Maximally safe resection followed by hypofractionated re-irradiation for locally recurrent ependymoma in children

BACKGROUND

Treatment failure in children with ependymoma is relatively common, with the majority of events consisting of local failure. Salvage therapy for these children historically had poor results, with repeated local recurrences. To improve these outcomes, we began to offer hypofractionated re-irradiation after resection at first local recurrence. To minimize the duration of therapy, we chose a hypofractionated regimen that has been shown to be well tolerated in adult patients.

PROCEDURE

We performed a review of the experience at the Children's Hospital in Denver and at the Department of Radiation Oncology at the University of Colorado Denver from 1995 to 2008 with hypofractionated re-irradiation after maximally safe resection in children with locally recurrent ependymoma.

RESULTS

Six children with locally recurrent ependymoma were seen in that time period. After maximally safe resection, all six received hypofractionated radiation therapy of 24-30 Gy delivered in three fractions. With a median follow-up of 28 months from the time of re-irradiation, all six children are alive with no evidence of disease. Three children had evidence of radiation necrosis, either clinically or based on imaging, but none required significant intervention.

CONCLUSIONS

Hypofractionated re-irradiation after resection for locally recurrent ependymoma is well tolerated. This approach also appears to provide good local control. Additional follow-up is required to determine the efficacy and potential late effects of hypofractionated re-irradiation in this patient population.

Phase II study of tirapazamine, cisplatin, and etoposide and concurrent thoracic radiotherapy for limited-stage small-cell lung cancer: SWOG 0222

PURPOSE

A SWOG pilot study (S0004) showed that tirapazamine (TPZ) when combined with concurrent chemoradiotherapy yielded a promising median survival of 22 months in limited-stage small-cell lung cancer (LSCLC). We report results of the phase II study designed to confirm this result.

PATIENTS AND METHODS

The concurrent phase consisted of two cycles of cisplatin, etoposide, and once-daily radiation to 61 Gy. TPZ was given at 260 mg/m(2) on days 1, 29, and at 160 mg/m(2) on days 8, 10, 12, 36, 38, and 40. Consolidation consisted of two cycles of cisplatin and etoposide. Complete responders received prophylactic cranial irradiation. Results were considered promising if the median survival time was at least 21 months and of no further interest if < or = 14 months.

RESULTS

S0222 was closed early due to a report of excess toxicity for TPZ in a head and neck cancer trial elsewhere. Of planned 85 patients, 69 were accrued. In 68 assessable patients, 17 (25%) had grade 3 to 4 esophagitis and eight (12%) had grade 3 febrile neutropenia during the concurrent phase. There were three possible treatment-related deaths, two in concurrent phase (one progressive disease not otherwise specified within 30 days, one pericardial effusion) and one in consolidation phase (esophageal hemorrhage). At a median follow-up of 35 months, median progression-free survival was 11 months (95% CI, 10 to 13 months) and median overall survival was 21 months (95% CI, 17 to 33 months).

CONCLUSION

S0222 showed acceptable levels of toxicity and similar promising median survival as S0004. Further study of hypoxia-targeted therapy is warranted in LSCLC.

Surprised by stage III: unexpected N2 lymph node involvement found during surgery for early-stage NSCLC

Dr. Camidge: To summarize, this patient is a relatively young, otherwise healthy female who is status post lobectomy. She has been diagnosed with stage IIIA NSCLC that is EGFR-positive by IHC and FISH, but EGFR and KRAS wild type. Optimal MLNS or MLND is ideally performed in the pre- and/or perioperative setting, but this did not happen in this case. While more extensive examination of the mediastinum after the primary operation could be undertaken--removing some of the unknowns about this patient's true stage and prognosis--the relative risks and benefits of such an additional procedure in the setting of PET-negative microscopic level 7 and 9 disease probably do not justify such an approach. Assuming the absence of additional information, the recommendation of the University of Colorado Clinical Thoracic Oncology program is to commence a course of four cycles of adjuvant cisplatin-based chemotherapy. The pros and cons of postoperative radiotherapy will be discussed with the patient. If she wishes to proceed with PORT, this will commence following the adjuvant chemotherapy. Due to the inadequate lymph node sampling, she would not be eligible for adjuvant therapy as part of the ECOG 1505 trial of cisplatin chemotherapy with or without bevacizumab, but if she declines PORT, she may be eligible for the RADIANT trial of erlotinib vs placebo following her adjuvant cisplatin-based therapy.

