Molecular alterations and clinical prognostic factors in resectable non-small cell lung cancer

BACKGROUND

EGFR inhibitor and immunotherapy have been approved for adjuvant treatment in resectable non-small cell lung cancer (NSCLC). Limited reports of molecular and clinical characteristics as prognostic factors in NSCLC have been published.

METHODS

Medical records of patients with resectable NSCLC stage I-III diagnosed during 2015-2020 were reviewed. Real time-PCR (RT-PCR) was performed for EGFR mutations (EGFRm). Immunohistochemistry staining was conducted for ALK and PD-L1 expression. Categorical variables were compared using chi-square test and Fisher's exact test. Survival analysis was done by cox-regression method.

RESULTS

Total 441 patients were included. The prevalence of EGFRm, ALK fusion, and PD-L1 expression were 57.8%, 1.9%, and 20.5% (SP263), respectively. The most common EGFRm were Del19 (43%) and L858R (41%). There was no significant difference of recurrence free survival (RFS) by EGFRm status whereas patients with PD-L1 expression (PD-L1 positive patients) had lower RFS compared to without PD-L1 expression (PD-L1 negative patients) (HR = 1.75, P = 0.036). Patients with both EGFRm and PD-L1 expression had worse RFS compared with EGFRm and PD-L1 negative patients (HR = 3.38, P = 0.001). Multivariable analysis showed higher CEA at cut-off 3.8 ng/ml, pT4, pN2, pStage II, and margin were significant poor prognostic factors for RFS in the overall population, which was similar to EGFRm population (exception of pT and pStage). Only pStage was a significant poor prognostic factor for PD-L1 positive patients. The predictive score for predicting of recurrence were 6 for all population (63% sensitivity and 86% specificity) and 5 for EGFRm population (62% sensitivity and 93% specificity).

CONCLUSION

The prevalence and types of EGFRm were similar between early stage and advanced stage NSCLC. While lower prevalence of PD-L1 expression was found in early stage disease. Patients with both EGFRm and PD-L1 expression had poorer outcome. Thus PD-L1 expression would be one of the prognostic factor in EGFRm patients. Validation of the predictive score should be performed in a larger cohort.

A Phase I Study of the CDK4/6 Inhibitor Palbociclib in Combination with Cetuximab and Radiotherapy for Locally Advanced Head and Neck Squamous Cell Carcinoma

PURPOSE

Palbociclib, a cyclin D kinase 4 (CDK4)/6 inhibitor, has shown radiosensitizing effects in preclinical studies. There is a strong rationale for adding palbociclib to cetuximab and radiotherapy in locally advanced head and neck squamous cell carcinoma (LA-HNSCC), especially in p16-negative HNSCC.

PATIENTS AND METHODS

We conducted a phase I dose-escalation study (NCT03024489) using a classical 3+3 design to determine safety, tolerability, and MTD of palbociclib, cetuximab, and intensity-modulated radiotherapy (IMRT) combination. At the recommended phase II dose (RP2D), additional p16-negative patients were enrolled.

RESULTS

Twenty-seven patients with LA-HNSCC (13 in dose escalation, 14 in expansion) with oropharyngeal (41%) and hypopharyngeal (30%) cancers were enrolled. The MTD was not reached, and the RP2D of palbociclib was established at the full standard palbociclib dose of 125 mg/day for 21 days per cycle, administered for two cycles during IMRT. The most common grade 3-4 toxicities were mucositis (59%), radiation dermatitis (22%), and neutropenia (22%), with a febrile neutropenia rate of 7%. Common genomic alterations included mutations in TP53 (57%), GNAQ (35%), and PIK3CA (17%), and copy-number gains in CCND1 (22%), CCND2 (9%), and EGFR (9%). Overall, p16 expression was positive in 15% of patients. No correlation was observed between p16 status, genomic alterations, and preliminary efficacy. The objective response rate was 84%. The rates for 2-year locoregional control, event-free survival, and overall survival were 73%, 48%, and 71%, respectively.

CONCLUSIONS

The palbociclib, cetuximab, and IMRT combination was well tolerated. The RP2D was established, while no MTD was determined. The regimen demonstrated promising preliminary efficacy, suggesting further investigation is warranted in patients with cisplatin-ineligible p16/human papilloma virus-unrelated LA-HNSCC.

