RTOG 0131: Phase II trial of pre-irradiation and concurrent temozolomide in patients with newly diagnosed anaplastic oligodendrogliomas and mixed anaplastic oligodendrogliomas: Relationship between 1p/19q status and progression-free survival

1517

Background: In a previous report, we showed in patients with newly diagnosed anaplastic oligodendrogliomas (AOs) and mixed anaplastic oligoastrocytomas (MAOs) that temozolomide (TMZ) can be given concurrently with radiation therapy (RT) with acceptable toxicity. We have now evaluated the efficacy of this regimen and correlated durability of response with tumor 1p/19q genotype. Methods: A phase II study was performed to evaluate the use of pre-RT TMZ followed by concurrent RT and TMZ in patients with newly diagnosed AO or MAO. The primary endpoint was to determine the pre-RT TMZ six-month progression rate, and secondary endpoints included progression-free survival and overall survival. Results: 40 eligible patients were entered into the trial. Thirty-two patients completed 6 months of pre-RT TMZ and concurrent RT and TMZ. Of the remaining eight patients, 4 withdrew due to toxicity and 4 other patients withdrew from study without evidence of toxicity or pre-RT progression. 1p/19q data are available in 37 cases; 23 tumors had loss of heterozygosity (LOH) of both 1p and 19q (double-deleted) while 14 tumors had LOH of either 1p or 19q (n = 3), or no LOH (n = 11). To date, 11 patients have experienced tumor progression; 1p/19q data are available for 10 of these cases (2 are double-deleted (2/23 = 9%), 8 have at least one intact chromosome (8/14 = 57%). Kaplan-Meier analysis demonstrates that progression free survival is significantly better for the double-deleted group (median time to progression not reached) than for the intact group (median time to progression = 15.2 months, p = 0.001). Overall survival is 98% (39/40) with a median follow-up of 17.5 months (2.8 - 31.1 months). Conclusions: LOH of both 1p and 19q is strongly correlated with a durable response of AO and MAO to a combined regimen of chemotherapy and radiation therapy. Tumors that are intact at 1p and/or 19q progress early despite an aggressive therapeutic regimen. These results suggest that future clinical trials should be prospectively stratified by tumor 1p/19q genotype.

[Table: see text]

An update of phase II results from RTOG 0211: A phase I/II study of gefitinib with radiotherapy in newly diagnosed glioblastoma

1527

Background: The epidermal growth factor receptor (EGFR) pathway is commonly deregulated in GBMs and its activity has been associated with treatment resistance in preclinical models. Accordingly, the Radiation Therapy Oncology Group (RTOG) recently conducted a Phase I/II study of Gefitinib, an EGFR tyrosine kinase inhibitor, in combination with radiotherapy for newly-diagnosed glioblastoma (GBM) patients. Methods: 178 GBM patients were entered on RTOG 0211 (Phase I: 31 patients and Phase II: 147 patients). The maximum tolerated dose (MTD) of Gefitinib was determined to be 500mg in non-EIACD patients, and the Phase II component of RTOG 0211 was continued at this dose level during radiation and as maintenance for 18 months afterward or until disease progression. Results: 119/147 patients completed treatment per protocol and/or with acceptable deviation. The median survival time for all patients in the study was 11.0 months. Progression-free survival was 5.1 months for all patients. When considering only patients who were treated per protocol, the median survival of RTOG 0211 patients was 11.5 months, compared to 11.0 months for historical controls treated in previous RTOG studies (p=0.14). RPA Class IV patients appeared to derive the greatest benefit from Gefitinib when combined with radiotherapy compared to historical controls, although not reaching statistical significance. Molecular and genetic profiling efforts are underway to determine which GBM patients derive greatest benefit from Gefitinib in the upfront setting, which will be reported at the time of the annual meeting. These include markers such as EGFRvIII and PTEN, which have been recently reported to be associated with response to anti-EGFR agents in the recurrent setting, and members of key signal transduction pathways regulated by EGFR. Conclusions: The observed survival advantage of newly-diagnosed GBM patients treated with Gefitinib in combination with radiotherapy compared to historical controls treated on previous RTOG studies does not reach statistical significance. Molecular and genetic profiling efforts are underway to identify subsets of GBM patients who might derive the greatest benefit from Gefitinib in the upfront setting.

