Conventional vs. Hypo-Fractionated, Radiotherapy for High-Risk Prostate Cancer (PCS5), Randomized, Non-Inferiority, Phase 3 Trial: Posthoc Analysis of IMRT vs. 3D-CRT Radiation Therapy Associated Toxicities

PURPOSE/OBJECTIVE(S)

The Prostate Cancer Study number 5 (PCS5), is a multi-centric non-inferiority, phase 3, randomized controlled trial of high-risk prostate cancer patients of treated with either conventionally fractionated radiotherapy (CFRT) or hypofractionated radiotherapy (HFRT). The 7 years' pre-planned analysis showed that HFRT (68 Gy in 25 fractions) was as effective and well tolerated as CFRT (76 Gy in 38 fractions). In this posthoc analysis we aim to report the genitourinary (GU) and gastrointestinal (GI) toxicities associated with radiation therapy techniques: intensity-modulated radiotherapy (IMRT) and 3D-conformal radiotherapy (3D-CRT).

MATERIALS/METHODS

PCS5 randomized patients in a 1:1 ratio to receive either CFRT or HFRT. All patients received long term neoadjuvant, concurrent and adjuvant androgen suppression, with a median duration of 24 months. The toxicities were reported as per the Common Terminology Criteria for Adverse Events version 4. Acute toxicities were defined as presenting ≤ 180 days post-RT start and delayed > 180 days. The cumulative acute and delayed GI and GU toxicities were classified in grade groups: grade 1 or higher (G1+), G2+, and G3+. For each grade group, acute and delayed, we performed multivariable logistic regression analyses, adjusting for age, CTV volume, diabetes, fractionation (CRFT or HFRT), hypertension, and stage < T3b or ≥ T3b. For efficacy analyses cox-regression was utilized. A p-value < 0.05 was considered significant.

RESULTS

Three hundred twenty of the 329 patients enrolled in the trial were included in this posthoc analyses. The mean age was 71.4 ± 6.1 years, and the mean CTV volume (n = 219) was 47.25 ± 19.9 cc. IMRT was used in 195 (60.6%) patients and 3D-CRT in 125 (39.1%) patients. Multivariable logistic regression showed a significant difference in favor of IMRT for GI G2+ acute toxicity (OR = 0.285 [0.14-0.59]; CI: 95%; p<0.001) and GI G2+ delayed toxicity (OR = 0.202 [0.60-0.69]; CI: 95%; p = 0.01). There were no differences in G3+ GI or GU toxicities and there were no grade 4 toxicities. There were no differences in efficacy at 7 years between the two treatment technics. Outcomes for IMRT vs. 3D-CRT respectively, overall survival (81.5% vs 79.2%; HR: 0.92 [0.55-1.53]; CI: 95%; p-value: 0.74), distant metastasis free survival (90,7% vs 92.8%; HR: 1.4 [0.63-3.1]; CI: 95%; p-value: 0.42), prostate cancer mortality (95.8% vs. 92.2%; HR: 0.93 [0.32-2.67]; CI: 95%; p-value: 0.89), and biochemical failure (85.1% vs 88%; HR: 1.35 [0.72-2.52]; CI: 95%; p-value: 0.35).

CONCLUSION

This is the first phase 3 randomized controlled trial assessing the use of HFRT vs. CFRT, exclusively in high-risk prostate cancer patients. Given that our efficacy data at 7 years follow-up establishes moderate HFRT as a new standard of care and no difference between IMRT and 3D-CRT, we strongly recommend that patients who are treated with EBRT should receive IMRT, given the reduced acute and delayed grade 2 or higher GI toxicities.

Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve: A Case Report

Among other valvular heart disease Aortic stenosis (AS) is the most common in the developed world. Transcatheter Aortic Valve Replacement (TAVR) is most acceptable treatment option for patient with severely calcified aortic stenosis with high and intermediate risk group. Among several challenges, one of the main challenges is to deal with bicuspid aortic valve (BAV). Non-circular annulus, bulky leaflets leading to perivalvular leaks and risk for rupture and often very severe calcification may contribute to periprocedural strokes leading to poor clinical outcome. This case, a 68-year-old woman with a history of type 2 diabetes mellitus (DM), hypothyroidism, bicuspid aortic valve and severe aortic stenosis, bronchial asthma, who had repeatedly refused any suggestion for open heart surgery, was our volunteer candidate for TAVR. After successful TAVR the peak pressure gradient decreased from 100mmHg to 17mmHg. So, TAVR could be a viable option for highly selected patients with severe aortic stenosis and bicuspid aortic valve who have favourable anatomy.

