Making stillbirths visible: a systematic review of globally reported causes of stillbirth

BACKGROUND

Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention.

OBJECTIVES

To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM.

SEARCH STRATEGY

We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016.

SELECTION CRITERIA

Reports of stillbirth causes in unselective cohorts.

DATA COLLECTION AND ANALYSIS

Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC).

MAIN RESULTS

Eighty-five reports from 50 countries (489 089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes.

CONCLUSIONS

There is a paucity of quality information on causes of stillbirth globally. Improving investigation of stillbirths and standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings.

FUNDING

HR, SH, SHL, and AW were supported by an NHMRC-CRE grant (APP1116640). VF was funded by an NHMRC-CDF (APP1123611).

TWEETABLE ABSTRACT

Urgent need to improve data on causes of stillbirths across all settings to meet global targets.

PLAIN LANGUAGE SUMMARY

Background and methods Nearly three million babies are stillborn every year. These deaths have deep and long-lasting effects on parents, healthcare providers, and the society. One of the major challenges to preventing stillbirths is the lack of information about why they happen. In this study, we collected reports on the causes of stillbirth from high-, middle-, and low-income countries to: (1) Understand the causes of stillbirth, and (2) Understand how to improve reporting of stillbirths. Findings We found 85 reports from 50 different countries. The information available from the reports was inconsistent and often of poor quality, so it was hard to get a clear picture about what are the causes of stillbirth across the world. Many different definitions of stillbirth were used. There was also wide variation in what investigations of the mother and baby were undertaken to identify the cause of stillbirth. Stillbirths in all income settings (low-, middle-, and high-income countries) were most frequently reported as Unexplained, Other, and Haemorrhage (bleeding). Unexplained and Other are not helpful in understanding why a baby was stillborn. In low-income countries, stillbirths were often attributed to Infection and Complications during labour and birth. In middle- and high-income countries, stillbirths were often reported as Placental complications. Limitations We may have missed some reports as searches were carried out in English only. The available reports were of poor quality. Implications Many countries, particularly those where the majority of stillbirths occur, do not report any information about these deaths. Where there are reports, the quality is often poor. It is important to improve the investigation and reporting of stillbirth using a standardised system so that policy makers and healthcare workers can develop effective stillbirth prevention programs. All stillbirths should be investigated and reported in line with the World Health Organization standards.

Spontaneous attention-capture by auditory distractors as predictor of distractibility: a study of domestic horses (Equus caballus)

Distractibility (i.e. individual distraction from his ongoing activity) is thoughts to affect daily life. The present study develops an easy way to assess inter-individual variations of distractibility of an animal model, the domestic horse. We developed the ‘distractibility test’ (DT), based on auditory stimuli, a major source of distraction in daily life. We hypothesized that the broadcast of unusual sounds would provide a reliable source of distraction and that the responses to these unusual sounds would yield a good estimation of a horse’s level of distractibility. Validity of the DT was assessed by comparing the subjects’ interest towards the sound in this test to their attentional state in experimental visual attention tasks and in a working task. Our results showed inter-individual differences in response to the stimuli, with consistency over time. The subjects’ responses to this DT were negatively correlated to their attentional skills in separate experimental tests and in a working task. This is to our knowledge the first ‘real-world’ estimate of an animal’s distractibility in its home environment that could potentially be adapted for humans.

