Radiotherapy Quality Assurance for the CHHiP Trial: Conventional Versus Hypofractionated High-Dose Intensity-Modulated Radiotherapy in Prostate Cancer

AIMS

The CHHiP trial investigated the use of moderate hypofractionation for the treatment of localised prostate cancer using intensity-modulated radiotherapy (IMRT). A radiotherapy quality assurance programme was developed to assess compliance with treatment protocol and to audit treatment planning and dosimetry of IMRT. This paper considers the outcome and effectiveness of the programme.

MATERIALS AND METHODS

Quality assurance exercises included a pre-trial process document and planning benchmark cases, prospective case reviews and a dosimetry site visit on-trial and a post-trial feedback questionnaire.

RESULTS

In total, 41 centres completed the quality assurance programme (37 UK, four international) between 2005 and 2010. Centres used either forward-planned (field-in-field single phase) or inverse-planned IMRT (25 versus 17). For pre-trial quality assurance exercises, 7/41 (17%) centres had minor deviations in their radiotherapy processes; 45/82 (55%) benchmark plans had minor variations and 17/82 (21%) had major variations. One hundred prospective case reviews were completed for 38 centres. Seventy-one per cent required changes to clinical outlining pre-treatment (primarily prostate apex and base, seminal vesicles and penile bulb). Errors in treatment planning were reduced relative to pre-trial quality assurance results (49% minor and 6% major variations). Dosimetry audits were conducted for 32 centres. Ion chamber dose point measurements were within ±2.5% in the planning target volume and ±8% in the rectum. 28/36 films for combined fields passed gamma criterion 3%/3 mm and 11/15 of IMRT fluence film sets passed gamma criterion 4%/4 mm using a 98% tolerance. Post-trial feedback showed that trial participation was beneficial in evolving clinical practice and that the quality assurance programme helped some centres to implement and audit prostate IMRT.

CONCLUSION

Overall, quality assurance results were satisfactory and the CHHiP quality assurance programme contributed to the success of the trial by auditing radiotherapy treatment planning and protocol compliance. Quality assurance supported the introduction of IMRT in UK centres, giving additional confidence and external review of IMRT where it was a newly adopted technique.

Assessment of the prevalence of Theileria lestoquardi in sheep from the Sudan using serological and molecular methods

Malignant theileriosis of sheep and goats caused by Theileria lestoquardi is considered to be among the most important tick borne diseases in the Sudan. Information on the prevalence of the disease in different parts of the Sudan is limited. The purpose of this study was to estimate the prevalence of the disease in five states of the Sudan using molecular and serological assays. A total of 393 blood and serum samples from clinically asymptomatic sheep were analysed using nested reverse line blot (nRLB) and loop mediated isothermal amplification (LAMP), as well as an enzyme-linked immunosorbent assay (ELISA). The results indicated a sero-prevalence of 33.8% while RLB and LAMP assays revealed molecular prevalences of 29.5 and 22.6% respectively. The prevalence of Theileria lestoquardi varied significantly according to the geographical origin of the infected animals, whereas age and gender did not have a significant effect. RLB data indicated that T. lestoquardi usually occurred as a co-infection with the non-pathogenic Theileria ovis. Using RLB as a gold standard, a sensitivity of 68.1% and a specificity of 96.4% were recorded for LAMP and a sensitivity of 75.9% and a specificity of 83.8% for ELISA. The Kappa coefficient between nRLB and LAMP indicated a significant level of agreement (0.692), but only moderate concordance (0.572) between nRLB and ELISA. The results of the present study confirm and extend earlier findings regarding the widespread of T. lestoquardi infections in sheep in the Sudan. The data provide evidence that should enable the veterinary authorities to deploy appropriate control measures.

