Clinical outcomes of melanoma brain metastases treated with stereotactic radiosurgery and anti-PD-1 therapy, anti-CTLA-4 therapy, BRAF/MEK inhibitors, BRAF inhibitor, or conventional chemotherapy

BACKGROUND

The effect of immunologic and targeted agents on intracranial response rates in patients with melanoma brain metastases (MBMs) is not yet clearly understood. This report analyzes outcomes of intact MBMs treated with single-session stereotactic radiosurgery (SRS) and anti-PD-1 therapy, anti-CTLA-4 therapy, BRAF/MEK inhibitors(i), BRAFi, or conventional chemotherapy.

PATIENTS AND METHODS

Patients were included if MBMs were treated with single-session SRS within 3 months of receiving systemic therapy. The primary end point of this study was distant MBM control. Secondary end points were local MBM control defined as a >20% volume increase on follow-up MRI, systemic progression-free survival, overall survival (OS) from both SRS and cranial metastases diagnosis, and neurotoxicity. Images were reviewed alongside two neuro-radiologists at our institution.

RESULTS

Ninety-six patients were treated to 314 MBMs over 119 SRS treatment sessions between January 2007 and August 2015. No significant differences were noted in age (P = 0.27), gender (P = 0.85), treated gross tumor volume (P = 0.26), or the diagnosis-specific graded prognostic assessment (P = 0.51) between the treatment cohorts. Twelve-month Kaplan-Meier (KM) distant MBM control rates were 38%, 21%, 20%, 8%, and 5% (P = 0.008) for SRS with anti-PD-1 therapies, anti-CTLA-4 therapy, BRAF/MEKi, BRAFi, and conventional chemotherapy, respectively. No significant differences were noted in the KM local MBM control rates among treatment groups (P = 0.25). Treatment with anti-PD-1 therapy, anti-CTLA-4 therapy, or BRAF/MEKi significantly improved OS on both univariate and multivariate analyses when compared with conventional chemotherapy.

CONCLUSION

In our institutional analysis of patients treated with SRS and various systemic immunologic and targeted melanoma agents, significant differences in distant MBM control and OS are noted. Prospective evaluation of the potential synergistic effect between these agents and SRS is warranted.

A Community study of obstructive sleep apnea hypopnea syndrome (OSAHS) in middle-aged Bangladeshi population

Obstructive sleep apnea hypopnea syndrome (OSAHS) is the occurrence of repetitive episodes of complete or partial upper airway obstruction during sleep in association with loud snoring and daytime sleepiness and is a risk factor for hypertension, cardiovascular and cerebrovascular diseases and more. The present study was performed to assess the prevalence as well as the clinical and anthropometric predictors of OSAHS in an urban community of middle aged Bangladeshi population. The study was a cross-sectional, community-based prevalence study which was performed in an urban community in Dhanmondi Thana Pourashava of Dhaka city from July 2007 to June 2008. About 2500 citizens, aged 30-60 years were included in the study. In stage one of the study, they were informed about the polysomnography (PSG) study (stage two of the study) and 2250 of them gave consent. Subjects were then divided into habitual (495) and non-habitual snorers (1755). Among 2250 subjects, the prevalence of obstructive sleep apnea hypopnea (OSAH) in habitual snorers was 48.33% (239/495), and that in non-habitual snorers was 1.66% (29/1755). So, the overall prevalence of OSAH in the screened population was 11.91%, and that of OSAHS was 3.29%. Likewise, the prevalence of OSAH and OSAHS in men were 17.37% and 4.49%, respectively and 6.25% and 2.14% in women. Multivariate analysis revealed that male gender, age, obesity (defined by a high body mass index), waist/hip ratio were significant risk factors for OSAHS. These findings can help us in identifying the prevalence of OSAHS in the community and further planning in the management of obesity and cardiovascular diseases.

Robotic partial nephrectomy - Evaluation of the impact of case mix on the procedural learning curve

INTRODUCTION

Although Robotic partial nephrectomy (RPN) is an emerging technique for the management of small renal masses, this approach is technically demanding. To date, there is limited data on the nature and progression of the learning curve in RPN.

AIMS

To analyse the impact of case mix on the RPN LC and to model the learning curve.