Risk-stratified papillary thyroid microcarcinoma: post-operative management and treatment outcome in a single center

PURPOSE

This article aims to review and assess the post-operative management and treatment outcomes of papillary thyroid microcarcinoma (PTMC) in risk-stratified patients.

METHODS

We retrospectively analyzed the data of PTMC patients who underwent thyroid surgery with or without radioactive iodine treatment (RAI) in a single center between January 2011 and December 2017. Demographic and clinicopathologic data were collected. Risk stratification according to the 2015 American Thyroid Association guideline was applied.

RESULTS

Three hundred forty PTMC patients were included. Post-operative RAI was performed in 216/340 (63.53%) patients. In the non-RAI scenario, there were 122 low-risk and two intermediate-risk patients. In total, 261 (76.77%), 57 (16.76%), and 22 (6.47%) patients were classified as low, intermediate, and high risk, respectively. With a median follow-up time of 36 months (interquartile range: 23, 52), we found unfavorable outcomes (evidenced by imaging or out-of-range serum tumor marker levels: high thyroglobulin [Tg] or rising Tg antibody [TgAb] levels) in 8/340 (2.35%) patients, all of which received RAI. PTMC patients with unfavorable outcomes were stratified as low risk (4/261 [1.53%]), intermediate risk (1/57 [1.75%]), or high risk (3/22 [13.64%]). One death occurred in a patient with initial distant metastasis in the high-risk group. Initial high-risk stratification and initial stimulated Tg (of at least 10 ng/mL) were demonstrated as independent predictors for PTMC unfavorable outcomes (persistent or recurrent disease). Five patients with unfavorable outcomes (four with persistent disease and one with recurrent disease) had abnormal Tg or TgAb values despite unremarkable imaging findings. Moreover, 79/124 (63.71%) patients in the non-RAI scenario were only followed up with neck ultrasound.

CONCLUSIONS

In general, at least 98% of low-risk and intermediate-risk PTMC patients showed favorable outcomes without persistent or recurrent disease, defined by either imaging or serum tumor markers. Nevertheless, aggressive disease could occur in few PTMC patients. Decisions on post-operative management and follow-up may be guided by initial high-risk stratification and initial stimulated Tg levels (≥10 ng/mL) as independent predictors for PTMC unfavorable outcomes. Monitoring using both imaging and serum tumor markers is crucial and should be implemented for patients with PTMC.

Precision and Effects of a Small Meal on DXA-Derived Visceral Adipose Tissue, Appendicular Lean Mass, and Other Body Composition Estimates In Nonobese Elderly Men

BACKGROUND

Information on precision errors and the least significant change (LSC) of dual energy X-ray absorptiometry (DXA)-derived body composition estimates is scarce, particularly for the appendicular lean mass (ALM) and appendicular lean mass index (ALMI). Overnight fasting is recommended for body composition measurements but has not been well tolerated by some elderly patients. This study aimed to establish precision errors and LSC values of body composition estimates in all regions-including visceral adipose tissue (VAT) and ALM-and the ALMI to assess the effect of a small meal on body composition and to estimate the changes it incurred.

METHODOLOGY

Our institutional review board approved the study protocol. Altogether, 36 non-obese men aged ≥60 years, having given written informed consent, underwent body composition assessment after fasting overnight except for water. They underwent DXA scans three times, each time with repositioning (to simulate the clinical setting), the last after consuming a standardized meal (210-250 g and 200 cc of water).

RESULTS

Precision errors and LSC values of DXA-derived body composition estimates in these elderly men tended to be higher than those in reports on younger subjects. Coefficients of variation (CVs (%)) of total bone mass (Tb.BMC) and total lean mass (Tb.LM) were <1%, whereas those of total fat mass (Tb.FM) and total %fat mass (Tb.%FM) were <2%, with LSCs of 45.8 g, 706.52 g, 731.4 g, and 1.15%, respectively. The CVs (LSC) of VAT, ALM, and ALMI were 8.9% (150.65 g), 0.93% (501 g), and 0.94% (0.19), respectively. After meal consumption, the mean changes in Tb.FM, Tb.BMC, and Tb.LM were -100, -8.2, and 440 g, respectively.

CONCLUSIONS

Effects of a small meal on most parameters were trivial, including those for VAT, ALM, and ALMI, where changes were not statistically significant. None exceeded the LSC of ALM and ALMI, suggesting that a small meal is allowable before these measurements.

