Evaluation of Fiducial Marker Migration and Respiratory-Induced Motion for Image Guided Radiotherapy in Whole Breast Irradiation

Purpose: Image guided radiation therapy (IGRT) may be beneficial to improve set up accuracy and reduce treatment margins, therefore improving efficacy while decreasing long term toxicity of whole breast irradiation (WBI). In order to assess if intraparenchymal fiducials can facilitate the use of IGRT, this study quantifies fiducial motion over the normal course of whole breast irradiation.Materials and Methods: On a prospective IRB-approved protocol, fiducials were placed in fourteen patients who were then treated with 3D conformal WBI. Three or four intraparenchymal gold fiducial markers were placed in each patient at the periphery of the surgical bed intraoperatively. Free breathing 4D CT image sets were obtained at pre-treatment simulation and then every two weeks over a six week course of treatment. Each fiducial marker was contoured at end-inspiration and end-expiration on all 4D CT image sets. The effects of respiration induced motion were assessed by comparing the positions of the fiducials between inspiration and expiration. Overall fiducial migration was determined by comparing the relative positions of each marker to one another from the pre-treatment and post-treatment 4D CT image sets.Results: The 4D CT image sets were acquired over a period of 55±4 days with a range of 49 to 60 days. The respiration induced fiducial motion, as measured by the average change in the fiducials' center of mass, was 0.8±0.6 mm with a range of 0 to 2.2 mm. The average fiducial displacement over the course of treatment as determined from relative seed position from the image sets was 1.5±1.2 mm with a range of 0.1 to 3.3 mm for all individual fiducials with 71% of the fiducials moving closer to each other and 29% away from each other.Conclusions: The preliminary results of using gold fiducials for breast IGRT are promising. Fiducial position was very stable during treatment, and there was very little respiration induced motion. Using IGRT, there is the potential to improve the accuracy of daily set-up and to reduce margins in WBI. Better tumor bed localization and reduced margin size will decrease the volume of normal tissue treated, which may translate into improved local control by ensuring accurate coverage of the target volumes throughout the treatment course and improvement in cosmesis and other long term toxicities.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4113.

Male breast cancer: follow-up recommendations after surgery

Abstract #4130

Introduction: National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but data on male breast cancers are not collected. As an NCCN institution, our objective was to examine practice patterns and follow-up for male breast cancer.
 Methods: After IRB approval, a prospective breast database from 1990-2008 was queried for male patients. Medical records were examined for traditional factors (TNM, receptor status, treatment, gynecomastia) and follow-up practices such as mammogram use. Survival analysis was performed using the Kaplan-Meier method with 95% confidence intervals (CI) generated for 5-yr estimates. The logrank test was used to compare node positive/negative cohorts.
 Results: Of the 19,132 patients in the database, 71 (0.4%) were male; 64 had complete data. The median age for the 64 patients was 68.8yrs (range 29-85yrs). 89.1% presented with a palpable mass. 12.5% had gynecomastia in the cancer breast and 9.4% had contralateral gynecomastia. 18/64 (28.1%) had a familial history of breast, ovarian or colon cancer. One patient had bilateral synchronous breast cancer. Seven (10.9%) had previous prostate cancer and 4 (6.25%) had other synchronous cancers (2 papillary thyroid, 2 lung). Genetic testing was offered to all 64; 3 accepted. Two men had contralateral prophylactic mastectomy years later. The mean/median invasive tumor size was 2.0/1.6cm (range 0.0-10.0cm) and all but 2 tumors were ductal. 63 had a mastectomy (65.1% with axillary node dissection; 34.9% with sentinel lymph node biopsy). Lymph node involvement occurred in 25/64 (39.1%). Under NCCN guidelines, 49/64 (76.6%) should receive chemotherapy and chest wall radiation should be given to 27/64 (42.2%) based on tumor size and nodal status. Chemotherapy was offered to 50.0%; 35.9% received chemotherapy. Chest wall radiation was given in 59.3%. 63/64 were ER positive; 49 (77.8%) received hormone therapy. Follow-up annual mammograms were obtained in 27/64 (42.2%)[all BIRADs 1 or 2], not obtained in 28/64 (43.8%), and unknown in 9/64 (14.0%). Median follow-up was 26.1mos (range: 0.26-377.8mos). The 5-yr survival estimates and 95% CI for node positive and negative diseases were 75% (95% CI=46-90%) and 93% (95% CI=74-98%) respectively. For comparison, 5-yr survival rates from the NSABP B-04 trial were 60% in node-positive and 75% in node-negative disease. Four patients (6.3%) died of disease; 10 (15.6%) are alive with distant disease; 47 (73.4%) have no evidence of disease; and 3 (4.7%) are unknown or dead of other causes. There were 2 local recurrences (3.1%) [1 chest wall, 1 in-breast] and no metachronous contralateral breast cancer development. Conclusions: Male breast cancer is uncommon, as is contralateral breast cancer. Men were less likely to receive/accept chemotherapy/hormone therapy/genetic testing/annual mammograms and more likely to receive radiation based on NCCN guidelines, but survival compared to historic females was no worse. Creation of follow-up guidelines for males may be different than females.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4130.

