Toward image-based personalization of glioblastoma therapy: A clinical and biological validation study of a novel, deep learning-driven tumor growth model

Background

The diffuse growth pattern of glioblastoma is one of the main challenges for accurate treatment. Computational tumor growth modeling has emerged as a promising tool to guide personalized therapy. Here, we performed clinical and biological validation of a novel growth model, aiming to close the gap between the experimental state and clinical implementation.

Methods

One hundred and twenty-four patients from The Cancer Genome Archive (TCGA) and 397 patients from the UCSF Glioma Dataset were assessed for significant correlations between clinical data, genetic pathway activation maps (generated with PARADIGM; TCGA only), and infiltration (Dw) as well as proliferation (ρ) parameters stemming from a Fisher-Kolmogorov growth model. To further evaluate clinical potential, we performed the same growth modeling on preoperative magnetic resonance imaging data from 30 patients of our institution and compared model-derived tumor volume and recurrence coverage with standard radiotherapy plans.

Results

The parameter ratio Dw/ρ (P < .05 in TCGA) as well as the simulated tumor volume (P < .05 in TCGA/UCSF) were significantly inversely correlated with overall survival. Interestingly, we found a significant correlation between 11 proliferation pathways and the estimated proliferation parameter. Depending on the cutoff value for tumor cell density, we observed a significant improvement in recurrence coverage without significantly increased radiation volume utilizing model-derived target volumes instead of standard radiation plans.

Conclusions

Identifying a significant correlation between computed growth parameters and clinical and biological data, we highlight the potential of tumor growth modeling for individualized therapy of glioblastoma. This might improve the accuracy of radiation planning in the near future.

SBRT of Spinal Metastases Using a Simultaneous Integrated Boost Concept in Oligometastatic Cancer Patients Is Safe and Effective

(1) Purpose: To assess the safety and effectivity of stereotactic body radiotherapy (SBRT) on spinal metastases utilizing a simultaneous integrated boost (SIB) concept in oligometastatic cancer patients. (2) Methods: 62 consecutive patients with 71 spinal metastases received SIB-SBRT between 01/2013 and 09/2022 at our institution. We retrospectively analyzed toxicity, local tumor control (LC), and progression-free (PFS) and overall survival (OS) following SIB-SBRT and assessed possible influencing factors (Kaplan-Meier estimator, log-rank test and Cox proportional-hazards model). (3) Results: SIB-SBRT was delivered in five fractions, mostly with 25/40 Gy (n = 43; 60.56%) and 25/35 Gy (n = 19, 26.76%). Estimated rates of freedom from VCF were 96.1/90.4% at one/two years. VCF development was significantly associated with osteoporosis (p < 0.001). No ≥ grade III acute and one grade III late toxicity (VCF) were observed. Estimated LC rates at one/two years were 98.6/96.4%, and histology was significantly associated with local treatment failure (p = 0.039). Median PFS/OS was 10 months (95% CI 6.01-13.99)/not reached. Development of metastases ≥ one year after initial diagnosis and Karnofsky Performance Score ≥ 90% were predictors for superior PFS (p = 0.038) and OS (p = 0.012), respectively. (4) Conclusion: Spinal SIB-SBRT yields low toxicity and excellent LC. It may be utilized in selected oligometastatic patients to improve prognosis. To the best of our knowledge, we provide the first clinical data on the toxicity and effectivity of SIB-SBRT in spinal metastases in a larger patient cohort.

[Tumour immunotherapy - mechanism and side effects]

INTRODUCTION

Since the development of the first immune checkpoint inhibitor, a new era in tumour immunotherapy has been initiated and response and survival rates have improved in many tumour entities. Despite this encouraging progress, the number of patients who achieve a durable response is limited by resistance mechanisms, and immune-related adverse events (irAEs) complicate treatment. The mechanism of irAE is not understood in all details. In this review, we summarise the mechanisms of action of immune checkpoint inhibitors, the different forms of irAE and their possible mechanisms of development, and describe possible prevention strategies and treatment options. strategies for prevention and treatment options.

Hypofractionated Stereotactic Radiotherapy vs. Single Fraction Stereotactic Radiosurgery to the Resection Cavity of Brain Metastases after Surgical Resection (SATURNUS trial): A Prospective, Randomized Phase III Trial

PURPOSE/OBJECTIVE(S)

The brain is a common site for metastases. Resection of large or symptomatic metastases is followed by stereotactic radiotherapy to prevent local recurrence. The optimal fractionation scheme is subject of ongoing research. Supported by emerging retrospective data, we hypothesize that hypofractionated stereotactic radiotherapy (HFSRT) is superior to single-fraction stereotactic radiosurgery (SRS) in terms of local control (LC). We designed the SATURNUS trial to prospectively demonstrate the superiority of HFSRT over SRS after resection of brain metastases in terms of LC.

