Dr. Narula.

RF IVUS at baseline revealed that most of the “nonculprit” coronary lesions - those that had been considered mild on the index angiography and were not treated at that time - were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.

“I think the major message is that the angiogram is a very poor discriminator of how much atherosclerosis is present and which type of atherosclerosis is going to go on and cause unexpected events,” Dr. Stone said in an interview. “Radiofrequency IVUS provides significantly more information than just regular gray-scale IVUS in helping differentiate the nature of these plaques and which ones are going to progress.”

Conventional gray-scale IVUS works by sending out ultrasound waves and the resulting reflection signal can reveal structural information. Gray-scale IVUS measures only the amplitude of the reflected waves. However, RF IVUS also interprets frequency information from the reflected waves.

“That radiofrequency signal has been mapped pixel by pixel to actual histology from human pathologic specimens.” So a four-color coded map with four different types of tissue can be created to map plaque composition.

“RF IVUS has a much higher signal-to-noise ratio because it's a catheter that is right next to the coronary plaque. So the resolution is much greater and you can see plaque composition the way that noninvasive modalities currently can't,” Dr. Stone said.

However, “there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention,” the investigators noted (N. Engl. J. Med. 2011:364:226-35).

First, this method lacks specificity at present. RF IVUS identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.

“Even when all three predictive variables were present, the event rate rose to only 18%,” they said.

Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 “nonculprit” lesions seen on angiography could be evaluated by RF IVUS.

Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.

While the ability of RF IVUS to assess luminal stenosis, plaque burden and positive remodeling is a useful tool, there are other diagnostic modalities to consider as well, said Dr. Narula. “Optical coherence tomography is the only technique that may accurately measure the cap thickness [and] CT angiography allows an assessment of both positive remodeling and the magnitude of necrotic cores.”

Intravascular optical coherence tomography (OCT) is similar to IVUS but light is used instead and resolution is greater. OCT uses a single fiberoptic wire that emits light and records the reflection as it is rotated and pulled back along the artery. OCT can be used to guide interventions, assess the lumen, visualize thrombi and dissections. It can also allow physicians to evaluate lesion cap thickness.

The advent of multislice CT - 264 slices and even greater - offers better and better resolution for non-invasive CT angiography. CTA can identify the presence of positive vessel remodeling and low-attenuation plaques, which along with a necrotic core, are thought to be associated with subsequent plaque rupture.

In the PROSPECT study, they also found that no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.

These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.

For now though, the early identification of such lesions needs to be validated in randomized trials and is limited by unclear therapeutical options.

“We need to answer two questions,” said Dr. Narula. “First, can we define the high-risk lesions especially when of intermediate angiographic severity? Second, even if it is possible, are we justified in recommending widespread imaging studies, especially when only a small fraction of nonculprit vessel plaques progress to acute events … plaques form, rupture, and heal all the time, and it would be difficult to precisely identify a high-risk plaque associated with a major event, let alone identify it in a treatable proximity to an event.”

Dr. Stone agreed. “We haven't yet done the randomized trials to say that if we find one of these lesions that the patients are better off if we then treat them. If so, what do we treat them with?”

“For now, statins remain the cornerstone of management of the non-obstructive disease. Whether new agents targeted at inflammation … or non-injurious stent implantation become worthy of clinical application, would depend upon the capability of imaging techniques to identify temporo-spatial proclivity of lesions for the occurrence of events, as also the demonstration of the virtue and benign nature of the intervention,” said Dr. Narula.

PROSPECT was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.

Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, and Boston Scientific. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.

It should not come as a surprise that approximately half of the acute coronary syndromes that recur within 3 years of an index ACS treated percutaneously involve a different lesion that was visualized on angiography at that time but was not severe enough to require treatment, as has been recently reported in the New England Journal of Medicine.

“Pathologic studies … have illustrated that plaques when ruptured were substantially bulky and associated with thin fibrous caps. These lesions at the time of diagnosis may not have been sizable but grow at a faster rate to become eligible for rupture,” Dr. Jagat Narula, who is chief of cardiology at the University of California in Irvine, said in an interview.

The bigger question concerns the potential role for newly available radiofrequency intravascular ultrasonography (RF IVUS) in early assessment of patients with ACS.

The study in question showed that the rate of recurrent major adverse cardiovascular events was 20% in this multicenter prospective study involving 697 patients with ACS who were successfully treated with PCI and medical therapy, then followed for 3 years, reported Dr. Gregg W. Stone of Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, and his associates.

The Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study was conducted at 37 medical centers in the United States and Europe.

Study subjects were enrolled after undergoing successful and uncomplicated PCI for all coronary lesions thought to be responsible for their index ACS. At that time, the subjects underwent angiography, then conventional gray-scale intravascular ultrasonography and the newly available RF IVUS of the left main coronary artery and the proximal 6-8 cm of each of the major epicardial coronary arteries.