Analysis of the different interventions scenario for programmatic measles control in Bangladesh: A modelling study

In recent years measles has been one of the most critical public health problem in Bangladesh. Although the Ministry of Health in Bangladesh employs a broad extension of measles control policies, logistical challenges exist, and there is significant doubt regarding the disease burden. Mathematical modelling of measles is considered one of the most effective ways to understand infection transmission and estimate parameters in different countries, such as Bangladesh. In this study, a mathematical modelling framework is presented to explore the dynamics of measles in Bangladesh. We calibrated the model using cumulative measles incidence data from 2000 to 2019. Also, we performed a sensitivity analysis of the model parameters and found that the contact rate had the most significant influence on the basic reproduction number R0. Four hypothetical intervention scenarios were developed and simulated for the period from 2020 to 2035. The results show that the scenario which combines enhanced treatment for exposed and infected population, first and second doses of vaccine is the most effective at rapidly reducing the total number of measles incidence and mortality in Bangladesh. Our findings also suggest that strategies that focus on a single interventions do not dramatically affect the decline in measles incidence cases; instead, those that combine two or more interventions simultaneously are the most effective in decreasing the burden of measles incidence and mortality. In addition, we also evaluated the cost-effectiveness of varying combinations of three basic control strategies including distancing, vaccination and treatment, all within the optimal control framework. Our finding suggested that combines distancing, vaccination and treatment control strategy is the most cost-effective for reducing the burden of measles in Bangladesh. Other strategies can be comprised to measles depending on the availability of funds and policymakers' choices.

Mathematical analysis of a measles transmission dynamics model in Bangladesh with double dose vaccination

Although the availability of the measles vaccine, it is still epidemic in many countries globally, including Bangladesh. Eradication of measles needs to keep the basic reproduction number less than one \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$(\mathrm{i}.\mathrm{e}. \, \, {\mathrm{R}}_{0}<1)$$\end{document}(i.e.R0<1). This paper investigates a modified (SVEIR) measles compartmental model with double dose vaccination in Bangladesh to simulate the measles prevalence. We perform a dynamical analysis of the resulting system and find that the model contains two equilibrium points: a disease-free equilibrium and an endemic equilibrium. The disease will be died out if the basic reproduction number is less than one \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$(\mathrm{i}.\mathrm{e}. \, \, {\mathrm{ R}}_{0}<1)$$\end{document}(i.e.R0<1), and if greater than one \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$(\mathrm{i}.\mathrm{e}. \, \, {\mathrm{R}}_{0}>1)$$\end{document}(i.e.R0>1) epidemic occurs. While using the Routh-Hurwitz criteria, the equilibria are found to be locally asymptotically stable under the former condition on \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathrm{R}}_{0}$$\end{document}R0. The partial rank correlation coefficients (PRCCs), a global sensitivity analysis method is used to compute \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\mathrm{R}}_{0}$$\end{document}R0 and measles prevalence \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\left({\mathrm{I}}^{*}\right)$$\end{document}I∗ with respect to the estimated and fitted model parameters. We found that the transmission rate \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$(\upbeta )$$\end{document}(β) had the most significant influence on measles prevalence. Numerical simulations were carried out to commissions our analytical outcomes. These findings show that how progression rate, transmission rate and double dose vaccination rate affect the dynamics of measles prevalence. The information that we generate from this study may help government and public health professionals in making strategies to deal with the omissions of a measles outbreak and thus control and prevent an epidemic in Bangladesh.

Association of Estimated GFR (By MDRD) with the Carotid Intima Media Thickness (CIMT) in Different Stages of CKD among Patients with Type 2 Diabetes Mellitus