MATERIALS/METHODS

The SATURNUS trial is a prospective, randomized phase III trial, currently recruiting patients at a single institution. Patients are 1:1 allocated to HFSRT or SRS using permuted block randomization. Affiliation to the treatment arm is solely blinded to the neuroradiologist assessing therapy response. HFSRT will be delivered with 6 - 7 x 5 Gy and SRS with 1 x 12-20 Gy, prescribed to the surrounding isodose, depending on cavity size and proximity to structures at risk. For SRS, doses do not exceed the maximum doses according to RTOG 90-05. Case number calculation was based on own institutional data on HFSRT (mean LC rate of 88% at 12 months) and data from large phase III trials on SRS (pooled mean LC rate of 66% at 12 months). Using a Chi-squared test of equal proportions (odds ratio = 1), setting test significance level (α) to 0.05, and allocating an equal number of patients to both treatment arms, 114 patients are needed to detect the superiority of HFSRT in terms of LC at 12 months (primary endpoint) with a power of at least 80%. Estimating a dropout rate of 10%, the case number was set to 126. The trial was registered with clinicaltrials.gov (NCT05160818). The first patient was enrolled in May 2021 and recruitment is ongoing. Patients with up to three resected brain metastases are considered for study participation. Further eligibility criteria are histologically confirmed solid tumor disease, resection cavity diameter ≤ 4 cm, consent to perform adjuvant radiotherapy by an interdisciplinary tumor board, completed wound healing, resection within the last six weeks at the time of study inclusion, age ≥ 18 years, KPS ≥ 60%, adequate contraceptive measures for fertile women / men and written informed consent. Patients are followed up clinically and with MRI at 6 weeks and 3, 6, 9 and 12 months after treatment. LC is assessed according to RANO-BM. Toxicity (CTCAE v4.03) is assessed as a secondary endpoint. The rather broad dose corridors allowed within the trial do justice to clinical reality, however, may represent a limitation of the trial. They are therefore addressed with a predefined subgroup analysis, as will be cavity size, among others. Participation of further study centers is desired. To the best of our knowledge, the SATURNUS trial is the only randomized phase III trial adequately powered to detect the superiority of HFSRT over SRS with regard to LC for resected brain metastases.

RESULTS

To be determined.

CONCLUSION

To be determined.

Hypofractionated stereotactic radiotherapy (HFSRT) versus single fraction stereotactic radiosurgery (SRS) to the resection cavity of brain metastases after surgical resection (SATURNUS): study protocol for a randomized phase III trial

BACKGROUND

The brain is a common site for cancer metastases. In case of large and/or symptomatic brain metastases, neurosurgical resection is performed. Adjuvant radiotherapy is a standard procedure to minimize the risk of local recurrence and is increasingly performed as local stereotactic radiotherapy to the resection cavity. Both hypofractionated stereotactic radiotherapy (HFSRT) and single fraction stereotactic radiosurgery (SRS) can be applied in this case. Although adjuvant stereotactic radiotherapy to the resection cavity is widely used in clinical routine and recommended in international guidelines, the optimal fractionation scheme still remains unclear. The SATURNUS trial prospectively compares adjuvant HFSRT with SRS and seeks to detect the superiority of HFSRT over SRS in terms of local tumor control.

METHODS

In this single center two-armed randomized phase III trial, adjuvant radiotherapy to the resection cavity of brain metastases with HFSRT (6 - 7 × 5 Gy prescribed to the surrounding isodose) is compared to SRS (1 × 12-20 Gy prescribed to the surrounding isodose). Patients are randomized 1:1 into the two different treatment arms. The primary endpoint of the trial is local control at the resected site at 12 months. The trial is based on the hypothesis that HFSRT is superior to SRS in terms of local tumor control.

DISCUSSION

Although adjuvant stereotactic radiotherapy after resection of brain metastases is considered standard of care treatment, there is a need for further prospective research to determine the optimal fractionation scheme. To the best of our knowledge, the SATURNUS study is the only randomized phase III study comparing different regimes of postoperative stereotactic radiotherapy to the resection cavity adequately powered to detect the superiority of HFSRT regarding local control.

TRIAL REGISTRATION

The study was retrospectively registered with ClinicalTrials.gov, number NCT05160818, on December 16, 2021. The trial registry record is available on  https://clinicaltrials.gov/study/NCT05160818 . The presented protocol refers to version V1.3 from March 21, 2021.

Outcome of patients with soft tissue sarcomas of the extremities and trunk treated by (neo)adjuvant intensity modulated radiation therapy with curative intent

BACKGROUND

Soft tissue sarcomas (STS) are a relatively rare group of malignant tumors. Currently, there is very little published clinical data, especially in the context of curative multimodal therapy with image-guided, conformal, intensity-modulated radiotherapy.

METHODS

Patients who received preoperative or postoperative intensity-modulated radiotherapy for STS of the extremities or trunk with curative intent were included in this single centre retrospective analysis. A Kaplan-Meier analysis was performed to evaluate survival endpoints. Multivariable proportional hazard models were used to investigate the association between survival endpoints and tumour-, patient-, and treatment-specific characteristics.

RESULTS

86 patients were included in the analysis. The most common histological subtypes were undifferentiated pleomorphic high-grade sarcoma (UPS) (27) and liposarcoma (22). More than two third of the patients received preoperative radiation therapy (72%). During the follow-up period, 39 patients (45%) suffered from some type of relapse, mainly remote (31%). The two-years overall survival rate was 88%. The median DFS was 48 months and the median DMFS was 51 months. Female gender (HR 0.460 (0.217; 0.973)) and histology of liposarcomas compared to UPS proved to be significantly more favorable in terms of DFS (HR 0.327 (0.126; 0.852)).

