Measurements of Groomed-Jet Substructure of Charm Jets Tagged by D^{0} Mesons in Proton-Proton Collisions at sqrt[s]=13 TeV

Understanding the role of parton mass and Casimir color factors in the quantum chromodynamics parton shower represents an important step in characterizing the emission properties of heavy quarks. Recent experimental advances in jet substructure techniques have provided the opportunity to isolate and characterize gluon emissions from heavy quarks. In this Letter, the first direct experimental constraint on the charm-quark splitting function is presented, obtained via the measurement of the groomed shared momentum fraction of the first splitting in charm jets, tagged by a reconstructed D^{0} meson. The measurement is made in proton-proton collisions at sqrt[s]=13  TeV, in the low jet transverse-momentum interval of 15≤p_{T}^{jet ch}<30  GeV/c where the emission properties are sensitive to parton mass effects. In addition, the opening angle of the first perturbative emission of the charm quark, as well as the number of perturbative emissions it undergoes, is reported. Comparisons to measurements of an inclusive-jet sample show a steeper splitting function for charm quarks compared with gluons and light quarks. Charm quarks also undergo fewer perturbative emissions in the parton shower, with a reduced probability of large-angle emissions.

Placental inflammation and pregnancy outcomes: A prospective, observational study in South Asia: The PURPOSe study

OBJECTIVE

To examine inflammatory lesions in placentas of stillbirths, preterm neonatal deaths and term controls in India and Pakistan.

DESIGN

Prospective, observational study.

SETTING

Three hospitals in India and a large maternity hospital in Pakistan.

POPULATION

The enrolled participants with placentas available for histology evaluation included stillbirths (n = 814), preterm live births who died within 28 days of birth (n = 618) and term live birth controls (n = 201). From this same population, polymerase chain reaction (PCR) analysis for pathogens was performed on 809 stillbirth placentas, 614 neonatal death placentas and the placentas of 201 term controls. Placentas from preterm infants who lived beyond day 28 (n = 1432) were only available from India.

METHODS

A prospective observational study of placental inflammatory lesions defined by the Amsterdam criteria and on the same placentas, multiplex PCR evaluation for 75 pathogens using TaqMan Array Cards.

MAIN OUTCOME MEASURES

Any placental inflammatory lesions, including chorioamnionitis, funisitis, villitis and intervillitis and their association with various pathogens.

RESULTS

In the Indian liveborn preterm infants, placental inflammation of any kind was present in 26.2% of those who died versus 16.6% of those who lived (p = 0.0002). Chorioamnionitis was present in 25.8% of those who died versus 16.3% of those who lived (p = 0.0002) and funisitis was present in 4.1% of those who died versus 1.5% of those who lived, (p = 0.005). Across all three sites, in the placentas of the 201 term controls, 18.9% had any inflammation, 16.9% had chorioamnionitis, 5.5% had funisitis, 0.5% had intervillitis and none had villitis. Overall, for stillbirths, any inflammation was observed in 30.2%, chorioamnionitis in 26.9%, funisitis in 5.7%, intervillitis in 6.0% and villitis in 2.2%. For the neonatal deaths, any inflammation was present in 24.9%, chorioamnionitis in 23.3%, funisitis in 8.1%, intervillitis in 1.9% and villitis in 0.5%. Compared with the placentas of term controls, in neonatal deaths, only chorioamnionitis was significantly increased (23.3% versus 16.9%, p = 0.05). Among stillbirths, the rates of any inflammation, chorioamnionitis, intervillitis and villitis were similar across the birthweight groups. However, funisitis was more common in the placentas of stillborn fetuses weighing 2500 g or more (13.8%) compared with 1.0% for those weighing less than 1000 g and 4.8% for stillborn fetuses weighing 1000-2499 g. In the PCR studies, Ureaplasma spp. were by far the most common pathogens found and generally were more commonly found in association with inflammatory lesions.

CONCLUSIONS

Chorioamnionitis was the most common type of placental inflammatory lesion regardless of whether the placentas evaluated were from term controls, stillbirths or neonatal deaths. For stillbirths, inflammation in each inflammation category was more common than in the term controls and significantly more so for any inflammation, chorioamnionitis, intervillitis and villitis. For neonatal deaths, compared with the placentas of term controls, all inflammation categories were more common, but only significantly so for chorioamnionitis. Ureaplasma spp. were the most common organisms found in the placentas and were significantly associated with inflammation.

Group B streptococcal prevalence in internal organs and placentas of deceased neonates and stillbirths in South Asia

OBJECTIVE

Group B streptococcus (GBS) has been associated with adverse pregnancy outcomes, but few prospective studies have assessed its prevalence in low- and middle-income country settings. We sought to evaluate the prevalence of GBS by polymerase chain reaction (PCR) in internal organ tissues and placentas of deceased neonates and stillbirths.

DESIGN

This was a prospective, observational study.

SETTING

The study was conducted in hospitals in India and Pakistan.

POPULATION

Pregnant women with stillbirths or preterm births were recruited at delivery, as was a group of women with term, live births, to serve as a control group.

METHODS

A rectovaginal culture was collected from the women in Pakistan to assess GBS carriage. Using PCR, we evaluated GBS in various tissues of stillbirths and deceased neonates and their placentas, as well as the placentas of live-born preterm and term control infants.

MAIN OUTCOME MEASURES

GBS identified by PCR in various tissues and the placentas; rate of stillbirths and 28-day neonatal deaths.

RESULTS

The most obvious finding from this series of analyses from India and Pakistan was that no matter the country, the condition of the subject, the tissue studied or the methodology used, the prevalence of GBS was low, generally ranging between 3% and 6%. Among the risk factors evaluated, only GBS positivity in primigravidae was increased.

CONCLUSIONS

GBS diagnosed by PCR was identified in <6% of internal organs of stillbirths and neonatal deaths, and their placentas, and control groups in South Asian sites. This is consistent with other reports from South Asia and is lower than the reported GBS rates from the USA, Europe and Africa.

The PURPOSe cause of death study in stillbirths and neonatal deaths in India and Pakistan: A review

The PURPOSe study was a prospective, observational study conducted in India and Pakistan to determine the cause of death for stillbirths and preterm neonatal deaths, using clinical data together with minimally invasive tissue sampling (MITS) and the histologic and polymerase chain reaction (PCR) evaluation of fetal/neonatal tissues and the placenta. After evaluating all available data, an independent panel chose a maternal, a placental and a fetal/neonatal cause of death. Here, we summarise the major results. Among the most important findings were that most stillbirths were caused by fetal asphyxia, often preceded by placental malperfusion, and clinically associated with pre-eclampsia, placental abruption and a small-for-gestational-age fetus. The preterm neonatal deaths were primarily caused by birth asphyxia, followed by various infections. An important finding was that many of the preterm neonatal deaths were caused by a nosocomial infection acquired after neonatal intensive care (NICU) admission; the most common organisms were Acinetobacter baumannii, followed by Klebsiella pneumoniae, Escherichia coli/Shigella and Haemophilus influenzae. Group B streptococcus was less commonly present in the placentas or internal organs of the neonatal deaths.

Measurement of the top quark mass using a profile likelihood approach with the lepton + jets final states in proton-proton collisions at s=13TeV

The mass of the top quark is measured in 36.3fb - 1 of LHC proton-proton collision data collected with the CMS detector at s = 13 Te V . The measurement uses a sample of top quark pair candidate events containing one isolated electron or muon and at least four jets in the final state. For each event, the mass is reconstructed from a kinematic fit of the decay products to a top quark pair hypothesis. A profile likelihood method is applied using up to four observables per event to extract the top quark mass. The top quark mass is measured to be 171.77 ± 0.37 Ge V . This approach significantly improves the precision over previous measurements.