Most of the mortalities among Diabetic Nephropathy patients are cardiovascular, if we identify the risk factor, measures can be taken to prevent it. Hence an objective was set to evaluate the association between carotid artery intima media thickness (CIMT) with eGFR in patients of CKD stage III, IV and V among patients with type 2 diabetes mellitus; also, correlation with age, BMI, lipid profile. This cross-sectional, observational study was performed in 70 patients in different stages of CKD in Diabetic Patients selected by Inclusion Criteria (Diabetic nephropathy patients with stages III, IV, V and exclusion Criteria (Acute kidney injury, History of carotid surgery, Patients of MI and stroke). This study was performed in Department of Nephrology, Dhaka Medical College in collaboration with the Department of Radiology and Imaging, laboratory of Department of Biochemistry and Department of Microbiology at Dhaka Medical College Hospital (By standard method in laboratory) from 1st January 2016 to 31st December 2016. eGFR was measured by MDRD formula and the CIMT was measured using an ultrasonographic examination. The mean CIMT was 0.9±0.21mm, and 62.9% of the subjects showed IMT thickening (≥1mm). The carotid IMT elevated significantly with the stage progression of CKD (Overall eGFR mean 28.8±14.5mL/min/1.73m² in CIMT<1mm with range from 6 to 54 and 9.1±9.0mL/min/1.73m² in CIMT ≥1mm with range from 3 to 32 (p=0.001). The eGFR was significantly lower in the patients with CIMT thickening than those without CIMT thickening. eGFR was also significantly associated with CKD stages (p=0.001), serum creatinine (p=0.001), BMI (r = -0.330, p=0.005), and negatively associated with age group, duration of hypertension, smoking. However, the CIMT was not significantly different among the patients at different stages of diabetic nephropathy (r = -0.172, p=156) and age group. It has been concluded that the mean CIMT was markedly high in patients with CKD compared to normal expected value. This study showed a relationship between the CIMT and the renal parameters as eGFR and the stages of diabetic nephropathy with a confirm association between the CIMT and diabetic macroangiopathy.

Seroprevalence of Leptospira infection in selected rural and urban areas of Bangladesh by rLipL32 based ELISA

Background and objectives: Leptospirosis is a zoonotic infection with worldwide distribution caused by the Leptospira species and predominant in the tropical and subtropical regions. Information on leptospirosis in Bangladesh is limited. The present study was designed to detect anti-leptospiral antibodies in human serum samples in Bangladeshi population by developing an in-house ELISA using recombinant LipL32 (rLipL32) antigen. The study was conducted from April 2014 to December 2014.Method: Healthy individuals from two rural areas and fever cases from one urban healthcare center were enrolled in the study. Rural health centers were located at Sonargoan and Bajitpur sub-district (Upozilla) of Narayaganj and Kishorganj districts. Sonargoan health center is located 26 km south-east and Bajitpur is located 71 km north-east of Dhaka city. About 1-2 ml of blood was collected with aseptic measure and serum was separated and stored at -200C until used. Anti-leptospiral IgG antibody was determined by recombinant LipL32 (rLipL32) antigen based indirect enzyme linked immunosorbent assay (ELISA). Seropositive cases were further confirmed by commercial Leptospira IgG ELISA.Results: The study included 250 febrile cases and 376 healthy individuals from urban and rural areas, respectively. Out of total 626 study population, anti-LipL32 specific IgG antibody was detected in 70 individuals (11.2%). The rate of positivity of anti-LipL32 antibody among the healthy individuals from rural area was 10.6% while the rate was 12.0% in urban febrile population. The rate of positivity in rural and urban population was not significantly (p>0.05) different. Among the urban population, the rate of seropositivity was 9.1% and 16.4% in 21- 40 yrs and above 40 years age group respectively while the rate was 7.2% and 14.0% in rural population respectively. Out of 70 seropositive cases detected by LipL32 ELISA, 65 (92.9%) were positive by commercial ELISA.Conclusion: The present study has revealed that leptospirosis is prevalent in Bangladesh and should be looked for in febrile and clinically suspected cases. The study has also demonstrated that rLipL32 protein may be used as a candidate antigen for the serodiagnosis of leptospirosis.IMC J Med Sci 2017; 11(2): 50-55

Alpha-Glucosidase Enzyme Biosensor for the Electrochemical Measurement of Antidiabetic Potential of Medicinal Plants