CONCLUSION

Conformal, intensity-modulated radiotherapy is an effective treatment modality in the preoperative or postoperative management of STS. Especially for the prevention of distant metastases, the establishment of modern systemic therapies or multimodal therapy approaches is necessary.

RADT-06. SPARING OF MOTOR STRUCTURES IN ADJUVANT RADIATION THERAPY AFTER RESECTION OF BRAIN METASTASES: APPLICATION OF NTMS-DERIVED DTI-BASED MOTOR FIBER TRACKING IN ADJUVANT STEREOTACTIC RT TREATMENT PLANNING

BACKGROUND

Resection of brain metastases (BM) close to the motor cortex and the corticospinal tract (CST) bears a significant risk for treatment-related morbidity. Navigated transcranial mapping (nTMS) combined with diffusion-tensor-imaging (DTI) based fiber tracking (DTI-FTTMS) is a valuable tool to guide the neurosurgeon along the CST to preserve motor function. This study aims to proof the practicability of DTI-FTTMS in local adjuvant stereotactic RT planning in the management of BM. Method: Pre-surgical generated DTI-FTTMS-based CST reconstructions of 24 patients with 25 resected BM were incorporated into the RT planning system and elastic fused with planning imaging. The CST was delineated as the planning risk volume (PRV-FTTMS). Fractionated stereotactic intensity-modulated RT (IMRT) plans (7 x 5 Gy) were retrospectively calculated and then optimized to preserve PRV-FTTMS. Areas covered by the planning target volume (PTV) were not spared (overlap).

RESULTS

In regular plans mean dose (Dmean) of complete PRV-FTTMS was 5.4 ± 2.5 Gy. Regarding PRV-FTTMS portions within the 8.75 Gy (25% of prescription dose) isodose level Dmean was 18.2 ± 4.3 Gy and after plan optimization 13.1 ± 3.8Gy (-28.0%, p &lt; 0.001). Within the 17.5 Gy (50%) isodose line PRV-FTTMS Dmean was reduced by 31.7% from 24.3 ± 3 Gy to 16.6 ± 4.8 Gy (p&lt; 0.001). There was no decline of the effective treatment dose, PTV Dmean in regular plans was 36.9 ± 0.7 Gy vs. 37.7 ± 1.4Gy (p=0.013) after adaption. PTV coverage (V35Gy(%)*100) did not change with plan optimization: 0.99 vs. 0.99 (p=0.43). Dose constraints of organs at risk were all met both in regular and optimized plans.

CONCLUSION

DTI-FTTMS based motor tracts could be implemented in the adjuvant stereotactic RT planning of cavities after resection of BM. A significant dose reduction of motor structures within critical dose levels seems possible without reducing PTV treatment dose. However, the functional benefit needs to be investigated prospectively within clinical trials.

Quality of life in patients treated with radiochemotherapy for primary diagnosis of anal cancer

Anal cancer and the related treatment are generally known to affect patients’ quality of life. The aim of this study was to assess self-reported quality of life (QoL) of anal cancer patients after combined radiation and chemotherapy, and to identify patient-, disease-, and therapy-related factors associated with QoL. A total of 94 patients treated with definitive chemoradiation for anal cancer at our institution in the period from 2004 to 2018 were identified from our database. QoL was assessed in the remaining 52 patients using the EORTC QLQ-C30 questionnaire (cancer-specific QoL) and the newly developed anal cancer module QLQ-ANL27 (site-specific QoL). Differences in QoL between anal cancer patients and a German age and sex adjusted reference population were examined. The median follow-up was 71 months (range, 7–176). In the cancer-specific QoL module, the anal cancer cohort presented with significantly lower scores in role (− 12.2 points), emotional (− 6.6 points), and social functioning (− 6.8 points), but higher scores in diarrhea (+ 36.3 points) and constipation (+ 13.3 points) than the German reference population. There were no significant differences in disease- or therapy-related factors, but age greater than 70 years and a follow-up time greater than 71 months had a negative impact on global QoL. As for the site-specific QoL, patients with a tumor relapse showed significantly higher symptom scores than patients with a complete clinical remission in all scales except of micturition frequency. Compared to 3D conformal radiotherapy, IMRT treatment seemed to improve non-stoma bowel function (+ 23.3 points), female sexual functioning (+ 24.2 points), and came along with less scores in the symptom scales pain (− 35.9 points), toilet proximity (− 28.6 points), and cleanliness (− 26.2 points). Most of the functional scores of anal cancer patients were lower compared to the general German population, but did not seem to affect the general QoL. Fatigue, physical, and role functioning had the strongest impact on global QoL causing psychological symptoms as important as physical.

Outcomes after stereotactic radiosurgery of brain metastases in patients with malignant melanoma and validation of the melanoma molGPA

INTRODUCTION

Malignant melanoma is the third most common primary in the diagnosis of brain metastases. Stereotactic radiosurgery (SRS) is a well-established treatment option in limited brain disease. We analyzed outcomes of SRS with a particular focus on the graded prognostic assessment (GPA, melanoma molGPA), prognostic factors, and toxicity.

METHODS

We evaluated 173 brain metastases in 83 patients with malignant melanoma. All were treated with SRS median dose of 20 Gy prescribed to the 80 or 100% isodose line between 2002 and 2019. All patients were followed-up regularly, including contrast-enhanced brain imaging as well as clinical examination, initially 6 weeks after treatment, then in quarterly follow-up.