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K, Yalvac M, Akgun B, Atakisi IO, Gülmez E, Kaya M, Kaya O, Tekten S, Cakir A, Cankocak K, Komurcu Y, Sen S, Aydilek O, Cerci S, Hacisahinoglu B, Hos I, Isildak B, Kaynak B, Ozkorucuklu S, Simsek C, Sunar Cerci D, Grynyov B, Levchuk L, Anthony D, Brooke JJ, Bundock A, Clement E, Cussans D, Flacher H, Glowacki M, Goldstein J, Heath HF, Kreczko L, Krikler B, Paramesvaran S, Seif El Nasr-Storey S, Smith VJ, Stylianou N, Pass KW, White R, Ball AH, Bell KW, Belyaev A, Brew C, Brown RM, Cockerill DJA, Cooke C, Ellis KV, Harder K, Harper S, Holmberg ML, Jain S, Linacre J, Manolopoulos K, Newbold DM, Olaiya E, Petyt D, Reis T, Salvi G, Schuh T, Shepherd-Themistocleous CH, Tomalin IR, Williams T, Bainbridge R, Bloch P, Bonomally S, Borg J, Brown CE, Buchmuller O, Cacchio V, Montoya CAC, Cepaitis V, Chahal GS, Colling D, Dancu JS, Dauncey P, Davies G, Davies J, Della Negra M, Fayer S, Fedi G, Hall G, Hassanshahi MH, Howard A, Iles G, Langford J, Lyons L, Magnan AM, Malik S, Martelli A, Mieskolainen M, Monk DG, Nash J, Pesaresi M, Radburn-Smith BC, Raymond DM, Richards A, Rose A, Scott E, Seez C, Shukla R, Tapper A, Uchida K, Uttley GP, Vage LH, Virdee T, Vojinovic M, Wardle N, Webb SN, Winterbottom D, Coldham K, Cole JE, Khan A, Kyberd P, Reid ID, Abdullin S, Brinkerhoff A, Caraway B, Dittmann J, Hatakeyama K, Kanuganti AR, McMaster B, Saunders M, Sawant S, Sutantawibul C, Toms M, Wilson J, Bartek R, Dominguez A, Escamilla CH, Uniyal R, Vargas Hernandez AM, Chudasama R, Cooper SI, Croce DD, Gleyzer SV, Perez CU, Rumerio P, Usai E, West C, Akpinar A, Albert A, Arcaro D, Cosby C, Demiragli Z, Erice C, Fontanesi E, Gastler D, May S, Rohlf J, Salyer K, Sperka D, Spitzbart D, Suarez I, Tsatsos A, Yuan S, Benelli G, Coubez X, Cutts D, Hadley M, Heintz U, Hogan JM, Kwon T, Landsberg G, Lau KT, Li D, Luo J, Narain M, Pervan N, Sagir S, Simpson F, Wong WY, Yan X, Yu D, Zhang W, Abbott S, Bonilla J, Brainerd C, Breedon R, Calderon De La Barca Sanchez M, Chertok M, Conway J, Cox PT, Erbacher R, Haza G, Jensen F, Kukral O, Mocellin G, Mulhearn M, Pellett D, Regnery B, Yao Y, Zhang F, Bachtis M, Cousins R, Datta A, Hauser J, Ignatenko M, Iqbal M, Lam T, Manca E, Nash WA, Saltzberg D, Stone B, Valuev V, Clare R, Gary JW, Gordon M, Hanson G, Long OR, Manganelli N, Si W, Wimpenny S, Branson JG, Cittolin S, Cooperstein S, Diaz D, Duarte J, Gerosa R, Giannini L, Guiang J, Kansal R, Krutelyov V, Lee R, Letts J, Masciovecchio M, Mokhtar F, Pieri M, Quinnan M, Sathia Narayanan BV, Sharma V, Tadel M, Vourliotis E, Würthwein F, Xiang Y, Yagil A, Campagnari C, Citron M, Collura G, Dorsett A, Incandela J, Kilpatrick M, Kim J, Li AJ, Masterson P, Mei H, Oshiro M, Richman J, Sarica U, Schmitz R, Setti F, Sheplock J, Siddireddy P, Stuart D, Wang S, Bornheim A, Cerri O, Dutta I, Latorre A, Lawhorn JM, Mao J, Newman HB, Nguyen TQ, Spiropulu M, Vlimant JR, Wang C, Xie S, Zhu RY, Alison J, An S, Andrews MB, Bryant P, Dutta V, Ferguson T, Harilal A, Liu C, Mudholkar T, Murthy S, Paulini M, Roberts A, Sanchez A, Terrill W, Cumalat JP, Ford WT, Hassani A, Karathanasis G, MacDonald E, Marini F, Perloff A, Savard C, Schonbeck N, Stenson K, Ulmer KA, Wagner SR, Zipper N, Alexander J, Bright-Thonney S, Chen X, Cranshaw DJ, Fan J, Fan X, Gadkari D, Hogan S, Monroy J, Patterson JR, Reichert J, Reid M, Ryd A, Thom J, Wittich P, Zou R, Albrow M, Alyari M, Apollinari G, Apresyan A, Bauerdick LAT, Berry D, Berryhill J, Bhat PC, Burkett K, Butler JN, Canepa A, Cerati GB, Cheung HWK, Chlebana F, Di Petrillo KF, Dickinson J, Elvira VD, Feng Y, Freeman J, Gandrakota A, Gecse Z, Gray L, Green D, Grünendahl S, Guerrero D, Gutsche O, Harris RM, Heller R, Herwig TC, Hirschauer J, Horyn L, Jayatilaka B, Jindariani S, Johnson M, Joshi U, Klijnsma T, Klima B, Kwok KHM, Lammel S, Lincoln D, Lipton R, Liu T, Madrid C, Maeshima K, Mantilla C, Mason D, McBride P, Merkel P, Mrenna S, Nahn S, Ngadiuba J, Noonan D, Norberg S, Papadimitriou V, Pastika N, Pedro K, Pena C, Ravera F, Hall AR, Ristori L, Sexton-Kennedy E, Smith N, Soha A, Spiegel L, Strait J, Taylor L, Tkaczyk S, Tran NV, Uplegger L, Vaandering EW, Zoi I, Avery P, Bourilkov D, Cadamuro L, Chang P, Cherepanov V, Field RD, Koenig E, Kolosova M, Konigsberg J, Korytov A, Kuznetsova E, Lo KH, Matchev K, Menendez N, Mitselmakher G, Muthirakalayil Madhu A, Rawal N, Rosenzweig D, Rosenzweig S, Shi K, Wang J, Wu Z, Adams T, Askew A, Bower N, Habibullah R, Hagopian V, Kolberg T, Martinez G, Prosper H, Viazlo O, Wulansatiti M, Yohay R, Zhang J, Baarmand MM, Butalla S, Elkafrawy T, Hohlmann M, Kumar Verma R, Rahmani M, Yumiceva F, Adams MR, Cavanaugh R, Dittmer S, Evdokimov O, Gerber CE, Hofman DJ, Lemos DS, Merrit AH, Mills C, Oh G, Roy T, Rudrabhatla S, Tonjes MB, Varelas N, Wang X, Ye Z, Yoo J, Alhusseini M, Dilsiz K, Emediato L, Karaman G, Köseyan OK, Merlo JP, Mestvirishvili A, Nachtman J, Neogi O, Ogul H, Onel Y, Penzo A, Snyder C, Tiras E, Amram O, Blumenfeld B, Corcodilos L, Davis J, Gritsan AV, Kyriacou S, Maksimovic P, Roskes J, Sekhar S, Swartz M, Vámi T, Abreu A, Alcerro Alcerro LF, Anguiano J, Baringer P, Bean A, Flowers Z, King J, Krintiras G, Lazarovits M, Le Mahieu C, Lindsey C, Marquez J, Minafra N, Murray M, Nickel M, Rogan C, Royon C, Salvatico R, Sanders S, Smith C, Wang Q, Wilson G, Allmond B, Duric S, Ivanov A, Kaadze K, Kalogeropoulos A, Kim D, Maravin Y, Mitchell T, Modak A, Nam K, Roy D, Rebassoo F, Wright D, Adams E, Baden A, Baron O, Belloni A, Bethani A, Eno SC, Hadley NJ, Jabeen S, Kellogg RG, Koeth T, Lai Y, Lascio S, Mignerey AC, Nabili S, Palmer C, Papageorgakis C, Wang L, Wong K, Busza W, Cali IA, Chen Y, D’Alfonso M, Eysermans J, Freer C, Gomez-Ceballos G, Goncharov M, Harris P, Kovalskyi D, Krupa J, Lee YJ, Long K, Mironov C, Paus C, Rankin D, Roland C, Roland G, Shi Z, Stephans GSF, Wang J, Wang Z, Wyslouch B, Yang TJ, Chatterjee RM, Crossman B, Hiltbrand J, Joshi BM, Kapsiak C, Krohn M, Kubota Y, Mahon D, Mans J, Revering M, Rusack R, Saradhy R, Schroeder N, Strobbe N, Wadud MA, Cremaldi LM, Bloom K, Bryson M, Claes DR, Fangmeier C, Finco L, Golf F, Joo C, Kamalieddin R, Kravchenko I, Reed I, Siado JE, Snow GR, Tabb W, Wightman A, Yan F, Zecchinelli AG, Agarwal G, Bandyopadhyay H, Hay L, Iashvili I, Kharchilava A, McLean C, Morris M, Nguyen D, Pekkanen J, Rappoccio S, Williams A, Alverson G, Barberis E, Haddad Y, Han Y, Krishna A, Li J, Lidrych J, Madigan G, Marzocchi B, Morse DM, Nguyen V, Orimoto T, Parker A, Skinnari L, Tishelman-Charny A, Wamorkar T, Wang B, Wisecarver A, Wood D, Bhattacharya S, Bueghly J, Chen Z, Gilbert A, Hahn KA, Liu Y, Odell N, Schmitt MH, Velasco M, Band R, Bucci R, Cremonesi M, Das A, Goldouzian R, Hildreth M, Hurtado Anampa K, Jessop C, Lannon K, Lawrence J, Loukas N, Lutton L, Mariano J, Marinelli N, Mcalister I, McCauley T, Mcgrady C, Mohrman K, Moore C, Musienko Y, Ruchti R, Townsend A, Wayne M, Yockey H, Zarucki M, Zygala L, Bylsma B, Carrigan M, Durkin LS, Hill C, Joyce M, Lesauvage A, Nunez Ornelas M, Wei K, Winer BL, Yates BR, Addesa FM, Das P, Dezoort G, Elmer P, Frankenthal A, Greenberg B, Haubrich N, Higginbotham S, Kopp G, Kwan S, Lange D, Loeliger A, Marlow D, Ojalvo I, Olsen J, Stickland D, Tully C, Malik S, Bakshi AS, Barnes VE, Chawla R, Das S, Gutay L, Jones M, Jung AW, Kondratyev D, Koshy AM, Liu M, Negro G, Neumeister N, Paspalaki G, Piperov S, Purohit A, Schulte JF, Stojanovic M, Thieman J, Virdi AK, Wang F, Xiao R, Xie W, Dolen J, Parashar N, Acosta D, Baty A, Carnahan T, Dildick S, Ecklund KM, Fernández Manteca PJ, Freed S, Gardner P, Geurts FJM, Kumar A, Li W, Padley BP, Redjimi R, Rotter J, Yang S, Yigitbasi E, Zhang Y, Bodek A, de Barbaro P, Demina R, Dulemba JL, Fallon C, Garcia-Bellido A, Hindrichs O, Khukhunaishvili A, Parygin P, Popova E, Taus R, Van Onsem GP, Goulianos K, Chiarito B, Chou JP, Gershtein Y, Halkiadakis E, Hart A, Heindl M, Jaroslawski D, Karacheban O, Laflotte I, Lath A, Montalvo R, Nash K, Osherson M, Routray H, Salur S, Schnetzer S, Somalwar S, Stone R, Thayil SA, Thomas S, Wang H, Acharya H, Delannoy AG, Fiorendi S, Holmes T, Nibigira E, Spanier S, Bouhali O, Dalchenko M, Delgado A, Eusebi R, Gilmore J, Huang T, Kamon T, Kim H, Luo S, Malhotra S, Mueller R, Overton D, Rathjens D, Safonov A, Akchurin N, Damgov J, Hegde V, Lamichhane K, Lee SW, Mengke T, Muthumuni S, Peltola T, Volobouev I, Whitbeck A, Appelt E, Greene S, Gurrola A, Johns W, Melo A, Romeo F, Sheldon P, Tuo S, Velkovska J, Viinikainen J, Cardwell B, Cox B, Cummings G, Hakala J, Hirosky R, Ledovskoy A, Li A, Neu C, Perez Lara CE, Karchin PE, Aravind A, Banerjee S, Black K, Bose T, Dasu S, De Bruyn I, Everaerts P, Galloni C, He H, Herndon M, Herve A, Koraka CK, Lanaro A, Loveless R, Madhusudanan Sreekala J, Mallampalli A, Mohammadi A, Mondal S, Parida G, Pinna D, Savin A, Shang V, Sharma V, Smith WH, Teague D, Tsoi HF, Vetens W, Warden A, Afanasiev S, Andreev V, Andreev Y, Aushev T, Azarkin M, Babaev A, Belyaev A, Blinov V, Boos E, Borshch V, Budkouski D, Bunichev V, Chadeeva M, Chekhovsky V, Danilov M, Dermenev A, Dimova T, Dremin I, Dubinin M, Dudko L, Epshteyn V, Ershov A, Gavrilov G, Gavrilov V, Gninenko S, Golovtcov V, Golubev N, Golutvin I, Gorbunov I, Ivanov Y, Kachanov V, Kardapoltsev L, Karjavine V, Karneyeu A, Kim V, Kirakosyan M, Kirpichnikov D, Kirsanov M, Klyukhin V, Kodolova O, Konstantinov D, Korenkov V, Kozyrev A, Krasnikov N, Lanev A, Levchenko P, Litomin A, Lychkovskaya N, Makarenko V, Malakhov A, Matveev V, Murzin V, Nikitenko A, Obraztsov S, Oskin A, Ovtin I, Palichik V, Perelygin V, Perfilov M, Petrushanko S, Popov V, Radchenko O, Rusinov V, Savina M, Savrin V, Shalaev V, Shmatov S, Shulha S, Skovpen Y, Slabospitskii S, Smirnov V, Sosnov D, Sulimov V, Tcherniaev E, Terkulov A, Teryaev O, Tlisova I, Toropin A, Uvarov L, Uzunian A, Vorobyev A, Voytishin N, Yuldashev BS, Zarubin A, Zhizhin I, Zhokin A. A search for decays of the Higgs boson to invisible particles in events with a top-antitop quark pair or a vector boson in proton-proton collisions at s=13TeV