A novel test for evaluating horses' spontaneous visual attention is predictive of attention in operant learning tasks

Attention is described as the ability to process selectively one aspect of the environment over others. In this study, we characterized horses' spontaneous attention by designing a novel visual attention test (VAT) that is easy to apply in the animal's home environment. The test was repeated over three consecutive days and repeated again 6 months later in order to assess inter-individual variations and intra-individual stability. Different patterns of attention have been revealed: 'overall' attention when the horse merely gazed at the stimulus and 'fixed' attention characterized by fixity and orientation of at least the visual and auditory organs towards the stimulus. The individual attention characteristics remained consistent over time (after 6 months, Spearman correlation test, P < 0.05). The validity of this novel test as a predictor of individual attentional skills was assessed by comparing the results, for the same horses, with those obtained in both a 'classical' experimental attention test the 'five-choice serial reaction time task' (5-CSRTT) and a work situation (lunge working context). Our results revealed that (i) individual variations remained consistent across tests and (ii) the VAT attention measures were not only predictive of attentional skills but also of learning abilities. Differences appeared however between the first day of testing and the following test days: attention structure on the second day was predictive of learning abilities, attention performances in the 5-CSRRT and at work. The VAT appears as a promising easy-to-use tool to assess animals' attention characteristics and the impact of different factors of variation on attention.

Kidney Cografts Enhance Fiber Outgrowth from Ventral Mesencephalic Grafts to the 6-Ohda–Lesioned Striatum, and Improve Behavioral Recovery

Recent studies have demonstrated the presence of many different neurotrophic factors in the developing and adult kidney. Due to its production of this mixture of neurotrophic factors, we wanted to investigate whether fetal kidney tissue could be beneficial for neuritic fiber growth and/or cell survival in intracranial transplants of fetal ventral mesencephalic tissue (VM). A retrograde lesion of nigral dopaminergic neurons was performed in adult Fischer 344 male rats by injecting 6-hydroxydopamine into the medial forebain. The animals were monitored for spontaneous locomotor activity in addition to apomorphine-induced rotations once a week. Four weeks following the lesion, animals were anesthetized and embryonic day 14 VM tissue from rat fetuses was implanted stereotaxically into the dorsal striatum. One group of animals received a cograft of kidney tissue from the same embryos in the same needle track. The animals were then monitored behaviorally for an additional 4 months. There was a significant improvement in both spontaneous locomotor activity (distance traveled) and apomorphine-induced rotations with both single VM grafts and VM–kidney cografts, with the VM–kidney double grafts enhancing the motor behaviors to a significantly greater degree. Tyrosine hydroxylase (TH) immunohistochemistry and image analysis revealed a significantly denser innervation of the host striatum from the VM–kidney cografts than from the single VM grafts. TH-positive neurons were also significantly larger in the cografts compared to the single VM grafts. In addition to the dense TH-immunoreactive innervation, the kidney portion of cografts contained a rich cholinergic innervation, as evidenced from antibodies against choline acetyltransferase (ChAT). The striatal cholinergic cell bodies surrounding the VM–kidney cografts were enlarged and had a slightly higher staining density for ChAT. Taken together, these data support the hypothesis that neurotrophic factors secreted from fetal kidney grafts stimulated both TH-positive neurons in the VM cografts and cholinergic neurons in the host striatum. Thus, these factors may be combined for treatment of degenerative diseases involving both dopaminergic and cholinergic neurons.

Chart review versus an automated bioinformatic approach to assess real-world crizotinib effectiveness in ALK-positive NSCLC

Purpose

The efficacy of targeted therapies such as crizotinib in anaplastic lymphoma kinase–positive non–small-cell lung cancer has been well established by multiple clinical trials. However, clinical trials involve highly selected participants, and manual data curation is resource intensive. With the increasing use of electronic medical records, there is potential for the development of electronic algorithms that could quickly generate outcomes data, but the validation of such algorithms requires comparison with historical methods, such as retrospective chart review.

Materials and Methods

Using a cohort of patients with anaplastic lymphoma kinase–positive non–small-cell lung cancer, we performed manual chart review to retrospectively evaluate time on treatment (TOT) for crizotinib and cytotoxic chemotherapies. Thirty-three patients were identified, with a total of 70 regimens administered. We developed a computational algorithm to mine electronic charts for crizotinib therapy data and correlated that with manually curated data.