Suppressing photorespiration for the improvement in photosynthesis and crop yields: A review on the role of S-allantoin as a nitrogen source

Environmental variations resulting in biotic and abiotic stresses demand adaptive changes in the photosynthetic machinery. To cope with these challenges, plant scientists are constantly striving to enhance photosynthetic activity. The photorespiration pathway, which fixes O₂ and releases CO₂ in C₃ plants, competes with photosynthesis. One method to increase yield would be to enhance photosynthesis by engineering the photorespiratory pathway. To date, three engineered photorespiratory pathways have been produced, of which two have been proven experimentally in the model plant, Arabidopsis thaliana. These approaches might be helpful in enhancing crop resilience to future environmental challenges. In partially photorespiratory suppressed plants, it is hypothesized that a gene cluster may have formed between bacterial glycolate dehydrogenase (GDH), glyoxylate carboligase (GCL), and tartronic semi aldehyde (TSR) genes with Arabidopsis allantoin degradation genes like Arabidopsis allantoinase (AtALN) to utilize S-allantoin as a source of nitrogen. Observations of the use of allantoin as an exclusive source of nitrogen or energy by Arabidopsis and Escherichia coli led us to propose a genetic switch control model between nitrogen assimilation and energy producing pathways in partially photorespiratory suppressed plants.

Cost-of-illness study for non-small-cell lung cancer using real-world data

Background

With recent advances in the treatment of non-small-cell lung cancer (nsclc) and current fiscal constraints within publicly funded health care systems, understanding the real-world economic effect of lung cancer management has become important. The objective of the present study was to determine the costs and resources used in the management of nsclc cohorts in Ontario.

Methods

Patients diagnosed between 1 April 2010 and 31 March 2015 were identified in the Ontario Cancer Registry and linked to provincial administrative databases, capturing resources such as hospitalizations, cancer clinic visits, physician services, and systemic therapies or radiotherapy. A cost-of-illness analysis using a bottom-up approach and the GETCOST macro available at ices determined the overall total and mean costs in 2017 Canadian dollars. Resource utilization results were analyzed according to the total number of encounters per resource, the number of patients using each resource, and the number of encounters per patient. A separate cost-and-resource analysis was conducted for radiotherapy.

Results

The 24,729 nsclc patients identified included 4542 with stage iii unresectable disease and 10,103 with stage iv nonsquamous disease. The overall total cost for all nsclc patients was $1.9 billion, with inpatient hospitalizations ($635.2 million), cancer clinic visits ($323.7 million), and physician services ($301.4 million) being the top cost contributors. The mean cost per patient was $76,816. The total cost of radiotherapy was $38.5 million.

Conclusions

Real-world costs for the management of nsclc during the 5-year period examined were substantial, despite the fact that median survival was poor and treatment information was limited.

Abstract P3-10-11: Clinical implications of 63-gene signature associated with response to PARP inhibition in triple-negative and luminal B breast cancer

Background: Two recent randomized phase 3 trials have demonstrated that treatment with PARP inhibitors results in an improvement in progression-free survival (PFS) in metastatic, BRCA-mutant, HER2-negative breast cancer patients. We have previously identified a pathway-enriched 63-gene expression signature predictive of response to olaparib in seven patient-derived xenograft breast tumors, with a high overall accuracy of 86%. We found that the prevalence of our gene signature was 45% in a cohort of triple-negative breast cancer (TNBC) patients. We wanted to better understand if there were correlations between our 63-gene signature and other known prognostic markers and to determine the prognostic significance of our mutational gene signature in different PAM50 breast cancer subtypes.

Methods: We used a publicly available dataset from the NCI GDC Data Portal of TNBC patients (n = 82) to undertake clinico-pathological correlations with our 63-gene expression signature. We correlated the presence or absence of the signature with age, tumor size, lymph node status, and stage using chi2 analysis, in addition to overall survival (OS) and PFS with STATA SE. We also correlated our gene signature with known TNBC subtypes from TNBCtype. Using the METABRIC cohort (n = 2509), we looked at the mutational frequency of our gene set in cBioPortal in different breast cancer subtypes and determined the prognostic value in each subtype.

