Extensive pelvic and abdominal lymphadenopathy with hepatosplenomegaly treated with radiotherapy-A case report

This is a case report of a 65-year-old female patient diagnosed with Grade II Follicular Lymphoma of the pelvic and abdomen was treated with a combination of R-CHOP chemotherapy and radiotherapy.

The effect of an intraorifice barrier and base under coronal restorations on the healing of apical periodontitis: a randomized controlled trial

AIM

To evaluate the effect of intraorifice barriers and bases on the healing of apical periodontitis following root canal treatment in mandibular molars.

METHODOLOGY

A total of 120 permanent mandibular molars with necrotic pulps and periapical radiolucencies (PAI score ≥ 3) were recruited. Root canal treatment was performed in all teeth using a standard protocol, following which they were randomly allocated to one of the three treatment groups: intraorifice barrier group: coronal 3-mm gutta-percha was removed and replaced with glass-ionomer cement (GIC) barrier. The floor of the pulp chamber was then sealed with 2-mm-thick GIC base followed by final composite resin restoration; base group: received 2-mm-thick GIC base before placement of composite resin restoration; and control group: had pulp chamber entirely filled with composite resin only. Follow-up was done at 3, 6, 9 and 12 months. Combination of clinical and radiographic parameters were used to assess treatment outcome. The data were analysed using Kruskal-Wallis, chi-square and Wilcoxon signed-rank tests and logistic regression analysis.

RESULTS

At the end of 12 months, the base group had the most favourable healing (97.1%), whilst the control group had the least favourable healing (83.8%). The intraorifice barrier group had healing of 92.1%. However, there was no significant difference in healing between groups at the end of the follow-up period (P > 0.05). Additional subgroup analysis revealed a nonsignificant effect of periodontal status and root filling level on periapical healing.

CONCLUSION

The use of an additional barrier under permanent restorations did not significantly improve the outcome of primary root canal treatment in posterior teeth after 12 months. However, its influence in the long term requires further evaluation.

P577Early experience with the first pacemakers to directly connect with smart devices for remote monitoring

Background

Remote monitoring is associated with improved patient outcomes; however, adoption and adherence to remote monitoring via home-based consoles remains suboptimal. BlueSync technology in new generation pacemaker and CRT-P models enables the implanted device to communicate directly with patient-owned, Bluetooth-equipped smartphones/tablets and an app (MyCareLink Heart). The app can automatically retrieve information from the cardiac device and transmit the data to the remote network, eliminating the need for traditional remote monitoring consoles.

Objectives

To characterize the communication process between implanted pacemakers and smart device remote monitoring apps by assessing the success of prescheduled remote transmissions in the first month of follow-up. Additionally, to assess the feedback of both patients and clinicians about the process of device pairing.

Methods

Enrollment in the BlueSync Field Evaluation began in April 2018 and was completed November 2018. Follow-up is ongoing. Prior to enrollment in the evaluation, patients completed the device pairing process with the app using their own compatible smartphone or tablet. Patient and clinician questionnaires were completed at the time of the device pairing process. After enrollment, successful completion of scheduled transmissions occurring in the first month were analyzed.

Results

Preliminary data includes 241 enrolled patients with mean age of 64.7±15.5 yrs (min 20, max 90 yrs), who completed device pairing between their implanted device and their smart device app. Of enrolled patients, 79% felt that the device paring was easy to do, 85% were satisfied with the amount of time it took to complete it, and 93% felt that they would be comfortable using the app. Clinicians reported that 67% of the device pairings took less than 20 minutes and 78% felt patients would be able to use the app independently. At the time of analysis 174 patients had at least one scheduled transmission within the first month, and collectively had a total of 322 scheduled transmissions. Out of these, 309 (96%, 95% CI: 93%-98%) were successfully completed.

MyCareLink Heart App

Conclusions

Initial experience with the world's first app based remote monitoring system for Bluetooth enabled pacemakers demonstrated success to scheduled transmissions in the first month across a wide range of patient ages. Patients and clinicians reported high satisfaction with this novel technology.

Acknowledgement/Funding

Medtronic PLC

P1913Implantable Loop Recorder Detected Pattern of Atrial Fibrillation Recurrence Following Cryoballoon Pulmonary Vein Isolation in Patients with Persistent Atrial Fibrillation

Background

Cryoballoon (CB) pulmonary vein isolation (PVI) is increasingly being used in patients (pts) with persistent atrial fibrillation (AF). However, there are limited data about the pattern of atrial fibrillation (AF) recurrence in these pts.

Objective

To assess, using an implantable loop recorder (ILR), the patterns of AF recurrence following CB PVI in pts with persistent atrial fibrillation.