Results

Among the 24 patients who received crizotinib, the median TOT was 8.5 months. The computational algorithm was able to extract TOT data for 15 out of 24 patients treated with crizotinib (62.5%). Most of the patients for whom data could not be automatically extracted were treated within a clinical trial. Pearson’s correlation coefficient between the two methods was 0.39 ( P = .15); however, there were five outliers as a result of incorrect provider notation and nonstandard treatment patterns that severely skewed the correlation.

Conclusion

An automated method of extracting patient TOT is feasible but requires additional optimizations to handle outliers. We are currently working on improving the algorithm to better correct for outliers. Automated generation of treatment data potentially represents a viable approach to perform retrospective outcomes analysis.

A natural language processing algorithm to measure quality prostate cancer care

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Background: Electronic health records (EHRs) are a widely adopted but underutilized source of data for systematic assessment of healthcare quality. Barriers for use of this data source include its vast complexity, lack of structure, and the lack of use of standardized vocabulary and terminology by clinicians. This project aims to develop generalizable algorithms to extract useful knowledge regarding prostate cancer quality metrics from EHRs. Methods: We used EHR ICD-9/10 codes to identify prostate cancer patients receiving care at our academic medical center. Patients were confirmed in the California Cancer Registry (CCR), which provided data on tumor characteristics, treatment data, treatment outcomes and survival. We focused on three potential pretreatment process quality measures, which included documentation within 6 months prior to initial treatment of prostate-specific antigen (PSA), digital rectal exam (DRE) performance, and Gleason score. Each quality metric was defined using target terms and concepts to extract from the EHRs. Terms were mapped to a standardized medical vocabulary or ontology, enabling us to represent the metric elements by a concept domain and its permissible values. The structured representation of the quality metric included rules that accounted for the temporal order of the metric components. Our algorithms used natural language processing for free text annotation and negation, to ensure terms such as ‘DRE deferred’ are appropriately categorized. Results: We identified 2,123 patients receiving prostate cancer treatment between 2008-2016, of whom 1413 (67%) were matched in the CCR. We compared accuracy of our data mining algorithm, a random sample of manual chart review, and the CCR. (See Table.) Conclusions: EHR systems can be used to assess and report quality metrics systematically, efficiently, and with high accuracy. The development of such systems can improve and reduce the burden of quality reporting and potentially reduce costs of measuring quality metrics through automation. [Table: see text]

Investigating attentional processes in depressive-like domestic horses (Equus caballus)

Some captive/domestic animals respond to confinement by becoming inactive and unresponsive to external stimuli. Human inactivity is one of the behavioural markers of clinical depression, a mental disorder diagnosed by the co-occurrence of symptoms including deficit in selective attention. Some riding horses display 'withdrawn' states of inactivity and low responsiveness to stimuli that resemble the reduced engagement with their environment of some depressed patients. We hypothesized that 'withdrawn' horses experience a depressive-like state and evaluated their level of attention by confronting them with auditory stimuli. Five novel auditory stimuli were broadcasted to 27 horses, including 12 'withdrawn' horses, for 5 days. The horses' reactions and durations of attention were recorded. Non-withdrawn horses reacted more and their attention lasted longer than that of withdrawn horses on the first day, but their durations of attention decreased over days, but those of withdrawn horses remained stable. These results suggest that the withdrawn horses' selective attention is altered, adding to already evidenced common features between this horses' state and human depression.

Preclinical to clinical translation of CNS transporter occupancy of TD-9855, a novel norepinephrine and serotonin reuptake inhibitor

BACKGROUND

Monoamine reuptake inhibitors exhibit unique clinical profiles that reflect distinct engagement of the central nervous system (CNS) transporters.

METHODS

We used a translational strategy, including rodent pharmacokinetic/pharmacodynamic modeling and positron emission tomography (PET) imaging in humans, to establish the transporter profile of TD-9855, a novel norepinephrine and serotonin reuptake inhibitor.