Chemoradiation for unresectable stage III non-small cell lung cancer

Patients with unresectable stage III nonsmall cell lung cancer (T4, N3, or bulky N2) live longer if they receive chemotherapy before or concurrent with thoracic irradiation. Randomized clinical trials have shown that concurrent chemoradiation is superior to sequential chemotherapy followed by radiation, with a 20% reduction in the risk of death compared with the sequential approach. However, concurrent chemoradiation is more toxic than the sequential approach, with an increased risk of radiation esophagitis, pneumonitis, and cytopenias, including febrile neutropenia. The phase III trials showing the superiority of the concurrent approach all used cisplatin-based chemotherapy and enrolled patients with a good performance status. For patients who are not eligible for cisplatin, or who have a poor performance status, weight loss, or poor lung function, a sequential approach may be used with full doses of chemotherapy followed by radiation. Another approach currently being studied in phase III trials is to use lower doses of chemotherapy concurrent with radiation followed by full-dose chemotherapy after radiation, so-called concurrent followed by consolidation therapy. Treatment should be planned by the radiation and medical oncologist with careful selection of approach based on the patient's fitness, comorbid medical illness, and size and location of the tumor. The goal of treatment is to maximize efficacy and minimize toxicity that may interfere with delivery of drug or radiation. In the future, more effective, less toxic chemotherapy drugs and better radiation techniques should improve outcomes for patients with unresectable stage III non-small cell lung cancer (NSCLC).

Multi-institutional phase I/II trial of stereotactic body radiation therapy for liver metastases

PURPOSE

To evaluate the efficacy and tolerability of high-dose stereotactic body radiation therapy (SBRT) for the treatment of patients with one to three hepatic metastases.

PATIENTS AND METHODS

Patients with one to three hepatic lesions and maximum individual tumor diameters less than 6 cm were enrolled and treated on a multi-institutional, phase I/II clinical trial in which they received SBRT delivered in three fractions. During phase I, the total dose was safely escalated from 36 Gy to 60 Gy. The phase II dose was 60 Gy. The primary end point was local control. Lesions with at least 6 months of radiographic follow-up were considered assessable for local control. Secondary end points were toxicity and survival.

RESULTS

Forty-seven patients with 63 lesions were treated with SBRT. Among them, 69% had received at least one prior systemic therapy regimen for metastatic disease (range, 0 to 5 regimens), and 45% had extrahepatic disease at study entry. Only one patient experienced grade 3 or higher toxicity (2%). Forty-nine discrete lesions were assessable for local control. Median follow-up for assessable lesions was 16 months (range, 6 to 54 months). The median maximal tumor diameter was 2.7 cm (range, 0.4 to 5.8 cm). Local progression occurred in only three lesions at a median of 7.5 months (range, 7 to 13 months) after SBRT. Actuarial in-field local control rates at one and two years after SBRT were 95% and 92%, respectively. Among lesions with maximal diameter of 3 cm or less, 2-year local control was 100%. Median survival was 20.5 months.

CONCLUSION

This multi-institutional, phase I/II trial demonstrates that high-dose liver SBRT is safe and effective for the treatment of patients with one to three hepatic metastases.

Multi-institutional phase I/II trial of stereotactic body radiation therapy for lung metastases

PURPOSE

To evaluate the efficacy and tolerability of high-dose stereotactic body radiation therapy (SBRT) for the treatment of patients with one to three lung metastases.

PATIENTS AND METHODS

Patients with one to three lung metastases with cumulative maximum tumor diameter smaller than 7 cm were enrolled and treated on a multi-institutional phase I/II clinical trial in which they received SBRT delivered in 3 fractions. In phase I, the total dose was safely escalated from 48 to 60 Gy. The phase II dose was 60 Gy. The primary end point was local control. Lesions with at least 6 months of radiographic follow-up were considered assessable for local control. Secondary end points included toxicity and survival.