RESULTS

The median age was 61 years (range 27-80); 36 female and 47 male patients were treated. After a median follow-up of 5.7 months, median OS (overall survival) was 9.7 months 95%-KI 4.7-14.7). LC (local control) at 6 months, 12, 24 months was 89%, 86%, and 72%, respectively (median was not reached). Median DBC (distant brain control) was 8.2 months (95%-KI 4.7-11.7). For OS, a KPS ≥ 80%, a positive BRAF mutation status, a small PTV (planning target volume), the absence of extracranial metastases, as well as a GPA and melanoma molGPA > 2 were prognostic factors. In the MVA, a small PTV and a melanoma molGPA > 2 remained significant.

CONCLUSION

The present survival outcomes support the use of the disease-specific melanoma molGPA as reliable prognostic score. Favorable outcomes for SRS compared to other studies were observed. In the treatment of brain metastases of malignant melanoma patients, a multidisciplinary approach consisting of surgery, SRS, chemotherapy, and immunotherapy should be considered.

A new, innovative, and safe treatment in vitiligo: Results of a randomized, double-blinded, parallel-group study

Vitiligo is a chronic autoimmune disease affecting around 1% of the population worldwide. No existing treatment is giving fully satisfactory results. Further investigations are welcomed for innovative and safe treatments bringing better results. This trial aimed to compare the efficacy and tolerance of various treatment protocols on vitiligo lesions. Four randomized groups of 10 patients with vitiligo covering 8% to 14% of skin surface, except hands and feet were assigned during 8 weeks to (a) UVB microphototherapy 300 to 320 nm (Bioskin-) 1 x week; (b) VITILSI- gel 2 x day; (c) VITILSI- gel 2xday + Bioskin- 1 x week; and (d) placebo 2 x day. Efficacy of the treatment was assessed by planimetry, comparing the photographs of the patients taken at baseline and after 8-week treatment. After completion of the treatment, the increase of the pigment area was 28% in G1 (Bioskin-), 19% in G2 (VITILSI-), 41% in G3 (Bioskin- + VITILSI-) and null in G4. No subject stopped the treatment and no side effect was observed. It was demonstrated that the gel under study was able per se to induce repigmentation in vitiligo lesions and that the results were significantly better when combined with NB-UVB. The protocols used in this trial resulted safe and efficient.

Is local radiotherapy a viable option for patients with an opening of the ventricles during surgical resection of brain metastases?

Background

Local hypofractionated stereotactic radiotherapy (HFSRT) of the resection cavity is emerging as the standard of care in the treatment of patients with a limited number of brain metastases as it warrants less neurological impairment compared to whole brain radiotherapy. In periventricular metastases surgical resection can lead to an opening of the ventricles and subsequently carries a potential risk of cerebrospinal tumour cell dissemination. The aim of this study was to assess whether local radiotherapy of the resection cavity is viable in these cases.

Methods

From our institutional database we analyzed the data of 125 consecutive patients with resected brain metastases treated in our institution with HFSRT between 2009 and 2017. The incidence of LMD, overall survival (OS), local recurrence (LC) and distant recurrence were evaluated depending on ventricular opening (VO) during surgery.

Results

From all 125 patients, the ventricles were opened during surgery in 14 cases (11.2%). None of the patients with VO and 7 patients without VO during surgery developed LMD (p = 0.371). OS (p = 0.817), LC (p = 0.524) and distant recurrence (p = 0.488) did not differ in relation to VO during surgical resection. However, the incidence of distant intraventricular recurrence was slightly increased in patients with VO (14.3% vs. 2.7%, p < 0.01).

Conclusion

VO during neurosurgical resection did not affect the outcome after HFSRT of the resection cavity in patients with brain metastases. Particularly, the incidence of LMD was not increased in patients receiving local HFSRT after VO. HFSRT can therefore be offered independently of VO as a local treatment of tumor bed after resection of brain metastases.

Stereotactic irradiation of the resection cavity after surgical resection of brain metastases - when is the right timing?

Purpose: This study aimed to evaluate whether an early beginning of the adjuvant stereotactic radiotherapy after macroscopic complete resection of 1-3 brain metastases is essential or whether longer intervals between surgery and radiotherapy are feasible.Material and methods: Sixty-six patients with 69 resection cavities treated with HFSRT after macroscopic complete resection of 1-3 brain metastases between 2009 and 2016 in our institution were included in this study. Overall survival, local recurrence and locoregional recurrence were evaluated depending on the time interval from surgery to the start of radiation therapy.Results: Patients that started radiotherapy within 21 days from surgery had a significantly decreased OS compared to patients treated after a longer interval from surgery (p < .01). There was no significant difference between patients treated ≥ 34 and 22-33 days from surgery (p = .210). In the univariate analysis, local control was superior for patients starting treatment 22-33 days from surgery compared to a later start (p = .049). This effect did not prevail in a multivariate model. There was no significant difference between patients treated within 21 days and patients treated more than 33 days after surgery (p = .203). Locoregional control was not influenced by RT timing (p = .508).Conclusion: A short delay in the start of radiotherapy does not seem to negatively impact the outcome in patients with resected brain metastases. We even observed an unexpected reduction in OS in patients treated within 21 days from surgery. Further studies are needed to define the optimal timing of postoperative radiotherapy to the resection cavity.