RESULTS

TD-9855 was a potent inhibitor of norepinephrine (NE) and serotonin 5-HT uptake in vitro with an inhibitory selectivity of 4- to 10-fold for NE at human and rat transporters. TD-9855 engaged norepinephrine transporters (NET) and serotonin transporters (SERT) in rat spinal cord, with a plasma EC50 of 11.7 ng/mL and 50.8 ng/mL, respectively, consistent with modest selectivity for NET in vivo. Accounting for species differences in protein binding, the projected human NET and SERT plasma EC50 values were 5.5 ng/mL and 23.9 ng/mL, respectively. A single-dose, open-label PET study (4-20mg TD-9855, oral) was conducted in eight healthy males using the radiotracers [(11)C]-3-amino-4- [2-[(di(methyl)amino)methyl]phenyl]sulfanylbenzonitrile for SERT and [(11)C]-(S,S)-methylreboxetine for NET. The long pharmacokinetic half-life (30-40 h) of TD-9855 allowed for sequential assessment of SERT and NET occupancy in the same subject. The plasma EC50 for NET was estimated to be 1.21 ng/mL, and at doses of greater than 4 mg the projected steady-state NET occupancy is high (>75%). After a single oral dose of 20mg, SERT occupancy was 25 (±8)% at a plasma level of 6.35 ng/mL.

CONCLUSIONS

These data establish the CNS penetration and transporter profile of TD-9855 and inform the selection of potential doses for future clinical evaluation.

Measurement of the inclusive leptonic asymmetry in top-quark pairs that decay to two charged leptons at CDF

We measure the inclusive forward-backward asymmetry of the charged-lepton pseudorapidities from top-quark pairs produced in proton-antiproton collisions and decaying to final states that contain two charged leptons (electrons or muons). The data are collected with the Collider Detector at Fermilab and correspond to an integrated luminosity of 9.1 fb(-1). We measure the leptonic forward-backward asymmetry, A(FB)(ℓ), to be 0.072 ± 0.060 and the leptonic pair forward-backward asymmetry, A(FB)(ℓℓ), to be 0.076 ± 0.082. The measured values can be compared with the standard model predictions of A(FB)(ℓ) = 0.038 ± 0.003 and A(FB)(ℓℓ) = 0.048 ± 0.004, respectively. Additionally, we combine the A(FB)(ℓ) result with a previous determination from a final state with a single lepton and hadronic jets and obtain A(FB)(ℓ) = 0.090(-0.026)(+0.028).

Visual attention, an indicator of human-animal relationships? A study of domestic horses (Equus caballus)

As visual attention is an intrinsic part of social relationships, and because relationships are built on a succession of interactions, their establishment involves learning and attention. The emotional, rewarding or punishing, content can modulate selective attention. In horses, the use of positive/negative reinforcement during training determines short and long-term human-horse relationships. In a recent study in horses, where either food or withers' grooming were used as a reward, it appeared that only the food-rewarded horses learned the task and show better relationship with humans. In the present study, we hypothesized that this differential effect of grooming/food rewards on learning performances could be due to attentional processes. Monitoring, gazes and behaviors directed towards the trainer revealed that the use of a food reward (FR) as positive reinforcement increased horses' selective attention towards their trainer. Conversely, horses trained with grooming reward (GR) expressed more inattentive responses and did not show a decrease of “agitated” behavior. However, individual plotting of attention vs. rate of learning performances revealed a complex pattern. Thus, while all FR horses showed a “window” of attention related to faster learning performances, GR horses' pattern followed an almost normal curve where the extreme animals (i.e., highest and lowest attention) had the slowest learning performances. On the other hand, learning was influenced by attention: at the end of training, the more attentive horses had also better learning performances. This study, based on horses, contributes to the general debate on the place of attentional processes at the interface of emotion and cognition and opens new lines of thought about individual sensitivities (only individuals can tell what an appropriate reward is), attentional processes and learning.

