Stereotactic Body Radiation Therapy for Stage IIA to IIIA Inoperable Non-Small Cell Lung Cancer: A Phase 1 Dose-Escalation Trial

PURPOSE

Larger tumors are underrepresented in most prospective trials on stereotactic body radiation therapy (SBRT) for inoperable non-small cell lung cancer (NSCLC). We performed this phase 1 trial to specifically study the maximum tolerated dose (MTD) of SBRT for NSCLC >3 cm.

METHODS AND MATERIALS

A 3 + 3 dose-escalation design (cohort A) with an expansion cohort at the MTD (cohort B) was used. Patients with inoperable NSCLC >3 cm (T2-4) were eligible. Select ipsilateral hilar and single-station mediastinal nodes were permitted. The initial SBRT dose was 40 Gy in 5 fractions, with planned escalation to 50 and 60 Gy in 5 fractions. Adjuvant chemotherapy was mandatory for cohort A and optional for cohort B, but no patients in cohort B received chemotherapy. The primary endpoint was SBRT-related acute grade (G) 4+ or persistent G3 toxicities (Common Terminology Criteria for Adverse Events version 4.03). Secondary endpoints included local failure (LF), distant metastases, disease progression, and overall survival.

RESULTS

The median age was 80 years; tumor size was >3 cm and ≤5 cm in 20 (59%) and >5 cm in 14 patients (41%). In cohort A (n = 9), 3 patients treated to 50 Gy experienced G3 radiation pneumonitis (RP), thus defining the MTD. In the larger dose-expansion cohort B (n = 25), no radiation therapy-related G4+ toxicities and no G3 RP occurred; only 2 patients experienced G2 RP. The 2-year cumulative incidence of LF was 20.2%, distant failure was 34.7%, and disease progression was 54.4%. Two-year overall survival was 53%. A biologically effective dose (BED) <100 Gy was associated with higher LF (P = .006); advanced stage and higher neutrophil/lymphocyte ratio were associated with greater disease progression (both P = .004).

CONCLUSIONS

Fifty Gy in 5 fractions is the MTD for SBRT to tumors >3 cm. A higher BED is associated with fewer LFs even in larger tumors. Cohort B appears to have had less toxicity, possibly due to the omission of chemotherapy.

Can bronchoscopically implanted anchored electromagnetic transponders be used to monitor tumor position and lung inflation during deep inspiration breath-hold lung radiotherapy?

PURPOSE

To evaluate the efficacy of using bronchoscopically implanted anchored electromagnetic transponders (EMTs) as surrogates for 1) tumor position and 2) repeatability of lung inflation during deep-inspiration breath-hold (DIBH) lung radiotherapy.

METHODS

41 patients treated with either hypofractionated (HF) or conventional (CF) lung radiotherapy on an IRB approved prospective protocol using coached DIBH were evaluated for this study. Three anchored EMTs were bronchoscopically implanted into small airways near or within the tumor. DIBH treatment was gated by tracking the EMT positions. Breath-hold cone-beam-CTs (CBCTs) were acquired prior to every HF treatment or weekly for CF patients. Retrospectively, rigid registrations between each CBCT and the breath-hold planning CT were performed to match to 1) spine 2) EMTs and 3) tumor. Absolute differences in registration between EMTs and spine were analyzed to determine surrogacy of EMTs for lung inflation. Differences in registration between EMTs and tumor were analyzed to determine surrogacy of EMTs for tumor position. The stability of the EMTs was evaluated by analyzing the difference between inter-EMT displacements recorded at treatment from that of the plan for the CF patients, as well as the geometric residual (GR) recorded at the time of treatment.

RESULTS

219 CBCTs were analyzed. The average differences between EMT centroid and spine registration among all CBCTs were 0.45±0.42cm, 0.29±0.28cm, and 0.18±0.15cm in superior-inferior (SI), anterior-posterior (AP) and lateral directions, respectively. Only 59% of CBCTs had differences in registration <0.5cm for EMT centroid compared to spine, indicating that lung inflation is not reproducible from simulation to treatment. The average differences between EMT centroid and tumor registration among all CBCTs were 0.13±0.13cm, 0.14±0.13cm and 0.12±0.12cm in SI, AP and lateral directions, respectively. 95% of CBCTs resulted in <0.5cm change between EMT centroid and tumor registration, indicating that EMT positions correspond well with tumor position during treatments. Six out of the 7 recorded CF patients had average differences in inter-EMT displacements to be ≤0.26cm and average GR ≤0.22cm, indicating that the EMTs are stable throughout treatment.

