Patient deprivation and perceived scan burden negatively impact the quality of whole-body MRI

AIM

To evaluate the association between the image quality of cancer staging whole-body magnetic resonance imaging (WB-MRI) and patient demographics, distress, and perceived scan burden.

MATERIALS AND METHODS

A sample of patients recruited prospectively to multicentre trials comparing WB-MRI with standard scans for staging lung and colorectal cancer were invited to complete two questionnaires. The baseline questionnaire, administered at recruitment, collated data on demographics, distress and co-morbidity. The follow-up questionnaire, completed after staging investigations, measured perceived WB-MRI scan burden (scored 1 low to 7 high). WB-MRI anatomical coverage, and technical quality was graded by a radiographic technician and grading combined to categorise the scan as "optimal", "sub-optimal" or "degraded". A radiologist categorised 30 scans to test interobserver agreement. Data were analysed using the chi-square, Fisher's exact, t-tests, and multinomial regression.

RESULTS

One hundred and fourteen patients were included in the study (53 lung, 61 colorectal; average age 65.3 years, SD=11.8; 66 men [57.9%]). Overall, 45.6% (n=52), scans were classified as "optimal" quality, 39.5% (n=45) "sub-optimal", and 14.9% (n=17) as "degraded". In adjusted analyses, greater deprivation level and higher patient-reported scan burden were both associated with a higher likelihood of having a sub-optimal versus an optimal scan (odds ratio [OR]: 4.465, 95% confidence interval [CI]: 1.454 to 13.709, p=0.009; OR: 1.987, CI: 1.153 to 3.425, p=0.013, respectively). None of the variables predicted the likelihood of having a degraded scan.

CONCLUSIONS

Deprivation and patients' perceived experience of the WB-MRI are related to image quality. Tailored protocols and individualised patient management before and during WB-MRI may improve image quality.

BACCHUS: A randomised non-comparative phase II study of neoadjuvant chemotherapy (NACT) in patients with locally advanced rectal cancer (LARC)

BACKGROUND

Chemoradiation (CRT) or short-course radiotherapy (SCRT) are standard treatments for locally advanced rectal cancer (LARC). We evaluated the efficacy/safety of two neoadjuvant chemotherapy (NACT) regimens as an alternative prior to total mesorectal excision (TME).

METHODS/DESIGN

This multi-centre, phase II trial in patients with magnetic resonance imaging (MRI) defined high-risk LARC (>cT3b, cN2+ or extramural venous invasion) randomised patients (1:1) to FOLFOX + Bevacizumab (Arm 1) or FOLFOXIRI + bevacizumab (Arm 2) every 14 days for 6 cycles prior to surgery. Patients were withdrawn if positron emission tomography (PET) standardised uptake value (SUV) after 3 cycles failed to decrease by >30% or increased compared to baseline. Primary endpoint was pathological complete response rate (pCR). Secondary endpoints included adverse events (AE) and toxicity. Neoadjuvant rectal (NAR) scores based on "T" and "N" downstaging were calculated.

FINDINGS

Twenty patients aged 18-75 years were randomised. The trial stopped early because of poor accrual. Seventeen patients completed all 6 cycles of NACT. One stopped due to myocardial infarction, 1 poor response on PET (both received CRT) and 1 committed suicide. 11 patients had G3 AE, 1 G4 AE (neutropenia), and 1 G5 (suicide). pCR (the primary endpoint) was 0/10 for Arm 1 and 2/10 for Arm 2 i.e. 2/20 (10%) overall. Median NAR score was 14·9 with 5 (28%), 7 (39%), and 6 (33%) having low, intermediate, or high scores. Surgical morbidity was acceptable (1/18 wound infection, no anastomotic leak/pelvic sepsis/fistulae). The 24-month progression-free survival rate was 75% (95% CI: 60%-85%).

INTERPRETATION

The primary endpoint (pCR rate) was not met. However, FOLFOXIRI and bevacizumab achieved promising pCR rates, low NAR scores and was well-tolerated. This regimen is suitable for testing as the novel arm against current standards of SCRT and/or CRT in a future trial.