Personalized Radiotherapy Design for Glioblastoma: Integrating Mathematical Tumor Models, Multimodal Scans, and Bayesian Inference

Glioblastoma (GBM) is a highly invasive brain tumor, whose cells infiltrate surrounding normal brain tissue beyond the lesion outlines visible in the current medical scans. These infiltrative cells are treated mainly by radiotherapy. Existing radiotherapy plans for brain tumors derive from population studies and scarcely account for patient-specific conditions. Here, we provide a Bayesian machine learning framework for the rational design of improved, personalized radiotherapy plans using mathematical modeling and patient multimodal medical scans. Our method, for the first time, integrates complementary information from high-resolution MRI scans and highly specific FET-PET metabolic maps to infer tumor cell density in GBM patients. The Bayesian framework quantifies imaging and modeling uncertainties and predicts patient-specific tumor cell density with credible intervals. The proposed methodology relies only on data acquired at a single time point and, thus, is applicable to standard clinical settings. An initial clinical population study shows that the radiotherapy plans generated from the inferred tumor cell infiltration maps spare more healthy tissue thereby reducing radiation toxicity while yielding comparable accuracy with standard radiotherapy protocols. Moreover, the inferred regions of high tumor cell densities coincide with the tumor radioresistant areas, providing guidance for personalized dose-escalation. The proposed integration of multimodal scans and mathematical modeling provides a robust, non-invasive tool to assist personalized radiotherapy design.

Impact of PET-imaging during treatment planning on outcome in meningioma patients

e13542

Background: Modern radiotherapy (RT) techniques such as IMRT combined with IGRT increased safety and precision over the years. However, during treatment planning, the definition of the planning target volume (PTV) remains challenging, and differentiation between healthy tissue, i.e., meninges, post-operative changes, and residual tumor can be difficult using MR and CT imaging alone. In this study, we evaluated the impact of additional PET-imaging on local control (LCR) and overall survival (OS). Methods: We analyzed 351 patients with primary RT of meningiomas treated between 1996 and 2018 and divided the cohort into low-grade (n = 283) and high-grade (n = 68) cases. All patients were treated with fractionated stereotactic radiotherapy (FSRT) with a median dose of 54.0 Gy and a median single dose of 1.8 Gy. A radiation oncologist delineated PTV based on diagnostic CT and MRI and, if available, additional PET-imaging. We used only PET-images acquired within 50 days before RT. In our clinic, PET-planned meningioma treatment started in 2000 with Methionine (2001-2010), between 2004 and 2011 F-18 FET tracer was used, and since 2011 only 68Ga-Dotanoc/Dotatoc PETs are acquired. This study is registered under the open science framework: DOI 10.17605/OSF.IO/RYX9D. Results: Median follow-up was 6.9 years (95%-KI: 6.3-7.4). For low-grade meningiomas, mean OS was 15.5 years (95%-KI: 14.7-16.2) and mean PFS was 15.7 years (95%-KI: 14.9-16.6); for high-grade cases, median OS was 13.8 years (95%-KI: 10.4-17.1), and median PFS was 8.9 years (95%-KI: 6.4-11.4). PET imaging had a significant impact on OS (p = 0.030) and PFS (p = 0.023) for low-grade meningiomas; however, in the multivariate analysis (with the prognostic factors age, gender, PTV, Karnofsky index, and time from resection to RT), it remained only significant for LCR. For high-grade cases, PET-imaging had no influence. Conclusions: PET-imaging improves the detection of tumor cells, especially during treatment planning. It showed a significant influence on OS and LCR. Further analyses will investigate the influence of PET regarding, e.g., residual tumor tissue, tumor size, and establish cut-off values for which tumors additional PET-imaging might be beneficial. With the further prognostic a weighted scoring system will be developed for prognostic assessment. [Table: see text]

Moderne Verfahren für die Strahlentherapie von Hirntumoren und Tumoren der Schädelbasis

Die moderne Radioonkologie verfügt über eine Reihe hochmoderner Techniken, sodass die Therapiekonzepte und Entscheidungen individualisiert vorgenommen werden. Moderne Techniken ermöglichen eine hohe lokale Dosisdeposition bei optimaler Schonung von gesundem Normalgewebe. Diese Entwicklungen haben die therapeutische Breite der Strahlentherapie entscheidend verbessert. Molekulare Eigenschaften von Tumoren bestimmen heute die Therapieentscheidung im interdisziplinären Kontext sowohl für primäre als auch für sekundäre Hirntumoren. Vor allem Patienten mit Tumoren an der Schädelbasis profitieren von einer hochpräzisen Strahlentherapie, hier kann die Bestrahlung oft auch als Alternative zu Resektion gesehen werden.

Multicenter analysis of stereotactic radiotherapy of the resection cavity in patients with brain metastases

Brain metastases show a recurrence rate of about 50% after surgical resection. Adjuvant radiotherapy can prevent progression; however, whole-brain radiotherapy (WBRT) can be associated with significant side effects. Local hypofractionated stereotactic radiotherapy (HFSRT) is a good alternative to provide local control with minimal toxicity. In this multicenter analysis, we evaluated the treatment outcome of local HFSRT after resection brain metastases in 181 patients. Patient's characteristics, treatment data as well as follow-up data were collected and analyzed with special focus on local control, locoregional control and survival. After a median follow-up of 12.6 months (range 0.3-80.2 months), the crude rate for local control was 80.5%; 1- and 2-year local recurrence-free survival rates were 75% and 70% (median not reached). Resection cavity size was a significant predictor for local recurrence (P = 0.033). The median overall survival was 16.0 months. Both graded prognostic assessment score and recursive partitioning analysis were accurate predictors of survival. HFSRT leads to excellent local control and has a high potential to consolidate results after surgery; acute and late toxicity is low. Distant intracerebral metastases occur frequently during follow-up, and therefore, a close patient monitoring needs to be warranted if whole-brain radiotherapy is omitted.