No significant financial relationships to disclose.

Prospective neurocognitive effects and quality of life (QOL) in patients with multiple brain metastases receiving whole brain radiation (WBRT) ± thalidomide on radiation therapy oncology group (RTOG) trial 0118

8589

Background: RTOG 0118 was a randomized trial of WBRT (37.5 Gy/15 fractions) ± thalidomide in patients (pts) with brain metastases, which showed no effect on survival (Knisely et al, ASCO, 2005). This analysis examined the relationship between neurocognitive progression (NCP) and QOL in patients on both arms. Methods: NCP was assessed with the Folstein Mini-Mental Status Exam (MMSE) and QOL with the Spitzer QOL Index (SQLI). Pts with MMSE scores below age/education adjusted cutoff levels were considered to have NCP. T-test and Chi-Square statistics were used to determine significant differences in NCP and QOL between the two treatment arms over time. Results: Of 176 pts, 88 and 92% had SQLI and MMSE scores at baseline (43% were below the MMSE cutoff). Baseline SQLI (but not MMSE) was a significant predictor for OS (p=0.034). From baseline, SQLI and MMSE compliance rates were 74 and 60% at 1–2 months (mo), 37 and 29% at 4 mo, and 21 and 19% at 6 months, respectively. While QOL was stable, those who failed to meet MMSE cutoffs increased by 60% by 6 mo, on both study arms. Although a weak correlation (r=.23) existed at baseline between QOL and MMSE for both the WBRT (0.04) and WBRT/thalidomide (0.058) arms, there was no correlation beyond baseline. Conclusions: Baseline QOL is a significant predictor of OS. While QOL remained essentially stable, the degree of neurocognitive decline (60%) over time is concerning. These findings suggest the importance of these outcome measures in pts with brain metastases and the need for interventions to conserve cognitive status. RTOG is developing a trial to study the role of preventive strategies for NCP in brain metastases.

No significant financial relationships to disclose.

Phase I study of concurrent motexafin gadolinium (MGd) with radiation therapy for children with newly diagnosed brain stem gliomas (BSG): A Children’s Oncology Group study

9014

Background: MGd, a radiosensitizer that selectively accumulates in tumors, generates reactive oxygen species intracellularly. In preclinical experiments, MGd enhances RT-induced apoptosis. Methods: A multi-institutional Phase I dose escalation and pharmacokinetic (PK) study was performed in children with newly diagnosed BSG to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT) of MGd administered i.v. 2 to 5 hours prior to involved field radiotherapy (RT) (1.8 Gy/day, total 54 Gy). Cohort 1 received MGd, 1.7 mg/kg/dose M-F × 3 wks and cohort 2 received the same dose M, W and F × 6 wks. The 6 subsequent cohorts of 3 to 6 pts received MGd M-F × 6 weeks at doses of 1.9, 3.4, 4.4, 5.5, 7.1 and 9.2 mg/kg/dose. Serum for PK analysis, and MRI scans (MGd is detectable by MR), were obtained for analysis of drug accumulation and responses. Results: 44 pts (42 fully evaluable for toxicity) with a median age of 6 years (range 2–20) were enrolled. At the 9.2 mg/kg/dose, 2/2 pts experienced DLT. During subsequent expansion of the 7.1 and 5.5 mg/kg/dose cohorts, DLTs, including transaminitis, hypertension and urticaria, were observed in 2/5 and 2/6 pts. At the MTD of 4.4 mg/kg/dose, 1/6 pts had reversible grade 3 serum transaminase elevations. PK analysis showed biphasic elimination with a terminal t 1/2 of 6.4 h. At the MTD, serum MGd concentrations were >250 ng/ml for 24 h. Serum clearance and steady-state volume of distribution were 0.0243 L/h/kg and 0.162 L/kg. MRI for intra-tumoral MGd distribution is ongoing. One patient had a CR and 4 had a PR. The estimated median survival is 10.3 months (95% confidence interval: 8.1 months-11.5 months). Conclusions: The recommended phase II dose of MGd for children with BSG is 4.4 mg/kg/d administered M-F × 6 weeks with involved field RT. A COG phase II trial is planned.

