Clinical Accuracy of 3D-Planned Maxillary Positioning Using CAD/CAM-Generated Splints in Combination With Temporary Mandibular Fixation in Bimaxillary Orthognathic Surgery

Study Design

The aim of this study was to evaluate the accuracy of 3-dimensional (3D)-planned maxillary positioning by using computer-assisted design (CAD)/computer-assisted manufacturing (CAM) splints combined with temporary mandibular fixation in bimaxillary orthognathic surgery. In orthognathic surgery, customized splints work sufficiently well to transfer preoperative planning into the operation site for transverse und sagittal positioning of the maxilla. The vertical positioning is more difficult due to the non-fixed mandibular reference. Therefore, the combined use of CAD/CAM splints and temporary mandibular fixation to the zygomatic region was applied for transferring the 3D-planned maxillary position into the operation site from 2012 until 2015 in our hospital.

Objective

In addition to the general accuracy, the precision should therefore be checked especially in the vertical plane compared to axial and sagittal plane.

Methods

In this retrospective study, we calculated the deviation of 5 occlusal landmarks of the maxilla in 35 consecutive patients by fusing preoperative 3D planning images and postoperative computed tomography scans after bimaxillary surgery.

Results

The overall median deviation of maxillary positioning between plan and surgical result was 0.99 mm. The accuracy of left-right positioning was median 0.96 mm. Anterior-posterior positioning of the maxilla showed a median accuracy of 0.94 mm. Just slightly higher values were determined for the upward-downward positioning (median 1.06 mm).

Conclusions

This demonstrates the predictability of maxillary positioning by using CAD/CAM splints in combination with temporary mandibular fixation in all 3 axes.

Seedling responses to salinity of 26 Neotropical tree species

Sea-level rise will result in increased salinization of coastal areas. Soil salinity is a major abiotic stress that reduces plant growth, yet tolerance to salinity varies across environmental conditions, habitats and species. To determine salinity tolerance of 26 common tropical tree species from Panama, we measured growth, gas exchange and mortality of 3-month-old seedlings subjected to weekly irrigation treatments using five seawater solutions (0 % = control, 20, 40, 60 and 90 % V/V of seawater) for ~2 months. In general, species from coastal areas were more tolerant to increased seawater concentration than inland species. Coastal species such as Pithecellobium unguis-cati, Mora oleifera, Terminalia cattapa and Thespesia populnea maintained growth rates close to those of controls at 90 % seawater. In contrast, inland species such as Minquartia guainensis, Apeiba membranacea, Ormosia coccinea and Ochroma pyramidale showed strong reductions in growth rates and high mortality. Plant height and leaf production also differed greatly between the two groups of plants. Furthermore, measurements of gas exchange parameters, i.e. stomatal conductance and maximum photosynthetic rate, were consistent with the contrasting growth responses of coastal and inland species. Our research reveals a great degree of variation in salinity tolerance among tropical tree species and demonstrates a close relationship between species habitat and the ability to thrive under increasing salt concentration in the soil, with coastal species being better adapted to withstand increased soil salinity than non-costal species.

TRLS-09. RTOG1119: PHASE II RANDOMIZED STUDY OF WHOLE BRAIN RADIOTHERAPY / STEREOTACTIC RADIOSURGERY IN COMBINATION WITH CONCURRENT LAPATINIB IN PATIENTS WITH BRAIN METASTASIS FROM HER2-POSITIVE BREAST CANCER

The addition of trastuzumab to cytotoxic chemotherapy has improved outcomes for patients with HER2 positive breast cancer. Increased survival coupled with limited blood-brain barrier (BBB) penetration of trastuzumab may contribute to the increased incidence of brain metastasis in these patients. Half of these patients die of intracranial disease progression rather than extracranial disease. Therefore, strategies to improve survival must include increased CNS disease control in these patients. Lapatinib crosses the BBB and demonstrates modest activity against intracranial metastases. Based upon preclinical data and results of a phase I study, we hypothesized that lapatinib plus WBRT /SRS can improve the intracranial disease control compared to WBRT / SRS alone. A randomized phase II trial of WBRT (37.5 Gy/3 weeks) or SRS plus or minus concurrent lapatinib (daily 1000 mg for 6 weeks) was initiated. CNS penetrating HER2 targeted therapy is permitted throughout the study, but patients not on trastuzumab, pertuzumab or any other breast cancer therapy at study entry are not permitted to begin this therapy while on protocol treatment, but may begin it 24 hours after completion of protocol treatment. Eligibility includes HER2+ breast cancer with at least one measurable, unirradiated parenchymal brain metastasis. The two populations targeted for accrual include patients with 1) newly diagnosed, multiple brain metastases or 2) progressive brain metastases after stereotactic radiosurgery (SRS) or surgical resection of 1–3 metastases. Prior lapatinib is allowed. Patients are stratified by breast-specific graded prognostic assessment; use of non-CNS penetrating HER2 targeted therapy; and prior SRS or surgical resection. The primary endpoint is complete response rate in the brain 12 weeks after WBRT. Secondary endpoints include objective response rate, lesion-specific response rate, CNS progression-free survival, and overall survival. 140 of 143 target accrual have enrolled (4/22/2019).