Results: We did not find any statistically significant correlations between the 63-gene expression signature and age, tumor size, lymph node status, or stage amongst the 82 TNBC patients. All TNBC subtypes including 2 basal-like, immunomodulatory, low androgen receptor, 2 mesenchymal-based, and unspecified were identified in both gene-signature predicted sensitive and resistant groups, but there were no statistically significant differences between groups. The median follow-up of the TNBC cohort was 24 months, and no statistically significant associations were identified with OS or PFS. In the METABRIC cohort, the mutational frequency of any of the 63 genes for the following subgroups was identified: basal (n = 209), 85.2%; HER2+ (n = 224), 68.8%; claudin-low (n = 218), 48.2%; luminal B (n=475), 25.1%; and luminal A (n=700), 12.7%. The median follow-up of the METABRIC cohort was 127 months. We found that patients with a mutation in any of the 63 genes demonstrated a poorer overall survival, 122.8 months, in comparison to patients without any mutation, 164.6 months (P = 0.0002). In particular, luminal B patients with a mutation in any of these genes demonstrated a poorer overall survival, 90.0 months, in comparison to patients without a mutation, 132.1 months (P = 0.009). No statistically significant difference in overall survival was observed for patients with or without any mutation amongst the luminal A subtype (P = 0.26).

Conclusion: We found that patients with a mutation from our 63-gene set demonstrated a worse prognosis in comparison to patients without a mutation amongst the luminal B subtype. This is suggestive that there may be a role for our 63-gene signature to select patients amongst the luminal B subtype who may benefit from PARP inhibition.

Citation Format: Beniey M, Marois F, Haque T, Hassan S. Clinical implications of 63-gene signature associated with response to PARP inhibition in triple-negative and luminal B breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-10-11.

Solitary ulnar shortening osteotomy for malunion of distal radius fractures: experience of a centre in the UK and review of the literature

INTRODUCTION

Isolated ulnar shortening osteotomies can be used to treat ulnocarpal abutment secondary to radial shortening following distal radius fractures. Given the increase of fragility distal radius fractures awareness of treating the sequelae of distal radius fractures is important. We present the largest reported case series in the UK of ulnar shortening osteotomies for this indication.

MATERIALS AND METHODS

Twenty patients with previous distal radial fractures were included, who presented with wrist pain and radiologically evident positive ulnar variance secondary to malunion of the distal radius with no significant intercalated instability. Patients were treated with a short oblique ulnar shortening osteotomy, using a Stanley jig and small AO compression plate system. Pre- and postoperative radiographical measurements of inclination, dorsal/volar angulation and ulnar variance were made. Patients were scored pre- and postoperatively using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and Patient-Rated Wrist Evaluation scores by two orthopaedic surgeons. Mean follow-up was 24 months after surgery.

RESULTS

Radiographical analysis revealed a change in the ulnar variance with an average reduction of 5.74 mm. Mean preoperative scores were 61.1 (range 25-95.5) for QuickDASH and 70.4 (range 33-92) for Patient-Rated Wrist Evaluation. At the latest follow-up, mean postoperative QuickDASH scores were 10.6 (range 0-43.2) and 17.2 (range 0-44) for Patient-Rated Wrist Evaluation. Differences in scores after surgery for both QuickDASH and Patient-Rated Wrist Evaluation were statistically significant (P < 0.01).

CONCLUSIONS

The ulnar shortening osteotomy is a relatively simple procedure compared with corrective radial osteotomy, with a lower complication profile. In our series, patients showed significant improvement in pain and function by correcting the ulnar variance thus preventing ulna-carpal impaction.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Clinicopathologic Profiles of Malignant Verrucopapillary Lesions of the Oral Cavity