Methods

We enrolled consecutive pts with persistent AF ablation undergoing their first CB ablation. Other cavotricuspid isthmus ablation when indicated, no other ablation was performed. A Reveal LINQ ILR (Medtronic) was implanted <3 months following ablation; all pts had a minimum of 1-year follow-up. The recurrence of any atrial arrhythmia was determined and adjudicated; 4 distinct AF patterns were characterized (Figure).

Results

We studied 64 pts (66±9 years; 50 [78%] male; CHA2DS2-VASc 2.6±1.9) with persistent AF; 52 (81%) pts were on an antiarrhythmic drug (AAD) peri-ablation. During 803±361 days of follow-up, 33 (52%) pts had their 1st AF recurrence 91–365 days post-ablation and another 17 (27%) pts had their 1st AF recurrence >365 days post-ablation. No AF was seen in 14 (31%) pts. Most pts (33 of 50, 66%) with AF recurrence presented with 1 of 3 distinct patterns of paroxysmal AF (Figure), which ranged from 22 min to 124 hours. In 2/3 of these pts, all AF recurrences lasted <24 hours. Only 17 (34%) pts recurred with persistent AF.

Conclusion

Following single CB PVI, most pts with persistent AF remained free of persistent AF during long-term follow-up. Most pts with recurrent AF have 1 of 3 distinct patterns with episodes commonly last <24 hours. These data suggest that CB PVI ablation may halt AF progression in pts initially presenting with persistent AF.

P3807Impact of unipolar vs bipolar left ventricular pacing using a quadripolar lead on heart failure hospitalization in patients undergoing cardiac resynchronization therapy

Background

Unipolar (uni) pacing from a bipolar left ventricular (LV) pacing lead in cardiac resynchronization therapy (CRT) patients (pts) has been associated with worse outcomes than bipolar (bi) pacing (MADIT CRT and ALTITUDE analyses). However, it is unknown whether the same is true with quadripolar LV pacing leads.

Purpose

To determine whether there is a difference in heart failure hospitalization (HFH) following CRT implantation in pts undergoing uni vs. bi LV pacing.

Methods

All pts enrolled in the NAVIGATE study were implanted with a CRT-D (RESONATE, Boston Scientific) using a quadripolar LV lead (ACUITY X4 Spiral Long, Spiral Short, or Straight). Pts were followed, and data collected on HFH and mortality. Vectors were programmed at the discretion of the implanter. Outcomes were adjusted for age, gender, NYHA class, ischemic etiology, conduction disorder pattern, EF, LV lead location, and LV lead shape.

Results

The study cohort included 2080 pts; 1781 pts had bi and 299 pts had uni LV pacing. Bi LV had higher % female, NYHA II/III, non-ischemic, LBBB, spiral shape, lateral and apical locations. During follow-up, the adjusted likelihood of HFH was significantly lower in pts undergoing bi LV pacing (HR 0.75, 0.58–0.97, p=0.027, Figure). Mortality was similar between the two groups.

Conclusions

In this large prospective study, uni LV pacing was associated with significantly greater likelihood of need for HFH during a 4-year follow-up period. These data suggest that routine programming in a bi configuration may be better for post-CRT pts. However, further study is needed to confirm causality and mechanism of this finding.

P14.69 Evaluation of electric field intensity delivered by Tumor-Treating Fields therapy to PET-defined metabolic volumes in recurrent glioblastomas

BACKGROUND

Tumor-Treating Fields (TTFields) therapy is a clinical treatment option for patients with newly-diagnosed and recurrent glioblastomas. Electric field intensities (EFIs) delivered to the tumor mass may affect treatment responses. In this study, we used the patients’ neuroimaging data to create realistic head models and evaluate: (i) the magnitude of EFIs delivered to the tumor mass; (ii) factors affecting the EFI values; and (iii) factors affecting treatment responses as assessed by amino acid PET.

MATERIAL AND METHODS

Fourteen recurrent glioblastomas in 9 patients were evaluated with α-[11C]-methyl-L-tryptophan (AMT)-PET before and up to 3 months after TTFields therapy (mean follow-up: 2.3 months). Individual MRI and CT scans were used to create patient-specific realistic head models and simulate TTFields delivery to the tumors. For each direction of treatment (antero-posterior, left-right), two 9-disk transducer arrays were simulated using disks placed according to the patients’ NovoTAL System™ based treatment plan. To generate TTFields, an alternating voltage difference (200V peak-to-peak, 200 kHz) was imposed on the outer surfaces of the disks. The simulations were performed using the Sim4Life V3.0 (ZMT-Zurich) quasi-electrostatic solver. The field intensities were normalized to simulate 2A peak-to-peak current supplied by the device. 3D EFI maps were created and fused with the pre- and post-TTFields PET images to measure EFIs delivered to the PET-defined metabolic tumor volume. Interval changes of static AMT uptake and kinetic PET variables were also evaluated.