A biosensor for measuring the antidiabetic potential of medicinal plants was developed by covalent immobilization of α-glucosidase (AG) enzyme onto amine-functionalized multi-walled carbon nanotubes (MWCNTs-NH2). The immobilized enzyme was entrapped in freeze-thawed polyvinyl alcohol (PVA) together with p-nitrophenyl-α-D-glucopyranoside (PNPG) on the screen-printed carbon electrode at low pH to prevent the premature reaction between PNPG and AG enzyme. The enzymatic reaction within the biosensor is inhibited by bioactive compounds in the medicinal plant extracts. The capability of medicinal plants to inhibit the AG enzyme on the electrode correlates to the potential of the medicinal plants to inhibit the production of glucose from the carbohydrate in the human body. Thus, the inhibition indicates the antidiabetic potential of the medicinal plants. The performance of the biosensor was evaluated to measure the antidiabetic potential of three medicinal plants such as Tebengau (Ehretis laevis), Cemumar (Micromelum pubescens), and Kedondong (Spondias dulcis) and acarbose (commercial antidiabetic drug) via cyclic voltammetry, amperometry, and spectrophotometry. The cyclic voltammetry (CV) response for the inhibition of the AG enzyme activity by Tebengau plant extracts showed a linear relation in the range from 0.423-8.29 μA, and the inhibition detection limit was 0.253 μA. The biosensor exhibited good sensitivity (0.422 μA/mg Tebengau plant extracts) and rapid response (22 s). The biosensor retains approximately 82.16 % of its initial activity even after 30 days of storage at 4 °C.

Effective spatially fractionated GRID radiation treatment planning for a passive grid block

OBJECTIVE

To commission a grid block for spatially fractionated grid radiation therapy (SFGRT) treatments and describe its clinical implementation and verification through the record and verify (R&V) system.

METHODS

SFGRT was developed as a treatment modality for bulky tumours that cannot be easily controlled with conventionally fractionated radiation. Treatment is delivered in the form of open-closed areas. Currently, SFGRT is performed by either using a commercially available grid block or a multileaf collimator (MLC) of a linear accelerator. In this work, 6-MV photon beam was used to study dosimetric characteristics of the grid block. We inserted the grid block into a commercially available treatment planning system (TPS), and the feasibility of delivering such treatment plans on a linear accelerator using a R&V system was verified. Dose measurements were performed using a miniature PinPoint(TM) ion chamber (PTW, Freiburg, Germany) in a water phantom and radiochromic film within solid water slabs. PinPoint ion chamber was used to measure the output factors, percentage depth dose (PDD) curves and beam profiles at two depths, depth of maximum dose (zmax) and 10 cm. Film sheets were used to measure dose profiles at zmax and 10-cm depth.

RESULTS

The largest observed percentage difference between output factors for the grid block technique calculated by the TPS and measured with the PinPoint ion chamber was 3.6% for the 5 × 5-cm(2) field size. Relatively significant discrepancies between measured and calculated PDD values appear only in the build-up region, which was found to amount to <4%, while a good agreement (differences <2%) at depths beyond zmax was observed. Dose verification comparisons performed between calculated and measured dose distributions were in clinically acceptable agreements. When comparing the MLC-based with the grid block technique, the advantage of treating large tumours with a single field reduces treatment time by at least 3-5 times, having significant impact on patient throughput.

CONCLUSION

The proposed method supports and helps to standardize the clinical implementation of the grid block in a safer and more accurate way.

ADVANCES IN KNOWLEDGE

This work describes the method to implement treatment planning for the grid block technique in radiotherapy departments.

Quorum-sensing autoinducers resuscitate dormant Vibrio cholerae in environmental water samples

Cholera epidemics have long been known to spread through water contaminated with human fecal material containing the toxigenic bacterium Vibrio cholerae. However, detection of V. cholerae in water is complicated by the existence of a dormant state in which the organism remains viable, but resists cultivation on routine bacteriological media. Growth in the mammalian intestine has been reported to trigger "resuscitation" of such dormant cells, and these studies have prompted the search for resuscitation factors. Although some positive reports have emerged from these investigations, the precise molecular signals that activate dormant V. cholerae have remained elusive. Quorum-sensing autoinducers are small molecules that ordinarily regulate bacterial gene expression in response to cell density or interspecies bacterial interactions. We have found that isolation of pathogenic clones of V. cholerae from surface waters in Bangladesh is dramatically improved by using enrichment media containing autoinducers either expressed from cloned synthase genes or prepared by chemical synthesis. These results may contribute to averting future disasters by providing a strategy for early detection of V. cholerae in surface waters that have been contaminated with the stools of cholera patients or asymptomatic infected human carriers.