RESULTS

Thirty-eight patients with 63 lesions were enrolled and treated at three participating institutions. Seventy-one percent had received at least one prior systemic regimen for metastatic disease and 34% had received at least two prior regimens (range, zero to five). Two patients had local recurrence after prior surgical resection. There was no grade 4 toxicity. The incidence of any grade 3 toxicity was 8% (three of 38). Symptomatic pneumonitis occurred in one patient (2.6%). Fifty lesions were assessable for local control. Median follow-up for assessable lesions was 15.4 months (range, 6 to 48 months). The median gross tumor volume was 4.2 mL (range, 0.2 to 52.3 mL). Actuarial local control at one and two years after SBRT was 100% and 96%, respectively. Local progression occurred in one patient, 13 months after SBRT. Median survival was 19 months.

CONCLUSION

This multi-institutional phase I/II trial demonstrates that high-dose SBRT is safe and effective for the treatment of patients with one to three lung metastases.

Vascular abnormalities in pediatric craniopharyngioma patients treated with radiation therapy

BACKGROUND

Craniopharyngioma is a benign brain tumor that can be treated with some combination of surgery, intracystic chemotherapy and radiation therapy. Treatment for craniopharyngioma, especially radiation therapy, is associated with a variety of long-term toxicities including vascular abnormalities. We report on the incidence of vascular abnormalities seen in the children with craniopharyngioma who received radiation therapy at our institution.

PROCEDURE

We reviewed our experience with craniopharyngioma patients who received radiation therapy from 1995 to 2008. We reviewed clinical data including surgery, chemotherapy, radiation therapy and imaging for vasculopathy.

RESULTS

Twenty of the 22 children with craniopharyngioma who received radiation therapy had imaging available. Six of the 20 were found to have some type of vasculopathy. One had bilateral temporal cavernomas, one had moyamoya syndrome, one had an aneurysm of the internal carotid artery and three children had decreases in the caliber of the carotid or cerebral arteries, but were asymptomatic. Two of the six children with abnormalities also received intracystic bleomycin prior to radiation therapy.

CONCLUSIONS

We report a high incidence of vascular abnormalities in children with craniopharyngioma. The data suggest that intracystic bleomycin may contribute to radiation-related vasculopathy. We now include magnetic resonance angiography as part of our routine follow up in these children.

Microscopic and macroscopic tumor and parenchymal effects of liver stereotactic body radiotherapy

PURPOSE

To describe the histologic and volumetric changes in normal liver tissue after stereotactic body radiotherapy (SBRT) for liver metastases.

METHODS AND MATERIALS

Pre- and post-SBRT imaging studies were analyzed to evaluate the effect of SBRT on normal liver volume (NLV) in 15 patients treated in a prospective clinical trial. Two other patients underwent exploratory surgery after SBRT and histologic analyses of the irradiated liver were performed to characterize the pathologic effects of SBRT.

RESULTS

In the 15 patients studied quantitatively, the total NLV had decreased transiently at 2-3 months after SBRT and then began to regenerate at 3-8 months after SBRT. The median NLV reduction at the maximal observed effect was 315 cm(3) (range, 125-600) or 19% (range, 13-33%). Among the several dosimetric parameters evaluated, the strongest linear correlation was noted for the NLV percentage receiving 30 Gy as a predictor of maximal NLV reduction (r(2) = 0.72). The histologic changes observed 2 and 8 months after SBRT demonstrated distinct zones of tissue injury consistent with localized veno-occlusive disease.

CONCLUSION

The well-demarcated focal parenchymal changes after liver SBRT (demonstrated both radiographically and histologically) within the high-dose zone are consistent with a threshold dose-induced set of phenomena. In contrast, the more global effect of NLV reduction, which is roughly proportional to whole organ dose parameters, resembles more closely an effect determined from radiobiologically parallel architecture. These observations suggest that modeling of normal tissue effects after liver SBRT might require different governing equations for different classes of effects.

Observation of a dose-control relationship for lung and liver tumors after stereotactic body radiation therapy

PURPOSE

To determine prognostic factors for local control of primary or metastatic tumors within the lung or liver treated with stereotactic body radiation therapy (SBRT) within a single institution.

METHODS AND MATERIALS

The records of 141 consecutive patients with 246 lesions treated with three-fraction SBRT from Oct 1999 through Aug 2005 were reviewed. Local control was assessed radiographically. Univariate and multivariate analyses were performed to evaluate the influence of the following factors on local control: total dose, expressed as either nominal prescription dose or equivalent uniform dose (EUD); gross tumor volume; primary site; treatment site (lung vs. other); histologic characteristics (adenocarcinoma vs. other); gender; age; and primary vs. metastatic tumor.