An investigator's introduction to statistical considerations in clinical trials

The purpose of this paper is to provide an introduction for investigators to many of the statistical considerations for clinical trials that will aid in their collaborations with statisticians for clinical trial research endeavors and when reading the clinical trials literature. The purpose of this paper is not to turn a physician into a statistician, that takes formal training and education, as well as day in and day out immersion in the statistical design and analysis of clinical trials, hence statistician as a profession. Successful clinical trials, not to be confused with only positive clinical trials, are ones that are well designed to answer the trial question, well conducted, and appropriately reported and published, regardless of the results. Physicians and statisticians each play integral roles in the realm of clinical trials and successful clinical trials are the result of collaborations between physicians and statisticians from the beginning of an idea through the manuscript publication.

[In vivo imaging of the corneal nerve plexus : From single image to large scale map]

The sub-basal nerve plexus (SNP) of the cornea provides the possibility of in vivo and non-invasive examination of peripheral nerve structures by corneal confocal microscopy (CCM). Thus morphological alterations of the SNP can be directly detected and quantified. A single CCM image is insufficient for a well-founded diagnosis because of the inhomogeneous distribution of the nerve fibers; therefore, there is a demand for techniques for large area imaging of the SNP. This article provides an overview of published approaches to the problem. Current developmental work at the Karlsruhe Institute of Technology and the University of Rostock Eye Clinic is expected to lead to a simplified handling of the technology and a further improvement in the image quality.

Effects of mesenchymal stromal cells versus serum on tendon healing in a controlled experimental trial in an equine model

BACKGROUND

Mesenchymal stromal cells (MSC) have shown promising results in the treatment of tendinopathy in equine medicine, making this therapeutic approach seem favorable for translation to human medicine. Having demonstrated that MSC engraft within the tendon lesions after local injection in an equine model, we hypothesized that they would improve tendon healing superior to serum injection alone.

METHODS

Quadrilateral tendon lesions were induced in six horses by mechanical tissue disruption combined with collagenase application 3 weeks before treatment. Adipose-derived MSC suspended in serum or serum alone were then injected intralesionally. Clinical examinations, ultrasound and magnetic resonance imaging were performed over 24 weeks. Tendon biopsies for histological assessment were taken from the hindlimbs 3 weeks after treatment. Horses were sacrificed after 24 weeks and forelimb tendons were subjected to macroscopic and histological examination as well as analysis of musculoskeletal marker expression.

RESULTS

Tendons injected with MSC showed a transient increase in inflammation and lesion size, as indicated by clinical and imaging parameters between week 3 and 6 (p < 0.05). Thereafter, symptoms decreased in both groups and, except that in MSC-treated tendons, mean lesion signal intensity as seen in T2w magnetic resonance imaging and cellularity as seen in the histology (p < 0.05) were lower, no major differences could be found at week 24.

CONCLUSIONS

These data suggest that MSC have influenced the inflammatory reaction in a way not described in tendinopathy studies before. However, at the endpoint of the current study, 24 weeks after treatment, no distinct improvement was observed in MSC-treated tendons compared to the serum-injected controls. Future studies are necessary to elucidate whether and under which conditions MSC are beneficial for tendon healing before translation into human medicine.

Effect of Standard vs Dose-Escalated Radiation Therapy for Patients With Intermediate-Risk Prostate Cancer: The NRG Oncology RTOG 0126 Randomized Clinical Trial

Importance

Optimizing radiation therapy techniques for localized prostate cancer can affect patient outcomes. Dose escalation improves biochemical control, but no prior trials were powered to detect overall survival (OS) differences.