METHODS

The records of the first 100 RPN performed, were analysed at our institution that were carried out by a single surgeon (B.C) (June 2010-December 2013). Cases were split based on their Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score into the following groups: 6-7, 8-9 and >10. Using a split group (20 patients in each group) and incremental analysis, the mean, the curve of best fit and R(2) values were calculated for each group.

RESULTS

Of 100 patients (F:28, M:72), the mean age was 56.4 ± 11.9 years. The number of patients in each PADUA score groups: 6-7, 8-9 and >10 were 61, 32 and 7 respectively. An increase in incidence of more complex cases throughout the cohort was evident within the 8-9 group (2010: 1 case, 2013: 16 cases). The learning process did not significantly affect the proxies used to assess surgical proficiency in this study (operative time and warm ischaemia time).

CONCLUSIONS

Case difficulty is an important parameter that should be considered when evaluating procedural learning curves. There is not one well fitting model that can be used to model the learning curve. With increasing experience, clinicians tend to operate on more difficult cases.

Abstract P3-12-03: Utilizing the genomically adjusted dose (GAD) to personalize radiotherapy in adjuvant breast cancer management

Background: We have previously validated a multi-gene model of tumor radiosensitivity (RSI) with validation in multiple independent cohorts including breast, rectal, esophageal, head and neck, glioblastoma, and prostate malignancies. Utilizing the linear quadratic model and RSI, we derived an expression for the genomically adjusted dose (GAD) to model radiation dose effect for individual patients.

Methods: As RSI models the surviving fraction of cells at 2 Gy (SF2), we are able to derive a patient specific alpha. These terms were used in the linear quadratic model to calculate a GAD to model radiation effect and its association with local control. A higher GAD implies a higher predicted radiation therapy effect. Clinical and array-based gene expression were obtained from 75 ER negative patients from the Netherlands Cancer Institute (NKI) and the Institut Curie treated with breast conservation therapy.

Results: Median follow-up for all patients was 10 years with a median age of 42 years (range: 23-50 years). Adjuvant radiation dose to the whole breast was 50 Gy (range: 45-55 Gy). When assessing local recurrence on multivariate analysis, we found GAD to be a significant predictor of local recurrence when dichotomized at the median (GAD-low vs GAD-high Hazard Ratio (HR) 4.5; 95% CI 1.7-13.5; p=0.0031). GAD was also significant per unit change (HR 0.91; 95% CI 0.83-0.99; p=0.021). We then modeled GAD for an escalated dose up to 60 Gy and found an additional 48% of GAD-low patients could achieve a GAD-high with dose escalation.

Conclusions: We found GAD to be significantly correlated with local control following breast conservation therapy. Modeling dose escalation with GAD, we identified a select population of patients whom we hypothesize may benefit from genomically guided increased dose in the adjuvant setting. This population may represent a cohort for future clinical trial enrollment.

Citation Format: Ahmed KA, Venkat PS, Scott JG, Diaz RJ, Fulp WJ, Torres-Roca JF. Utilizing the genomically adjusted dose (GAD) to personalize radiotherapy in adjuvant breast cancer management. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-03.

Abstract P3-12-04: The genomically adjusted radiation dose (GAD) and its association with distant metastases in breast cancer: A feasible approach to precision medicine in radiation oncology

Background: Clinical validation studies in over 2,200 patients across 8 different disease sites, including breast cancer, have shown the radiosensitivity index (RSI), a gene expression signature, predicts outcomes in patients treated with radiation. We hypothesize that an approach to personalize radiation dose could be developed by integrating RSI into the linear quadratic model of dose and fractionation.

Methods: Utilizing the linear quadratic model and RSI, we derived an expression for the genomically adjusted dose (GAD) to model radiation dose effect for individual patients. A higher GAD implies a higher predicted radiation therapy effect. GAD was evaluated as a predictor of clinical outcome in two independent datasets of breast cancer patients treated with surgery and radiation. The association between GAD and distant-metastasis free survival (DMFS) and relapse-free survival (RFS) using univariate (UVA) and multivariate (MVA) Cox proportional hazard models was assessed. Clinical and array-based gene expression were obtained from two independent, previously described cohorts from the Karolinska Institutet and Erasmus University Medical Center.