[Table: see text]

Initial report of Radiation Therapy Oncology Group (RTOG) 9802: Prospective studies in adult low-grade glioma (LGG)

1500

Background: Treatment of adult LGG is controversial. Favorable patients (pts) (age <40 years [yrs] who undergo gross total resection [GTR]) are typically observed. Unfavorable pts (age ≥40 who have subtotal resection [STR] or biopsy [B]) are usually given initial radiation therapy (RT), reserving chemotherapy (historically procarbazine, CCNU and vincristine [PCV]) for recurrence. In 1998, the RTOG, in conjunction with SWOG, NCCTG, and ECOG initiated prospective studies of adult LGG, the results of which are reported herein. Methods: Favorable pts were observed postoperatively in a single arm Phase II study (Arm 1). Unfavorable pts were stratified by age, histology, KPS, and presence/absence of contrast enhancement on preoperative magnetic resonance imaging and randomized to either RT alone (54Gy in 30 fractions to a local treatment field) (Arm 2) or RT followed by 6 cycles of standard dose PCV (Arm 3). Reported results include overall survival (OS) rate, median overall survival time (MOST), progression-free survival (PFS) rate, and median progression-free survival time (MPFST). Survival data are compared using Wilcoxon p-values. Results: A total of 362 eligible/analyzable pts were accrued between 1998 and 2002. Median follow-up time is 4 years. For the 111 favorable pts observed on Arm 1, OS at 2- and 5-yrs is 99% and 94%. PFS at 2- and 5-yrs is 82% and 50%. For the 251 unfavorable pts on Arms 2 (RT alone) and 3 (RT+PCV), there was no difference in OS or PFS. OS at 2- and 5-yrs was 87% and 61% with RT alone versus (vs) 86% and 70% with RT+PCV (p=0.72). MOST was not reached in RT alone pts and was 6.0 yrs in RT+PCV pts. PFS at 2- and 5-yrs was 73% and 39% with RT alone vs 72% and 61% with RT+PCV (p=0.38). MPFST was 4.0 yrs with RT alone vs 6.0 yrs with RT+PCV. Acute grade 3–4 toxicity occurred in 9% of pts who received RT alone, 67% who received RT+PCV (mostly hematologic). There were no treatment deaths on either arm. Conclusions: 5-yr PFS was poor in all three arms ranging from 39% to 61%. Only half of favorable pts were disease-free at 5 yrs. In unfavorable pts, there was no OS advantage with the addition of PCV to RT. Both PFS and MPFST were better with the addition of PCV, but not significantly. Analysis of outcome by 1p19q status is pending.

No significant financial relationships to disclose.

Phase II trial of concomitant low dose temozolomide with external beam radiation (EBRT) followed by 12 months of temozolomide and irinotecan for newly diagnosed glioblastoma (GBM): Preliminary results of RTOG 04–20

1510

Background: Irinotecan and temozolomide compare favorably to regimens tested in recurrent GBM. RTOG 04–20 intensifies the Stupp R, et al. (N Engl J Med. 2005 Mar 10;352(10):987–96) adjuvant regimen, using irinotecan and temozolomide in place of temozolomide alone. Methods: Adult patients with newly diagnosed histologically confirmed, supratentorial GBM were eligible. Subjects began temozolomide 75mg/m2 daily the night before initiation of EBRT, and continued until the final day of RT. Pneumocystis prophylaxis was begun prior to RT and for 2 weeks following RT. Within 6 wks after EBRT, subjects with stable or improved MRI were scheduled to receive temozolomide 150mg/m2 on days 1–5, and irinotecan 200mg/m2 on days 1 and 15 of 28 day cycles × 12. Clinical assessments and post contrast MRI are required prior to EBRT, after RT, and after every 2 treatment cycles. Only nonenzyme inducing anticonvulsants were allowed. Results: Accrual of 170 patients was completed in September 2005 with 140 patients currently evaluable. Median age is 57yr, 80% were RPA class III or IV. Prior to cycle 1 of adjuvant therapy, 32 subjects withdrew (20 progressed, 4 toxicity). Of the first 25 subjects receiving irinotecan, 10 suffered grade 3–4 hematologic toxicities in the initial 3 cycles. The protocol was modified by dose reducing irinotecan to 100mg/m2 in cycle 1, escalating to 150 and 200mg/2 in subsequent cycles only if no dose limiting hematologic toxicity occured. No data is yet available on patients who started adjuvant therapy at the lower dose of irinotecan. Diarrhea and constitutional symptoms are the most common nonhematologic toxicies Conclusions: Irinotecan 200mg/m2 days 1 and 15 with temozolomide 150mg/m2 days 1–5 of 28 day cycles was well tolerated treating recurrent GBM, but this regimen was too myelosuppressive when given after concomitant low dose temozolomide and EBRT. Primary outcome data should be available in late 2006.