RESULTS

On univariate analysis, increased dose (either nominal or EUD) and smaller gross tumor volume were significant predictors of higher local control. Lesions treated to a nominal dose of 54 Gy or greater had a 3-year actuarial local control rate of 89.3% compared with 59.0% and 8.1% for those treated to 36-53.9 Gy and less than 36 Gy. On multivariate analysis, only increased nominal dose and EUD retained statistical significance. Treatment was well tolerated; 5.7% of patients experienced Grade 3 or higher toxicity.

CONCLUSIONS

This large single-institution series suggests a dose-control relationship within the range of SBRT doses applied. Excellent local control rates are achieved with a nominal dose of 54 Gy or greater, corresponding to an EUD greater than 65.3 Gy. These results support the use of aggressive SBRT regimens when durable tumor control is the primary objective.

Phase III trial of maintenance gefitinib or placebo after concurrent chemoradiotherapy and docetaxel consolidation in inoperable stage III non-small-cell lung cancer: SWOG S0023

PURPOSE

Early clinical studies with gefitinib showed promising efficacy and mild toxicity in patients with advanced non-small-cell lung cancer (NSCLC). Thus, gefitinib was an ideal agent to evaluate in a maintenance setting in stage III disease.

PATIENTS AND METHODS

Untreated patients with stage III NSCLC, a performance score of 0 to 1, and adequate organ function were eligible. All patients received cisplatin 50 mg/m(2) on days 1 and 8 plus etoposide 50 mg/m(2) on days 1 to 5, every 28 days for two cycles with concurrent thoracic radiation (1.8- to 2-Gy fractions per day; total dose, 61 Gy) followed by three cycles of docetaxel 75 mg/m(2). Patients whose disease did not progress were randomly assigned to gefitinib 250 mg/d or placebo until disease progression, intolerable toxicity, or the end of 5 years. The planned sample size was 672 patients to confer power of 0.89 to detect a 33% increase over the expected median survival time of 21 months (one-sided P = .025, log-rank test). Random assignment was stratified by stage, histology, and measurable versus nonmeasurable disease.

RESULTS

Enrollment began in July 2001. An unplanned interim analysis conducted in April 2005 rejected the alternative hypothesis of improved survival at the P = .0015 level for 243 randomly assigned patients. The study closed, and preliminary results were reported. Now, with a median follow-up time of 27 months, median survival time was 23 months for gefitinib (n = 118) and 35 months for placebo (n = 125; two-sided P = .013). The toxic death rate was 2% with gefitinib compared with 0% for placebo.

CONCLUSION

In this unselected population, gefitinib did not improve survival. Decreased survival was a result of tumor progression and not gefitinib toxicity.

Cancer Care Ontario and American Society of Clinical Oncology adjuvant chemotherapy and adjuvant radiation therapy for stages I-IIIA resectable non small-cell lung cancer guideline

PURPOSE

To determine the role of adjuvant chemotherapy and radiation therapy in patients with completely resected stage IA-IIIA non-small-cell lung cancer (NSCLC).

METHODS

The Cancer Care Ontario Program in Evidence-Based Care and the American Society of Clinical Oncology convened a Joint Expert Panel in August 2006 to review the evidence and draft recommendations for these therapies.

RESULTS

Available data support the use of adjuvant cisplatin-based chemotherapy in completely resected NSCLC; however, the strength of the data and consequent recommendations vary by disease stage. Adjuvant radiation therapy appears detrimental to survival in stages IB and II, with a possible modest benefit in stage IIIA.

CONCLUSION

Adjuvant cisplatin-based chemotherapy is recommended for routine use in patients with stages IIA, IIB, and IIIA disease. Although there has been a statistically significant overall survival benefit seen in several randomized clinical trials (RCTs) enrolling a range of people with completely resected NSCLC, results of subset analyses for patient populations with stage IB disease were not significant, and adjuvant chemotherapy in stage IB disease is not currently recommended for routine use. To date, very few patients with stage IA NSCLC have been enrolled onto RCTs of adjuvant therapy; adjuvant chemotherapy is not recommended in these cases. Evidence from RCTs demonstrates a survival detriment for adjuvant radiotherapy with limited evidence for a reduction in local recurrence. Adjuvant radiation therapy appears detrimental to survival in stage IB and II, and may possibly confer a modest benefit in stage IIIA.