Referral trends for reproductive-age patients with breast cancer to a reproductive endocrinology clinic for fertility preservation counseling between 2004 and 2012

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Background: As of October 2012, both embryo and oocyte cryopreservation are considered non-experimental fertility preservation (FP) options for cancer patients facing potentially gonadotoxic therapy. This study aims to assess the historical referral frequency of reproductive aged breast cancer patients from a major cancer center to an associated reproductive endocrinology and infertility (REI) clinic for counseling regarding FP and also assess how frequently these patients underwent FP after referral. Methods: Using the Stanford Cancer Center Research Database in conjunction with our EMR, a query was made for patients of reproductive age (13-45) who were seen at the Stanford Cancer Center for a new breast cancer diagnosis between 2004 and 2012. These patients’ records were then searched for referral encounters in the REI department. Those who were seen by REI were assessed for having undergone FP via embryo or oocyte cryopreservation prior to starting chemotherapy. Results: 420 women, ages 20 to 45, were seen at our cancer center for a new diagnosis of breast cancer between 2004 and 2012. Sixty (14.3%) of these patients, ages 20 to 42 at diagnosis, were referred to the REI department for FP counseling. Patients who were referred for FP counseling were 5.1 years younger at diagnosis than those who were not (p<.005). Of those referred, 33.3% underwent FP with embryo (77%) or oocyte cryopreservation (23%) under an experimental protocol. Among breast cancer patients ≤35 years old, 35% were referred to our REI department for FP counseling and 53.5% of those referred underwent FP. Conclusions: Despite advances in FP technology, the majority of reproductive aged breast cancer patients are still not referred for FP counseling by a reproductive endocrinologist. This trend was also seen among patients younger than 35—a subgroup who is more likely to undergo and benefit most from FP. This study does not reflect patients who decline this opportunity or seek FP elsewhere, however additional study and outreach is needed to improve referral rates, which are now a measure of the Quality Oncology Practice Initiative (QOPI).

Explaining the temperature dependence of spirilloxanthin's S* signal by an inhomogeneous ground state model

We investigate the nature of the S* excited state in carotenoids by performing a series of pump–probe experiments with sub-20 fs time resolution on spirilloxanthin in a polymethyl-methacrylate matrix varying the sample temperature. Following photoexcitation, we observe sub-200 fs internal conversion of the bright S₂ state into the lower-lying S₁ and S* states, which in turn relax to the ground state on a picosecond time scale. Upon cooling down the sample to 77 K, we observe a systematic decrease of the S*/S₁ ratio. This result can be explained by assuming two thermally populated ground state isomers. The higher lying one generates the S* state, which can then be effectively frozen out by cooling. These findings are supported by quantum chemical modeling and provide strong evidence for the existence and importance of ground state isomers in the photophysics of carotenoids.

Tracking geomagnetic fluctuations to picotesla accuracy using two superconducting quantum interference device vector magnetometers

SQUIDs can be used to monitor the three vector components of the geomagnetic field to a high precision at very low frequencies, yet as they are susceptible to external interference, the accuracy to which they can track changes in the dc field over long periods has been unclear. We have carried out simultaneous measurements of the geomagnetic field recorded using two independent 3-axis SQUID magnetometers at the Laboratoire Souterrain à Bas Bruit (LSBB). We demonstrate a technique to take the difference between a linear transform of the three signals from one magnetometer, and a reference signal from the other, in order to account for any difference in alignment and calibration, and track local signals at a sub-nT level. We confirmed that both systems tracked the same signal with an RMS difference as low as 56pT over a period of 72 h. To our knowledge this is the first such demonstration of the long term accuracy of SQUID magnetometers for monitoring geomagnetic fields.

Phase II study of figitumumab in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck: clinical activity and molecular response (GORTEC 2008-02)

BACKGROUND

Preclinical studies suggest that insulin-like growth factor-1 receptor (IGF-1R) blockage could be a promising therapeutic target in squamous cell carcinoma of the head and neck (SCCHN). Therefore, we investigated the efficacy and toxicity of figitumumab, an anti-IGF-1R monoclonal antibody, in palliative SCCHN.