Background: Morphologically, oral SCC (OSCC) may present with verrucopapillary (VP) features. Those with VP features may have a different histologic presentation and different growth pattern. Histologically, papillary SCC, verrucous carcinoma and conventional OSCC (CSCC) with VP features are designated as the verrucopapillary (VP) variants. Aim: The objective of this study was to determine the clinicopathologic profiles of OSCC with VP features and to compare it with OSCC with non-VP features. Methods: A retrospective search of the Malaysian Oral Cancer Database and Tissue Bank System (MOCDTBS) at Oral Cancer Research & Coordinating Center (OCRCC), Faculty of Dentistry, University of Malaya on verrucopapillary OSCC (VP) and nonverrucopapillary OSCC (non-VP) cases diagnosed from 2004 to 2016 was conducted to identify suitable cases for this study. 23 cases of VP and 29 cases of non-VP were studied based on the inclusion criteria. Formalin-fixed paraffin embedded (FFPE) samples from surgical specimens of VP and non-VP were retrieved. All cases were initially reviewed by two oral pathologists and consensus achieved to subdivide into VP and non-VP group. Clinicopathologic parameters were analyzed using frequency and % (for categorical variables). The χ2 test was used for appropriate P values. Results: The age group of VP patients ranged from 38 to 79 years old (mean age, 64.3 ± 11.23 years) while the non-VP group ranged from 20 to 81 years old (mean age, 54.1 ± 12.3 years). Both groups had a female predilection with a male to female ratio of 1:3.8 and 1:1.4 for VP and non-VP patients, respectively. Indians predominated in both the groups and the results were found to be statistically significant ( P < 0.05). Most cases of VP were located on the buccal mucosa (45.8%) while most of non-VPL cases were located on the tongue and floor of the mouth (75.9%). Most of non-VP (85.7%) cases presented with significant lymph node involvement when compared with the VP group (36%), ( P < 0.05). In the VP group, 29.2% were treated by surgical excision alone while 70.8% were treated with a combination of surgical excision with neck dissection. Conclusion: This study showed that patients with OSCC exhibiting VP features were significantly older (> 60 years old). The OSCC with non-VP features behaved more aggressively than the OSCC with the VP features necessitating surgical excision in combination with neck dissection as the preferred treatment modality.

Obesity and weight misperception among adults in the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study

OBJECTIVE

Prior studies have suggested that weight misperception - underestimating one's actual weight - may be associated with reduced engagement in weight loss programmes, decreasing the success of initiatives to address obesity and obesity-related diseases. The purpose of this study was to examine the factors associated with weight misperception among Eastern Caribbean adults and its influence on engagement in weight control behaviour.

METHODS

Data from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study were analysed (adults aged 40 and older, residing in the US Virgin Islands, Puerto Rico, Barbados and Trinidad). Weight misperception is defined as participants who under-assess their weight measured by body mass index (BMI). Multivariable logistic regression (n = 1,803 participants) was used to examine the association of weight misperception with BMI category, age, gender, education, history of non-communicable disease and attempt to lose weight.

RESULTS

Weight misperception was common, with 54% of overweight (BMI 25-29 kg m-2), and 23% of obese class I (BMI 30-34.9 kg m-2) participants under-assessing their actual weight. Participants with higher levels of education, versus lower, had decreased odds of weight misperception (OR 0.5, p < 0.001). There were no significantly reduced odds of weight misperception in women versus men (OR 1.13, p = 0.367) or in individuals with history of diabetes versus none (OR 0.88, p = 0.418). Participants with weight misperception had 85% (p < 0.0001) lower odds of attempting weight loss than those with accurate weight perception.

CONCLUSION

Weight misperception is common among adults with overweight and obesity in the Eastern Caribbean and is associated with lower likelihood of attempting weight loss. Obesity interventions, targeting similar populations, should incorporate approaches for addressing weight misperception to achieve measurable success.

Factor VIII products and inhibitor development in previously treated patients with severe or moderately severe hemophilia A: a systematic review

Essentials Data on product-related immunogenicity in previously treated haemophilia A patients is scarce. A systematic review and meta-analysis of all currently available evidence was conducted. The overall incidence rate was 2.06 per 1000 person-years (95% confidence interval: 1.06-4.01). Some recombinant factor VIII products were associated with increased immunogenicity.