Psychosocial problems in traumatized refugee families: overview of risks and some recommendations for support services

This article is an abridged version of a report by an advisory council to the German government on the psychosocial problems facing refugee families from war zones who have settled in Germany. It omits the detailed information contained in the report about matters that are specific to the German health system and asylum laws, and includes just those insights and strategies that may be applicable to assisting refugees in other host countries as well. The focus is on understanding the developmental risks faced by refugee children when they or family members are suffering from trauma-related psychological disorders, and on identifying measures that can be taken to address these risks. The following recommendations are made: recognizing the high level of psychosocial problems present in these families, providing family-friendly living accommodations, teaching positive parenting skills, initiating culture-sensitive interventions, establishing training programs to support those who work with refugees, expanding the availability of trained interpreters, facilitating access to education and health care, and identifying intervention requirements through screening and other measures.

Getting personal: Endogenous adenosine receptor signaling in lymphoblastoid cell lines

Genetic differences between individuals that affect drug action form a challenge in drug therapy. Many drugs target G protein-coupled receptors (GPCRs), and a number of receptor variants have been noted to impact drug efficacy. This, however, has never been addressed in a systematic way, and, hence, we studied real-life genetic variation of receptor function in personalized cell lines. As a showcase we studied adenosine A2A receptor (A2AR) signaling in lymphoblastoid cell lines (LCLs) derived from a family of four from the Netherlands Twin Register (NTR), using a non-invasive label-free cellular assay. The potency of a partial agonist differed significantly for one individual. Genotype comparison revealed differences in two intron SNPs including rs2236624, which has been associated with caffeine-induced sleep disorders. While further validation is needed to confirm genotype-specific effects, this set-up clearly demonstrated that LCLs are a suitable model system to study genetic influences on A2AR response in particular and GPCR responses in general.

Radiotherapy plus concomitant temozolomide in primary gliosarcoma

Clinical guidelines for gliosarcoma (GSM) are poorly defined and GSM patients are usually treated in accordance with existing guidelines for glioblastoma (GBM), with maximal surgical resection followed by chemoradiation with temozolomide (TMZ). However, it is not clear yet if GSM patients profit from TMZ therapy and if O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation is crucial. We retrospectively evaluated 37 patients with histologically proven, primary GSM who had received radiation therapy since the temozolomide era (post-2005). Twenty-five patients (67.6 %) received combined chemoradiation with temozolomide, and 12 cases (32.4 %) received radiation therapy alone. Molecular markers were determined retrospectively. Survival and correlations were calculated using log-rank, univariate, and multivariate Cox proportional hazards-ratio analyses. All cases were isocitrate dehydrogenase 1 (IDH1) wildtype, MGMT promoter methylation could be observed in 33.3 % of the assessable cases (10/30) and TERT promoter mutation was seen in a high frequency of 86.7 % (26/30). The influence of TMZ therapy on overall survival (OS) was significantly improved compared with cases in which radiation therapy alone was performed (13.9 vs. 9.9 months; p = 0.045), independently of MGMT promoter methylation. The positive effect of TMZ on OS was confirmed in this study's multivariate analyses (p = 0.04), after adjusting our results for potential confounders. In conclusion, this study demonstrates that concomitant TMZ together with radiation therapy increases GSM-patient survival independent of MGMT promoter methylation. Thus, GSM can be treated in accordance to GBM guidelines. MGMT promoter methylation was infrequent and TERT promoter mutation common without influencing the survival rates. The mechanisms of TMZ effects in GSM are still not fully understood and merit further clinical and molecular-genetic and -biological evaluation.

Intracranial tumour haemorrhage following intravenous thrombolysis

Intravenous administration of thrombolytic agents is considered to be contraindicated in patients with intracranial neoplasms. However, only a single case of thrombolysis-related intracranial tumour haemorrhage has been reported to our knowledge and several studies have suggested that systemic thrombolysis can be safely carried out in these patients. Here we report a patient who developed haemorrhage into a previously unknown intracranial tumour following intravenous thrombolysis for acute myocardial ST-elevation infarction. Identification of abnormal tissue during surgical haematoma evacuation initiated histopathological examination which revealed meningioma World Health Organization Grade I. Intracranial tumours may represent the causative pathology in cases of thrombolysis-related intracranial haemorrhage and this should be considered in the treatment of these patients.

Efficacy of topical 4% Quassia amara gel in facial seborrheic dermatitis:a randomized, double-blind, comparative study

BACKGROUND

Seborrheic dermatitis (SD) is a chronic mild skin disorder with high prevalence. Various treatment options are available, including topical antifungals and anti-inflammatories. Antifungal and anti-inflammatory properties of Quassia amara have been reported.