A search for decays to invisible particles of Higgs bosons produced in association with a top-antitop quark pair or a vector boson, which both decay to a fully hadronic final state, has been performed using proton-proton collision data collected at s = 13 Te V by the CMS experiment at the LHC, corresponding to an integrated luminosity of 138fb - 1 . The 95% confidence level upper limit set on the branching fraction of the 125Ge V Higgs boson to invisible particles, B ( H → inv ) , is 0.54 (0.39 expected), assuming standard model production cross sections. The results of this analysis are combined with previous B ( H → inv ) searches carried out at s = 7 , 8, and 13Te V in complementary production modes. The combined upper limit at 95% confidence level on B ( H → inv ) is 0.15 (0.08 expected).

Observation of τ Lepton Pair Production in Ultraperipheral Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

We present an observation of photon-photon production of τ lepton pairs in ultraperipheral lead-lead collisions. The measurement is based on a data sample with an integrated luminosity of 404  μb^{-1} collected by the CMS experiment at a center-of-mass energy per nucleon pair of sqrt[s_{NN}]=5.02  TeV. The γγ→τ^{+}τ^{-} process is observed for τ^{+}τ^{-} events with a muon and three charged hadrons in the final state. The measured fiducial cross section is σ(γγ→τ^{+}τ^{-})=4.8±0.6(stat)±0.5(syst)  μb, where the second (third) term corresponds to the statistical (systematic) uncertainty in σ(γγ→τ^{+}τ^{-}) in agreement with leading-order QED predictions. Using σ(γγ→τ^{+}τ^{-}), we estimate a model-dependent value of the anomalous magnetic moment of the τ lepton of a_{τ}=0.001_{-0.089}^{+0.055}.

The Landscape of Genetic Alterations Associated with Metachronous Metastasis in Patients with Pancreatic Ductal Adenocarcinoma and Its Prognostic Significance

PURPOSE/OBJECTIVE(S)

Metachronous metastasis is one of the major pathologic processes which significantly increases the mortality of patients with pancreatic ductal adenocarcinoma (PDA) who completed initial curative treatment. Genetic signatures that drive the metachronous mutations are not well investigated. In this study, we aimed to identify the landscape of genetic alterations associated with metachronous metastasis in patients with PDA and its prognostic significance.

MATERIALS/METHODS

We retrospectively identified patients with histologically confirmed PDA who underwent next-generation sequencing using a panel of 324 pre-specified genes. The landscape of somatic mutations was stratified by metastasis types [no metastasis (nMet) vs. de novo metastasis (dMet) vs. metachronous metastasis (mMet)]. Outcomes of interest included overall survival (OS), local recurrence (LR) following radiotherapy, and association of CA 19-9 level with metastasis types. The OS was calculated using the Kaplan-Meier estimates and log-rank test, and LR was measured using cumulative incidence. A multivariate cox-regression analysis was performed to identify prognostic factors. Pathway analysis of mMet exclusive genes was performed using DAVID (Database for Annotation, Visualization, and Integrated Discovery).