Risk factors associated with recent transmission of tuberculosis: systematic review and meta-analysis

A systematic review of published articles was performed to identify risk factors associated with recent transmission of tuberculosis (TB). The computerized search identified studies in PubMed, Ovid, CDSR, CINAHL and EMBASE published between 1994 and 2005. Of 137 articles, 30 satisfied all the inclusion criteria for meta-analysis. A random effects model estimated the odds ratio (OR), confidence interval (CI), and heterogeneity between studies. Recent transmission of TB was associated with: ethnic minority (OR 3.03, 95%CI 2.21- 4.16), being a native of the country (OR 2.33, 95%CI 1.76-3.08), residing in an urban area (OR 1.52, 95%CI 1.35-1.72), drug use (OR 3.01, 95%CI 2.14-4.22), excessive alcohol consumption (OR 2.27, 95%CI 1.69-3.06), homelessness (OR 2.87, 95%CI 2.04-4.02), previous incarceration (OR 2.21, 95%CI 1.71-2.86), human immunodeficiency virus infection/acquired immune-deficiency syndrome (OR 1.66, 95%CI 1.36-2.05), young age (OR 2.09, 95%CI 1.69-2.59), sputum smear positivity (OR 1.39, 95%CI 1.20-1.60) and male sex (OR 1.37, 95%CI 1.19-1.58). The results should be useful for improving prevention and control strategies, thus contributing to a reduction in Mycobacterium tuberculosis transmission.

Elation or frustration? Outcomes following the provision of equipment during the Communication Aids Project: data from one CAP partner centre

BACKGROUND

The Communication Aids Project (CAP) was a 4-year initiative by the UK Department for Education and Skills to provide communication equipment for students who were unable to speak in order to facilitate their access to education. Each child was given three goals or targets which were then evaluated after 6 months of provision of the communication aid.

METHODS

We evaluated the targets of 60 children, between the ages of 3 and 18 years. Six months after receipt of equipment, the targets were mailed to the initial referrer who was requested to record whether the child had achieved, partially achieved or not achieved each target. Evidence and explanations of these outcomes were also requested. Data were analysed using descriptive statistics, and the explanations were grouped into common themes using a keyword analysis.

RESULTS

Sixty-three per cent of targets were not achieved and 36% were achieved. We investigated any possible associations to attempt to explain some of the possible reasons for the children's non-achievement of targets. Targets were grouped into operational, linguistic, social and academic, but there were no differences between the successes because of target type. Age may be an influence on success, but neither school placement or type of communication aid influenced success. The explanations for non-achievement highlighted the misunderstanding or interpreting of the underlying skills of the communication aid user as a potential cause.

CONCLUSION

The CAP raised the profile of children with Augmentative and Alternative Communication needs within education. However, only one-third of the targets of children using the equipment were achieved. The reasons for this include inappropriate provision of equipment, demands of the equipment, lack of appropriate support and targets. The major consequence, however, is the need for detailed assessment and provision appropriate to the individual needs of each child. There is a need for research into the best methods of providing communication aids and the support needed for successful communication.