Prophylactic Cranial Irradiation for Patients with Lung Cancer

The central nervous system is a common site of metastasis in patients with small cell lung cancer (SCLC) and non-small-cell lung cancer. Despite advances in combined modality therapy, intracranial relapse continues to be a common site of recurrence and a major cause of morbidity for patients with lung cancer. Prophylactic cranial irradiation (PCI) has proven to be effective in reducing the incidence of brain metastases in patients with lung cancer. Based upon results of a metaanalysis demonstrating a small improvement in overall survival, PCI is now routinely offered to patients with limited-stage SCLC after a complete or near-complete response to initial treatment. However, many questions remain unanswered regarding the optimal dose, fractionation, and toxicity of PCI in patients with limited-stage SCLC. Additionally, the role of PCI in patients with extensive-stage SCLC and locally advanced non-small-cell lung cancer is unclear. Several important collaborative group trials are under way in an attempt to further define the role of PCI in patients with lung cancer.

National survey of non-small cell lung cancer in the United States: epidemiology, pathology and patterns of care

PURPOSE

To determine the epidemiology, pathology and patterns of care for patients with non-small cell lung cancer (NSCLC) in the United States.

METHODS

In 2001 the National Cancer Data Base, under direction of the American College of Surgeons, conducted a patient care evaluation study in 719 hospitals. We collected information on patient demographics and histories, diagnostic and staging methods, pathology, and initial treatment.

RESULTS

Information on 40,909 patients was obtained; 93% were smokers. Slightly more than half were older than 70 years; 58.5% were male and 35% had adenocarcinoma. Comorbid conditions were present in 71.8% and 22% had a prior malignancy. A chest CT scan was performed in 92% of patients and PET scans in 19.3%. Mediastinoscopy was performed in 20.3%. 67.2% of patients had Stage III or IV disease. More of the Hispanic, Asian or Black patients than White had Stage IV disease (p<0.01). Treatment was multimodality in a little over 30% of patients. Surgery alone was primarily utilized for patients in Stage I or II. Choice of treatment correlated more with stage and age than comorbidities.

CONCLUSION

Our results substantiated the pattern of increasing proportions of women with NSCLC and the increasing frequency of adenocarcinoma. Most patients presented with Stage III or IV disease. Ethnic minorities were more likely to present in late stage disease than Whites. Treatment strategies depended more on stage and age than comorbid burden. Older patients were less likely to receive surgery and more likely to be treated with radiation only or have no treatment.

Update in the treatment of brain metastases from lung cancer

Brain metastases from lung cancer represent a prevalent and challenging clinical dilemma. The brain is an extremely common site of failure for non-small-cell lung cancer and small-cell lung cancer, often as a solitary site of disease. Despite steady research developments during recent years, survival rates remain poor. Some research suggests that the outcomes and characteristics of brain metastases that result from lung cancer primary sites are perhaps different than those from other primary sites. Clinical treatment strategies should therefore be adjusted accordingly. This article reviews the clinical characteristics, prognostic factors, and treatment strategies of brain metastases from lung cancer with a particular emphasis on recent research developments in the field.

Interim analysis of a prospective phase I/II trial of SBRT for liver metastases

Stereotactic Body Radiation Therapy (SBRT) is a potent means of systemic cytoreductive therapy for selected patients with metastatic cancer. We here report an interim analysis of a prospective Phase I/II study of SBRT for liver metastases. Eligible patients with liver metastases met these criteria: (1) maximum tumor diameter < 6 cm; (2) < or =3 discrete lesions; (3) treatment planning confirmed > or = 700 cm3 of normal liver receives < or =15 Gy. The gross tumor volume (GTV) was expanded 5-10 mm to yield the planning target volume, which received 60 Gy in 3 fractions of SBRT over 3-14 days in the Phase II component of the trial. As of July, 2006, 36 patients have been enrolled: 18 in Phase I, 18 in Phase II. The median age was 58 years (range 27-91); the M:F ratio was 20:16. The most common primary sites were lung (n = 10), colorectal (n = 9), and breast (n = 4). Among 21 pts with > or = 6 months post-SBRT follow-up (median 19 months, range 6-29), one instance of SBRT-related grade 3 toxicity occurred in subcutaneous tissue superficial to the liver. No grade IV toxicity occurred. For 28 discrete lesions treated (median GTV 14 cm3, range 1-98) the 18 month actuarial local control estimate is 93%. This interim analysis indicates that a very high rate of durable in-field tumor control can be safely achieved with SBRT to 1-3 liver lesions as administered in this protocol, to a prescription dose of 60 Gy in 3 fractions.