RESULTS

A total of 328 patients with PDA were included. Among them, 56 (17%), 145 (44%), and 127 (39%) patients had nMet, dMet, and mMet, respectively. The median follow up was 21.6 months (range 0.7 -136 months). The median age at the time of diagnosis was 65.5 years (range 26.77 -87.31 years). ANOVA test showed that CA 19-9 level was associated with metastasis types (p = 0.034). The median OS was 48.4 (95% CI 28.3-NA), 27.4 (95% CI 23.3-33.9), and 15 (95% CI 13.9-17.8) months for patients with nMet, mMet, and dMet, respectively (p<0.0001). The multivariate analysis (MVA) revealed that KRAS mutation (HR 2.31; 95% CI 1.37-3.9; p = 0.001), mMet (HR 0.45; 95% CI 0.34-0.61; p<0.0001), nMet (HR 0.27; 95% CI 0.16-0.45; p<0.0001), age (HR 1.01; 95% CI 1-1.02; p = 0.03), and male gender (HR 1.5; 95% CI 1.15-2.01; p = 0.002) were associated with OS. Mutations in other PDA driver genes (TP53, SAMD4, CDKN2A) were not associated with OS (p>0.05). The LR rate at 12 months post-radiotherapy was 28% and 27% for nMet and mMet, respectively (p = 0.5). Heatmap analysis identified 31 genes that were exclusively mutated in patients with mMet. These genes were enriched in pathways of transcription regulation by RNA polymerase II promoter binding, a negative regulator of apoptosis, and telomerase maintenance.

CONCLUSION

This study identified metachronous metastasis-associated genetic alterations and molecular pathways. Future prospective studies incorporating whole exome sequencing are warranted to validate these findings.

Utility of Stereotactic Body Radiation Therapy (SBRT) in Establishing Local Control for Invasive Breast Cancer Patients Not Undergoing Definitive Surgery

PURPOSE/OBJECTIVE(S)

Breast cancer (BC) treatment involves a multi-modal approach where surgical resection is the backbone of therapy. However, due to medical comorbidities precluding surgery, unresectable disease, or patient preference, some patients do not undergo surgery. In the absence of resection, it is paramount to improve local control (LC) of the primary tumor. To that end, this study explored the role of ablative RT dose delivered with SBRT.

MATERIALS/METHODS

Between 2015-2022, 21 patients (10 metastatic, 11 stage IA-IIIC) received 23 SBRT courses to primary BC lesions without planned surgery at our institution. One patient had undergone whole breast RT 20 years prior to SBRT. 7 patients were analyzed retrospectively; 15 are currently enrolled in a prospective study. SBRT dose was 40 Gy/5 fractions delivered every other day. Follow-up imaging (PET, CT, MRI, MMG/US) was reviewed to evaluate the response. CTCAE v.3 was used to document any acute (≤3 months) and late toxicities. Kaplan-Meier curves were used to estimate local control (LC) and overall survival (OS).

RESULTS

Median age was 78.4 (45.9-97.3) years. Median follow-up was 14.7 (3.3-70.3) months after RT completion. Initial post-treatment imaging was available for all cases and was performed at a median of 4.0 (0.6-11.9) months after SBRT. The median pre-SBRT index lesion size was 3.1 (0.5-14.5) cm and PTV was 32.4 (11.5-522.4) cc. At a median 4 months post-SBRT, the median decrease in index lesion size was 20.8 (0-100) % and SUV reduction was 65.2 (20.8-100) %. Further improvement was seen on the 2nd follow-up scans at a median 7.8 months post-SBRT, with 62 (0-100) % and 88 (33.3-100) % median reduction in the tumor size and SUV, respectively, compared to pre-SBRT values. The estimated LC rate was 100% at 6 months and 93.3% at 12 months. The sole case of local progression occurred 9.5 months after SBRT, after an initial interval decrease in the primary lesion. Among the patients with available systemic follow-up scans, regional progression occurred in 4 (17.4%) cases at a median 18.6 (5.2-22.7) months post-SBRT. Six (37.5%) patients developed distant progression at a median 4.8 (0.9-16.2) months, all of whom had metastatic disease at diagnosis. The estimated OS was 85.7% at 6 months and 63.8% at 12 months. Most patients tolerated the treatment well. There was no grade 4 toxicity. Complete acute toxicity data is presented in Table 1. Only one patient experienced late grade 2 breast edema.

CONCLUSION

Based on our preliminary results, definitive SBRT to the primary BC appears to have a role in providing LC in the treatment of non-surgical patients and is well-tolerated. Since the disease progression tends to occur outside the treated primary tumor, additional approaches to improve regional and distant control should be investigated.

Impact of carbapenem-targeted antimicrobial stewardship interventions: an interrupted time-series analysis

BACKGROUND

The development of carbapenem-resistant Gram-negative bacilli (CR-GNB) is largely favoured by indiscriminate and prolonged carbapenem use, which is a significant contributing factor.

AIM

To evaluate the impact of two carbapenem antibiotic stewardship programme interventions on both carbapenem prescriptions and the clinical isolation rates of CR-GNBs, using interrupted time-series analysis.

METHODS

A time-series analysis was performed using data for carbapenem usage from a tertiary hospital in South Korea from January 2017 to July 2022. Two carbapenem antibiotic stewardship programme interventions were implemented sequentially: (i) a prospective audit and feedback (PAF) from November 2018 to April 2020 (intervention 1), and (ii) preauthorization from May 2020 to August 2020 (intervention 2). Monthly carbapenem usage and incidence of CR-GNB before and after each intervention were compared using an autoregressive integrated moving average model.

FINDINGS

Implementation of PAF resulted in a significant reduction in carbapenem consumption, followed by an additional decrease after the preauthorization was implemented. The incidence of carbapenem-resistant Escherichia coli and Klebsiella pneumoniae increased after intervention 1, but there was a significant change from an increasing trend to a stationary trend after intervention 2. The incidence of carbapenem-resistant Pseudomonas aeruginosa, which had increased during the baseline period, became stationary after intervention 1. A significant decrease was observed in the incidence of carbapenem-resistant Acinetobacter baumannii during the implementation of intervention 1 and 2.

CONCLUSION

This study emphasizes the importance of adopting comprehensive antibiotic management and rigorous infection control to prevent infections caused by antibiotic-resistant bacteria.

Mapping the Anatomical Distribution of MRI-Identified Locoregional Recurrence following Robotic-Assisted Laparoscopic Prostatectomy for Prostate Adenocarcinoma

PURPOSE/OBJECTIVE(S)

The pattern of locoregional recurrence specifically after robotic-assisted laparoscopic prostatectomy (RALP) for prostate adenocarcinoma is still unknown. In this study, we reviewed pelvic magnetic resonance images (MRI) after postoperative biochemical recurrence (BCR) and drew a map of locoregional recurrence to support evidence of determining the optimal target volume of salvage radiotherapy in a post-RALP BCR scenario.

MATERIALS/METHODS

We have retrospectively searched 7,583 prostate adenocarcinoma patients who have received RALP in our institution between January 2010 and December 2021, and found a pool of highly selected patients with gross tumor recurrence confirmed by post-BCR pelvic MRIs and did not have other histories of malignancy. BCR was defined as the serum PSA more or equal to 0.2 ng/mL, or three consecutive increases. Patients with serum PSA nadir more or equal to 0.2 ng/mL on the 90th postoperative day (POD 90) were excluded to guarantee successful tumor removal. We have reviewed serum PSA levels using R codes, MRI and pathological reports using Excel, and descriptive statistics using SPSS 25. The gross lesions were contoured on the correlating MRIs using MIM Maestro 7.1. The RT structure DICOM files were merged into a map using MATLAB 2022b. In addition, we have conducted Fisher exacted test, Mann-Whitney U test, and logistic regression to identify risk factors for regional recurrence.

RESULTS

A total of 173 patients were identified with locoregional recurrence from post-BCR pelvic MRIs, and 139 (80.3%) patients were in the high-risk group or very-high-risk group according to the NCCN guidelines: 57 (32.9%) patients with histological grade group 5, 50 (28.9%) patients with initial PSA over 20 ng/mL, 114 (65.9%) patients with extracapsular extension, 55 (31.8%) patients with seminal vesicle invasion, and 15 (9%) patients with pN1. The median follow-up was 4.7 (IQR 2.8-6.9) years for pelvic MRIs and 5.8 (IQR 4.0-8.6) years for serum PSA. The BCF survival was median of 10.7 (IQR 4.6-19.1) months, and the locoregional recurrence-free survival was median of 24.6 (IQR 9.7-49.4) months for this subgroup of patients. At first locoregional recurrence, 148 (85.5%) patients were local only, 20 (11.6%) patients were regional only, and 5 (2.9%) patients were both local and regional. Out of the 25 patients with regional recurrence, the incidence of gross tumor recurrence differed by nodal sites: 3 (12%) in perirectal space, 5 (20%) in internal iliac, 7 (28%) in obturator, 13 (52%) in external iliac, and 6 (24%) in common iliac lymph nodes.