The median age of the study subjects was 58 years; 24% were women, and 17% had diabetes.

“We found that approximately one in five patients with [ACS] ... had recurrent major adverse cardiovascular events within 3 years. Events were nearly equally divided between those related to initially treated lesions and those related to previously untreated lesions,” Dr. Stone and his colleagues said.

“Most events were rehospitalizations for unstable or progressive angina; death from cardiac causes, cardiac arrest, and MI were less common,” they noted.

“Despite [certain] caveats, PROSPECT study has contributed immensely to understanding plaque anatomy, plaque composition and the prognostic relevance of the atherosclerotic lesions,” said Dr. Narula.

RF IVUS at baseline revealed that most of the “nonculprit” coronary lesions - those that had been considered mild on the index angiography and were not treated at that time - were characterized by a large plaque burden, a small luminal area, or both. Half of them also were thin-cap fibroatheromas. These traits had not been visible on conventional angiography.

“I think the major message is that the angiogram is a very poor discriminator of how much atherosclerosis is present and which type of atherosclerosis is going to go on and cause unexpected events,” Dr. Stone said in an interview. “Radiofrequency IVUS provides significantly more information than just regular gray-scale IVUS in helping differentiate the nature of these plaques and which ones are going to progress.”

Conventional gray-scale IVUS works by sending out ultrasound waves and the resulting reflection signal can reveal structural information. Gray-scale IVUS measures only the amplitude of the reflected waves. However, RF IVUS also interprets frequency information from the reflected waves.

“That radiofrequency signal has been mapped pixel by pixel to actual histology from human pathologic specimens.” So a four-color coded map with four different types of tissue can be created to map plaque composition.

“RF IVUS has a much higher signal-to-noise ratio because it's a catheter that is right next to the coronary plaque. So the resolution is much greater and you can see plaque composition the way that noninvasive modalities currently can't,” Dr. Stone said.

However, “there are several reasons why the methods we have used are not currently suitable for clinical application as a means of identifying sites in the coronary vasculature for potential intervention,” the investigators noted (N. Engl. J. Med. 2011:364:226-35).

First, this method lacks specificity at present. RF IVUS identified a total of 595 thin-cap atheromas in these subjects, but only 26 of them caused recurrent ACS. Similarly, fewer than 10% of the lesions that carried plaque burdens of 70% or more and the lesions with a 4-mm or smaller luminal area caused recurrent ACS.

“Even when all three predictive variables were present, the event rate rose to only 18%,” they said.

Second, catheters used for this type of ultrasonography could only access the proximal 6-8 cm of the coronary tree. This meant that only 51 of the 106 “nonculprit” lesions seen on angiography could be evaluated by RF IVUS.

Third, the technique was associated with very serious adverse events in 11 patients in this study: 10 coronary dissections and 1 perforation, which in turn caused 4 nonfatal MIs.

While the ability of RF IVUS to assess luminal stenosis, plaque burden and positive remodeling is a useful tool, there are other diagnostic modalities to consider as well, said Dr. Narula. “Optical coherence tomography is the only technique that may accurately measure the cap thickness [and] CT angiography allows an assessment of both positive remodeling and the magnitude of necrotic cores.”

Intravascular optical coherence tomography (OCT) is similar to IVUS but light is used instead and resolution is greater. OCT uses a single fiberoptic wire that emits light and records the reflection as it is rotated and pulled back along the artery. OCT can be used to guide interventions, assess the lumen, visualize thrombi and dissections. It can also allow physicians to evaluate lesion cap thickness.

The advent of multislice CT - 264 slices and even greater - offers better and better resolution for non-invasive CT angiography. CTA can identify the presence of positive vessel remodeling and low-attenuation plaques, which along with a necrotic core, are thought to be associated with subsequent plaque rupture.

In the PROSPECT study, they also found that no major events arose from arterial segments with a plaque burden that blocked less than 40% of the lumen. And nonfibroatheromas rarely caused such events, regardless of their plaque burden or the luminal area they blocked.

These study findings suggest that thin-cap fibroatheromas, lesions with a large plaque burden, and lesions with a small luminal area are particularly prone to cause recurrent ACS.

For now though, the early identification of such lesions needs to be validated in randomized trials and is limited by unclear therapeutical options.

“We need to answer two questions,” said Dr. Narula. “First, can we define the high-risk lesions especially when of intermediate angiographic severity? Second, even if it is possible, are we justified in recommending widespread imaging studies, especially when only a small fraction of nonculprit vessel plaques progress to acute events … plaques form, rupture, and heal all the time, and it would be difficult to precisely identify a high-risk plaque associated with a major event, let alone identify it in a treatable proximity to an event.”