CONCLUSIONS

Bronchoscopically implanted anchored EMTs are good surrogates for tumor position and are reliable for maintaining tumor position when tracked during DIBH treatment, as long as the tumor size and shape are stable. Large differences in registration between EMTs and spine for many treatments suggest that lung inflation achieved at simulation is often not reproduced. This article is protected by copyright. All rights reserved.

Treatment planning and outcomes effects of reducing the preferred mean esophagus dose for conventionally fractionated non-small cell lung cancer radiotherapy

Based on an analysis of published literature, our department recently lowered the preferred mean esophagus dose (MED) constraint for conventionally fractionated (2 Gy/fraction in approximately 30 fractions) treatment of locally advanced non-small cell lung cancer (LA-NSCLC) with the goal of reducing the incidence of symptomatic acute esophagitis (AE). The goal of the change was to encourage treatment planners to achieve a MED close to 21 Gy while still permitting MED to go up to the previous guideline of 34 Gy in difficult cases. We compared all our suitable LA-NSCLC patients treated with plans from one year before through one year after the constraint change. The primary endpoint for this study was achievability of the new constraint by the planners; the secondary endpoint was reduction in symptomatic AE. Planners were able to achieve the new constraint in statistically significantly more cases during the year following its explicit implementation than in the year before (P = 0.0025). Furthermore, 38% of patients treated after the new constraint developed symptomatic AE during their treatment as opposed to 48% of the patients treated before. This is a clinically desirable endpoint although the observed difference was not statistically significant. A subsequent power calculation suggests that this is due to the relatively small number of patients in the study.

Analysis of pneumonitis and esophageal injury after stereotactic body radiation therapy for ultra-central lung tumors

OBJECTIVES

SBRT has been associated with serious toxicity in ultra-central lung tumors, but little is known about the incidence and dosimetric correlates of pulmonary and esophageal complications in this setting.

MATERIALS AND METHODS

We retrospectively reviewed SBRT patients whose lung tumor abutted proximal airways, or whose planning target volume overlapped esophagus. All patients received 5-15 fractions of high-dose, image-guided radiation. The primary endpoint was SBRT-related toxicity, with local control and survival as secondary endpoints.

RESULTS

We included 88 patients. Nineteen patients (22 %) experienced grade ≥3 (G3+) toxicity, including 6 cases of G3+ radiation pneumonitis and 4 cases of G3+ esophageal injury. Two patients developed trachea-esophageal fistula. Overall incidence of radiation pneumonitis was 23 %. Ten patients (11.4 %) succumbed to SBRT-related complications. Multiple dosimetric parameters for lung (including mean lung dose and V20_Gy) and esophagus (including maximum point dose) correlated with radiation pneumonitis and esophageal toxicity, respectively. No impact of fractionation on toxicity was seen.

CONCLUSION

This analysis indicates that high rate and multiple manifestations of pulmonary and esophageal toxicity occur after SBRT for ultra-central tumors. In particular, severe radiation pneumonitis and tracheoesophageal fistula are possible. Dosimetric parameters such as mean lung dose and maximum esophageal dose are significantly correlated with toxicity. Further study is needed to optimize the safe delivery of SBRT in these patients.

Association of the missense variant p.Arg203Trp in PACS1 as a cause of intellectual disability and seizures

Graphical abstract key: ADHD, attention deficit hyperactivity disorder; ASD, atrial septal defect; DD, developmental delay; EEG, electroencephalogram; Ht, height; ID, intellectual disability; OCD, obsessive-compulsive disorder; OFC, open fontanelle; PDA, patent ductus arteriosis; PFO, patent foramen ovale; VSD, ventricular septal defect; Wt, weight.