Clinicopathological stages of carcinoma breast patient

Carcinoma of breast is the second most common cancer among women next to uterine cervical cancer in Bangladesh. It was well established that 5 years survival rates greatly vary among the different stages of carcinoma of breast disease. The study was carried out to see the stages of presentation of carcinoma of breast patient to a tertiary level hospital attended first time for medical help as well as to find out the factors responsible for the late (advanced) stage presentation. This descriptive type of cross sectional study was carried out in the department of surgery, Mymensingh Medical College and Hospital (MMCH) during the period of May 2010 to April 2011. A total of 110 cases admitted with carcinoma breast diagnosed by means of FNAC positive or suspicious findings were selected purposively during the study period. Patients were staged initially according to the TNM staging system by through clinical examination as well as final clinicopathological stages were done after histopathological examination of the resected specimen (breast with or without axillary lymphnode) in resectable cases. Among the advanced stage presentation, attempts were made to find out the factors responsible for advanced stage of the disease. The results showed that carcinoma of breast predominantly a disease of female and comparatively younger age group 40-49 years affected mostly in 40.9% cases with a mean age of 44.02 ± 10.32 years. Premenopausal lady mostly affected in 63.6% cases. Majority of patients presented in advanced stage of the disease in 62.8% cases. Multiple factors were observed responsible for the advanced stage of the disease - among them delay in hospital presentation, poor socioeconomic condition and illiteracy have found to be associated which were statistically significant (p<0.001). It was needed for mass awareness program against the breast cancer in our society. Necessary steps should be taken for the initiation of breast self examination (BSE) to patients and clinical breast examination (CBE) to health care providers.

Pattern of malignancy in clinically solitary thyroid nodule

Solitary thyroid nodule (STN) is a common thyroid disorder. Clinically recognized thyroid carcinoma constitutes less than 1% of human malignant tumours. The risk of malignancy in solitary thyroid nodule is greater than other thyroid swelling. The risk of malignancy in generalized thyroid swelling is about 3% and in solitary thyroid nodule it is about 15%. This study was carried out in Surgery and ENT Department, Mymensingh Medical college Hospital from November 2008 to October 2009 to see pattern of malignancy in clinically solitary thyroid nodule. Total 108 patients of STN was included in this study, majority of the patients were within 20-39 years age group with female predominance. In addition to thyroid swelling some patients presented with other symptoms like cervical lymphadenopathy in 6(5.56%), dysphagia 2(1.85%), hoarseness of voice 2(1.85%) and metastatic lesion in bone 1(0.92%) cases. Among 108 cases of solitary thyroid nodule only 19 cases were malignant. Patients with malignant lesion presented with shorter duration of symptoms. Out of 19 malignant cases 6(31.58%) cases presented with features of metastasis. Malignancy was more predominant in male (25.00%) than the female (14.47%) in STN. Out of 19 malignant cases, 12(63.16%) were papillary carcinoma, 5(26.31%) were follicular carcinoma and 2(10.53%) cases were medullary carcinoma. Study showed significant difference (p<0.01) between papillary & follicular carcinoma and significant difference (p<0.001) between papillary & medullary carcinoma. Papillary carcinoma was most common among all thyroid malignancies in patients with solitary thyroid nodule.

A young lady with secondary tuberculosis of breast

Tuberculosis of breast is an extremly rare form of extrapulmonary tuberculosis even in endemic area like Bangladesh and the incidence is 0.25-4.5% of all breast lesions. The diagnosis is difficult because of nonspecific clinical, radiological and histopathological findings. Very often biopsy specimens are inadequate and microscopy or culture is negative. It is usually suspected in a multiparous woman who may be immunocompromised. We report a case of breast tuberculosis in a 26 years old multiparous lady who previously present with two times attack of right sided breast lump and then diagnosed as a case of breast abscess and treated by incision and drainage with antibiotics in a nearby local hospital. During her third time attack she admitted into Mymensingh Medical College Hospital with right sided breast lump with multiple discharging sinuses for one month. Biopsy was taken from the lump and sinus tract and histopathological report confirmed the diagnosis as a case of tuberculosis of breast. Her X-ray chest showed tubercular lesion in lungs. So this is a case of secondary breast tuberculosis. This case highlights how difficult is the diagnosis of a case of breast tuberculosis for which the patient may require even mastectomy at very late case. So this case is reported.