Dr. Stone agreed. “We haven't yet done the randomized trials to say that if we find one of these lesions that the patients are better off if we then treat them. If so, what do we treat them with?”

“For now, statins remain the cornerstone of management of the non-obstructive disease. Whether new agents targeted at inflammation … or non-injurious stent implantation become worthy of clinical application, would depend upon the capability of imaging techniques to identify temporo-spatial proclivity of lesions for the occurrence of events, as also the demonstration of the virtue and benign nature of the intervention,” said Dr. Narula.

PROSPECT was funded by Abbott Vascular and Volcano. Abbott participated in the study design, site selection, data collection, and data analysis.

Dr. Stone reports receiving grant support, consulting fees, and/or lecture fees from numerous pharmaceutical and device firms, including Abbott Vascular, TherOx, the Medicines Company, and Boston Scientific. Other investigators reported financial relationships with Abbott Vascular, Boston Scientific, Volcano, Bristol-Myers Squibb, Sanofi-Aventis, the Medicines Company, and others.

The STS meeting in January led to many discussions within the TSRA including both future and current events. Future events included the results of the recent resident survey, upcoming thoracic surgery review book, new opportunities in using social media and further improvement of the "boot camp" weekend for new residents. More immediate conversation included continued adjustments in work hour restrictions, job hunting strategies and a discussion on the steps of completing the board exam.

A Message from Dr. William A. Baumgartner on Behalf of the ABTS to the TSRA at the STS Annual Meeting

Passing a board exam necessitates proving to the examiners you have an accurate plan on where to go with a patient. Applying for the board exam on the other hand necessitates an accurate map of where you have been as a training physician. Documentation of cases performed by a trainee serves as this "map" of past accomplishments. A case journal is not only used as a requirement for board exams. Hospitals, insurers, and industry can also use these data to choose who is going to perform their next test or treatment.

It is the responsibility of the trainee to maintain their case log to confirm they are getting their index cases completed. More and more applicants for the ABTS are applying with holes in their resume with categories of cases not completed. Often the cause of this is not a program's lack of exposure, but poor documentation during the period of training.

Much like not getting paid for poor documentation of procedures when out in practice, the ABTS will soon become stricter on documentation of index cases.
The good news is that the program for logging cases will soon follow the CPT coding system for CT Surgery residents starting in July, 2011. The program will provide for more accurate documentation and will also give a more "real world" experience. In the meantime, check your case log regularly and expeditiously discuss with your program director any deficiencies that may exist.

The STS meeting in January led to many discussions within the TSRA including both future and current events. Future events included the results of the recent resident survey, upcoming thoracic surgery review book, new opportunities in using social media and further improvement of the "boot camp" weekend for new residents. More immediate conversation included continued adjustments in work hour restrictions, job hunting strategies and a discussion on the steps of completing the board exam.

A Message from Dr. William A. Baumgartner on Behalf of the ABTS to the TSRA at the STS Annual Meeting

Passing a board exam necessitates proving to the examiners you have an accurate plan on where to go with a patient. Applying for the board exam on the other hand necessitates an accurate map of where you have been as a training physician. Documentation of cases performed by a trainee serves as this "map" of past accomplishments. A case journal is not only used as a requirement for board exams. Hospitals, insurers, and industry can also use these data to choose who is going to perform their next test or treatment.

It is the responsibility of the trainee to maintain their case log to confirm they are getting their index cases completed. More and more applicants for the ABTS are applying with holes in their resume with categories of cases not completed. Often the cause of this is not a program's lack of exposure, but poor documentation during the period of training.

Much like not getting paid for poor documentation of procedures when out in practice, the ABTS will soon become stricter on documentation of index cases.
The good news is that the program for logging cases will soon follow the CPT coding system for CT Surgery residents starting in July, 2011. The program will provide for more accurate documentation and will also give a more "real world" experience. In the meantime, check your case log regularly and expeditiously discuss with your program director any deficiencies that may exist.

The STS meeting in January led to many discussions within the TSRA including both future and current events. Future events included the results of the recent resident survey, upcoming thoracic surgery review book, new opportunities in using social media and further improvement of the "boot camp" weekend for new residents. More immediate conversation included continued adjustments in work hour restrictions, job hunting strategies and a discussion on the steps of completing the board exam.

A Message from Dr. William A. Baumgartner on Behalf of the ABTS to the TSRA at the STS Annual Meeting

Passing a board exam necessitates proving to the examiners you have an accurate plan on where to go with a patient. Applying for the board exam on the other hand necessitates an accurate map of where you have been as a training physician. Documentation of cases performed by a trainee serves as this "map" of past accomplishments. A case journal is not only used as a requirement for board exams. Hospitals, insurers, and industry can also use these data to choose who is going to perform their next test or treatment.