Iodine-131 metaiodobenzylguanidine (131I-mIBG) treatment in relapsed/refractory neuroblastoma

BACKGROUND

I-meta-iodo-benzylguanidine (I-mIBG) therapy has been used in treatment of for advanced neuroblastoma for many years with promising results. There are several studies regarding predictors and outcomes of I-mIBG therapies in relapsed/refractory neuroblastoma patients.

OBJECTIVE

To identify the predictors and outcomes of I-mIBG treatment in relapsed/refractory neuroblastoma.

METHODS

This study was a retrospective review of 22 patients with high risk stage IV relapsed/refractory neuroblastoma who received at least one cycle of I-mIBG therapy. Patient' characteristics, hematologic toxicity, scintigraphic semi-quantitative scoring, and overall survival were recorded. Factors predicting survival were analyzed.

RESULTS

Twenty-two patients (50% male) with mean age of 3.7 years (4.8 months to 8.3 years) received I-mIBG therapies at an average of 3.8 and mean dose of 136 mCi (5032 MBq) per treatment. Most common acute hematologic toxicity was thrombocytopenia. Overall 5-year survival rate was 37% (95% confidence interval: 16.3-58.0) and median survival time was 2.8 year (95% confidence interval: 1.38-6.34). Patients with rising Curie score of ≥25% upon the second therapy were major determinants of overall survival with poorer response to treatment. At least three treatments of I-mIBG were needed to identify some degrees of survival prolongation (crude hazard ratio: P-value = 0.003). Age, sex, metastatic status, and baseline Curie scoring system were good predictors associated with survival. Seven patients (32%) demonstrated objective responses.

CONCLUSION

Despite multimodality therapy, high risk neuroblastoma had a propensity of treatment failure in terms of relapsed or refractory, with some objective responses after I-mIBG treatments. The declined or non-rising Curie score upon second post-treatment total body scan was an important predictor of survival and aided a decision whether or not to proceed with bone marrow transplantation.

Errors in Patient Positioning for Bone Mineral Density Assessment by Dual X-Ray Absorptiometry: Effect of Technologist Retraining

Improper positioning is one of the factors that can lead to incorrect bone mineral density (BMD) results. This study aimed to assess the frequencies of erroneous positioning during three periods: before retraining of the technologists (BR), after retraining (AR), and at the current timepoint 8 years after retraining (C). The BMD images of the first 150 consecutive patients who underwent DXA of the lumbar spine and hip during each of the three periods were retrospectively reviewed. Patients were excluded if they had severe scoliosis, rendering proper positioning impossible. Each BMD image was assessed by an International Society of Clinical Densitometry certified clinical densitometrist who was blinded to the date of the initial examination. For the lumbar spine in the BR group, the criteria frequently not met were inclusion of both iliac crests (33.8%), straightness (30.3%), and midline positioning (20.4%); the respective frequencies were significantly reduced to 0.8%-5.6%, 2.1%-3.0%, and 0%-2.8% in the AR and C groups (p < 0.05). For the hip in the BR group, the criteria frequently not met were straightness (52.8%) and internal rotation (21.8%); the respective frequencies were significantly reduced to 0%-4.2% and 8.3%-8.4% in the AR and C groups (p < 0.05). Overall improper positioning in the BR group was 49.3% and 57.3% at the lumbar spine and the hip, respectively; the respective frequencies were reduced to 9.3% and 12.7% in the AR group, and to 2.7% and 7.3% in the C group. The least significant change values for the lumbar spine, femoral neck, and total hip also became smaller after retraining. Retraining the technologists improved patient positioning, as evidenced by the decreased frequencies of erroneous positioning and the improved least significant change values after the retraining.

Factors affecting disease-free status of differentiated thyroid carcinoma patients

PURPOSE

The study aim was to assess factors that impact on the outcome of radioiodine therapy in patients diagnosed with differentiated thyroid carcinoma (DTC).

MATERIALS AND METHODS

We performed a retrospective cohort study on 256 patients with DTC who underwent thyroidectomy and received radioiodine therapy during December 2003 to January 2012. All patients were followed up for at least 1 year. They were considered disease- free by the criteria of the revised American Thyroid Association Management Guideline for Patients with Thyroid nodules and DTC (ATA guideline 2009).