Drug Response Indicator Test (DRIT) as a predictive test for treatment outcomes in advanced breast cancer patients (ABC)

1119

Background: There are limited options for selecting an optimal treatment regimen for ABC patients (pts). DRIT is a platform technology that provides a profile of a patient's tumor's sensitivity or resistance to commonly used chemotherapeutic, hormonal, or biological agents as a basis for individualized anticancer treatment approach. DRIT may allow physicians to choose more effective drug treatments before initiation of therapy and improve the efficacy and toxicity profile of cancer therapies. Methods: DRIT analysis is based on fluorescent dye-labeled monoclonal antibody staining followed by computer-assisted microscopy to quantitatively measure expression levels in tumor sections. The interpretation of DRI expression levels results in classification of tumors as sensitive or resistant to treatment with a mechanistically related drug. This study utilized the following drug/DRI combinations: hormonal therapy/estrogen receptor; capecitabine/thymidylate synthase; docetaxel, paclitaxel, abraxane/β-tubulin isoform III; trastuzumab/HER-2; gemcitabine/ribonucleotide reductase. DRIT was performed on the tumor tissue of consented study participants with ABC who were then deemed to be sensitive or resistant to a given agent/agents. We then analyzed retrospectively clinical treatment outcomes (clinically sensitive to therapy defined as-stable disease+partial response+complete response or resistant to therapy-no response to therapy) for 91 treatment interventions in 71 pts with the DRIT tissue data. Results: We found that the DRIT sensitivity was 0.99, with specificity of 0.59, positive predictive value of 0.88, negative predictive value of 0.93 and overall predictive value of 88% for treatment outcomes for this cohort of ABC pts. Conclusions: This study suggests that DRIT can provide more accurate prediction of treatment outcomes for ABC pts than the standard of care approach and therefore has a potential to avoid unnecessary ineffective drug treatment exposure. Prospective study in ABC pts is currently conducted at the UMGCC.

[Table: see text]

Comparative analysis of the post-lumpectomy target volume versus the use of pre-lumpectomy tumor volume for early stage breast cancer: implications for the future

Abstract #5134

Purpose: Accelerated partial breast irradiation (APBI) is increasingly being utilized for the treatment of early stage breast cancer. Planning target volume (PTV) generation with this approach is based on the post-lumpectomy cavity volume (post-LPC) and is often associated with treatment of large amounts of normal breast tissue which can result in patient ineligibility for external beam APBI (EB-APBI). In malignancies such as soft tissue sarcomas, neoadjuvant radiation therapy (RT) has been shown to be associated with smaller volumes of tissue irradiated compared to adjuvant RT. However, neoadjuvant RT has not been attempted in the setting of APBI. We hypothesized that a PTV generation based on an expansion of the pre-lumpectomy (pre-LP) intact tumor volume would result in a significant reduction in the volume of irradiated normal breast tissue compared to the current approach of using the post-LPC. We further hypothesize that the use of EB-APBI utilizing the pre-LP tumor will result in greater patient eligibility for APBI.&#x2028; Materials and Methods: 40 patients with 41 early stage breast cancers previously treated with breast conserving lumpectomy and RT were analyzed. Pre-operative imaging and pathology reports were used to determine a pre-LP tumor volume. A sphere, the diameter of which was the largest determined radiographic dimension, representing the pre-LP tumor volume was placed in the center of the previously contoured and treated lumpectomy cavity. PTVs were developed for the pre-LP tumor volume and the post-LPC volume as per the NSABP-B39 protocol guidelines. The pre-LP and post-LPC PTV volumes were compared. Suitability for APBI was analyzed using criteria set forth by NSABP-B39 guidelines.&#x2028; Results: For all patients, the pre-LP PTV was smaller than the post-LPC PTV. The median volume for the pre and post-LPC PTVs were 93 cc (range 24 – 570 cc) and 250 cc (range 45 – 879 cc), respectively. Paired t-test analysis demonstrated the pre-LP PTV to be significantly smaller than the post-LPC PTV, p &lt; 0.001. The average difference between pre-LP and post-LPC PTVs represented 173 cc (range 21 – 482 cc) or 18% (range 3 - 42%) of the whole breast volume. Based on our analysis, only 3 of 41 cases were ineligible for EB-APBI when using the pre-LP tumor volume, (2 based on pathologic criteria and 1 based on dose/volume constraints) while 13 of 41 cases were ineligible when using the post-LPC PTV (2 based on pathologic criteria and 11 based on dose/volume constraints).&#x2028; Conclusion: PTVs based on the pre-LP tumor expansion are likely to be associated with a significantly reduced amount of normal breast tissue irradiated compared to post-LPC PTVs potentially leading to improved breast cosmesis, decreased dose to critical structures and decreased toxicities. Additionally, eligibility for EB-APBI would potentially increase if administered in the pre-lumpectomy setting. The findings from this study support future investigation as to the implications and feasibility of neoadjuvant APBI.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5134.