It is the responsibility of the trainee to maintain their case log to confirm they are getting their index cases completed. More and more applicants for the ABTS are applying with holes in their resume with categories of cases not completed. Often the cause of this is not a program's lack of exposure, but poor documentation during the period of training.

Much like not getting paid for poor documentation of procedures when out in practice, the ABTS will soon become stricter on documentation of index cases.
The good news is that the program for logging cases will soon follow the CPT coding system for CT Surgery residents starting in July, 2011. The program will provide for more accurate documentation and will also give a more "real world" experience. In the meantime, check your case log regularly and expeditiously discuss with your program director any deficiencies that may exist.

Genentech Inc. and partner OSI Pharmaceuticals Inc. are set to pursue a broader label for Tarceva (erlotinib) in the United States as a first-line treatment of advanced non-small cell lung cancer with epidermal growth factor receptor mutations, after reporting positive top-line results in that setting from a phase III European study.

Genentech announced that compared with platinum-based chemo-therapy, Tarceva, an EGFR inhibitor, improved progression-free survival in an interim analysis of the EURTAC study of 178 newly-diagnosed advanced NSCLC patients who had tested positive for the mutations. Safety was in line with Tarceva's profile. In light of the efficacy and safety results, the trial was halted early on the recommendation of its independent data monitoring committee.

Tarceva is currently approved in the United States and Europe as a maintenance and second-line treatment for advanced or metastatic NSCLC with and without EGFR activating mutations. An estimated 10% of NSCLC carries the EGFR mutations and according to Genentech a first-line indication would mean Tarceva could emerge as the first-choice for that sliver of the patient population, ahead of chemotherapy and other drugs approved for first-line NSCLC.

Genentech's parent company, Roche, had already submitted a bid to expand the drug's label to the European Medicines Agency in June 2010.

Then, in November 2010, Roche announced that it was sublicensing a diagnostic assay for EGFR mutations from Genzyme Corporation and collaborating with OSI on the development of a PCR- based companion diagnostic test to identify people with non-small cell lung cancer that harbors EGFR activating mutations.

Genentech and OSI plan to talk to the Food and Drug Administration about possibilities for a first-line indication in NSCLC and also for the companion diagnostic test in development, but timing on these discussions has not yet been decided.

It's unclear whether the drug would be submitted to the FDA simultaneously with a diagnostic test, which was the case in a recent approval of a new, narrow indication for Herceptin in a particular type of gastric cancer.

The test in development by Roche and OSI was not the same diagnostic used in the EURTAC study, which was designed and sponsored by the Spanish Lung Cancer Group. Genentech said it still needs to validate the test used in the EURTAC study using samples from the trial, prior to talks with FDA. It's also unclear at this time whether another study beyond EURTAC would be needed to expand the U.S. label.

Genentech did not disclose the magnitude of the benefit for progression-free survival - the primary end point - in the EURTAC trial. Secondary end points include overall survival, 1-year survival, objective response rate, and safety profile.

In the SATURN trial of Tarceva as a maintenance therapy for NSCLC, the drug showed only a modest PFS benefit for NSCLC patients overall (12.3 weeks for the drug versus 11.1 weeks for placebo). Its use as a maintenance treatment has proven controversial since the FDA approved the indication despite a negative vote by an advisory committee.
 
However, SATURN showed dramatically better results for patients who had EGFR mutations. In this subgroup, which accounted for 11% of the total population, PFS was 44.6 weeks for the treated group versus the 11 weeks for placebo. Based on the data, some physician surveys have suggested more willingness to use Tarceva as a maintenance treatment in the case of EGFR mutations.

Elsevier Global Medical News and "The Pink Sheet" are published by Elsevier.

Genentech Inc. and partner OSI Pharmaceuticals Inc. are set to pursue a broader label for Tarceva (erlotinib) in the United States as a first-line treatment of advanced non-small cell lung cancer with epidermal growth factor receptor mutations, after reporting positive top-line results in that setting from a phase III European study.

Genentech announced that compared with platinum-based chemo-therapy, Tarceva, an EGFR inhibitor, improved progression-free survival in an interim analysis of the EURTAC study of 178 newly-diagnosed advanced NSCLC patients who had tested positive for the mutations. Safety was in line with Tarceva's profile. In light of the efficacy and safety results, the trial was halted early on the recommendation of its independent data monitoring committee.