RESULTS

The mean EFI delivered to the tumors varied between 1.34–2.43 V/cm (mean: 1.86 V/cm). Fronto-parietal tumors received higher mean EFI than temporal lobe tumors (p=0.05). Most tumors showed decreasing (n=9) or stable (n=4) AMT uptake on follow-up PET imaging after TTFields therapy. Higher EFIs delivered to the tumors (r=-0.56, p=0.04) and concomitant bevacizumab treatment (n=7, p=0.01) were associated with a greater PET response. On tracer kinetic analysis, the AMT uptake responses correlated with transport rate changes (p=0.04).

CONCLUSION

TTFields treatment of recurrent glioblastomas delivers variable EFIs to the metabolic tumor volume. Treatment responses on PET are driven by decreased amino acid transport rates, whose magnitude is associated with higher EFIs delivered to the tumor mass and also with concomitant antiangiogenic treatment in those with combined therapy. (The cost of the PET scans was supported by a grant from NovoCure Ltd., Haifa, Israel)

P14.57 Association of tryptophan metabolism and depression in patients with primary brain tumors

BACKGROUND

Patients with brain tumor have an increased risk for depressive disorder, whose underlying pathomechanism may involve dysregulated tryptophan/kynurenine metabolism. In this study, we analyzed the relation of depression to cerebral and systemic tryptophan metabolism in patients with primary brain tumors.

MATERIAL AND METHODS

Thirty-four patients with newly-diagnosed (n=19) or recurrent (n=15) primary brain tumors (25 gliomas, 8 meningiomas, 1 dysembryoplastic neuroepithelial tumor) underwent pre-treatment alpha-[11C]methyl-L-tryptophan (AMT)-PET and completed the Beck Depression Inventory-II (BDI-II) questionnaire. MRI and AMT-PET images were co-registered, and AMT K values (estimate of unidirectional tryptophan uptake, related to tryptophan metabolism) were measured in contralateral non-tumoral cortical and subcortical regions and correlated with BDI-II total and subscale (cognitive, affective, and somatic) scores. In a subset of 28 patients, plasma tryptophan metabolite levels were also measured and correlated with BDI-II scores.

RESULTS

In the whole group (n=34), 35% of the patients (n=12) had BDI-II scores indicating depression, while only a minority of them (n=5) were treated with selective serotonin reuptake inhibitors (SSRI). No difference was observed in AMT K values between gliomas vs. non-gliomas or between newly-diagnosed vs. recurrent tumors. Frontal cortical and thalamic AMT K values positively correlated with BDI-II total and somatic subscale scores (r=0.49, p=0.004 and r=0.53, p=0.001, respectively), and these correlations became stronger when patients with SSRI treatment were excluded. Levels of plasma tryptophan and its metabolites were not different between gliomas vs. non-gliomas, newly-diagnosed vs. recurrent tumor nor depressed vs. non-depressed patients. SSRI treatment showed no effect on plasma tryptophan metabolite levels. No correlation was found between depression and plasma tryptophan and its metabolite levels.

CONCLUSION

While plasma levels of tryptophan metabolites are not associated with depressive symptoms, higher tryptophan metabolism in the frontal cortex and thalamus, measured by PET, may serve as an imaging biomarker of brain tumor-associated depression and supports the role of dysregulated tryptophan/kynurenine metabolism in this condition.

P14.37 Depression in patients with primary brain tumors: Relation to clinical variables and tumor characteristics

BACKGROUND

Patients with brain tumor have an increased risk for depressive disorder, however, the association between depression and clinical or tumor-related variables remains mostly unclear. In this study, we analyzed the relation of depression to several clinical and tumor-related characteristics in patients with primary brain tumors.

MATERIAL AND METHODS

Sixty patients with newly-diagnosed (n=34) or recurrent (n=26) primary brain tumors (50 gliomas, 10 meningiomas) underwent testing with the Beck Depression Inventory-II (BDI-II). Relation of BDI-II scores to clinical and tumor-related characteristics, including age, Karnofsky Performance Status (KPS) scores, presence of antiepileptic, antidepressant, or steroid treatment, as well as tumor grade, lateralization, and lobar localization, were analyzed. In a subset of recurrent malignant glioma patients, the prognostic value of BDI-II scores on overall survival was also analyzed.