Abstract P4-09-18: Characterization of circulating myeloid derived suppressor cells and cytokines in patients undergoing neo-adjuvant chemotherapy for breast cancer

Myeloid derived suppressor cells (MDSC) are immature immune cells that expand in patients (pts) with cancer and suppress anti-tumor immunity. MDSC are also known to support angiogenesis. Higher circulating MDSC levels are seen in patients with greater tumor burden. Therefore, circulating MDSC levels could be affected by chemotherapy and could correlate with response. In this prospective pilot trial, peripheral blood (PB) levels of granulocytic (G-MDSC) and monocytic (M-MDSC) MDSC were measured in pts with operable breast cancer (BC) treated with neo-adjuvant chemotherapy (NAC) to study their association with pathologic complete response. It was hypothesized that MDSC % would show an association with complete pathologic response (pCR). The association of 10 different cytokine levels (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, IL-13, IFN-γ, TNF-α) with pCR was also explored. Linear mixed models tested the associations between MDSC % or cytokines across time points with pCR. Levels of MDSC were measured by flow cytometry as a % of PB mononuclear cells prior to cycle (C) 1 and 2 of doxorubicin and cyclophosphamide (AC) and 1st and last administration of paclitaxel (T) or T and anti-HER2 therapy (in HER2+ pts). For other regimens, MDSC were measured prior to 1st, 2nd and last cycle. MDSC were defined as HLA-DR-, CD11b+, CD33+ cells with G-MDSC and M-MDSC cells expressing CD15 and CD14, respectively. Plasma cytokine levels were measured using a multiplex assay (Bio-Rad). Of 24 enrolled pts, 1, 20 and 3 had clinical stage I, II, IIIA, respectively. Median age was 48 (range 32-70). 11, 6 and 7 pts were triple negative (TN), HER2+ and hormone receptor (HR)+, respectively. PCR rate was 45.8% (46%, 50%, 43%, 20% for TN, HER2+, HR+ and >10% HR+ pts). Rate of residual cancer burden (RCB) class 0-1 was 58.3% (63.6%, 50%, 57.1%, 40% in TN, HER2+, HR+ and >10% HR+ pts). Mean M-MDSC % were <1 at all time points. Mean G-MDSC % and 95% confidence intervals (CI) were 0.88 (0.23-1.54), 5.07 (2.45-7.69), 9.32(4.02-14.61) and 1.97 (0.53-3.41) at times 1-4. The increase in MDSC by C1 of T was significant (p<0.0001) in all BC types. Baseline G-MDSC % did not differ in pts with or without pCR. G-MDSC levels at the last time point were also not statistically different but were numerically slightly lower in pts with pCR (1.15; 95%CI 0.14-2.16) versus pts with no pCR (2.71; 95%CI 0-5.47). Levels of all 10 cytokines were measurable in pts throughout NAC. The mean levels of IL-1β, IL-2, IL-4, IL-13 and IFN-γ peaked by C1 of T, while levels of IL-5, IL-6, IL-10, IL-12 and TNF-α were the highest at draw 1 and decreased during NAC. This pilot study confirmed feasibility of measuring circulating MDSC and cytokines in breast cancer pts receiving neo-adjuvant chemotherapy. The results showed that G-MDSC % increase during AC and then decrease during T and that a mixture of Th1 and Th2 cytokines peak during treatment. Levels of MDSC and cytokines did not significantly differ between pts with or without a pCR. However, a larger study with greater power to detect smaller differences and evaluate association between MDSC levels and pCR in different BC subtypes is needed.

Citation Format: Wesolowski R, Duggan M, Stiff A, Trikha P, Schoenfield L, Abdel-Rasoul M, Layman R, Ramaswamy B, Macrae E, Lustberg MB, Mrozek E, Carson WE. Characterization of circulating myeloid derived suppressor cells and cytokines in patients undergoing neo-adjuvant chemotherapy for breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-09-18.

Staff attitudes to an ultrasound-guided peripheral nerve block room for orthopaedic patients

Ultrasound-guided peripheral nerve blocks have well recognised benefits in orthopaedic patients. Some hospitals, to maximise these benefits, establish dedicated "block rooms" to deliver this service. Orthopaedic surgery makes up a large proportion of our hospitals work load, and many of these patients would benefit from ultrasound-guided peripheral nerve blocks. We analysed the attitudes of key staff in our hospital towards the establishment of a block room. Sixty questionnaires were distributed and 47 (78%) were completed. Orthopaedic surgeons (n = 6) were concerned ultrasound-guided peripheral nerve blocks would delay theatre lists (83%), and cause patients pain (67%) and increased anxiety (67%). Anaesthetists (n = 10) and Nurses (n = 30) were concerned there was insufficient experience in their departments to deliver this service (80% and 77%, respectively). However, 91% of all staff believed funding should be available for a block room. Our survey has identified areas of concern, and deficiencies that we must address before proceeding with the development of such a service.