CONCLUSION

We have found 173 patients and were able to map reliable gross tumor recurrence sites after RALP and confirmed by pelvic MRIs following BCR. The map supports evidence of using the existing consensus pelvic clinical target volume of salvage radiotherapy, in a post-RALP BCR scenario.

Comparison of Early Outcomes of Stereotactic Accelerated Partial Breast Irradiation vs. Volumetric Modulated Arc Therapy-Based FAST-FORWARD Whole Breast Irradiation for Breast Cancer

PURPOSE/OBJECTIVE(S)

Despite evidence supporting APBI from 8 published prospective randomized trials enrolling over 10,000 women, the uptake of APBI in clinical practice is surprisingly low. This is being exacerbated by a new, convenient, and safe shortened WBI schedule. Here, we report the dosimetric and early outcome analyses of the first >1000 patients treated at our institution since the first adoption of stereotactic APBI and the ultra-hypofractionated WBI regimen.

MATERIALS/METHODS

From 2016 to 2022, 801 women with breast cancers in the suitable or cautionary categories according to the ASTRO APBI consensus panel guidelines, received 30 Gy in 5 fractions (92%) either using a robotic stereotactic radiation system (83%) or stereotactic volumetric-based arc therapy (VMAT, 17%). Between 2020 and 2022, 468 women, who were not candidates for APBI and not undergoing any regional irradiation received 26 Gy in 5 fractions using VMAT to the whole breast with the addition of cardiac sparing technique in left-sided breast cancer patients. Tumor bed boosts were delivered in 99% of FF-WBI patients. We evaluated dose-volume histogram parameters for target volumes and organs-at-risk and radiation-related toxicities during RT or within 6 months after the end of RT.

RESULTS

Target volume coverage was acceptable in both groups, with mean 96% of the target volumes receiving 95% of the prescribed doses and 0 cm3 within target volumes exceeding 105% of the prescribed doses. S-APBI resulted in small, but statistically significant, reductions in the radiation dose delivered to the ipsilateral breast, contralateral breast, lungs, heart, and coronary artery compared with FF-WBI. Comparing WBI to APBI, the mean contralateral breast dose, ipsilateral lung V20 Gy, mean contralateral lung dose, and mean heart dose, were reduced by 89%, 78%, 73%, and 29%, respectively. With median follow-up periods of 32 months for s-APBI and 19 months for FF-WBI, acute toxicity was assessable in all patients. The risks of any grade acute toxicity were 21% for s-APBI and 25% for FF-WBI (p = .117). Among them, grade 2 rates were 1.3% in both groups and no severe toxicity has been reported.

CONCLUSION

We found s-APBI and VMAT-based FF WBI were associated with favorable dosimetric and acute toxicity profiles. However, considering significantly less irradiated volume in the breast, lungs, and heart, APBI with advanced available technique options should be considered over any WBI-based approach for patients at low risk for local recurrence.

Plasma EBV DNA in Nasopharyngeal Cancer (NPC) Treated with Definitive Radiotherapy (RT)

PURPOSE/OBJECTIVE(S)

EBV DNA has well-studied roles in NPC including early detection and surveillance. There are limited North American data on EBV DNA testing. Our center has used EBV DNA testing since 2010. We hypothesized: (1) higher first post-RT EBV DNA level is associated with worse prognosis, and (2) surveillance EBV DNA is specific for recurrence at a low detection threshold.

MATERIALS/METHODS

We retrospectively reviewed all patients with non-metastatic (TNM-7 stage I-IVB) NPC treated with definitive RT/chemoRT (CRT) ± adjuvant chemotherapy (AC) between 2010-2017. EBV DNA was assayed by quantitative PCR in a CAP/CLIA-certified laboratory and reported in copies/mL of plasma. Pre-RT is defined as 0-90 days before the first RT fraction and post-RT within one year after RT. We report log odds ratios (LOR) from a linear model of T- and N-category with log-adjusted EBV DNA as the response variable. Survival outcomes were analyzed with log-rank tests and Cox multivariate analyses (MVA) adjusted for age, stage, and treatment, reporting hazard ratios (HR). A total of 95% confidence intervals of LOR and HR are reported. The detection threshold that maximized the F1 accuracy score was considered optimal.

RESULTS

Of 271 patients in the study window, 179 had pre-RT +/- post-RT EBV DNA testing. Six received RT, 43 CRT, and 130 CRT+AC. With 7-yr median follow-up, 37 recurred and 37 died. Detectable pre-RT EBV DNA was found in 154 (86%) with a median of 928 copies/mL (range: 1-239214). EBV DNA level correlated with higher N category (LOR: 0.28, 0.15-0.42, p<0.001), but not T category (0.04, -0.06-0.13, p = 0.5). Above-median pre-RT EBV DNA was associated with worse recurrence-free survival (RFS) by log-rank test (p = 0.016) and Cox MVA (HR: 2.2, 1.1-4.8, p = 0.03) along with N category, age, and no AC. Post-RT EBV DNA was available in 99 patients at a median of 54 days. RFS, progression-free survival (PFS), and overall survival (OS) were worse in patients with detectable post-RT EBV DNA (Table). RFS and PFS drop further to 20% if EBV DNA was detectable after the full treatment (RT±AC, n = 71). In Cox MVA, post-RT EBV DNA remained independently prognostic (Table). EBV DNA was performed within 30 days of recurrence in 30 patients, and 24 were detectable (80% sensitivity). Conversely, of 152 patients without recurrence and at least 3-yr follow-up, 95 had post-RT EBV DNA testing and 84 were undetectable (88% specificity). An EBV DNA threshold of 31 copies maximized F1 accuracy metric, yielding 74% sensitivity and 97% specificity.

CONCLUSION

Pre-RT EBV DNA is prognostic and associated with higher N-category. Post-RT EBV DNA is a strong, independent predictor of RFS, PFS, and OS; 31 copies/mL may be a useful threshold to detect recurrence.

Combination of Radiotherapy and Atezolizumab plus Bevacizumab in Patients with Advanced Hepatocellular Carcinoma: A Pilot Study

PURPOSE/OBJECTIVE(S)

Following the results of the IMbrave150 study, Atezolizumab plus bevacizumab (Atezo/beva) became the first-line treatment in patients with advanced hepatocellular carcinoma (HCC). However, its real-world efficacy has been less satisfied. In this study, we investigated the efficacy of radiotherapy (RT) combined with Atezo/beva in patients with advanced HCC.

MATERIALS/METHODS

Twenty patients received combination of RT and Atezo/beva between December 2021 and December 2022 at our institution. RT was administered in 10 fractions of 5 Gy between Atezo/beva cycles. Tumor response were evaluated on both imaging and tumor marker basis. The iRECIST guideline was used to assess treatment response after the combination treatment of RT and Atezo/beva. Primary endpoints were disease control rate (DCR) and overall response rate (ORR), and secondary endpoint was treatment related toxicity.

RESULTS

All patients were BCLC C with advanced tumors associated with lymph node metastasis (7, 35%) or distant metastasis (8, 40%). Patients received RT between cycles of Atezo/beva, mostly (14, 70%) between 2nd and 3rd cycles. After a median follow-up of 3.2 months, DCR was 65% and ORR was 20%. Significant decrease in tumor marker of over 2-fold was shown in 10 patients (50%). Regarding treatment related toxicity, only 1 patient (5%) showed grade 3 neutropenic fever, and no grade 4 or 5 toxicity was seen.

CONCLUSION

Combination of radiotherapy and Atezo/beva showed high response rate with tolerable treatment related toxicity in advanced HCC patients. Further prospective studies with larger patient cohort are warranted.

Comprehensive Genomic Analysis Stratified by KRAS Status in Patients with Pancreatic Adenocarcinoma and Its Prognostic Significance

PURPOSE/OBJECTIVE(S)

KRAS mutations (MUT) are one of the major drivers in pancreatic ductal adenocarcinoma (PDA) with over 90% of patients having alterations. However, the genetic landscape of PDA based on KRAS status is not well studied. The aim of this study is to investigate genomic alterations based on KRAS status and to identify driver mutations in patients with KRAS wild type (WT).