RESULTS

The mean total BDI-II score was 10±8 (range: 0–37); while 27% of patients (n=16) had BDI-II scores indicating at least mild depressive disorder (≥13), only a portion of them (17%) was on antidepressant treatment. No BDI-II difference was found between gliomas vs. meningiomas or newly-diagnosed vs. recurrent tumors; also, no association was found with any tumor-related characteristics. Antiepileptic or steroid therapy had no association with BDI-II scores, while higher BDI-II scores were observed in patients with ongoing antidepressant therapy (15±10 vs. 8±7, p=0.017). Higher BDI-II total and somatic subscale scores correlated with lower KPS scores (r=-0.32, p=0.014 and r=-0.31, p=0.017, respectively). In recurrent malignant glioma patients (n=18), higher depression scores were associated with shorter survival (hazard ratio: 3.7; 95% confidence interval: 1.0–13.6; p=0.048).

CONCLUSION

Depression affected more than ¼ of patients with primary brain tumors in this single-center cohort and was independent from most clinical and tumor-related characteristics, except KPS scores. Although most of these patients have mild depression that is often overlooked without targeted screening, higher BDI-II scores may predict shorter overall survival in recurrent malignant glioma patients. These data reinforce the importance of early recognition and treatment of depressive symptoms in patients with primary brain tumors.

P11.35 Fluorine-18-labeled PET radiotracers for imaging tryptophan uptake and metabolism in brain tumors

BACKGROUND

Abnormal metabolism of tryptophan via the serotonin and kynurenine pathways plays a key role in multiple disease processes including cancer. Upregulation of key enzymes of the kynurenine pathway (such as indoleamine 2,3-dioxygenase [IDO] and tryptophan 2,3-dioxygenase [TDO]) plays an important role in immune resistance in human brain tumors. IDO inhibitors have recently entered in human clinical trials, and their use can benefit from molecular imaging evaluating IDO activity. Imaging tryptophan uptake and metabolism in vivo can be achieved with tryptophan derivative PET radiotracers. Human studies with such tracers showed promise but have been confined to carbon-11-labeled compounds (such as alpha-[11C]methyl-L-tryptophan). Preclinical development of fluorine-18-labeled tryptophan-based radiotracers has surged only in recent years. We performed a systematic review of studies reporting on such tracers and summarized their biological characteristics and their potential for imaging key enzymes of the kynurenine pathway.

MATERIAL AND METHODS

A PubMed search using the key words “tryptophan” and “PET”/”positron emission tomography” was performed. English language original articles including data on the preparation and/or radiochemical or biological characteristics of fluorine-18-labeled tryptophan derivative radiotracers have been reviewed.

RESULTS

Nineteen original papers identified by the search included data on 15 unique fluorine-18-labeled tryptophan-derived radiotracers. Automated synthesis was reported for 1-(2-[18F]fluoroethyl)-L-tryptophan, the most extensively evaluated tracer among the 15. Biodistribution studies showed high uptake in the pancreas, and the L-type amino acid transporter was the dominant transport mechanism for most of the reported radiotracers. Multiple tracers showed accumulation in various tumor cell lines, including glioma cell lines, in vitro and in xenografts in vivo, with favorable tumor-to-background uptake ratios in comparison to clinically used fluorine-18-labeled radiotracers (such as glucose and non-tryptophan amino acid analogs). Five of the 15 tracers showed promise for imaging IDO activity, including a fluorine-18-labeled analog of alpha-[11C]methyl-L-tryptophan. Two of the 15 radiotracers were metabolized by TDO but showed rapid defluorination in vivo.

CONCLUSION

Most fluorine-18-labeled tryptophan derivative PET tracers share common transport mechanisms and biodistribution characteristics. Several of these radiotracers show promise for imaging IDO activity in vivo, and, therefore, could be leading candidates for testing and validation toward human tumor PET imaging applications.

Enablers and Barriers of Follow-Up Care: An Experience From an HPV DNA Detection–Based Cervical Cancer Screening Program in Rural India