AIM

To check the efficacy and safety of a topical gel with 4% Quassia amara extract and compare it with topical 2% ketoconazole and 1% topical ciclopiroxolamine in the treatment of facial SD.

METHODS

A group of 60 patients displaying facial SD were randomly distributed in 3 groups and given either a topical gel with 4% Quassia amara extract, a topical gel with 2% ketoconazole, or a topical gel with 1% ciclopirox olamine for 4 weeks. Disease severity was assessed at the start and weekly along treatment, as well as 4 weeks after the end of treatment. In each selected area, severity of erythema, scaling, pruritus, and papules were scored from 0 to 3, the sum of these values representing the score of SD on the face. This evaluation was conducted at each visit. The decrease in SD score with all 3 products was compared at each visit. At each stage, overall improvement, safety, and tolerability were also assessed.

RESULTS

Of the 60 patients, 54 (90%) completed the study. The 3 therapeutic options resulted to be very effective, with a significant advantage in efficacy for 4% Quassia extract. For the other 2 drugs, the results were in line with those previously published in the literature.

CONCLUSION

Topical gel with 4% Quassia extract represents a new, safe, and effective treatment for facial SD.

Article Commentary: OB-GYN Surgeries: Why We Should Recommend to Our Patients a Preventive Management for Keloids and Hypertrophic Scars

As with all surgical specialties, gynecologists and obstetricians routinely employ surgical interventions, depending on the exact nature of the problem that they are treating. Surgery is the mainstay of gynecological therapies, and in obstetrics, surgery is frequent.

Ion optical design of a collinear laser-negative ion beam apparatus

An apparatus for photodetachment studies on atomic and molecular negative ions of medium up to heavy mass (M ≃ 500) has been designed and constructed. Laser and ion beams are merged in the apparatus in a collinear geometry and atoms, neutral molecules and negative ions are detected in the forward direction. The ion optical design and the components used to optimize the mass resolution and the transmission through the extended field-free interaction region are described. A 90° sector field magnet with 50 cm bending radius in combination with two slits is used for mass dispersion providing a resolution of M∕ΔM≅800 for molecular ions and M∕ΔM≅400 for atomic ions. The difference in mass resolution for atomic and molecular ions is attributed to different energy distributions of the sputtered ions. With 1 mm slits, transmission from the source through the interaction region to the final ion detector was determined to be about 0.14%.

Antipruritic effect of natural superoxide dismutase--sensory evaluation

The primary objective of the study was to evaluate the antipruritic effect of natural superoxide dismutase in the cosmetic product Sodermix cream. In this randomized intra-individual study including 15 volunteers, 14 female and one male, mean age 41 +/- 4 (range 18-66) years, the cosmetic product Sodermix cream was evaluated according to the Dermscan Group protocol by recording thermal sensitivity levels using Cutaneous Thermal Sensitivity analyzer before and 30 and 90 minutes after the product application. The study was conducted from April to June 2008. Study results showed a decrease in the lengths of pruritus 30 minutes of the product application onto the treated zone and a significant decrease in pruritus intensity 90 minutes of the product application onto the treated zone. The study allows for evaluation of physical sensation and quantification of heat with cutaneous thermal sensitivity measurements as a psycho-physical method to evaluate variables of thermal sensations in relation to variables by thermal stimuli. The study demonstrated a significant antipruritic effect of Sodermix cream.

The basis of topical superoxide dismutase antipruritic activity

In humans, as in all mammals and most chordates, three forms of superoxide dismutase (SOD) are present: SOD1 is located in the cytoplasm, SOD2 in the mitochondria, and SOD3 is extracellular. SOD is used in cosmetic products to reduce free radical damage to the skin, for example, to reduce fibrosis following radiation for breast cancer. Pruritus is one of the most common symptoms of skin diseases, but can also be a major symptom of systemic diseases (e.g., malignancy, infection or metabolic disorders). There are various antihistaminics used as antipruritogenic substances. In the genesis of pruritus there are many pruritogens involved, not only histamine and leukotrienes such as acetylcholine, cytokines, kallikreins, proteases, kinins, opioids, etc., which are described. On many occasions, we observed that topical SOD seemed to possess strong antipruritic activity, even in anti-histamine-resistant pruritus. We analyzed literature data on the effect of SOD as an anti-pruritogen on NK-1 receptors and proinflammatory cytokines, its regulatory role in calcitonin gene-related peptide production and expression, down-regulation of TNF- and numerous cytokines, and suppression of nitric oxide production.

Standardization across multiple sites

Standardizing products, procedures, and processes in clinical departments across multiple sites has significant potential for improving clinical outcomes, enhancing financial savings, and simplifying management processes. This is true whether a network of owned hospitals is working toward a full-scale clinical integration or a group of community hospitals is collaborating to gain cost efficiencies. By developing a functional team and designing a relatively simple program, the results can be very rewarding. The author describes some of the basic principles in designing a standardization program and cites some examples of successful programs as well as listing some pitfalls to be avoided along the way.