Tarceva is currently approved in the United States and Europe as a maintenance and second-line treatment for advanced or metastatic NSCLC with and without EGFR activating mutations. An estimated 10% of NSCLC carries the EGFR mutations and according to Genentech a first-line indication would mean Tarceva could emerge as the first-choice for that sliver of the patient population, ahead of chemotherapy and other drugs approved for first-line NSCLC.

Genentech's parent company, Roche, had already submitted a bid to expand the drug's label to the European Medicines Agency in June 2010.

Then, in November 2010, Roche announced that it was sublicensing a diagnostic assay for EGFR mutations from Genzyme Corporation and collaborating with OSI on the development of a PCR- based companion diagnostic test to identify people with non-small cell lung cancer that harbors EGFR activating mutations.

Genentech and OSI plan to talk to the Food and Drug Administration about possibilities for a first-line indication in NSCLC and also for the companion diagnostic test in development, but timing on these discussions has not yet been decided.

It's unclear whether the drug would be submitted to the FDA simultaneously with a diagnostic test, which was the case in a recent approval of a new, narrow indication for Herceptin in a particular type of gastric cancer.

The test in development by Roche and OSI was not the same diagnostic used in the EURTAC study, which was designed and sponsored by the Spanish Lung Cancer Group. Genentech said it still needs to validate the test used in the EURTAC study using samples from the trial, prior to talks with FDA. It's also unclear at this time whether another study beyond EURTAC would be needed to expand the U.S. label.

Genentech did not disclose the magnitude of the benefit for progression-free survival - the primary end point - in the EURTAC trial. Secondary end points include overall survival, 1-year survival, objective response rate, and safety profile.

In the SATURN trial of Tarceva as a maintenance therapy for NSCLC, the drug showed only a modest PFS benefit for NSCLC patients overall (12.3 weeks for the drug versus 11.1 weeks for placebo). Its use as a maintenance treatment has proven controversial since the FDA approved the indication despite a negative vote by an advisory committee.
 
However, SATURN showed dramatically better results for patients who had EGFR mutations. In this subgroup, which accounted for 11% of the total population, PFS was 44.6 weeks for the treated group versus the 11 weeks for placebo. Based on the data, some physician surveys have suggested more willingness to use Tarceva as a maintenance treatment in the case of EGFR mutations.

Elsevier Global Medical News and "The Pink Sheet" are published by Elsevier.

Genentech Inc. and partner OSI Pharmaceuticals Inc. are set to pursue a broader label for Tarceva (erlotinib) in the United States as a first-line treatment of advanced non-small cell lung cancer with epidermal growth factor receptor mutations, after reporting positive top-line results in that setting from a phase III European study.

Genentech announced that compared with platinum-based chemo-therapy, Tarceva, an EGFR inhibitor, improved progression-free survival in an interim analysis of the EURTAC study of 178 newly-diagnosed advanced NSCLC patients who had tested positive for the mutations. Safety was in line with Tarceva's profile. In light of the efficacy and safety results, the trial was halted early on the recommendation of its independent data monitoring committee.

Tarceva is currently approved in the United States and Europe as a maintenance and second-line treatment for advanced or metastatic NSCLC with and without EGFR activating mutations. An estimated 10% of NSCLC carries the EGFR mutations and according to Genentech a first-line indication would mean Tarceva could emerge as the first-choice for that sliver of the patient population, ahead of chemotherapy and other drugs approved for first-line NSCLC.

Genentech's parent company, Roche, had already submitted a bid to expand the drug's label to the European Medicines Agency in June 2010.

Then, in November 2010, Roche announced that it was sublicensing a diagnostic assay for EGFR mutations from Genzyme Corporation and collaborating with OSI on the development of a PCR- based companion diagnostic test to identify people with non-small cell lung cancer that harbors EGFR activating mutations.

Genentech and OSI plan to talk to the Food and Drug Administration about possibilities for a first-line indication in NSCLC and also for the companion diagnostic test in development, but timing on these discussions has not yet been decided.

It's unclear whether the drug would be submitted to the FDA simultaneously with a diagnostic test, which was the case in a recent approval of a new, narrow indication for Herceptin in a particular type of gastric cancer.

The test in development by Roche and OSI was not the same diagnostic used in the EURTAC study, which was designed and sponsored by the Spanish Lung Cancer Group. Genentech said it still needs to validate the test used in the EURTAC study using samples from the trial, prior to talks with FDA. It's also unclear at this time whether another study beyond EURTAC would be needed to expand the U.S. label.

Genentech did not disclose the magnitude of the benefit for progression-free survival - the primary end point - in the EURTAC trial. Secondary end points include overall survival, 1-year survival, objective response rate, and safety profile.

In the SATURN trial of Tarceva as a maintenance therapy for NSCLC, the drug showed only a modest PFS benefit for NSCLC patients overall (12.3 weeks for the drug versus 11.1 weeks for placebo). Its use as a maintenance treatment has proven controversial since the FDA approved the indication despite a negative vote by an advisory committee.
 