De novo loss of function mutations in KIAA2022 are associated with epilepsy and neurodevelopmental delay in females

Intellectual disability (ID) affects about 3% of the population and has a male gender bias. Of at least 700 genes currently linked to ID, more than 100 have been identified on the X chromosome, including KIAA2022. KIAA2022 is located on Xq13.3 and is expressed in the developing brain. The protein product of KIAA2022, X‐linked Intellectual Disability Protein Related to Neurite Extension (XPN), is developmentally regulated and is involved in neuronal migration and cell adhesion. The clinical manifestations of loss‐of‐function KIAA2022 mutations have been described previously in 15 males, born from unaffected carrier mothers, but few females. Using whole‐exome sequencing, we identified a cohort of five unrelated female patients with de novo probably gene damaging variants in KIAA2022 and core phenotypic features of ID, developmental delay, epilepsy refractory to treatment, and impaired language, of similar severity as reported for male counterparts. This study supports KIAA2022 as a novel cause of X‐linked dominant ID, and broadens the phenotype for KIAA2022 mutations.

The NARC (Nonsteroidal Anti-inflammatory in Renal Colic) Trial. Single-dose intravenous ketorolac versus titrated intravenous meperidine in acute renal colic: a randomized clinical trial

Objectives:

Intravenous (IV) opioid titration is an accepted method of relieving acute renal colic. Studies have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) are also effective in this setting. Our objective was to compare single-dose ketorolac and titrated meperidine, both administered intravenously, with respect to speed and degree of analgesia, adverse effects and functional status. Our primary hypothesis was that these agents provide equivalent analgesia within 60 minutes. Our secondary hypotheses were that ketorolac-treated patients would experience fewer adverse effects and would be better able to resume usual activity.

Methods:

This was a multicentre, double-blind randomized equivalence trial in a convenience sample of patients age 18–65 with moderate or severe renal colic, documented by intravenous pyelogram, ultrasound or stone passage. Meperidine-treated patients received 50 mg IV meperidine at 0 minutes, then 25–50 mg every 15 minutes as needed for ongoing pain. Ketorolac-treated patients received 30 mg IV ketorolac at 0 minutes and placebo injections every 15 minutes as needed. Pain levels and adverse effects were assessed every 15 minutes, and functional status was evaluated at 60 minutes. Our primary outcome was the proportion of patients with mild or no pain at 60 minutes.

Results:

Overall, 49 of 77 meperidine-treated patients (64%; 95% confidence interval [CI], 53%–75%) and 47 of 65 ketorolac-treated patients (72%; 95% CI, 61%–83%) achieved successful pain relief at 60 minutes (pvalue for equivalence = 0.002). Ten percent of meperidine-treated patients and 44% of ketorolac-treated patients were able to resume usual activity at 60 minutes (p= 0.001).

Conclusions:

In the doses studied, single-dose IV ketorolac is as effective as titrated IV meperidine for the relief of acute renal colic and causes less functional impairment.

First-trimester diagnosis of Meckel-Gruber syndrome by fetal ultrasound with molecular identification of CC2D2A mutations by next-generation sequencing

We describe a first-trimester ultrasound examination in which the finding of fetal encephalocele and the cystic appearance of the kidneys raised suspicion of Meckel-Gruber syndrome (MKS). On the basis of sonographic findings, the patient elected termination of pregnancy, and post-termination studies using next-generation sequencing of a gene panel revealed two mutations (one previously described and the other novel) in the gene CC2D2A. Mutations in CC2D2A are known to cause MKS and Joubert syndrome, thus providing molecular confirmation of the clinical suspicion of MKS and opening the possibility for future prenatal diagnosis. This case highlights the ability to detect important anomalies in the first trimester using ultrasound, even in low-risk situations. It also demonstrates the growing role of new sequencing technologies in fetal testing.

Long-term effects of feeding diets without mineral phosphorus supplementation on the performance and phosphorus excretion in high-yielding dairy cows

The objective of this study was to assess the long-term effects of feeding a diet with no mineral phosphorus (P) supplementation on performance and P excretion in high-yielding dairy cows. In exp. 1, 24 primiparous (PP) and 40 multiparous (MP) Holstein cows were allocated to one of two treatments at calving: (1) regular corn silage and alfalfa haylage based milking cow total mixed ration (TMR; 0.42% P diet) or (2) milking cow total mixed ration (TMR) without supplemental mineral P (0.35% P diet) in a completely randomized design. The trial lasted until after two lactations were completed or the cow was culled. In exp. 2, eight MP Holstein cows (108 ± 8.0 d in milk) were used to determine P digestibility and retention in a completely randomized block design. In exp. 1, the 0.35% P diet cows had lower body weight, body condition score and milk urea nitrogen and higher faecal P than the 0.42% P cows. The dry matter intake (DMI) of PP cows on the 0.35% P diet was lower than that of PP cows on the 0.42% P diet. There was no difference in the DMI of MP cows. The P intake of 0.35% P diet PP cows was 30% lower than that of 0.42% P diet PP cows. The P intake of 0.35% P diet MP cows was 20% lower than that of 0.42% P diet MP. The digestibility coefficient of P for the 0.35% P diet was higher than that for the 0.42% P diet. These results suggest that the forages used in the present study contained adequate amounts of P to sustain milk production in high-yielding MP cows. However, for PP cows some mineral P supplementation is recommended especially during early lactation. Key words: Phosphorus, environmental pollution, intensive dairy operations