MATERIALS/METHODS

Next-generation sequencing with 324 pre-specified genes was performed on patients with histologically confirmed PDA. The landscape of somatic mutations was stratified by KRAS status. Outcomes of interest included overall survival (OS), local failure (LF) following radiotherapy, time to metastasis, and CA 19-9 level. All outcomes were stratified by KRAS status. Genetic alterations exclusive to patients with KRAS WT were analyzed. OS was calculated using the Kaplan-Meier estimates and log-rank test, and LF was measured using cumulative incidence. A multivariate cox-regression analysis (MVA) was performed to identify prognostic factors for survival. Gene ontology analysis of KRAS WT exclusive genes was performed via DAVID (Database for Annotation, Visualization, and Integrated Discovery).

RESULTS

A total of 272 patients with metastatic PDA were included. The median age at diagnosis was 65.4 (range, 26.77-83.21) years. The median follow-up was 15.7 (0.06-136.7) months. 91% percent (n = 248) of patients were found to be KRAS MUT. The chi-square test showed that the primary tumor site (p = 0.027) and perineural invasion (p = 0.006) were associated with KRAS status. The median CA 19-9 was 143.6 (15.5-27996) U/ml and 341.15 (0-100000) U/ml for KRAS WT and KRAS MUT, respectively (p = 0.23). The median OS for KRAS WT and MUT was 31.4 (95% CI 25.1-NA) and 13.3 (95% CI 11.3-14.5) months, respectively (p = 0.0008). In patients with metachronous recurrence, the median time to metastasis was 22.4 (1.37-52.97) months and 12.8 (1.8-84.97) months for KRAS WT and KRAS MUT, respectively (p = 0.057). KRAS MUT types including G12 and Q21 were not associated with OS (p = 0.58). On MVA, including KRAS status, age, sex, and metastatic types (de novo vs. metachronous), only KRAS mutation was associated with worse OS [HR 2.64; 95% CI 1.53 to 4.56; p = 0.0004]. In patients treated with radiation, the LF rate at 12 months was 12.5% in patients with KRAS WT and 33.8% in KRAS MUT (p = 0.13). Heatmap analysis identified that RAD50, ALK, BCORL1, BRAF, CDC73, FAM123B, NF2, ERBB4, and ERCC4 were exclusively mutated in patients with KRAS WT. These genes were enriched in pathways associated with tyrosine kinase catalytic domain activity, ubiquitination, and nuclear localization signal.

CONCLUSION

This study identified driver mutations in patients with KRAS WT. KRAS status was associated with pathologic features and disease prognosis after treatment. Further study leveraging more powered cohorts is warranted.

Outcomes after Contemporary Definitive Radiotherapy Alone in Patients with TNM-7 Stage III/IV Head and Neck Squamous Cell Carcinoma

PURPOSE/OBJECTIVE(S)

This study was undertaken to determine outcomes and prognostic factors of definitive intensity-modulated radiotherapy (IMRT) alone for patients with TNM-7 stage III/IV HNSCC who did not receive concurrent chemotherapy.

MATERIALS/METHODS

We evaluated TNM-7 stage III/IV HNSCC patients treated with definitive IMRT alone in our institution from 2004-2019. Patients were reclassified according to TNM-8 staging. Stage II HPV+ oropharyngeal cancers (OPC) were subdivided into T1-2N2 and T3N0-2 for analysis. The rationale for chemotherapy omission was obtained retrospectively from clinical documentation. Recurrence-free survival (RFS) and overall survival (OS) were estimated stratified by HPV status (determined by p16 staining, sometimes supplemented by HPV DNA testing). Multivariable analysis (MVA) identified prognostic factors for RFS and OS, taking into account stage and IMRT regimen. Age, performance status, and smoking were also examined for OS.

RESULTS

A total of 1083 patients were included (460 HPV+ and 623 HPV-). Reasons for omission of chemotherapy were: age >70 years or frailty (n = 551, 51%), cisplatin contraindication (n = 241, 22%), patient refusal (n = 106, 10%), and clinician's decision (n = 185, 17%). Median age was 67 years for HPV+ and 70 years for HPV- cohorts. IMRT mostly utilized altered fractionation regimens (n = 1016, 94%): moderately accelerated (Acc) (70 Gy/35 fractions [f]/6 weeks [w], 55%), hypofractionated (Hypo) (60 Gy/25f/5w, 14%), and hyperfractionated-accelerated (Hyper) (64 Gy/40f/4w, 25%). Median follow-up was 5 years. Five-year RFS and OS for HPV+ TNM-8 stage I/T1-2N2/T3N0-N2/III were 89%/86%/76%/52% and 83%/80%/64%/33% respectively (p<0.01). The same outcomes for HPV- TNM-8 stage III/IVA/IVB were 58%/52%/39% and 47%/27%/13%, respectively (p<0.01). MVA confirmed that HPV+ T3N0-2 subset within stage II and stage III (vs stage I) had lower RFS, and HPV- stage IVA and IVB (vs stage III) carried worse RFS and OS (Table).

CONCLUSION

Despite the retrospective nature and inherent selection bias, this large single institutional study shows that altered fractionated IMRT alone is an acceptable alternative for elderly, frail or cisplatin ineligible patients with HPV+ stage I/IIA (T1-2N2) OPC. Patients with HPV+ T3N0-2/stage III OPC and HPV- stage III/IV HNSCC have poor outcomes with IMRT alone and may benefit from alternative strategies.

Deep Learning vs. Handcrafted Radiomics to Predict Chemoradiotherapy Response for Locally Advanced Cervical Cancer

PURPOSE/OBJECTIVE(S)

To predict CRT response in locally advanced cervical cancer (LACC) with handcrafted radiomics (HCR) and deep learning radiomics (DLR) using pretreatment MRI. Furthermore, we investigate whether the incorporation of clinical factors improves prediction performance.

MATERIALS/METHODS

Two hundred and fifty-two patients with LACC are enrolled. All patients are treated with external beam radiotherapy, followed by high-dose-rate intracavitary brachytherapy with concurrent cisplatin. The patients are randomly divided into two independent groups for the training (167 patients) and test datasets (85 patients). Contrast-enhanced T1- and T2-weighted MR scans are obtained. Patients in the training and test sets have similar characteristics in terms of age, tumor size, FIGO stage, HPV infection status, or CRT response. For HCR analysis, 1890 imaging features are extracted and a support vector machine classifier with a five-fold cross-validation is trained using training dataset to predict CRT response and validated using test dataset. For DLR analysis, a 3-dimensional convolutional neural network was trained and validated using test dataset.

RESULTS

A comparison of the DLR and HCR models reveals that the DLR model exhibits better prediction performance than the HCR model for the test dataset (AUC = 0.721 vs. 0.597, p = 0.097). The incorporation of clinical factors could improve performance in both DLR and HCR models.

CONCLUSION

The DLR models outperform the HCR models in predicting CRT responses in patients with LACC. Combining clinical factors and MRI may improve the prediction performance in both HCR and DLR analyses.

Predictive Value of Dynamic Tumor Volume Changes in Stage III Non-Small Cell Lung Cancer Treated with Chemoradiation and Consolidative Immunotherapy

PURPOSE/OBJECTIVE(S)

Concurrent chemoradiation (CRT) followed by Immunotherapy is standard of care in unresectable, locally advanced, non-small cell lung cancer (NSCLC). We hypothesize that on-treatment dynamic changes in tumor volume may predict oncologic outcome in Stage III NSCLC.

MATERIALS/METHODS

Stage III NSCLC patients who were treated with definitive CRT of 60 Gy in 30 fractions over 6 weeks with concurrent platinum-based concurrent chemotherapy followed by consolidative immunotherapy were retrospectively reviewed. We manually delineated the gross tumor volumes (GTV) of patients on cone beam computed tomography (CBCT) acquired on day 1, 15, 29 and 43. GTV reduction was quantified as the percent difference in volume on each CBCT as compared to CBCT Day 1. Mid-treatment response (MTR) and End of treatment response (ETR) was defined at day 29 (at 40 Gy) and day 43 (at 60 Gy), respectively. Loco-regional control (LRC) and overall survival (OS) was evaluated by Kaplan-Meier analysis, with log-rank test for groups stratified as per treatment response. Multivariate Cox regression analysis was performed to identify additional prognostic factors.