However, SATURN showed dramatically better results for patients who had EGFR mutations. In this subgroup, which accounted for 11% of the total population, PFS was 44.6 weeks for the treated group versus the 11 weeks for placebo. Based on the data, some physician surveys have suggested more willingness to use Tarceva as a maintenance treatment in the case of EGFR mutations.

Elsevier Global Medical News and "The Pink Sheet" are published by Elsevier.

SAN DIEGO - Although the right internal thoracic artery is biologically identical to the left internal thoracic artery, it is rarely used in coronary artery bypass grafting.

In a study comparing the use of different graft sources for coronary artery bypass grafting (CABG), Dr. James Tatoulis and his colleagues found that the right internal thoracic artery (RITA) showed equivalent results to using the left internal thoracic artery (LITA).

Dr. Tatoulis of the Royal Melbourne Hospital and his colleagues evaluated consecutive RITA graft angiograms performed from 1986 to 2008. Patency was examined over time by coronary territory and by whether the RITA was in situ or free, and was compared with other coronary conduits, according to the study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 5,766 patients had a RITA graft, usually as part of bilateral internal thoracic artery CABG. The operative mortality was 1.1%, and the rate of deep sternal infection was 1.5%. Of the nearly 7,800 coronary conduits studied, 991 RITA conduits were examined at a mean of 100 months postoperatively.

The overall 10-year RITA patency was 90%. RITA graft patency to the left anterior descending artery (n = 149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal artery was 91% (n = 436), 85% (n = 199) to the right coronary artery (RCA), and 86% (n = 207) to the posterior descending artery (PDA). Ten-year patencies of RITA and LITA to the left anterior descending artery were identical.

In situ RITA (n=451) and free RITA (n=540) had similar 10-year patencies, 89% vs. 91% respectively.

RITA patency was found to be significantly better than radial artery and saphenous vein grafts for the circumflex marginal artery, the RCA, and the PDA. The 10-year survival of patients with RITA and LITA for triple-vessel coronary disease were identical at 89%.

Dr. Tatoulis and his colleagues stated that late patencies of RITA are excellent, equivalent to the LITA for identical territories, and always better than radial artery and saphenous vein grafts.

“Unfortunately, less than 10% of all coronary artery surgery worldwide is performed with two internal thoracic arteries," Dr. Tatoulis said in an interview.
He added that the use of this technique could improve patient outcomes and could offer an even better revascularization alternative to stents, particularly for triple-vessel coronary disease.

Dr. Tatoulis and his colleagues reported that they had no relevant disclosures.

SAN DIEGO - Although the right internal thoracic artery is biologically identical to the left internal thoracic artery, it is rarely used in coronary artery bypass grafting.

In a study comparing the use of different graft sources for coronary artery bypass grafting (CABG), Dr. James Tatoulis and his colleagues found that the right internal thoracic artery (RITA) showed equivalent results to using the left internal thoracic artery (LITA).

Dr. Tatoulis of the Royal Melbourne Hospital and his colleagues evaluated consecutive RITA graft angiograms performed from 1986 to 2008. Patency was examined over time by coronary territory and by whether the RITA was in situ or free, and was compared with other coronary conduits, according to the study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 5,766 patients had a RITA graft, usually as part of bilateral internal thoracic artery CABG. The operative mortality was 1.1%, and the rate of deep sternal infection was 1.5%. Of the nearly 7,800 coronary conduits studied, 991 RITA conduits were examined at a mean of 100 months postoperatively.

The overall 10-year RITA patency was 90%. RITA graft patency to the left anterior descending artery (n = 149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal artery was 91% (n = 436), 85% (n = 199) to the right coronary artery (RCA), and 86% (n = 207) to the posterior descending artery (PDA). Ten-year patencies of RITA and LITA to the left anterior descending artery were identical.

In situ RITA (n=451) and free RITA (n=540) had similar 10-year patencies, 89% vs. 91% respectively.

RITA patency was found to be significantly better than radial artery and saphenous vein grafts for the circumflex marginal artery, the RCA, and the PDA. The 10-year survival of patients with RITA and LITA for triple-vessel coronary disease were identical at 89%.

Dr. Tatoulis and his colleagues stated that late patencies of RITA are excellent, equivalent to the LITA for identical territories, and always better than radial artery and saphenous vein grafts.

“Unfortunately, less than 10% of all coronary artery surgery worldwide is performed with two internal thoracic arteries," Dr. Tatoulis said in an interview.
He added that the use of this technique could improve patient outcomes and could offer an even better revascularization alternative to stents, particularly for triple-vessel coronary disease.