Atypical cutaneous leishmaniasis cases display elevated antigen-induced interleukin-10

In humans, Leishmania chagasi parasites can produce subclinical infections, atypical cutaneous leishmaniasis (ACL) and visceral leshmaniasis that is potentially fatal if not treated in a timely fashion. L. chagasi parasites that cause both ACL and visceral disease appear to be genetically similar, which suggests that host factors such as the immune response play an important role in controlling infection. We evaluated the immunologic response in ACL using peripheral blood mononuclear cells (PBMCs) of 37 subjects divided into three groups: (i) active ACL cases, (ii) asymptomatic cases and (iii) persons with no history of Leishmania infection. The supernatants of stimulated PBMCs were analysed for production of IL-10, IFN-gamma and IL-2. Robust production of IL-10 in response to Leishmania stimulation was observed in active ACL cases, compared to low levels in asymptomatic cases and negative controls. Serum IgE levels, measured by ELISA, were not significantly different among the three groups. In addition, ACL cases displayed depressed levels of all cytokines in response to mitogen. Thus, this first characterization of the immune response in ACL suggests a role for IL-10 as well as partial immunosuppression.

Phase II trial of bevacizumab plus pemetrexed and carboplatin in previously untreated advanced nonsquamous non-small cell lung cancer

18163

Background: A randomized phase III trial has demonstrated the efficacy and safety of high dose bevacizumab (15 mg/kg) with carboplatin and paclitaxel in previously untreated advanced nonsquamous NSCLC (Sandler et al, NEJM 2006). Pemetrexed has also shown significant activity in advanced NSCLC. Clinical investigation of combination bevacizumab (BEV), pemetrexed (PEM) and carboplatin (CARBO) is therefore of interest in this population. Methods: Phase II, open label study in stage IIIB/IV NSCLC: eligible patients have non- squamous histology and no prior chemotherapy, brain metastasis, gross hemoptysis, tumor proximity to major vessels, uncontrolled hypertension or anticoagulation. All patients receive PEM (500 mg/m2), CARBO (AUC 6) and BEV (15 mg/kg) every 21 days. Patients are pretreated with vitamin B12 1,000 mcg every 9 weeks and folic acid 1 mg daily. Responses are assessed every 2 cycles. Patients with CR, PR or SD receive maximum of 6 cycles followed by BEV (15 mg/kg) maintenance. Our primary objective is to determine time to progression and secondary objectives include response rate, overall survival, and safety of the combination. Results: 14 patients (9 female/ 5 male; median age 62 years; range 34–77; 2 stage IIIB/12 stage IV, all ECOG PS 0 or 1) have been entered. Median number of cycles received is 5.5 (range 2 - 15). 12 patients are evaluable for response. 9 patients continued to have disease control at a median duration of 20.2 weeks (range 5–52) with 6 PRs and 3 SDs (response rate 60%; disease control rate 75%). 5 patients proceeded to BEV maintenance with 2 still ongoing. Overall survival data is immature to date. Toxicity data is available for all patients. Grade 3/4 toxicities have included neutropenia (4), nausea/vomiting (2), BEV related allergic reaction (1) and epistaxis (1). Conclusions: Combination BEV, PEM and CARBO is safe, well tolerated and shows promising activity to date. The regimen is not associated with alopecia, neuropathy or arthralgias/myalgias, and is conveniently administered. Enrollment continues and updated results will be presented.

No significant financial relationships to disclose.

Role of pharmacogenetic studies in early clinical development: Phase I studies with lapatinib

3029

Background: Rash and diarrhea are a class effect of ERBB1 inhibitors. These events are relatively mild with Lapatinib (a dual ERBB1/ERBB2 kinase inhibitor). Finding a genetic basis for patients who may be predisposed to these adverse events, from the outset of clinical development, may improve the understanding of the mechanisms of these side effects and may have implications for use and dosing. Methods: DNA was isolated from peripheral blood of 107 Caucasian subjects from eight monotherapy phase I studies including 73 healthy volunteers and 34 cancer patients, 100 of whom had associated pharmacokinetic data. 284 single nucleotide polymorphisms (SNPs) from five candidate genes of transporters (ABCB1, ABCG2) and enzymes (CYP 3A4 and 3A5, and 2C19) for which lapatinib is a substrate were genotyped and examined for associations with pharmacokinetic variables (dose-normalized AUC, Cmax, and Tmax) as well as rash (15 cases) and diarrhea (18 cases). Results: Skin rash and diarrhea in this phase I cohort were only mild, (i.e. grade I or II). Statistically significant associations were observed between 34 SNPs in CYP2C19, rash (22 SNPs) and diarrhea (6 SNPs), and between 15 SNPs in ABCB1 and Tmax. Notably, 3/3 subjects (2 healthy volunteers, one patient) homozygous for the CYP2C19*2 allele experienced both mild rash and diarrhea. Extensive linkage disequilibrium was observed among these associated SNPs. Conclusions: Our results suggest that it is possible to determine pharmacogenetic associations with side effect phenotypes during the earliest phase of clinical drug development. These results are currently being validated on a larger cohort of patients from phase II lapatinib clinical trials.