[Table: see text]

Secondary Analysis of Radiation Therapy Oncology Group study (RTOG) 9310: An Intergroup Phase II Combined Modality Treatment of Primary Central Nervous System Lymphoma

PURPOSE

To determine whether a lower dose of hyperfractionated whole brain radiation reduces central nervous system morbidity without compromising survival for primary CNS lymphoma (PCNSL) patients receiving combined modality treatment.

MATERIALS AND METHODS

One hundred and two patients received a course of pre-radiation chemotherapy, followed by whole brain radiation, followed by cytosine-arabinoside. Initial radiation dose was 45 Gy/25 fractions (RT) then the study was amended to reduce this dose for complete responders to induction chemotherapy to 36 Gy/30 fractions/3 weeks (HFX). Eighty-two patients received radiotherapy and were evaluable for toxicity analysis (66 RT patients and 16 HFX patients). MMSE scores and survival for the 40 patients who received radiotherapy after complete response to chemotherapy (27 RT and 13 HFX) were compared. There were no notable differences in pre-treatment patient characteristics between the RT and HFX groups.

RESULTS

Neurotoxicity: By 4 years, there were 8/82 (10%) grade 5 neurotoxicities which included 2/16 (13%) grade 5 encephalopathies and 0/27 in the RT group of complete responders to chemotherapy. Survival: There was no statistically significant difference in overall or progression-free survival (PFS) between the chemotherapy-complete responders who received RT and HFX. Cognitive function testing: MMSE scores improved at 8 months across both treatment groups. Analysis of the area under the MMSE curve at 8 months showed no statistically significant difference between RT and HFX groups (P=0.81). Leukoencephalopathy occurred later in the HFX group than in the RT patients.

CONCLUSION

Although the HFX schedule represented a 25% reduction in biologically effective tumor dose in comparison, PFS and overall survival were not significantly affected. The HFX regimen delayed but did not eliminate severe neurotoxicity from chemoradiation in PCNSL patients.

A preliminary evaluation of optometric management and referral protocols for pa-tients with diabetic retinopathy