Objective

To determine whether radiation dose escalation to 79.2 Gy compared with 70.2 Gy would improve OS and other outcomes in prostate cancer.

Design, Setting, and Participants

The NRG Oncology/RTOG 0126 randomized clinical trial randomized 1532 patients from 104 North American Radiation Therapy Oncology Group institutions March 2002 through August 2008. Men with stage cT1b to T2b, Gleason score 2 to 6, and prostate-specific antigen (PSA) level of 10 or greater and less than 20 or Gleason score of 7 and PSA less than 15 received 3-dimensional conformal radiation therapy or intensity-modulated radiation therapy to 79.2 Gy in 44 fractions or 70.2 Gy in 39 fractions.

Main Outcomes and Measures

Time to OS measured from randomization to death due to any cause. American Society for Therapeutic Radiology and Oncology (ASTRO)/Phoenix definitions were used for biochemical failure. Acute (≤90 days of treatment start) and late radiation therapy toxic effects (>90 days) were graded using the National Cancer Institute Common Toxicity Criteria, version 2.0, and the RTOG/European Organisation for the Research and Treatment of Cancer Late Radiation Morbidity Scoring Scheme, respectively.

Results

With a median follow-up of 8.4 (range, 0.02-13.0) years in 1499 patients (median [range] age, 71 [33-87] years; 70% had PSA <10 ng/mL, 84% Gleason score of 7, 57% T1 disease), there was no difference in OS between the 751 men in the 79.2-Gy arm and the 748 men in the 70.2-Gy arm. The 8-year rates of OS were 76% with 79.2 Gy and 75% with 70.2 Gy (hazard ratio [HR], 1.00; 95% CI, 0.83-1.20; P = .98). The 8-year cumulative rates of distant metastases were 4% for the 79.2-Gy arm and 6% for the 70.2-Gy arm (HR, 0.65; 95% CI, 0.42-1.01; P = .05). The ASTRO and Phoenix biochemical failure rates at 5 and 8 years were 31% and 20% with 79.2 Gy and 47% and 35% with 70.2 Gy, respectively (both P < .001; ASTRO: HR, 0.59; 95% CI, 0.50-0.70; Phoenix: HR, 0.54; 95% CI, 0.44-0.65). The high-dose arm had a lower rate of salvage therapy use. The 5-year rates of late grade 2 or greater gastrointestinal and/or genitourinary toxic effects were 21% and 12% with 79.2 Gy and 15% and 7% with 70.2 Gy (P = .006 [HR, 1.39; 95% CI, 1.10-1.77] and P = .003 [HR, 1.59; 95% CI, 1.17-2.16], respectively).

Conclusions and Relevance

Despite improvements in biochemical failure and distant metastases, dose escalation did not improve OS. High doses caused more late toxic effects but lower rates of salvage therapy.

Trial Registration

clinicaltrials.gov Identifier: NCT00033631.

Crassulacean acid metabolism in the Basellaceae (Caryophyllales)

C₄ and crassulacean acid metabolism (CAM) have evolved in the order Caryophyllales many times but neither C₄ nor CAM have been recorded for the Basellaceae, a small family in the CAM-rich sub-order Portulacineae. 24 h gas exchange and day-night changes in titratable acidity were measured in leaves of Anredera baselloides exposed to wet-dry-wet cycles. While net CO₂ uptake was restricted to the light period in well-watered plants, net CO₂ fixation in the dark, accompanied by significant nocturnal increases in leaf acidity, developed in droughted plants. Plants reverted to solely C₃ photosynthesis upon rewatering. The reversible induction of nocturnal net CO₂ uptake by drought stress indicates that this species is able to exhibit CAM in a facultative manner. This is the first report of CAM in a member of the Basellaceae.

Postresection CA19-9 and margin status as predictors of recurrence after adjuvant treatment for pancreatic carcinoma: Analysis of NRG oncology RTOG trial 9704

Purpose

NRG Oncology RTOG 9704 was the first adjuvant trial to validate the prognostic value of postresection CA19-9 levels for survival in patients with pancreatic carcinoma. The data resulting from this study also provide information about predictors of recurrence that may be used to tailor individualized management in this disease setting. This secondary analysis assessed the prognostic value of postresection CA19-9 and surgical margin status (SMS) in predicting patterns of disease recurrence.