Results: Full radiation treatment details were available for 263 patients in the Erasmus dataset, median follow-up 60 months. GAD-low patients (<75% GAD distribution) were found to have decreased DMFS when compared to GAD-high patients (≥25% GAD distribution) (Hazard Ratio (HR) = 2.31 (95% CI 1.25, 4.25), p=0.006). On MVA, GAD was an independent predictor of DMFS for the whole cohort (HR= 2.11 (1.13, 3.94), p=0.02). When the analysis was restricted to the ER positive cohort, GAD was an independent predictor of outcome both as a continuous (HR=0.977, (0.955, 1.0), p = 0.049) and as a dichotomous variable (HR = 3.42, (1.53, 7.67), p=0.003). These results were independently confirmed in the second Karolinska dataset. The 5 year RFS was 95% for GAD-high patients and 76% in GAD-low patients (p=0.027) and GAD was a significant predictor on MVA for RFS (HR =7.42, (1.41, 137.6), p=0.014). In the Karolinska cohort, we estimate a significant proportion of GAD-low patients (59%) would achieve GAD-high with dose escalation up to 70 Gy.

Conclusions: In this study, we develop and validate GAD, a novel and patient-specific measure of radiation dose effect. Importantly, GAD is a clinically actionable metric by adjusting radiation dose. We propose that GAD based radiation dosing is a feasible approach to precision medicine in breast radiation oncology.

Citation Format: Ahmed KA, Scott JG, Diaz RJ, Fulp WJ, Torres-Roca JF. The genomically adjusted radiation dose (GAD) and its association with distant metastases in breast cancer: A feasible approach to precision medicine in radiation oncology. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-12-04.

Clinical outcomes of melanoma brain metastases treated with stereotactic radiation and anti-PD-1 therapy

BACKGROUND

The anti-programmed death-1 (anti-PD-1) therapy nivolumab has significant clinical activity in patients with metastatic melanoma. However, little is known about the safety and outcomes in patients receiving anti-PD-1 therapy and stereotactic radiation for the treatment of brain metastases (BMs).

PATIENTS AND METHODS

Data were analyzed retrospectively from two prospective nivolumab protocols enrolling 160 patients with advanced resected and unresectable melanoma at a single institution. Patients were included if BMs were diagnosed and treated with stereotactic radiation within 6 months of receiving nivolumab. The primary end point of this study was neurotoxicity; secondary end points included BM control and survival.

RESULTS

Twenty-six patients with a total of 73 BMs treated over 30 sessions were identified. Radiation was administered before, during and after nivolumab in 33 lesions (45%), 5 lesions (7%), and 35 lesions (48%), respectively. All BMs were treated with stereotactic radiosurgery (SRS) in a single session except 12 BMs treated with fractionated stereotactic radiation therapy, nine of which were in the postoperative setting. One patient experienced grade 2 headaches following SRS with symptomatic relief with steroid treatment. No other treatment-related neurologic toxicities or scalp reactions were reported. Eight (11%) local BM failures with a ≥20% increase in volume were noted. Of these lesions, hemorrhage was noted in 4, and edema was noted in 7. Kaplan-Meier estimates for local BM control following radiation at 6 and 12 months were 91% and 85%, respectively. Median overall survival (OS) from the date of stereotactic radiation and nivolumab initiation was 11.8 and 12.0 months, respectively, in patients receiving nivolumab for unresected disease (median OS was not reached in patients treated in the resected setting).

CONCLUSIONS

In our series, stereotactic radiation to melanoma BMs is well tolerated in patients who received nivolumab. BM control and OS appear prolonged compared with standard current treatment. Prospective evaluation is warranted.

Systematic review of the relationship between artificial sweetener consumption and cancer in humans: analysis of 599,741 participants

BACKGROUND

The effect of artificial sweetener consumption on cancer risk has been debated in animal models for over four decades. To further investigate this relationship, this study aims to synthesise results from several of the most recent studies in humans.

METHODS

An online literature search was performed in MEDLINE from 2003 to 2014 using Ovid, PubMed, Web of Science, and Scopus using keywords 'artificial', 'sweetener' and 'cancer'. Ninety-two results were then manually assessed for eligibility. Studies were included if the relationship between artificial sweeteners and cancer was their central hypothesis, and if they adjusted for age, gender, smoking status and body mass index. Extracted data included study design, patient characteristics, outcome measure and results.