Aim: The purpose of this pilot study was to investigate  the  assessment,  management  and referral practices of South African optometrists in  the  care  of  patients  with  diabetic  retinop-athy  (DR)  and  to  recommend  strategies  to improve  and  standardize  patient  management as required.  Methods:  The  study  design  incorporated quantitative,  qualitative  and  clinical  measures that were administered to fourteen experienced optometrists from the Durban area. The quan-titative measure, the questionnaire in appendix I, evaluated the optometrists’ management pro-tocols of patients with diabetes mellitus (DM).  These  included  the  optometrists’  referral  and co-management practices, their awareness and usage  of  appropriate  guidelines  in  the  man-agement  and  referral  of  these  patients,  their perceived levels of competence and confidence in their education, levels of service offered to the patients and finally the role of Continuous Professional  Development  (CPD).  This  self-report information was supplemented by a set of clinical measures where the study sample grad-ed levels of DR, chose appropriate management options  and  indicated  prognosis  for  disease progression based on a set of slides presented to  them.  Finally  the  fourteen  optometrists,  as well as two ophthalmologists, were interviewed using tailored, semi-structured interview sched-ules. These interviews were used to elaborate and corroborate information obtained from the other two research approaches.  Results:  Descriptive  analysis  was  used  to analyse  the  data  from  the  quantitative  and clinical  measures,  whilst  the  interviews  were analysed  thematically.  Although  86%  of  the sample routinely screened for ocular manifesta-tions of DM, there was no standardization in the criteria used by the fourteen optometrists. Only  15%  of  the  sample  reportedly  assessed their  patients  using  dilated  fundus  examina-tions  (DFE),  which  is  the  internationally  rec-ommended standard of care. The results of the clinical measures indicated that there was a lack of standardization in the management and refer-ral of patients with DR by the study sample, contrary  to  their  own  levels  of  confidence  in their  educational  competencies  regarding  DR and their perception of the level of service that they  offered  to  their  patients.  The  interviews with the optometrists provided crucial insights into this lack of standardised care of patients with DR, with the ophthalmologists confirming the  urgent  need  for  CPD  aimed  at  enhancing clinical  skills  and  ensuring  standardization  in the  management  and  referral  of  patients  with DR.  This finding was particularly relevant for co-management models.Conclusion: This  pilot  study  indicates  that the  performance  of  the  optometrists  (albeit  a relatively small group) in the assessment, man-agement and referral of patients with DR was inconsistent  and  not  in  keeping  with  interna-tionally recommended guidelines. It is recom-mended  that  CPD  programmes  focus  on  the improvement of clinical skills and on the imple-mentation of existing standardised management protocols  for  patients  with  DR.  This  should result in improved patient care, patient confi-dence and loyalty with regard to care received, efficient and effective models of management and  co-management  and  decreased  costs  to patients and the health care system.

Techniques in Cardiology : PDA Closure in Children

BACKGROUND

Transcatheter closure of patent ductus arteriosus (PDA) with various devices has been evaluated worldwide and in selected cases can be performed successfully, thus avoiding the morbidity associated with surgical closure.

METHODS AND RESULTS

A 2 year old female child presented with PDA and aortic angiography showed large PDA (tubular). This defect can be closed nonsurgically by coils and devices. The coil used are normally 0.038" having delivery system called Flipper, but this child had a large PDA and so was closed by thicker coil 0.052" using a coil-Bioptome-sheath system, which is the first reported case from the Armed Forces.

CONCLUSIONS

We report the initial experience at our center of closure of PDA with a new coil-Bioptome-sheath system.

Relationship of proximal fixation to renal dysfunction in patients undergoing endovascular aneurysm repair