PATIENTS AND METHODS

Patients with palliative SCCHN progressing after platinum-based therapy were treated with figitumumab i.v. 20 mg/kg, every 3 weeks. The primary end point was the disease control rate at 6-8 weeks after treatment initiation. Tumor biopsies and plasma samples were collected before and after figitumumab administration to monitor the molecular response.

RESULTS

Seventeen patients were included. Only two patients achieved stable disease at 6-8 weeks. Median overall survival and progression-free survival were 63 and 52 days, respectively. The main grade 3-4 adverse event was hyperglycemia (41%). Translational research showed that figitumumab downregulated IGF-1R at the surface of tumor cells with activation of the epidermal growth factor receptor (EGFR) pathway, as shown by the upregulation of p-EGFR in tumor cells (P=0.016), and an increase in the plasma level of tumor growth factor-alpha (P=0.006).

CONCLUSION

Figitumumab monotherapy has no clinically significant activity in unselected palliative SCCHN.

[Terminology for classifying the porcine reproductive and respiratory syndrome virus (PRRSV) status of swine herds]

Standardized terminology for the porcine reproductive and respiratory syndrome virus (PRRSV) status of swine herds is necessary to facilitate communication between veterinarians, swine producers, genetic companies, and other industry participants. It is also required for implementation of regional and national efforts towards PRRSV control and elimination. The purpose of this paper is to provide a herd classification system for describing the PRRSV status of herds, based upon a set of definitions reflecting the biology and ecology of PRRSV. The herd classification system was developed by a definitions committee formed jointly by the American Association of Swine Veterinarians (AASV) and the United States Department of Agriculture PRRS-Coordinated Agricultural Project, and was approved by the AASV Board of Directors on March 9, 2010. The committee included veterinarians from private practice and industry, researchers, and representatives from AASV and the National Pork Board. Breeding herds, with or without growing pigs on the same premises, are categorized as Positive Unstable (Category I), Positive Stable (Category II), Provisional Negative (Category III), or Negative (Category IV) on the basis of herd shedding and exposure status. Growing-pig herds are categorized as Positive or Negative. Recommended testing procedures and decision rules for herd classification are detailed.

In situ temperature measurements through i-anvils in diamond anvil cells

This study is devoted to in situ temperature measurement in diamond anvil cells (DACs) with intelligent anvils (i-anvils). I-anvils consist of diamonds implanted with B and/or C ions, situated below the diamond's surface at a depth of 1-3 microm; forming sensors which are placed below the culet at the location of the DAC's sample chamber. I-anvils can be employed as temperature or pressure sensors, exploiting their electrical properties. We have tested the sensor's behavior with temperatures up to 900 degrees C, at ambient pressure and up to 6 GPa in real experimental conditions in two types of DAC. For this purpose, we performed experiments in four different i-anvils at temperatures up to 900 degrees C. We have compared the signal measured by the sensors with the temperature measured by a thermocouple attached to the i-anvil. The temperature gradient between the sample chamber and the thermocouple position was taken into account by phase transition measurements of calibration standards. Reproducible laws of current variation with temperature have been established. We conclude that i-anvils are reliable and sensitive to measure the temperature in-situ in DACs with an accuracy of better than 1 degree C.