Long-term survival with concurrent chemoradiation therapy followed by consolidation docetaxel in stage IIIB non-small-cell lung cancer: a phase II Southwest Oncology Group Study (S9504)

PURPOSE

Here we report 5-year survival data from S9504, a Southwest Oncology Group phase II trial evaluating consolidation docetaxel after concurrent cisplatin/etoposide and thoracic radiation therapy in patients with pathologically documented stage IIIB non-small-cell lung cancer. Survival outcomes were compared with a predecessor study (S9019) with identical eligibility, staging criteria, and treatment, excepting docetaxel consolidation.

PATIENTS AND METHODS

Treatment consisted of cisplatin 50 mg/m(2) per day on days 1, 8, 29, and 36; etoposide 50 mg/m(2) per day on days 1-5 and 29-33; and concurrent thoracic radiation therapy (total dose, 61 Gy). Consolidation docetaxel (75 mg/m(2) initial dose) started 4-6 weeks after completion of chemotherapy.

RESULTS

Concurrent chemotherapy was generally well tolerated, with a low level of radiation-related esophagitis; 2 patients died from pneumonitis. Grade 3/4 neutropenia during consolidation docetaxel was common. At a median follow-up of 71 months, median progression-free survival was 16 months; median survival 26 months; and 3-, 4-, and 5-year survival rates were 40%, 29%, and 29%, respectively. Brain metastasis was the most common site of failure. In the predecessor trial S9019, median survival was 15 months, and 3-, 4-, and 5-year survival rates were 17%, 17%, and 17%, respectively.

CONCLUSION

The 5-year survival rate in S9540 of 29% compares favorably with the predecessor trial S9019 and other treatment approaches currently used in this patient population. A phase III trial designed to validate the concept of consolidation docetaxel is presently under way.

Phase II Study of Consolidation Paclitaxel After Concurrent Chemoradiation in Poor-Risk Stage III Non–Small-Cell Lung Cancer: SWOG S9712

Purpose

A previous Southwest Oncology Group (SWOG) study (S9429) demonstrated efficacy and tolerability of concurrent chemoradiotherapy in poor-risk stage III non–small-cell lung cancer (NSCLC). This study evaluated adding consolidation paclitaxel after chemoradiotherapy for a similar patient cohort.

Patients and Methods

Patients with histologically/cytologically determined stage III NSCLC were eligible based on performance status (PS) 2 and either low albumin or weight loss more than 10%, poor pulmonary function, or comorbidities precluding cisplatin use. Treatment was carboplatin 200 mg/m2 days 1, 3, 29, and 31, and etoposide 50 mg/m2 days 1 through 4, and 29 to 32. Beginning day 1, thoracic radiation was delivered at 1.8 Gy in 25 fractions plus 16-Gy boost (total dose, 61 Gy). Patients without disease progression received paclitaxel 175 mg/m2 every 21days for three cycles.

Results

Characteristics of 87 eligible patients were age 51 to 82 years; 57% PS 0 to 1, 43% PS 2; and 51% stage IIIA, 49% stage IIIB. Toxicities of concurrent chemoradiotherapy included grade 3 esophagitis (7%) and grade 3/4 neutropenia (43%). Fifty-four assessable patients received paclitaxel consolidation. Four treatment-related deaths occurred during chemoradiotherapy and four occurred during consolidation. Overall response rate was 53%. Median progression free- and overall survival were 6.1 and 10.2 months, respectively. One- and 2-year survival rates were 43% and 25%.

Conclusion

Compared with a previous SWOG trial in a similar patient population, the addition of consolidation paclitaxel after chemoradiotherapy resulted in increased toxicity without a survival advantage. More PS 2 patients (43% v 18%) enrolled onto S9712, which may explain increased toxicity and lack of benefit. The optimal chemoradiotherapy approach for poor-risk patients remains to be defined.