RESULTS

We evaluated 24 consecutively treated patients from 01/2016 to 08/2019, with a median follow-up of 30.5 months. Median age was 69 years (range 51-84). Adenocarcinoma histology was present in 58 % and squamous cell carcinoma in 42% patients. The tumor stage IIIA in 38% and Stage IIIB in 62% patients. All patients received definitive CRT with at least 2 cycles of immunotherapy (median 8 cycles). The median ETR at CBCT43 was 49.5% (range, 1%-84.7%). 1-year cumulative incidence of loco-regional failure (LRF) was 27% versus 10% in patients with ETR <49.5% as compared to patients with greater ETR (p = 0.31). The median MTR at CBCT29 was 32.7% (range, 1%-81%). 1-year cumulative incidence of LRF was 28% versus 9% in patients MTR <32.7% as compared to patients with higher response (p = 0.03). The 3-year actuarial LRC of all patients was 51% which was significantly better in higher MTR (70% vs 30%; p = 0.02, log-rank) as compared to lower MTR. The 3-year actuarial OS for all patients was 45% which was 54% in patients with higher MTR verses 37% in low responders (p = 0.09). On multivariate analysis, age and T-stage were significant factors associated with LRC. Histologic subtype showed no impact on our findings.

CONCLUSION

Stage III NSCLC patients with approximately one-third (33%) reduction of GTV on mid-treatment CBCT during CRT have significantly improved LRC and a trend towards improved OS. This approach may justify early adaptive intensification of RT or application of additional therapies in patients with non-optimal response. Additional large prospective study of CBCT is needed to determine whether treatment can be tailored based on tumor response, to improve outcomes.

Predictive Value of Tumor Volume on Local Control in Hepatocellular Carcinoma Treated with Image Guided Hypofractionated Radiation Treatment

PURPOSE/OBJECTIVE(S)

External beam radiation treatment (EBRT) is an important local treatment in liver-confined hepatocellular carcinoma (HCC) patients who are not candidates for curative therapy. EBRT dose, technique and prognostic factors are evolving. We hypothesized that tumor volume to liver volume ratio can be a predictor of local control (LC) in patients treated with hypo-fractionated radiation (HFRT) in HCC MATERIALS/METHODS: We retrospectively reviewed 50 patients of HCC treated with HFRT at our institution. HFRT schedule was chosen such that the radiation dose to the remaining liver and other organs at risk (OAR) met the standard dosimetric constraints. Image guided techniques were used for motion management, internal target volume (ITV) and planning target volume (PTV) delineation. Tumor to Liver Ratio (TLR) was defined as ratio of PTV volume to whole liver volume. TLR ≤ 0.3 was considered as low volume disease and TLR > 0.3 was considered as high-volume disease. The radiation dose ranged from 45 Gy to 67.5 Gy in 5 - 15 fractions. The biologically equivalent dose (BED) for tumor ranged from 58.5 Gy10 to 100 Gy10. Local control (LC) was evaluated by Kaplan-Meier analysis, with log-rank test for groups stratified as per TLR. Multivariate Cox regression analysis was performed to identify additional prognostic factors.

RESULTS

The mean duration of follow-up was 24 months. The median age was 69 years (range 50 - 90) and 76% were males. 32 patients had CP-A class cirrhosis while 17 had CP-B and 1 had CP-C class. BCLC stage A, B, C and D was seen in 2, 14, 33 and 2 patients, respectively. Portal vein thrombosis was present in 9 patients and prior trans-arterial chemo embolization (TACE) was done in 23 patients. The median volume of PTV was 551 cc (range 52 - 1990 cc). The TLR ranged from 0.04 - 0.67 with a median of 0.29. The median BED radiation dose was 78.4 Gy10 (range - 58.5 Gy10 to 100 Gy10). Nine patients had local recurrence with overall LC rate of 82%. The LC was better in low volume tumors, with the TLR cut-off of 0.3 as a significant factor associated with LC (p = 0.007). The 1-year actuarial LC with TLR ≤ 0.3 was 88% as compared 61% in TLR of > 0.3 (p = 0.007). BED ≥60 Gy10 was associated with better 1 year LC as compared to BED < 60 Gy10 (89% vs 62%; p = 0.11). ALBI grade 1 was associated with better 1 year LC as compared to ALBI grade 2 (80% versus 75%; p = 0.40). On multivariate analysis, high volume disease and TLR >0.3 were significant prognostic factor for LC.

CONCLUSION

HFRT has good 1-year local control of 82% in carefully selected unresectable HCC. Radiation with BED greater than 60 Gy10 and ALBI grade 1 showed a trend towards better LC. Smaller tumors had better LC with a PTV to liver ratio (TLR) of < 0.3. This information can help in identifying the poor responders, intensifying the radiation treatment and adding additional therapy to improve the oncological outcomes.

The Prognostic and Predictive Value of Pre-Treatment Total Lymphocyte Count in HPV+ Oropharyngeal Carcinoma Receiving Definitive (Chemo-) Radiation

PURPOSE/OBJECTIVE(S)

Evidence of prognostic importance of pre-radiotherapy (RT) total lymphocyte counts (TLC) and interaction with addition of cisplatin (CRT) in HPV-positive oropharyngeal carcinoma (HPV+OPC) is conflicting. Recent data suggest patients with high TLC may not benefit from the addition of chemotherapy (Price et al, JCO 2022). We assess the prognostic and predictive value of TLC in a large single center HPV+OCP cohort.

MATERIALS/METHODS

All HPV+OPC patients treated at a single academic center with definitive RT/CRT between 2005-2018 were included. Pre-treatment TLC up to 6 weeks prior to RT start were considered. Multivariable analysis (MVA) was applied to assess the prognostic importance of TLC (continuous variable), adjusted for age, gender, performance status, TNM-8 stage, and smoking status in the CRT and RT subgroups. The actuarial rates of locoregional control (LRC), distant control (DC), and overall survival (OS) were calculated using Kaplan-Meier and competing risk methods, stratified by low vs high TLC (determined using Contal and O'Quigley method for optimal cutoff).

RESULTS

Among 1153 eligible patients, 707 (61%) were treated with CRT. Median age was 59.7 (range 22.7-92.2) years. 526 patients were (46%) TNM-8 stage I, 366 (32%) stage II and 261 (23%) stage III. Median TLC was 1.6 x 109/L (range 0.1-8.5). Median follow-up was 5.5 years. On MVA, TLC was prognostic for patients receiving CRT (OS [adjusted hazard ration (aHR) 0.55 (0.38-0.79), p = 0.002], DC [aHR 0.57 (0.37-0.88), p = 0.011], LRC [aHR 0.57 (0.36-0.89), p = 0.014]) but not RT (OS [aHR 1.04 (0.82-1.31), p = 0.74], LRC [aHR 1.26 (0.86-1.85), p = 0.23], DC [aHR 0.87 (0.64-1.19), p = 0.4)]. The optimal TLC cut-off for OS with CRT was 1.9 x 109/L. Low vs high TLC patients receiving CRT had significantly inferior 5-year DC (87% vs 93%, p = 0.017) and OS (84% vs 90%, p = 0.026). The benefit of higher TLC was most evident in stage II disease (table 1). CRT vs RT improved OS for stage II/III disease at high and low TLC.

CONCLUSION

Pre-treatment TLC is prognostic in a large cohort of HPV+OPC patients receiving CRT but not RT alone. Further investigation of the interaction of cisplatin and immune response during RT is warranted. The omission of chemotherapy based on TLC is not supported.

Prediction of Lymphopenia and Survival with Baseline Absolute Lymphocyte Count and Irradiated Dose to Immune Cells in Patients with Non-Small Cell Lung Cancer Treated with Concurrent Chemoradiotherapy

PURPOSE/OBJECTIVE(S)

This study aimed to investigate the effect of effective dose to immune cell (EDIC) combined with pre-radiotherapy (RT) absolute lymphocyte count (ALC) on treatment-related lymphopenia during RT and treatment outcome in patients with locally advanced non-small cell lung cancer (NSCLC). A subgroup analysis in patients who received consolidation immunotherapy was also conducted.

MATERIALS/METHODS

Between August 2008 and December 2021, 517 patients with locally advanced NSCLC treated with definitive concurrent chemoradiotherapy (CRT) were retrospectively analyzed. All patients had serial complete-blood-count tests at pre-, and during-CRT. Severe lymphopenia was defined as ALC < 0.5x109cells/L during RT. EDIC was calculated according to mean doses of the lung, heart and the total body. The patients were grouped according to high and low EDIC and pre-RT ALC and was assessed for its correlation with radiation induced lymphopenia and survival outcomes.