Phase II study of sunitinib in patients with recurrent and/or metastatic squamous head and neck carcinoma: The GORTEC 2006–01 study

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Background: Up to 90% of head and neck squamous cell carcinoma (HNSCC) express the vascular endothelial growth factor (VEGF) or the VEGF receptors (VEGFR) 1–3. Angiogenic factors could have prognostic implication making anti-angiogenic therapies an attractive treatment modality. Sunitinib inhibits multiple tyrosine kinase receptors including VEGFR1–3 and PDGFR. Methods: Palliative HNSCC in PD after platinum therapy received sunitinib 37.5 mg/day continuously. The primary endpoint was the disease control rate (SD, PR, CR) at 6–8 wks. A two-stage design was used (Simon; a = 0.15,b = 0.10, H0 = 10%, H1 = 25%) meaning that at least 6 patients out of 37 should achieve a SD. Dynamic contrast enhanced (DCE) magnetic resonance (MR) perfusion-weighted imaging before and 6 wks after treatment initiation was performed on a 3T system. Results: 37 pts (M/F:28/9;PS 0/1:5/32) were included.11 pts were not evaluable by imaging due to rapid clinical PD (7 pts) or toxicity (4 pts) and were considered in PD.PR was found in 1 pts, SD in 18, and PD in 18 (RECIST). Among the SD, 6 had a minor response and 5 had an unconfirmed PR (maximum % reduction in sum of the largest diameters: 2%, 4%, 7%, 10%, 16%, 17%, 30%, 45%, 48%, 65%, 73%). PR could not be confirmed due to PD within 4 wks (3 pts) or treatment termination due to toxicity (2 pts). 4 pts had MR DCE monitoring. In 3, a significant decrease in the volume transfer constant Ktrans measuring the tumor perfusion and endothelial permeability was found during sunitinib treatment. The main Gr3–4 toxicities (N pts) were fatigue (12), tumor bleedings (2), LVEF decrease (2), hypertension (2). Gr5 tumor bleedings occurred in 4 pts. Other local complications included apparition/worsening of tumor skin ulceration or tumor fistula in 15 pts. Conclusions: This trial met its primary endpoint with modest activity of sunitinib in HNSSC. The rate of complications (i.e., fatal bleedings) outlines the importance of a better patient selection. DCE-MRI may be useful to predict response.

No significant financial relationships to disclose.

Clival chordoma molecular subtypes and clinical behavior

10538

Background: Chordoma is a primary bone cancer of the axial skeleton with predilection for local invasion. Primary treatment modalities consist of surgery and radiation therapy with limited role for chemotherapy. Because patients with chordoma exhibit heterogeneous clinical history and response to therapy, we investigated potential markers predictive of clinical behavior. Methods: This study analyzed 35 clival chordoma specimens with documented immunohistochemistry (IHC) staining for Ki-67 proliferation index from 29 patients. Detailed additional pathologic studies were performed prospectively on 12 consecutive patients. This consisted of the following: IHC for brachyury, cytokeratin, p53, and epidermal growth factor receptor (EGFR); fluorescent in situ hybridization (FISH) analysis for EGFR amplification and presence of 1p36, 9p21, and 19q13 loci; polymerase chain reaction based loss of heterozygosity analysis (LOH) of 1p, 9p, 10q, 17p, and 19p loci. Results: All confirmed chordoma specimens were positive for brachyury and negative for amplification of EGFR. Increase in Ki-67 index was associated with recurrence in 5 of 6 cases. Out of the 12 patients with detailed molecular pathologic studies, 5 had loss of 1p, 2 had deletion of 9p21 (p16), and 2 had loss of 10q (PTEN). The loss of 1p and 9p were detected via both FISH and LOH analyses. 3 of the 12 patients’ tumor specimens showed a Ki-67 index of greater than 10%; the remaining specimens were less than 5%. All 3 patients with high Ki-67 index had loss of either 9p (p16) or 10q (PTEN). The tumor specimen from these 3 patients also exhibited enhanced in vitro propagation. Conclusions: Subtyping of clival chordomas based on molecular phenotype may provide prognostic information. The prospective nature of this study in concert with assessment of residual disease after surgery may allow for identification of distinct subpopulations of patients at greater risk of disease recurrence for consideration of adjuvant therapy. The correlative in vitro study will provide an opportunity to evaluate targeted therapies customized to individual molecular subgroups.

No significant financial relationships to disclose.