SUMMARY

Background Patients with severe hemophilia A who have been treated extensively with factor VIII products have a low but potentially serious risk of inhibitor development. It is unknown why these patients develop inhibitors, and data on product-related immunogenicity are scarce. Aims To summarize the currently available evidence on the relationship between inhibitor development and recombinant FVIII product type in previously treated patients (PTPs) with severe hemophilia A. Methods Longitudinal studies were included that reported on de novo inhibitor formation in patients with baseline FVIII activity levels of < 0.02 IU mL-1 who had been treated with FVIII for at least 50 days. Pooled incidence rates of inhibitor development according to product types were calculated with a random intercept Poisson regression model. Results Forty-one independent cohorts were included; 39 patients developed de novo inhibitors during 19 157 person-years of observation. The overall incidence rate was 2.06 per 1000 person-years, with a 95% confidence interval (CI) of 1.06-4.01. According to product type, the pooled incidence rates were 0.99 (95% CI 0.37-2.70) per 1000 person-years for patients treated with Advate, 5.86 (95% CI 0.25-134.92) per 1000 person-years for those treated with Kogenate/Helixate, 1.35 (95% CI 0.66-2.77) per 1000 person-years for those treated with Kogenate FS/Helixate NexGen, 12.05 (95% CI 1.53-94.78) per 1000 person-years for those treated with Refacto, and 4.64 (95% CI 0.82-26.43) per 1000 person-years for those treated with Refacto AF. Conclusion These results suggest that some products may be associated with increased immunogenicity. However, the low incidence of inhibitors in PTPs and the differences in study design may cause significant variation in estimates of risk.

Litter Type and Number of Flocks Affect Sex Hormones in Broiler Litter

Broiler litter contains 17β-estradiol, estrone, and testosterone, which can contaminate surface waters when surface applied to grasslands and no-till fields. The objective of this study was to evaluate the effects of litter type (full or cake cleanout), litter treatment (none or sodium bisulfate), and number of flocks raised on the litter (1-5) on sex hormone concentrations. Our results showed that in untreated broiler litter, cake cleanout had greater concentrations of 17β-estradiol, estrone, and testosterone than full cleanout, whereas in litter treated with sodium bisulfate, only the concentration of 17β-estradiol was greater in cake than in full cleanout. The concentrations of 17β-estradiol and estrone in untreated broiler litter increased as the number of flocks increased from one to three, with the largest increase observed for estrone in cake cleanout. We also sampled three broiler houses in brooding and nonbrooding sections during the growout period. We found no differences in hormone concentrations between sections of each house, but changes in hormone concentrations during growout varied depending on broiler litter water content. Water contents corresponding to ∼60% water-filled porosity favored a decrease in hormone concentrations with time, whereas a water-filled porosity of 44% was associated with increases in hormone concentration, probably due to slow decomposition rates. Our results suggest that cake cleanout of untreated litter, as well as all cleanouts from houses that have raised several flocks on the same bedding, may be good targets for treatments that can reduce hormone concentrations before the litter is surface applied to fields.

Pyomyositis of the pectineus muscle in an adolescent male

The 'irritable hip' continues to pose a challenge for clinicians. Even with predictive clinical algorithms, decision making can be difficult. Emergency treatment is required if septic arthritis is suspected. Other differential diagnoses such as transient synovitis, pyomyositis of the pelvic girdle muscles and osteomyelitis must be considered in order to help guide appropriate investigations and allow early treatment. We report the case of a 13-year-old boy presenting to our institution with an acutely painful left hip but still able to weight bear. Despite a fever and raised inflammatory markers, the clinical examination did not correspond to that of an infected hip joint. Urgent magnetic resonance imaging (MRI) confirmed pyomyositis of the pectineus muscle. To our knowledge, this is the first reported case in the literature. The child was treated with seven days of intravenous antibiotics. There was a good clinical response as well as normalisation of the C-reactive protein level and white cell count. The patient was discharged home with a further week of oral antibiotics. Follow-up MRI at two weeks demonstrated a dramatic reduction in the inflammation of the pectineus. At the clinic follow-up appointment, the child was asymptomatic and back to normal function. Pyomyositis is typically found in tropical areas but its rates in temperate climates have been rising. It usually affects large groups of muscles such as the quadriceps and gluteal muscles. MRI is the gold standard investigation. If diagnosed early, the condition can be treated successfully with intravenous antibiotics alone. Given the widespread availability of MRI, we recommend its increased use to distinguish between pyomyositis and other paediatric hip pathologies.