Dr. Tatoulis and his colleagues reported that they had no relevant disclosures.

SAN DIEGO - Although the right internal thoracic artery is biologically identical to the left internal thoracic artery, it is rarely used in coronary artery bypass grafting.

In a study comparing the use of different graft sources for coronary artery bypass grafting (CABG), Dr. James Tatoulis and his colleagues found that the right internal thoracic artery (RITA) showed equivalent results to using the left internal thoracic artery (LITA).

Dr. Tatoulis of the Royal Melbourne Hospital and his colleagues evaluated consecutive RITA graft angiograms performed from 1986 to 2008. Patency was examined over time by coronary territory and by whether the RITA was in situ or free, and was compared with other coronary conduits, according to the study presented at the annual meeting of the Society of Thoracic Surgeons.

A total of 5,766 patients had a RITA graft, usually as part of bilateral internal thoracic artery CABG. The operative mortality was 1.1%, and the rate of deep sternal infection was 1.5%. Of the nearly 7,800 coronary conduits studied, 991 RITA conduits were examined at a mean of 100 months postoperatively.

The overall 10-year RITA patency was 90%. RITA graft patency to the left anterior descending artery (n = 149) was 95% at 10 years and 90% at 15 years. Ten-year RITA patency to the circumflex marginal artery was 91% (n = 436), 85% (n = 199) to the right coronary artery (RCA), and 86% (n = 207) to the posterior descending artery (PDA). Ten-year patencies of RITA and LITA to the left anterior descending artery were identical.

In situ RITA (n=451) and free RITA (n=540) had similar 10-year patencies, 89% vs. 91% respectively.

RITA patency was found to be significantly better than radial artery and saphenous vein grafts for the circumflex marginal artery, the RCA, and the PDA. The 10-year survival of patients with RITA and LITA for triple-vessel coronary disease were identical at 89%.

Dr. Tatoulis and his colleagues stated that late patencies of RITA are excellent, equivalent to the LITA for identical territories, and always better than radial artery and saphenous vein grafts.

“Unfortunately, less than 10% of all coronary artery surgery worldwide is performed with two internal thoracic arteries," Dr. Tatoulis said in an interview.
He added that the use of this technique could improve patient outcomes and could offer an even better revascularization alternative to stents, particularly for triple-vessel coronary disease.

Dr. Tatoulis and his colleagues reported that they had no relevant disclosures.

SAN DIEGO - Adding a simple question to the daily ICU checklist about handwashing before touching patients significantly improved handwashing compliance and was associated with a decreased rate of central line-associated bloodstream infections in a surgical intensive care unit over the course of 6 months, according to a presentation at the annual congress of the Society of Critical Care Medicine.

"If you look at how people address hand hygiene compliance overall, most of the time it's with fairly elaborate and expensive educational and marketing campaigns," Dr. Jeremy Pamplin said in an interview after the study was presented during a poster session at the congress. "Inevitably, you improve hand hygiene compliance for a while. Then the campaign goes away and you start to have fading of the compliance."

As part of a process improvement project, Dr. Pamplin, medical codirector of the 20-bed surgical/trauma ICU at Brooke Army Medical Center, Fort Sam Houston, Tex., and his associates added the following question to their daily ICU checklist: "Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours?" The question was asked during multidisciplinary ICU rounds for every patient, and only "yes" or "no" answers were allowed.

If respondents answered "yes," they were asked to provide the name of the offender, which was recorded. Compliance was measured by a third-party observer and was defined as washing hands or using hand sanitizer prior to touching a patient or the patient's immediate surroundings.

Dr. Pamplin and his associates collected data for 3 months before and 3 months after this question was added to the ICU checklist. Over that period, the rate of handwashing compliance significantly increased from 69% to 89%, while the rate of central line-associated bloodstream infections decreased from 13.7/1,000 central line days to 2.7/1,000 central line days, an improvement that did not reach statistical significance.

"Before we introduced this question to our checklist, it was very rare for a provider to tell another provider, 'Hey, I didn't see you wash your hands," Dr. Pamplin said. "After we introduced this question, people started doing it because we gave leadership and emphasis to it."

This resulted in a change of culture, he continued, "so if nurses, residents, or technicians saw someone walk into the room without washing their hands, they would stop them and say, 'Hang on a second; you didn't wash your hands.' Everyone knows that hand hygiene is an important part of infection control. The hard part is remembering to do it. It's a rare circumstance that someone gets upset by another health care provider who says, 'Hey, you forgot to wash your hands.' Because we have talked about hand hygiene compliance on rounds as a team, it has elevated that component of infection control so that everyone recognizes it as being important."

Dr. Pamplin said that he had no relevant financial disclosures to make.