Technological advancements have lead to dramatic improvements in stentgraft device design resulting in more trackable delivery systems and transrenal uncovered stents and barbs for better fixation. Transrenal bare-stents may limit stentgraft migration, particularly in patients with short or flared proximal aortic necks. However, potential disadvantages might be in worsening renal function, particularly in patients with preexisting renal insufficiency. We retrospectively analyzed our recent 7 year experience of patients undergoing endovascular aneurysm repair (EVAR) using a variety of stentgrafts with and without transrenal bare-stent fixation. Patients were divided into 2 groups; infrarenal fixation (IRF) vs transrenal fixation (TRF), or patients with preoperative serum Cr values that were normal (= or <1.5 mg/dl) vs slightly elevated (1.6-2 mg/dl), vs markedly elevated (2.1- 3.5 mg/dl). The exclusion criteria included patients with chronic renal insufficiency (CRI) on hemodialysis, and preoperative high-grade renal artery stenoses requiring angioplasty and stenting. Of 705 patients that underwent EVAR, 496 (IRF: 385 [78%], and TRF: 111 [22%]) were available with routine evaluations of serum Cr and CT scans. Preexisting comorbidities, mean procedure contrast volume, and postprocedure follow-up were similar in both groups. In the immediate postoperative period, mean serum Cr did not change significantly in either the IRF group (1.3+/-0.7 mg/dl to 1.2+/-0.9 mg/dl) or the TRF group (1.3+/-0.5 mg/dl to 1.3+/-0.6 mg/dl). Mean serum Cr did, however, significantly increase over longer follow-up in both groups: 1.4+/-0.8 mg/dl for IRF (P<0.03), and 1.5 +/- 0.8 mg/dl for TRF (P<0.01). Cr clearance was similarly unchanged in the immediate postoperative period (58+/-23 to 61+/-25 ml/min/1.73 m2 for IRF group, 53+/-17 to 55+/-17 ml/min/1.73 m2 for TRF group), but was significantly decreased in longer follow-up (53+/-23 ml/min/1.73 m2 for IRF, p<0.02: and 48+/-16 ml/min/1.73 m2 for TRF, P<0.01). There were no significant differences in serum Cr increase (p=0.19) or Cr clearance decrease (p=0.68) between the IRF and TRF groups. Small renal infarcts were noted in 6 patients (1.6%) in the IRF group, and in 8 patients (7%) in the TRF group (p=0.37). Of patients with normal preoperative renal function, renal dysfunction developed in 7.7% of IRF group and 6.1% of TRF group (p=0.76). In patients with preexisting CRI, renal dysfunction developed in 18.2% of IRF group, and 17.1% of TRF group (p=0.95). Eight patients with postoperative renal dysfunction, 5 (1.3%) from IRF group and 3 (2.7%) from TRF group subsequently required hemodialysis, and this difference was not statistically significant (p=0.91). We also analyzed 200 consecutive patients undergoing EVAR with intra-arterial contrast agents with and without preexisting CRI not on dialysis. The groups were identified on the basis of preprocedure serum Cr: group 1 (n=108), Cr less than 1.5 mg/dL (normal range); group 2 (n=65), Cr 1.5 to 2.0 mg/dL; group 3 (n=27), Cr 2.1 to 3.5 mg/dL. Routine precautions in patients with CRI included preoperative intravenous hydration with 2 L of normal saline solution, discontinuation of all nephrotoxic drugs, intraoperative administration of mannitol (0.5 g/kg intravenously), and use of nonionic, low osmolar intra-arterial contrast agent (Omnipaque 350). One-hundred and eight patients had normal renal function (group 1), and 92 patients had preexisting CRI with baseline Cr 1.5 to 2.0 mg/dL (group 2, n=65) or 2.1 to 3.5 mg/dL (group 3, n=27). Comorbid conditions included coronary artery disease (group 1, 51%; group 2, 49%; group 3, 59%), hypertension (group 1, 39%; group 2, 46%; group 3, 52%), and diabetes mellitus (group 1, 25%; group 2, 35%; group 3, 48%). In groups 1, 2, and 3, the mean volume of low osmolar contrast agent used was 210 cc, 160 cc, 130 cc, respectively; hemodynamic instability developed in 3, 1, and 1 patient, respectively. The incidence of postoperative complications between the 3 study groups was not statistically different. In grications between the 3 study groups was not statistically different. In group 1 a transient increase in serum Cr (>30% over baseline and >1.4 mg/dL) was noted in 3 patients (2.7%), 2 of whom (1.9%) required temporary hemodialysis and 1 (0.9%) who died of renal failure. In group 2 a transient increase in serum Cr was noted in 2 patients (3.1%); both patients (3.1%) required temporary hemodialysis, and 1 patient (1.5%) died of renal failure. In group 3 a transient increase in serum Cr was noted in 2 patients (7.4%); 1 patient (3.7%) required temporary hemodialysis, and 1 patient (3.7%) died of renal failure. Perioperative hypotension significantly increased the risk for elevated serum Cr and death (p<0.05), and larger contrast volume was associated with an increase in serum Cr (p<0.05) during the postoperative period. Following EVAR renal function declines slightly with both IRF and TRF. Our data show no overall difference between patients with IRF and TRF with respect to infarcts, decline in renal function, or onset of dialysis. There were a slightly greater number of renal infarcts in the TRF group, but these infarcts were clinically inconsequential. In patients with CRI, EVAR with intra-arterial radiographic contrast agents is believed to impair renal function, and CRI is considered a relative contraindication to the procedure. Results of our investigation indicate that risk for worsening renal insufficiency, dialysis, and death is only slightly and not significantly greater in patients with CRI compared with patients with normal renal function. With appropriate precautions of avoiding perioperative hypotension and limiting the volume of nonionic contrast agents, CRI need not be a contraindication for EVAR with intra-arterial contrast agents.