RESULTS

Of 517 eligible patients, most of the patients received weekly paclitaxel with carboplatin (90.3%) and 195 patients (37.7%) received consolidation immunotherapy following CRT. A median radiation dose of 63 Gy (IQR, 60-64.5) was delivered in 30 fractions. The optimal cutoff value of EDIC and pre-RT ALC for predicting severe lymphopenia were 2.89 Gy and 2.03x109cells/L, respectively. High risk group was defined as EDIC ≥ 2.89 Gy and pre-RT ALC < 2.03x109cells/L, low risk group as EDIC <2.89 Gy and pre-RT ALC ≥ 2.03x109cells/L, and intermediate group as EDIC ≥ 2.89 Gy and pre-RT ALC ≥ 2.03x109cells/L or EDIC < 2.89 Gy and pre-RT ALC < 2.03x109cells/L. The incidence of severe lymphopenia during RT in high, intermediate, and low risk group was 90.1%, 77.1%, and 52.3%, respectively (p<0.001). The risk groups were independent predictors for both progression-free survival (PFS) (p<0.001) and overall survival (OS) (p<0.001). The high-risk group had higher incidence of locoregional and distant recurrences (p<0.001). In the subset of patients who were treated with consolidation immunotherapy, the risk groups were predictive of severe lymphopenia (p = 0.001), PFS (p = 0.004), and OS (p = 0.012).

CONCLUSION

This study demonstrated that the combination of EDIC and pre-RT ALC is a predictor for severe lymphopenia during RT, recurrence, and survival in patients with locally advanced NSCLC who received CRT. Moreover, the combination of EDIC and pre-RT ALC may serve as a potential biomarker for the benefit of maintenance immunotherapy.

BLZ8 activates a plastidial peroxiredoxin and a ferredoxin to protect Chlamydomonas reinhardtii against oxidative stress

Reactive oxygen species (ROS) cause damage to various cellular processes in almost all organisms, in particular photosynthetic organisms that depend on the electron transfer chain for CO2 fixation. However, the detoxifying process to mitigate ROS damage has not been studied intensively in microalgae. Here, we characterized the ROS detoxifying role of a bZIP transcription factor, BLZ8, in Chlamydomonas reinhardtii. To identify downstream targets of BLZ8, we carried out comparative genome-wide transcriptomic profiling of BLZ8 OX and its parental CC-4533 under oxidative stress conditions. Luciferase reporter activity assays and RT-qPCR were performed to test whether BLZ8 regulates downstream genes. We performed an in silico functional gene network analysis and an in vivo immunoprecipitation assay to identify the interaction between downstream targets of BLZ8. Comparative transcriptomic analysis and RT-qPCR revealed that overexpression of BLZ8 increased the expression levels of plastid peroxiredoxin1 (PRX1) and ferredoxin-5 (FDX5) under oxidative stress conditions. BLZ8 alone could activate the transcriptional activity of FDX5 and required bZIP2 to activate transcriptional activity of PRX1. Functional gene network analysis using FDX5 and PRX1 orthologs in A. thaliana suggested that these two genes were functionally associated. Indeed, our immunoprecipitation assay revealed the physical interaction between PRX1 and FDX5. Furthermore, the complemented strain, fdx5 (FDX5), recovered growth retardation of the fdx5 mutant under oxidative stress conditions, indicating that FDX5 contributes to oxidative stress tolerance. These results suggest that BLZ8 activates PRX1 and FDX5 expression, resulting in the detoxification of ROS to confer oxidative stress tolerance in microalgae.

Optimal Planning Target Margin for Prostate Radiotherapy Based on Interfractional and Intrafractional Variability Assessment during 1.5T MR-Guided Radiotherapy

PURPOSE/OBJECTIVE(S)

MR-guided radiotherapy (MRgRT) provides superior soft-tissue contrast over CT-based image guidance. We collected and analyzed daily pre-treatment (PRE) and real-time motion-monitoring (MM) MR images of patients receiving prostate radiotherapy to assess interfractional and intrafractional variability of prostate using two localization methods: pelvic bony anatomy (bone) and prostate during online adaptive radiotherapy (ART).

MATERIALS/METHODS

PRE and MM MRIs for the first five fractions of twenty prostate cancer patients who received definitive MRgRT with 1.5T MRI were collected. Using MIM software, rigid registration between PRE MRI and planning CT images based on pelvic bony anatomy and prostate reproduced bone localization and online ART, respectively. To determine interfractional setup margin (SM), prostate was delineated on all PRE MRIs registered after bone and prostate localizations by a radiation oncologist, and centroid values of prostate contours between planning CT and PRE MRIs were compared. To determine interobserver variability, another radiation oncologist, a medical physicist, and a radiotherapist contoured prostate for both localization methods. For internal margin (IM) assessment, we used MM MRIs of the five patients who had all three sets of coronal, sagittal, and axial cine images and determined the maximum contour displacement using in-house MATLAB-based software converting binary image files to 2D cine images with a superimposed grid of 1 mm spacing.

RESULTS

A total of 100 PRE and 25 MM MRIs were analyzed. Four hundred prostate contours were delineated on MR images registered with planning CT based on both bony anatomy and prostate. After bone localization, SM was 0.57±0.42 mm in left-right (LR), 2.45±1.98 mm in anterior-posterior (AP), and 2.28±2.08 mm in superior-inferior (SI) directions, and IO was 1.06±0.58 mm in LR, 2.32±1.08 mm in AP, and 3.30±1.85 mm in SI directions. After prostate localization, SM was 0.76±0.57 mm in LR, 1.89±1.60 mm in AP, and 2.2±1.79 mm in SI directions, and IO was 1.11±0.55 mm in LR, 2.13±1.07 mm in AP, and 3.53±1.65 mm in SI directions. Average IM was 2.12±0.86 mm, 2.24±1.07 mm, and 2.84±0.88 mm in LR, AP, and SI directions, respectively.

CONCLUSION

Using daily MRIs from MRgRT, we showed that movements in the SI direction were the largest source of variability in prostate definitive RT. In addition, interobserver variability was a non-negligible source of margin. Optimal PTV margin should also consider internal margin, especially in the SI direction.

Choosing Wisely between Radiotherapy Dose-Fractionation Schedules: The Molecular Graded Prognostic Assessment (molGPA) for Elderly Glioblastoma (eGBM-molGPA)

PURPOSE/OBJECTIVE(S)

This study aimed to develop a graded prognostic assessment (GPA) model integrating genomic characteristics in patients with elderly glioblastoma (eGBM), and compare the efficacy between conventionally fractionated radiotherapy (CFRT) vs. hypofractionated radiotherapy (HFRT) in each risk group.

MATERIALS/METHODS

Patients aged ≥65 years who underwent surgical resection followed by radiotherapy (RT) with or without temozolomide (TMZ) for newly diagnosed IDH-wildtype eGBM between 2006 and 2021 were included in this multicenter cohort study. Patients who were planned for a ≥6-week or ≤4-week radiotherapy were regarded as being treated with CFRT or HFRT, respectively. Based on the prognostic factors significantly identified through multivariate analysis for overall survival (OS), we developed the molecular GPA for eGBM (eGBM-molGPA) and assigned 0.0, 0.5, and 1.0 points in proportion to the corresponding hazard ratio (HR) of each factor. Then, the survival outcomes by treatment groups were evaluated according to the eGBM-molGPA scores.

RESULTS

A total of 334 and 239 patients who underwent CFRT and HFRT were included, respectively, and 86% of patients were treated with TMZ-based chemoradiation. With a median follow-up of 17.4 months for survivors, the median OS was 18.7 months for CFRT plus TMZ group, 15.1 months for HFRT plus TMZ group, and 10.4 months for RT alone group, respectively (all p<0.001). In the multivariate analysis, Karnofsky performance scale, surgical extent, TMZ, and the methylation status of the MGMT promoter were identified as strong prognostic factors for OS, with an estimated HR of greater than 1.5 (all p<0.001). Additionally, subventricular zone involvement, temporalis muscle thickness, RT regimen, and the mutation status of TERT promoter and TP53 gene were found to be significant prognostic factors for OS, with an estimated HR of less than 1.5. The eGBM-molGPA was established based on these prognostic factors (Table 1) and patients were allocated to three risk groups, which included high risk (total score of 3.0-4.5), intermediate risk (1.5-2.5), and low risk (0.0-1.0). Patients treated with CFRT plus TMZ had significantly improved OS compared to those treated with HFRT plus TMZ or RT alone in the low and intermediate risk groups (p<0.001). However, in the high-risk group, there was no significant difference in OS between treatment options (p = 0.770).

CONCLUSION

CFRT plus TMZ can be a more effective strategy for selected eGBM patients compared to HFRT. For high-risk patients, a protracted treatment schedule might not be beneficial. The novel eGBM-molGPA can be used as a clinical tool for choosing wisely among treatment options. Further prospective studies are warranted to establish optimal RT guidelines for eGBM patients.