Results of intraarterial cisplatin and hyperfractionated radiotherapy in locally advanced cancer of the oropharynx and oral cavity

5563

Background: Intraarterial cisplatin and hyperfractionated radiation (HYPERADPLAT) is an accepted therapy for Stage III and IV head and neck cancer. We present long-term follow-up of patients with OP and OC cancer treated with HYPERADPLAT at a single institution. Methods: 44 patients with Stage III-IV squamous cell carcinomas of the OP or OC were treated with the HYPERRADPLAT regimen consisting of external beam radiotherapy (76.8–81.6 Gy) delivered in 1.2 Gy BID fractions with intraarterial cisplatin (150 mg/m2) administered when patients had reached 60 Gy. Tumor response, disease free survival (DFS), overall survival (OS), and toxicity were assessed for all patients according to NCI CCT criteria. Results: Of 44 patients, 21 had tumors of the base of tongue, 14-tonsil, 4-floor of mouth, and 5-other. Eighty eight percent of patients had T4 tumors and 7% had T3 tumors. Complete tumor response was observed in 86% of patients and 14% had a partial response. Lymph node metastases were present in 84% of patients with 78% of node positive patients having a complete nodal response and 19% with a partial response to treatment. Three-year DFS was 55% and OS was 45%. Locoregional recurrence was noted in 30% of patients and 16% had distant failure. Overall recurrence was noted in 47% of patients with a median time to recurrence of 8 months (range 4–55 months). Median weight loss during treatment was 9% of initial body weight and 28 patients required a feeding tube within 6 months of starting treatment. Grade 3 mucositis was noted in 68% of patients and 3 patients developed Grade 4 toxicity (2 mucosal, 1 hematologic). Conclusions: HYPERRADPLAT results in excellent tumor control that is well tolerated with minimal Grade 4 toxicity in patients with advanced poor prognosis cancers of the OP and OC. These results compare favorably with historically reported control rates and response for patients with a significantly high percentage of T4 tumors of the oropharynx and oral cavity.

No significant financial relationships to disclose.

Results of reduction of treatment intensity based on response to a novel induction therapy in stage III and IV head and neck cancer

5561

Background: Concurrent cisplatinum based chemotherapy and qd radiotherapy (RT) to 70 Gy is standard therapy for stage III-IV head and neck (H/N) SCCA. Presented is a prospective IRB approved study tailoring the definitive therapy based on response to induction therapy. Methods: 25 patients with Stage III-IV H/N SCCA were treated with 2 cycles of induction therapy every 21 days comprised of carboplatin (AUC 6 day 1), paclitaxel (75 mg/m2 days 1, 8, and 15), and low dose RT (0.5 Gy BID days 1, 2, 8, and 15) for chemosensitization. The response rates of this mode of induction therapy have been presented previously (ASCO 2005 #3184). Patients with complete response (CR) to induction were treated with reduced dose RT at the primary site (reduced from 70 to 60–66 Gy) and 2 cycles of IV cisplatin (100 mg/m2) instead of 3. Those with partial response (PR) or stable disease (SD) were treated with surgery and adjuvant therapy or with altered fractionation regimens. The impact of dose reduction on survival (OS and DFS), failure patterns, compliance and toxicity (according to NCI CTCAE) were used as end points for the study. Results: Patients included 9 with tonsil, 5-L, 3-HP, 3-OC, and 5-BOT. There were 4-T1,9-T2,9-T3,and 3-T4 tumors. The nodal involvement was N0–5, N1–3, N2–13, N3–4. Patients presented with Stage III (28%), IVA (52%), and IVB (20%). Sixty percent had a CR, 32% had a PR, and 8% had SD after induction therapy. Two patients with CR were non-compliant after induction therapy and not further evaluated. With a median FU of 20.5 months (range 11–36 mo) the OS and DFS is 100% (13/13) in the dose reduced group (CR) and 60% (6/10) in the PR/SD treated with more aggressive regimens. The incidence of distant failure is 40% (4/10) in the PR vs 0% (0/13) in the CR. No patients in the dose reduced group required feeding tubes; however 30% (3/10) were required in patients with PR. Compliance with chemotherapy was 79% (10/13) in the CR vs 80% (8/10) in the PR. Conclusions: Our early results show that the patients showing a CR to induction chemotherapy are a favorable group of patients and they may be treated with reduced treatment intensity. This report provides strong evidence that RT dose deescalation for head and neck cancers may be feasible following assessment after induction therapy.