RESULTS

On Cox univariate analysis, factors associated with disease-free status were age<45, stage I tumor, low risk group by histopathology, unifocal tumor involvement, stimulated serum Tg level at 1st dose of radioiodine therapy and no distant metastasis from 1st post-treatment WBS (post RxWBS). On multivariate analysis, stage I tumor and stimulated serum Tg level at 1st dose of radioiodine therapy<30 ng/mL were the significant prognostic factors that increased disease-free rate by 1.73 times and 2.60 times, respectively (P-value<0.05).

CONCLUSIONS

Factors affecting the outcome of radioiodine therapy in our study were age, stage, risk of recurrence by histopathology, unifocal tumor involvement and 1st postRxWBS findings. From these factors, stage I tumor and stimulated serum Tg level at 1st dose of radioiodine therapy were independent prognostic factors that substantial increase the disease-free rate.

131I-rituximab treatment in patient with relapsed non-Hodgkin's lymphoma: the first case report in Thailand

Radioimmunotherapy (RIT) with 131-rituximab is a safe and effective treatment in patients with relapsed, refractory follicular lymphoma. The authors demonstrated the first case of 131-rituximab treatment in the patient with relapsed non-Hodgkin's lymphoma (NHL) in Thailand. There was no immediate complication after treatment. Impressive treatment response occurred.

FDG PET with contrast-enhanced CT: a critical imaging tool for laryngeal carcinoma

Fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET) has evolved to be an essential imaging modality in the evaluation of laryngeal carcinoma. Although the modality has limited utility in assessing the extent of the primary tumor, FDG PET has proved to be superior to anatomic modalities in the detection of lymph node and distant metastases. The role of FDG PET in the evaluation of patients with laryngeal tumors that are clinically classified as N0 has not shown consistent usefulness because of the innate resolution limitations of the camera. In the posttherapy setting, however, FDG PET has consistently demonstrated a high negative predictive value in the identification of recurrent disease, both during the course of therapy and during long-term follow-up. In addition, contrast material-enhanced computed tomography (CT) in conjunction with FDG PET has demonstrated a complementary role by allowing for superior anatomic coregistration and therefore more definitive diagnosis. There is sufficient evidence that with further advances in PET technology, this modality will likely become more useful in the detection of small lesions and occult nodal disease, as well as in guiding the management of laryngeal carcinoma.

PET/CT in oral cavity and oropharyngeal cancer in post therapy setting

18F-FDG PET/CT is an immerging tool for follow-up a head and neck cancerpatients. Accurate PET/CT interpretation in a post therapy setting is crucial for proper management. However there are many limitations in post therapy settings. For example, variable degree of normal physiologic uptake is noted. Physiologic processes cannot be identified by symmetrical FDG uptake in a post therapy setting. The present article demonstrates case series including asymmetrical, abnormal, or unusual patterns of FDG uptake within the oral cavity and oropharyngeal structures in both benign and malignant conditions.

Correlation between myocardial perfusion imaging findings and cardiac events

OBJECTIVE

The excellent prognostic value of a normal or near normal stress myocardial perfusion imaging (MPI) has been confirmed in numerous studies. The aim of the present study was to determine the association of MPI findings and cardiac events.

MATERIAL AND METHOD

Consecutive patients referred from January 2003 to December 2004 by Nuclear Medicine Unit in Ramathibodi Hospital for myocardial perfusion imaging were studied. Visual scoring of perfusion images used 17-segments and a scale of 0-4 was done. Sum stress score (SSS) was generated Cardiac death, death from any cause and nonfatal acute myocardial infarction (MI) were considered major cardiac events, and chest pain and late revascularization > 60 days after testing were considered minor cardiac events.

RESULTS

Of the 320 patients studied, 218 subjects who had complete 1-year follow-up, were enrolled. There were 99 patients with normal MPI (SSS < or = 3) and 119 patients with abnormal MPI (SSS > 3). Statistical significance between cardiac events in two groups (p < 0.001) was detected. Among hard events, there were three cardiac deaths (of these, 1 occurred in a patient with normal MPI and 2 in those with abnormal MPI) and no patients had non-fatal MI in both groups. Among minor cardiac events, 17 patients developed chest pain and 11 patients underwent late revascularization. No patient with normal MPI underwent revascularization (included early and late revascularization) was found.

CONCLUSION

These results show that SSS can be used to provide incremental prognostic information beyond clinical data, which confirms the conclusions drawn from the results of previous studies by using nuclear stress test results.