A survey of physiotherapists' experience using outcome measures in total hip and knee arthroplasty

PURPOSE

To identify physiotherapists' familiarity with and experience using outcome measures (OMs) along the care continuum for patients undergoing total joint arthroplasty (TJA) of the hip and knee. Views on future use and barriers were also captured.

METHODS

A stratified random sample of physiotherapists in one Canadian province completed a questionnaire about 19 standardized and clinically feasible OMs. Analyses included descriptive statistics and chi-square and McNemar tests to compare use of OMs for clinical decision making and program evaluation.

RESULTS

Of 694 physiotherapists surveyed, 298 (43%) responded. Of these, 172 (58%) treated TJA clients and completed the full questionnaire. A majority worked in public practice settings and >1 care phase (e.g., pre-op, acute, rehab). All physiotherapists reported using ≥1 OM and having greater experience using performance-based measures than patient-reported OMs. OMs were used more often for clinical decision making than for program evaluation. Dissatisfaction with available tools was evident from respondents' comments. Several barriers to using OMs were identified in varied clinical settings and care phases.

CONCLUSIONS

While physiotherapists use a variety of OMs along the TJA continuum, there remain challenges to routine use across clinical settings, care phases, and patient sub-groups.

Prevention of nonimmunologic loss of transplanted islets in monkeys

The nonimmunologic loss of islets in the pre-, peri-, and early post-islet transplant periods is profound. To determine the potential role that transplantation of only a marginal mass of functioning beta cells may play in triggering late nonimmunologic graft loss, we studied the effect of treatment with alpha-1-antitrypsin (AAT) in the autologous cynomolgus islet transplant model. A marginal mass of autologous islets, that is islets prepared from 70% to 80% of the pancreas, was transplanted at 1600-4100 IEQ/kg into subtotal pancreatectomized, streptozotocin-treated and insulin-deficient diabetic hosts. In this marginal mass islet transplant model, islet function is insidiously lost over time and diabetes recurs in all untreated monkeys by 180 days posttransplantation. Short-term treatment with AAT, an acute phase reactant, in the peri-transplant period serves to terminate inflammation through effects upon expression of TGFβ, NFκB and AKT and favorably altering expression of cell death and survival pathways, as detected by a system biology approach and histology. These effects enabled functional expansion of the islet mass in transplanted hosts such that graft function improves rather than deteriorating over time.

A proposed modification to the McDonald 2010 criteria for the diagnosis of primary progressive multiple sclerosis

Background:

The diagnostic criteria for primary–progressive multiple sclerosis (PPMS) have undergone revision over the last 20 years. Cerebrospinal fluid oligoclonal bands (CSFOBs) have received less emphasis in recent revisions of the McDonald criteria. The aim of this study was to examine the sensitivity of the diagnostic criteria for PPMS with particular reference to spinal cord criteria and examine the utility of CSFOBs in a cohort of PPMS patients.

Methods:

All new PPMS diagnoses between 1990 and 2011 were identified. Baseline clinical details and paraclinical evaluations including MRI of the brain, spinal cord, CSF and visually evoked responses (VERs) were assessed. The proportion of patients who met the requirements for diagnosis of PPMS on the basis of Thompson’s and the McDonald Criteria (2001, 2005, 2010) were determined.

Results:

There were 88/95 PPMS patients who had at least two diagnostic investigations. The sensitivity of Thompson’s and the McDonald 2001 criteria was 64%; the McDonald 2010 revisions gave the highest sensitivity (77%); the McDonald 2005 criteria had intermediate sensitivity (74%). The combination of CSFOBs and MRI of the brain yielded the greatest number of patients demonstrating dissemination in space (DIS) on only two investigations. VERs did not aid diagnosis. Reducing requirements for the number of spinal cord lesions (symptomatic or not) to one increased diagnostic sensitivity to 84%.

Conclusion:

An alternative criterion requiring two of: i) MRI of the brain with one or more lesions in two of three regions typical for demyelination; ii) the presence of one T2-weighted spinal cord plaque (typical for demyelination); iii) CSFOBs; would increase the diagnostic sensitivity for PPMS.