Background: Success of a cervical cancer screening program is intrinsically linked with appropriate management of women detected positive on screening tests. While routine screening can be done in any setting, the follow-up care of screen positive women is linked with settings that are equipped with diagnostic and treatment facilities, and trained medical providers. In low resource settings, the major obstacles to deliver follow-up care are lack of adequate healthcare infrastructure and trained service providers at district or subdistrict levels. Aim: To assess feasibility of implementing community based interventions to increase uptake of follow-up care of screen positive women in a HPV detection based screening program conducted by Chittaranjan National Cancer Institute (CNCI), Kolkata. Strategy: A network of key stakeholders including government authorities and civil society organizations was developed to deliver continuum of care at the doorsteps of screen positive women. The infrastructure of government's primary health care delivery system was used to set up temporary clinics at district and subdistrict levels. The clinics were organized on prescheduled dates and times that were convenient to the women. Community health workers (CHWs) were trained in community mobilization strategies to increase uptake of follow-up services. All instruments, equipment and consumables required for providing follow-up services were carried to the clinics in a vehicle. Program: The CHWs played a key role in counseling and recalling the screen positive women. The temporary clinics were arranged in the government primary health centers. A team of trained doctors and paramedics provided the diagnostic and treatment services. Colposcopy was performed on all screen positive women using portable colposcopes and guided biopsies were taken as indicated. Women who were eligible for ablative treatment were counseled and treated in the same sitting. All women were advised yearly follow-up. Outcomes: A total of 43,325 women were screened by HC2 test during July 2010 to March 2015, and 2045 (4.7%) women were detected to be high-risk HPV positive. Compliance to first recall was good with 78.6% (1608/2045) of women undergoing diagnostic evaluation at field clinics. But overall compliance to at least one follow-up visit after 1 year was poor (23.2%). Follow-up compliance rate was higher in women who were diagnosed with CIN1 as compared with those with normal diagnosis ( P < 0.001). What was learned: Diagnostic and treatment services could be effectively organized in the community in convergence with existing healthcare delivery system. High compliance to initial diagnostic evaluation and treatment was achieved by making the services available close to the doorsteps of the women. The reasons for low compliance to yearly follow-up were lack of understanding of future cancer risk, unwilling to undergo speculum examination again, and lack of cooperation of spouse/family.

Reconfigurable Topological Phases in Next-Nearest-Neighbor Coupled Resonator Lattices

We present a reconfigurable topological photonic system consisting of a 2D lattice of coupled ring resonators, with two sublattices of site rings coupled by link rings, which can be accurately described by a tight-binding model. Unlike previous coupled-ring topological models, the design is translationally invariant, similar to the Haldane model, and the nontrivial topology is a result of next-nearest couplings with nonzero staggered phases. The system exhibits a topological phase transition between trivial and spin Chern insulator phases when the sublattices are frequency detuned. Such topological phase transitions can be easily induced by thermal or electro-optic modulators, or nonlinear cross phase modulation. We use this lattice to design reconfigurable topological waveguides, with potential applications in on-chip photon routing and switching.

Clinical Effectiveness of a Resin-modified Glass Ionomer Cement and a Mild One-step Self-etch Adhesive Applied Actively and Passively in Noncarious Cervical Lesions: An 18-Month Clinical Trial

OBJECTIVES:

To evaluate the clinical effectiveness of two methods of application of a mild one-step self-etch adhesive and composite resin as compared with a resin-modified glass ionomer cement (RMGIC) control restoration in noncarious cervical lesions (NCCLs).

METHODS:

A total of 294 restorations were placed in 56 patients, 98 in each one of the following groups: 1) G-Bond active application combined with Solare-X composite resin (A-1SEA), 2) G-Bond passive application combined with Solare-X composite resin (P-1SEA), and 3) GC II LC RMGIC. The restorations were evaluated at baseline and after six, 12, and 18 months according to the FDI criteria for fractures/retention, marginal adaptation, marginal staining, postoperative sensitivity, and secondary caries. Cumulative failure rates were calculated for each criterion at each recall period. The effect of adhesive, method of application, and recall period were assessed. The Kruskal-Wallis test for intergroup comparison and Friedman and Wilcoxon signed ranks tests for intragroup comparison were used for each criterion ( α=0.05).

RESULTS:

The retention rates at 18 months were 93.26% for the A-1SEA group, 86.21% for the P-1SEA group, and 90.91% for the RMGIC group. The active application improved the retention rates compared with the passive application of mild one-step self-etch adhesive; however, no statistically significant difference was observed between the groups. Marginal staining was observed in 13 restorations (1 in A-1SEA, 4 in P-1SEA, and 8 in RMGIC) with no significant difference between the groups. The RMGIC group showed a significant increase in marginal staining at 12 and 18 months from the baseline. There was no significant difference between the groups for marginal adaptation, secondary caries, or postoperative sensitivity.

CONCLUSION:

Within the limitations of the study, we can conclude that mild one-step self-etch adhesive followed by a resin composite restoration can be an alternative to RMGIC with similar retention and improved esthetics in restoration of NCCLs. Agitation could possibly benefit the clinical performance of mild one-step self-etch adhesives, but this study did not confirm that the observed benefit was statistically significant.