Delayed toxicity following ingestion of enteric-coated divalproex sodium (Epival)

Toxicity occurs rapidly after overdose with regular-release valproic acid, but there is less experience with enteric-coated formulations. We report a case of delayed onset of toxicity and time to peak levels after ingestion of enteric-coated divalproex sodium (Epival). The patient was a 24-year-old female who ingested an unknown amount of Epival together with ibuprofen, dimenhydrinate, and ethanol. Ninety minutes after ingestion, the patient had only mild toxicity, and valproic acid was undetectable in her blood. By 13 h post-ingestion, valproate levels were 7450 micromol/L (1,075 mg/L), and the patient was comatose and required endotracheal intubation and mechanical ventilation. The toxicity and pharmacokinetics of valproic acid are discussed in the context of this case, and management guidelines are proposed.

Conservation and laundry: using outside vendors to clean reusable linens

Using outside laundry facilities is a viable and efficient means for hospitals to clean and sanitize soiled linens. Such services also allow hospitals to achieve cost-effective linen systems. All kinds of linen products, including gowns, sheets, blankets, pillowcases, mops, diapers, and surgical textiles, are easily processed through such purveyors. Even newer fabrics with improved barrier protection qualities can be serviced. The three elements that make up the laundry cost equation are purchasing, processing, and usage. Improvements and reductions in any one of these areas positively affect the other two. With this in mind, a hospital and an outside laundry service should work closely together to improve linen management, to control usage, and to remove waste, thus reducing hospitals' per-patient-day costs. Close interaction and teamwork will make the relationship work with dynamic results. Together, both parties will grow and meet the ever-evolving needs of the health care industry.

Treatment of imipramine-resistant recurrent depression, IV: A double-blind crossover study of tranylcypromine for anergic bipolar depression

OBJECTIVE

Few trials of monoamine oxidase inhibitors (MAOIs) in tricyclic-resistant depression have had double-blind conditions. In the authors' previous double-blind comparison of tranylcypromine and imipramine in anergic bipolar depression, tranylcypromine was significantly more effective. This investigation was a crossover study of nonresponders in the initial study.

METHOD

The subjects were 16 outpatients with anergic bipolar depression. Fourteen had not responded to 4 weeks of treatment with at least 30 mg/day of tranylcypromine or 150 mg/day of imipramine, and two patients were crossed over because of intolerable side effects from the initial drug. The crossover medication was prescribed as in the initial double-blind study.

RESULTS

Twelve patients were crossed over from imipramine to tranylcypromine; nine of them responded to tranylcypromine. Highly significant improvements were documented on the Hamilton, Beck, and Pittsburgh Reversed Vegetative Symptom Scales. Four patients were switched from tranylcypromine to imipramine, but only one responded.

CONCLUSIONS

The high rates of response to tranylcypromine in both the initial and crossover double-blind studies document the efficacy of MAOI treatment for anergic bipolar depression. Moreover, the results further illustrate the utility of MAOIs in tricyclic-resistant depressions.

Epidemiology of blindness and visual impairment in Vanuatu

A population-based survey of blindness was conducted in Vanuatu. Data were gathered on a sample of 3520 of the approximately 150,000 inhabitants of Vanuatu aged at least 6 years, in order to estimate the prevalence and causes of blindness among the whole population. An overall prevalence of blindness of 4.0 per 1000 was found, 85% of which was due to cataract, an avoidable cause of this disability.

Modeling, coffee drinking, and smoking

The relative effects of coffee and modeling on cigarette smoking were examined for 30 undergraduate smokers. Smoking rate was not significantly influenced by either coffee or modeling. These results are discussed in relation to previous research which has demonstrated effects for both variables.