RESULTS

In the five publications that satisfied the inclusion criteria, significant direct associations with artificial consumption were found for laryngeal (odds ratio, OR 2.34, 95% CI: 1.20-4.55), urinary tract tumours (OR 2.12, 95% CI: 1.22-3.89), non-Hodgkin lymphoma in men (RR 1.31, 95% CI: 1.01-1.72), multiple myeloma in men (RR 2.02, 95% CI: 1.20-3.40) and leukaemia (RR 1.42, 95% CI: 1.00-2.02). Inverse relationships were found in breast (OR 0.70, 95% CI: 0.54-0.91, p trend = 0.015) and ovarian (OR 0.56, 95% CI: 0.38-0.81, p trend < 0.001) cancers.

CONCLUSION

The statistical value of this review is limited by the heterogeneity and observational designs of the included studies. Although there is limited evidence to suggest that heavy consumption may increase the risk of certain cancers, overall the data presented are inconclusive as to any relationship between artificial sweeteners and cancer.

Bufavirus genotype 3 in Turkish children with severe diarrhoea

Recently a parvovirus called bufavirus (BuV) has been implicated as a causative agent of diarrhoea. To further reveal the epidemiology and genetic characteristics of BuV, this study was performed in Turkish children with diarrhoea. BuV was detected in 1.4% (8/583) of stool samples. All stool samples from healthy children (n = 148) were negative for BuV. Diarrhoea in BuV-positive patients was severe and occurred mainly during the colder months of the year. Complete genome sequences were generated from four BuVs. Only BuV3 was found, which was genetically and phylogenetically similar to Bhutanese BuV3, indicating that BuV3 is prevalent in Asian countries.

Medfest: the effect of a national medical film festival on attendees' attitudes to psychiatry and psychiatrists and medical students' attitudes to a career in psychiatry

OBJECTIVE

The authors proposed that a national film festival organized by psychiatrists could change attendees' views toward psychiatry and psychiatrists positively and increase the numbers of medical students considering psychiatry as a career.

METHODS

Medfest held events at nine UK universities in 2011. The program consisted of short films (The Family Doctor, Shadowscan, Beards & Bow Ties) and panelist discussions. Data were gathered using an anonymous "before and after" questionnaire.

RESULTS

A total of 450 attendees across all sites returned 377 feedback forms (84 % response rate). Views of psychiatry and psychiatrists changed for the better for 42 % (98 % of those who answered the question) and 40 % (96 % of those who answered the question) of all respondents, respectively. Respondents' views were significantly more likely to change for the better than for the worse toward both psychiatry (p < 0.001) and psychiatrists (p < 0.001). Post-event, 46 % of the 232 medical students that attended were more likely to consider a career in psychiatry (48 % of those who answered the question).

CONCLUSIONS

A multicenter film festival organized by psychiatrists was associated with more positive attitudes to psychiatry and psychiatrists and an increase in students considering psychiatry as a career. The festival is now an annual event, continuing to expand.

Systematic review of prostate cancer risk and association with consumption of fish and fish-oils: analysis of 495,321 participants

INTRODUCTION

Fish-oils have a potential role in inflammation, carcinogenesis inhibition and favourable cancer outcomes. There has been increasing interest in the relationship of diet with cancer incidence and mortality, especially for eicosapantaenoic acid (EPA) and docosahexaenoic acid (DHA). This systematic-analysis of the literature aims to review evidence for the roles of dietary-fish and fish-oil intake in prostate-cancer (PC) risk, aggressiveness and mortality.

METHODS

A systematic-review, following PRISMA guidelines was conducted. PubMed, MEDLINE and Embase were searched to explore PC-risk, aggressiveness and mortality associated with dietary-fish and fish-oil intake. 37 studies were selected.