[Table: see text]

The effect of induction therapy with carboplatin-paclitaxel and low dose radiotherapy followed by hyperfractionated radiotherapy and intraarterial chemotherapy on advanced cancers of the head and neck

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Background: The purpose of this study is to evaluate the potential benefits of induction therapy followed by intraarterial cisplatin and hyperfractionated radiation (HYPERRADPLAT) on patients with advanced head and neck tumors. Methods: 20 patients with Stage III-IV squamous cell carcinoma of the head and neck were treated with induction therapy consisting of 2 cycles of carboplatin (AUC 6) and paclitaxel (225 mg/m2) and 0.8 Gy BID on the day of and the day following chemotherapy. Induction therapy was given over 2 cycles separated by 3 weeks (previously described in ASCO 2002 abstract # 921 and 2004 abstract # 5593). Patients were then treated with the HYPERRADPLAT regimen consisting of external beam radiotherapy (74.4–81.6 Gy) delivered in 1.2 Gy BID fractions with intraarterial cisplatin (150 mg/m2) administered when patients had reached 60 Gy. Tumor response, disease free survival, overall survival, and toxicity were assessed for all patients according to NCI CTCAE criteria. Results: Of 20 patients, 9 had tumors of the oropharynx, 9-supralaryngeal, and 2-hypopharyngeal. Fifty percent of patients had T4 tumors and 35% had T3 tumors. Complete tumor response was observed in 80% of patients and 20% had a partial response. Three-year disease free survival was 75% and overall survival was 75%. Locoregional recurrence was noted in 25% of patients and 15% had distant failure. Overall recurrence was noted in 40% of patients with a median time to recurrence of 12 months (range 6–55 months). Median weight loss during treatment was 10% of initial body weight and 13 patients required a feeding tube within 6 months of starting treatment. Grade 3 mucositis was noted in 65% of patients and no patients developed Grade 4 toxicity. Conclusions: Two cycles of carboplatin-paclitaxel induction therapy followed by intraarterial cisplatin and hyperfractionated radiotherapy produces excellent tumor response and reduces distant failure. These results compare favorably with historical controls and produce tolerable toxicity profiles.

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Aggressive fibromatosis--impact of prognostic variables on management

OBJECTIVE

To determine the impact of prognostic variables on local control in patients with aggressive fibromatosis treated with or without radiation.

MATERIALS AND METHODS

Forty-two patients presenting to the combined sarcoma clinic at Johannesburg Hospital with aggressive fibromatosis from 1990 to 2003 were analysed retrospectively. There were 14 males and 28 females. The lesions involved the head and neck in 6 cases (14%), the thorax in 6 (14%), the extremities in 19 (45%) and the abdomen in 11 (26%). Thirty-seven patients (88%) presented to the clinic for the first time, whereas 5 (12%) had recurrent disease at presentation. Fifteen patients (36%) underwent excision only, 15 (36%) had excision followed by postoperative radiation, 8 (19%) had biopsy only, and 4 (9%) had radiation only. The median dose of radiation was 60 Gy (range 9 - 70 Gy).

RESULTS

One patient had local failure following excision and postoperative radiation therapy. The local control was 100% for surgery alone and 86% for surgery followed by postoperative radiation at > or = 24 months. On univariate analysis, age, sex, positive margins, primary or recurrent presentation, site of involvement and initial treatment did not affect local control significantly. Eight of 19 patients (42%) receiving radiation developed severe moist desquamation following treatment, and all these patients had doses of 60 Gy or more.

CONCLUSION

Surgery with or without radiation therapy gave excellent local control. The addition of radiation therapy to surgery as well as other known prognostic parameters did not impact on local control. The morbidity of radiation treatment is considerable, as noted in this series, and adjuvant radiation therapy should therefore be considered only in situations where the risk of recurrence and the morbidity of re-excision are high.