Local and systemic delivery of low molecular weight heparin following PTCA: acute results and 6-month follow-up of the initial clinical experience with the porous balloon (PILOT-study). Preliminary Investigation of Local Therapy Using Porous PTCA Balloons

The purpose of this study was to assess safety and feasibility of intracoronary delivery of reviparin using a porous balloon following percutaneous transluminal coronary angioplasty. The 2.7 mm porous balloon used in this study had 35 holes arranged in a spiral pattern. Eighteen patients (male n = 10, female n = 8, age 63 +/- 9 years) undergoing successful PTCA in coronary arteries with a vessel diameter of 2.5 to 3.0 mm determined by online QCA (LAD = 11, RCX = 3, RCA = 4) were included. They received a bolus of 7,000 anti-Xa-IU reviparin followed by local delivery of 1,500 anti-Xa-IU in 4 ml with an injection pressure of 2 atm. The patients received additionally 10500 anti-Xa-units intravenously during the following 24 hours and a daily dose of 7000 anti-Xa-units reviparin subcutaneously for the following 28 days. Angiograms were obtained before and after PTCA, directly after local delivery, at 24 hours postintervention and after 6 months. The primary success rate was 100%. Quantitative coronary angiography showed a minimum luminal diameter of 0.42 +/- 0.14 mm before PTCA, 1.87 +/- 0.45 after PTCA, 1.67 +/- 0.43 after LDD, 1.63 +/- 0.46 after 24 hours, and 1.06 +/- 0.6 after 6 months. Angiographic follow-up was obtained in all patients. No major complications occurred during the 6-month follow-up period. The angiographic restenosis rate was 28% (5/18) at follow-up. This study demonstrates safety and feasibility of local intracoronary delivery of reviparin with a porous balloon following PTCA even in smaller diameter coronary arteries.

Long-term preservation of islets of Langerhans in hydrophilic macrobeads

Several obstacles have hindered the successful transplantation of islets of Langerhans to human patients in efforts to cure type I diabetes mellitus. One problem is the necessity for short- and long-term storage of islets after isolation and before transplantation. Current long-term storage methods, such as incubation in a physiological medium and cryopreservation, are suboptimal, resulting in significant loss of viable islet mass or function. Better storage methods are needed. In this study we examined the long-term storage of rat islets in macrobeads composed of agarose and collagen. Islets isolated from Wistar-Furth rats were placed into macrobeads (1000 islets/macrobead) and maintained in culture for periods of up to 189 days at 37 degrees C. Insulin released from the cultured macrobeads remained constant for periods of at least 154 days. In one group, insulin release was 1050 mU/24 hr/4 beads on day 3 and 1040 mU/24 hr/4 beads on day 154. In another group, insuling release was 1305 Xenotransplantation of Wistar Furth islet macrobeads, stored for 10 to 112 days at 37 degrees C, degrees C into 42 B6AF/1 mice with streptozotocin-induced diabetes resulted in a return to euglycemia in the recipients within 24 hr. Thereafter, euglycemia was maintained for more than 100 days in 32/42 of the recipients, and removal of the macrobeads caused a return to hyperglycemia within 48 hr in all animals. In addition, a group of 7 mice receiving macrobeads containing 1000 islets stored for 84 days had normal glucose tolerance tests (compared with those of 7 nontreated, nontransplanted mice with streptozotocin-induced diabetes and 7 normal mice), demonstrating that the islets in the macrobeads were functioning as they would in an intact pancreas. Finally, 5 macrobeads transplanted after initial storage of 112 days, removed from the first recipient after 100 days or more, stored again for 4 days in vitro, and retransplanted into 5 other diabetic mice also restored and maintained euglycemia for at least 45 days. Our results indicate that collagen-agarose macrobeads are capable of preserving rat pancreatic islets for extended periods without loss of in vitro insulin release capability or ability to achieve and maintain euglycemia in vivo. As such they should be useful for human islet transplantation efforts.

Retrievable, replaceable, macroencapsulated pancreatic islet xenografts. Long-term engraftment without immunosuppression

Prevention of rejection and prolongation of graft survival are critical to achieving successful islet cell transplantation. Various techniques have been utilized to prolong graft survival. Recently, protection of pancreatic islets from host immune mechanisms by isolating the islets in artificial membranes has emerged as an attractive alternative to the use of immunosuppression. In this Rapid Communication, we describe a novel method for macroencapsulation of rat islets in hydrophilic macrobeads made with various combinations of agarose, collagen, and Gelfoam. Encapsulated xenotypic islets were placed intraperitoneally in mice in which diabetes was induced by streptozotocin. The encapsulated xenografts maintained normoglycemia > 170 days. Recipients mice had normal glucose tolerance tests, which indicates that the islets in the macrobeads were functioning as they would in an intact pancreas. Macrobeads retrieved up to 103 days after transplantation showed no evidence of tissue reaction or local inflammation. These retrieved macrobeads could also be retransplanted and replaced. Our studies indicate that the agarose-collagen/Gelfoam macrobeads we have developed serve both to protect islet xenografts from rejection and to provide a microenvironment in which the islets maintain and support their normal function in vivo. Because they may be retrieved after implantation and replaced, these macrobeads may be suitable for human clinical islet cell xenotransplantation.

The brain-dead pregnant woman: finding meaning to help cope

Caring for brain-dead pregnant women is a new critical care challenge. Rather than the usual life/death situations involving catastrophic events, critical care nurses have the added burden of caring for a life in suspension to maintain the viability of the fetus. Nurses struggle with keeping the brain-dead patient alive and yet know that as soon as the infant is delivered the mother will be allowed to die. These authors use interviews with clinical nurses to show how they used the coping strategy of creating meaning to successfully cope with this difficult situation.