SAN DIEGO - Adding a simple question to the daily ICU checklist about handwashing before touching patients significantly improved handwashing compliance and was associated with a decreased rate of central line-associated bloodstream infections in a surgical intensive care unit over the course of 6 months, according to a presentation at the annual congress of the Society of Critical Care Medicine.

"If you look at how people address hand hygiene compliance overall, most of the time it's with fairly elaborate and expensive educational and marketing campaigns," Dr. Jeremy Pamplin said in an interview after the study was presented during a poster session at the congress. "Inevitably, you improve hand hygiene compliance for a while. Then the campaign goes away and you start to have fading of the compliance."

As part of a process improvement project, Dr. Pamplin, medical codirector of the 20-bed surgical/trauma ICU at Brooke Army Medical Center, Fort Sam Houston, Tex., and his associates added the following question to their daily ICU checklist: "Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours?" The question was asked during multidisciplinary ICU rounds for every patient, and only "yes" or "no" answers were allowed.

If respondents answered "yes," they were asked to provide the name of the offender, which was recorded. Compliance was measured by a third-party observer and was defined as washing hands or using hand sanitizer prior to touching a patient or the patient's immediate surroundings.

Dr. Pamplin and his associates collected data for 3 months before and 3 months after this question was added to the ICU checklist. Over that period, the rate of handwashing compliance significantly increased from 69% to 89%, while the rate of central line-associated bloodstream infections decreased from 13.7/1,000 central line days to 2.7/1,000 central line days, an improvement that did not reach statistical significance.

"Before we introduced this question to our checklist, it was very rare for a provider to tell another provider, 'Hey, I didn't see you wash your hands," Dr. Pamplin said. "After we introduced this question, people started doing it because we gave leadership and emphasis to it."

This resulted in a change of culture, he continued, "so if nurses, residents, or technicians saw someone walk into the room without washing their hands, they would stop them and say, 'Hang on a second; you didn't wash your hands.' Everyone knows that hand hygiene is an important part of infection control. The hard part is remembering to do it. It's a rare circumstance that someone gets upset by another health care provider who says, 'Hey, you forgot to wash your hands.' Because we have talked about hand hygiene compliance on rounds as a team, it has elevated that component of infection control so that everyone recognizes it as being important."

Dr. Pamplin said that he had no relevant financial disclosures to make.

SAN DIEGO - Adding a simple question to the daily ICU checklist about handwashing before touching patients significantly improved handwashing compliance and was associated with a decreased rate of central line-associated bloodstream infections in a surgical intensive care unit over the course of 6 months, according to a presentation at the annual congress of the Society of Critical Care Medicine.

"If you look at how people address hand hygiene compliance overall, most of the time it's with fairly elaborate and expensive educational and marketing campaigns," Dr. Jeremy Pamplin said in an interview after the study was presented during a poster session at the congress. "Inevitably, you improve hand hygiene compliance for a while. Then the campaign goes away and you start to have fading of the compliance."

As part of a process improvement project, Dr. Pamplin, medical codirector of the 20-bed surgical/trauma ICU at Brooke Army Medical Center, Fort Sam Houston, Tex., and his associates added the following question to their daily ICU checklist: "Has anyone seen anyone else touch the patient without washing their hands in the past 24 hours?" The question was asked during multidisciplinary ICU rounds for every patient, and only "yes" or "no" answers were allowed.

If respondents answered "yes," they were asked to provide the name of the offender, which was recorded. Compliance was measured by a third-party observer and was defined as washing hands or using hand sanitizer prior to touching a patient or the patient's immediate surroundings.

Dr. Pamplin and his associates collected data for 3 months before and 3 months after this question was added to the ICU checklist. Over that period, the rate of handwashing compliance significantly increased from 69% to 89%, while the rate of central line-associated bloodstream infections decreased from 13.7/1,000 central line days to 2.7/1,000 central line days, an improvement that did not reach statistical significance.

"Before we introduced this question to our checklist, it was very rare for a provider to tell another provider, 'Hey, I didn't see you wash your hands," Dr. Pamplin said. "After we introduced this question, people started doing it because we gave leadership and emphasis to it."

This resulted in a change of culture, he continued, "so if nurses, residents, or technicians saw someone walk into the room without washing their hands, they would stop them and say, 'Hang on a second; you didn't wash your hands.' Everyone knows that hand hygiene is an important part of infection control. The hard part is remembering to do it. It's a rare circumstance that someone gets upset by another health care provider who says, 'Hey, you forgot to wash your hands.' Because we have talked about hand hygiene compliance on rounds as a team, it has elevated that component of infection control so that everyone recognizes it as being important."

Dr. Pamplin said that he had no relevant financial disclosures to make.