[Table: see text]

Evaluating Access to and use of Primary Health Care: Diabetes-related Case Study using the 2002/3 NSW Health Survey

This paper investigates the use of the 2002/3 NSW Health Survey to provide information on access to and use of quality primary health care (PHC) using type 2 diabetes as a case study. The 2002/3 NSW Health Survey is a telephone survey using Computer Assisted Technology to survey a random sample of NSW residents stratified by area health services. We investigated the population characteristics that were associated with access to and use of PHC relating to the diagnosis, proactive management, complication screening and health outcomes of diabetes for participants. Older participants reported increased diabetes, but not diabetes-related risk factors, increased hospitalisation, and increased medication use, but decreased blood pressure screening. Relatively disadvantaged participants reported greater health care needs not reflected in access to and use of health services. While these participants reported increased use of medication to treat diabetes they were less likely to report using three or more accepted management strategies. This work indicates that the NSW Health Survey can provide information on access to and use of health services. Discussion is needed to identify ways in which information on access to and use of PHC can be enhanced.

Evaluation of the efficacy of nebulised lignocaine as adjunctive local anaesthesia for fibreoptic bronchoscopy: a randomised, placebo-controlled study

Optimisation of topical anaesthesia for flexible fibreoptic bronchoscopy (FOB) is becoming increasingly important as a wider range of more complex, and thereby more prolonged, interventional endoscopic procedures are becoming available. Lignocaine is the most commonly used topical anaesthetic agent for bronchoscopy, but there is variability in current practice as to its optimum mode of administration. In this prospective, randomised, placebo-controlled, blinded study, we examine whether there was enhanced effectiveness of additional nebulised lignocaine as compared to our current regime utilising two visual analogue scales as markers of efficacy. Treatment groups were matched in terms of age (p = 0.39), gender, concomitant sedation (p = 0.51 midazolam; p = 0.12 fentanyl) and dose of background administered lignocaine (290 mg). We found no significant additional differences between any of the treatment groups in terms of general ease of procedure (p = 0.09) or in cough severity (p = 0.12). We conclude that this study does not support the hypothesis that additional nebulised lignocaine confers any additional benefit to the ease of procedure or cough severity in patients undergoing fibreoptic bronchoscopy. We suggest that preparation regimes for bronchoscopic examinations need optimization.

Hyperparathyroidism in dogs with hyperadrenocorticism

OBJECTIVES

To assess the effect of canine hyperadrenocorticism (HAC) on parathyroid hormone (PTH), phosphate and calcium concentrations.

METHODS

PTH concentrations and routine biochemical parameters were measured in 68 dogs with HAC. Ionised calcium was measured in 28 of these dogs. The results obtained were compared with an age- and weight-matched group of 20 hospital patients that did not show signs of HAC.

RESULTS

There were significant differences between the PTH, phosphate, alkaline phosphatase, creatinine and albumin concentrations between the two groups. Total and ionised calcium concentrations were not significantly different. Most of the dogs (92 per cent) with HAC had PTH concentrations that were greater than the reference range (10 to 60 pg/ml), and in 23 dogs they were greater than 180 pg/ml. There were significant positive correlations between the PTH and basal cortisol, post-adrenocorticotropic hormone (ACTH) cortisol and alkaline phosphatase concentrations, and also the phosphate and post-ACTH cortisol concentrations.

CLINICAL SIGNIFICANCE

Adrenal secondary hyperparathyroidism is a cause of increased PTH concentrations and may be associated with abnormalities in calcium and phosphate metabolism in dogs with HAC. The findings of this study could explain why canine HAC may cause clinical signs such as calcinosis cutis that are associated with altered calcium metabolism.