RESULTS

A total of 495,321 (37-studies) participants were investigated. These revealed various relationships regarding PC-risk (n = 31), aggressiveness (n = 8) and mortality (n = 3). Overall, 10 studies considering PC-risk found significant inverse trends with fish and fish-oil intake. One found a dose-response relationship whereas greater intake of long-chain-polyunsaturated fatty acids increased risk of PC when considering crude odds-ratios [OR: 1.36 (95% CI: 0.99-1.86); p = 0.014]. Three studies addressing aggressiveness identified significant positive relationships with reduced risk of aggressive cancer when considering the greatest intake of total fish [OR 0.56 (95% CI 0.37-0.86)], dark fish and shellfish-meat (p < 0.0001), EPA (p = 0.03) and DHA (p = 0.04). Three studies investigating fish consumption and PC-mortality identified a significantly reduced risk. Multivariate-OR (95% CI) were 0.9 (0.6-1.7), 0.12 (0.05-0.32) and 0.52 (0.30-0.91) at highest fish intakes.

CONCLUSIONS

Fish and fish-oil do not show consistent roles in reducing PC incidence, aggressiveness and mortality. Results suggest that the specific fish type and the fish-oil ratio must be considered. Findings suggest the need for large intervention randomised placebo-controlled trials.

Systematic review of live surgical demonstrations and their effectiveness on training

BACKGROUND

Live surgical demonstrations are commonly performed for surgical conferences. These live procedures have recently come under scrutiny, in particular with issues pertaining to patient safety. This systematic review aimed to explore the evidence for live surgery as a training tool, and to investigate the safety of live surgical broadcasts.

METHODS

PubMed, Embase, MEDLINE and Cochrane Library databases were searched using a predefined search strategy from January 1980 to October 2013. Specialty Societies and primary Colleges of Surgeons were searched for guidelines or position statements on live surgical teaching.

RESULTS

Educational value criteria demonstrated for live surgery included feasibility, acceptability, construct and concurrent validity. Complication rates during live procedures were not compromised in the majority of studies. Patient safety, however, may be affected during live procedures as success rates have been found to be lower in some studies. Only Cardiothoracic, Urology and Vascular Surgical Societies currently offer guidelines on conducting live surgical demonstrations.

CONCLUSION

Little evidence exists on the safety and educational value of live surgery, with few studies of high quality conducted. Guidance on live procedures is scarce, with only three major surgical specialties offering any advice. More needs to be done to establish and promote evidence for the value of live surgery demonstrations.

Noninvasive carotid duplex study may be used as predictor test for ischaemic heart disease

A prospective observational study was carried out to detect carotid atherosclerosis using high resolution B-Mode in 150 in-hospital patients with clinically diagnosed ischemic heart disease in various forms in the department of Cardiology, University Cardiac Center, BSMMU, Bangladesh. The duration of study was from April 2006 to December 2008. Carotid Ultrasound evaluation was performed in 150 patients diagnosed as Ischemic Heart Disease by single operator (NF). Mean age of the patients was 53.62±10.92 with, male to female ratio of 9.5:0.5. Mean IMT was 0.96±0.21mm in 85% of the patient of clinically diagnosed IHD, which was higher than the normal (normal IMT ≤0.8mm). Among them, about 77% had atherosclerotic plaque. A significant correlation between Carotid atherosclerosis determined by IMT and Ischemic Heart Disease (IHD) was found. Non invasive carotid duplex study might be useful for predicting ischaemic heart disease.

Pathology of gastric lesions in donkeys: A preliminary study

REASONS FOR PERFORMING STUDY

Donkeys (Equus africanus asinus) are important working animals, particularly in countries where the majority of the population lives below the poverty line. Gastric ulceration has been shown to be common in British donkeys but donkeys from other parts of the world have not been as extensively researched.

OBJECTIVES

This study was performed as a preliminary overview of the severity and distribution of gastric lesions in mature donkeys and to document which parasites were present.

STUDY DESIGN

Descriptive study of pathological findings.

METHODS

Stomachs of 35 mature draught donkeys were examined grossly and histopathology samples taken from 5 regions of the gastric mucosa.

RESULTS

Gross examination revealed hyperaemia, oedema, erosions and ulcers in addition to parasitic lesions. Histopathological examination revealed hyperkeratosis, acanthosis, vacuolar degeneration of stratified squamous cells, gastritis, erosions, ulcerations, scarring, hyperactivity of mucus glands, periglandular fibroplasia and parasitic granulomes with infestation by Gasterophilus spp. larvae, Habronema spp. and Draschia megastoma.

CONCLUSIONS

In donkeys, ulceration of the nonglandular regions of the stomach is more prominent than the glandular regions and parasitic infestations were frequent.