Methods and materials

This multicenter cooperative trial included participants who were enrolled as patients at oncology treatment sites in the United States and Canada. The study included 451 patients analyzable for SMS, of whom 385 were eligible for postresection CA19-9 analysis. Postresection CA19-9 was analyzed at cut points of 90, 180, and continuously. Patterns of disease recurrence included local/regional recurrence (LRR) and distant failure (DF). Multivariable analyses included treatment, tumor size, and nodal status. To adjust for multiple comparisons, a P value of ≤ .01 was considered statistically significant and > .01 to ≤ .05 to be a trend.

Results

For CA19-9, 132 (34%) patients were Lewis antigen-negative (no CA19-9 expression), 200 (52%) had levels <90, and 220 (57%) had levels <180. A total of 188 patients (42%) had negative margins, 152 (34%) positive, and 111 (25%) unknown. On univariate analysis, CA19-9 cut at 90 was associated with increases in LRR (trend) and DF. Results were similar at the 180 cut point. SMS was not associated with an increase in LRR on univariate or multivariate analyses. On multivariable analysis, CA19-9 ≥ 90 was associated with increased LRR and DF. Results were similar at the 180 cut point.

Conclusions

In this prospective evaluation, postresection CA19-9 was a significant predictor of both LRR and DF, whereas SMS was not. These findings support consideration of adjuvant radiation therapy dose intensification in patients with elevated postresection CA19-9.

Effect of the Addition of Cetuximab to Paclitaxel, Cisplatin, and Radiation Therapy for Patients With Esophageal Cancer: The NRG Oncology RTOG 0436 Phase 3 Randomized Clinical Trial

Importance

The role of epidermal growth factor receptor (EGFR) inhibition in chemoradiation strategies in the nonoperative treatment of patients with esophageal cancer remains uncertain.

Objective

To evaluate the benefit of cetuximab added to concurrent chemoradiation therapy for patients undergoing nonoperative treatment of esophageal carcinoma.

Design, Setting, and Participants

A National Cancer Institute (NCI) sponsored, multicenter, phase 3, randomized clinical trial open to patients with biopsy-proven carcinoma of the esophagus. The study accrued 344 patients from 2008 to 2013.

Interventions

Patients were randomized to weekly concurrent cisplatin (50 mg/m2), paclitaxel (25 mg/m2), and daily radiation of 50.4 Gy/1.8 Gy fractions with or without weekly cetuximab (400 mg/m2 on day 1 then 250 mg/m2 weekly).

Main Outcomes and Measures

Overall survival (OS) was the primary endpoint, with a study designed to detect an increase in 2-year OS from 41% to 53%; 80% power and 1-sided α = .025.

Results

Between June 30, 2008, and February 8, 2013, 344 patients were enrolled. This analysis used all data received at NRG Oncology through April 12, 2015. Sixteen patients were ineligible, resulting in 328 evaluable patients, 159 in the experimental arm and 169 in the control arm. Patients were well matched between the treatment arms for patient and tumor characteristics: 263 (80%) with T3 or T4 disease, 215 (66%) N1, and 62 (19%) with celiac nodal involvement. Incidence of grade 3, 4, or 5 treatment-related adverse events at any time was 71 (46%), 35 (23%), or 6 (4%) in the experimental arm and 83 (50%), 28 (17%), or 2 (1%) in the control arm, respectively. A clinical complete response (cCR) rate of 81 (56%) was observed in the experimental arm vs 92 (58%) in the control arm (Fisher exact test, P = .66). No differences were seen in cCR between treatment arms for either histology (adenocarcinoma or squamous cell). Median follow-up for all patients was 18.6 months. The 24- and 36-month local failure for the experimental arm was 47% (95% CI, 38%-57%) and 49% (95% CI, 40%-59%) vs 49% (95% CI, 41%-58%) and 49% (95% CI, 41%-58%) for the control arm (HR, 0.92; 95% CI, 0.66-1.28; P = .65). The 24- and 36-month OS rates for the experimental arm were 45% (95% CI, 37%-53%) and 34% (95% CI, 26%-41%) vs 44% (95% CI, 36%-51%) and 28% (95% CI, 21%-35%) for the control arm (HR, 0.90; 95% CI, 0.70-1.16; P = .47).

Conclusions and Relevance

The addition of cetuximab to concurrent chemoradiation did not improve OS. These phase 3 trial results point to little benefit to current EGFR-targeted agents in an unselected patient population, and highlight the need for predictive biomarkers in the treatment of esophageal cancer.

Trial Registration

clinicaltrials.gov Identifier: NCT00655876.