Isocitrate Dehydrogenase 1/2 Wildtype Adult Astrocytoma with WHO Grade 2/3 Histological Features: Molecular Re-Classification, Prognostic Factors, Clinical Outcomes

BACKGROUND

Isocitrate Dehydrogenase 1/2 (IDH 1/2)-wildtype (WT) astrocytomas constitute a heterogeneous group of tumors and have undergone a series of diagnostic reclassifications over time. This study aimed to investigate molecular markers, clinical, imaging, and treatment factors predictive of outcomes in WHO grade 2/3 IDH-WT astrocytomas ('early glioblastoma').

METHODOLOGY

Patients with WHO grade 2/3 IDH-WT astrocytomas were identified from the hospital archives. They were cross-referenced with the electronic medical records systems, including neuroimaging. The expert neuro-pathology team retrieved data on molecular markers-MGMT, TERT, IDH, and EGFR. Tumors with a TERT mutation and/or EGFR amplification were reclassified as glioblastoma.

RESULTS

Fifty-four patients were identified. Sixty-three percent of the patients could be conclusively reclassified as glioblastoma based on either TERT mutation, EGFR amplification, or both. On imaging, 65% showed gadolinium enhancement on MRI. Thirty-nine patients (72%) received long-course radiotherapy, of whom 64% received concurrent chemotherapy. The median follow-up of the group was 16 months (range: 2-90), and the median overall survival (OS) was 17.3 months. The 2-year OS of the whole cohort was 31%. On univariate analysis, older age, worse performance status (PS), and presence versus absence of contrast enhancement on diagnostic MRI were statistically significant for poorer OS.

CONCLUSION

IDH-WT WHO grade 2/3 astrocytomas are a heterogeneous group of tumors with poor clinical outcomes. The majority can be reclassified as glioblastoma, based on current WHO classification criteria, but further understanding of the underlying biology of these tumors and the discovery of novel targeted agents are needed for better outcomes.

The Feasibility of Dose-Escalated Radiation Therapy for Glioblastoma Using Biological Image Guided Adaptive Radiotherapy (BIGART)

PURPOSE/OBJECTIVE(S)

Radiotherapy dose escalation (DE) for glioblastoma (GBM) has been an area of active research. We aimed to study the imaging changes within residual gross tumor volumes (GTV) through the course of concurrent chemo-radiotherapy (CCRT) using multiparametric magnetic resonance imaging (mpMRI). Diffusion, perfusion and chemical exchange saturation transfer (CEST) characteristics of the tumor and its microenvironment were investigated to identify a GTV subvolume potentially associated with radio resistance. We used biological image-guided adaptive radiotherapy (BIGART) to study the feasibility of DE to this GTV subvolume using either photon or proton beam therapy (PBT).

MATERIALS/METHODS

We prospectively identified GBM patients with >5cc residual tumor post-resection who were candidates for radical CCRT (60 Gy in 30 daily fractions over 6-weeks with concurrent temozolomide 75mg/m2 daily). We observed the imaging changes with serial mpMRI scans done at baseline, after 2, 4 and 6-weeks of CCRT. Regions of interest (ROIs) within the GTV associated with the following abnormal values at week 2 were identified: apparent diffusion coefficient (ADC): 750-1000 ×10-6 mm2/s; relative cerebral blood volume (rCBV): 1.75-6; and APT-w CEST signal intensity >1.79%. The overlap regions of these ROIs were defined as a novel biological target volume (BTV), identifying the potential area of maximal radioresistance. An in silico study was performed using a technology company's treatment planning system to evaluate the feasibility of planning adaptive treatment to the BTV to total dose of 75 Gy in 30 fractions. This is given in two phases: 30 Gy/15# to the whole PTV as per standard practice, followed by a simultaneous integrated boost (SIB) of 45 Gy/15 fractions while maintaining the dose to the rest of the of the PTV to 60 Gy. Either photons or PBT were used to keep doses to organs at risk (OARs) within standard clinical tolerances.

RESULTS

Nine patients were recruited for this analysis and a total of 27 mpMRI scans were studied. Median BTVs to GTVs ratio was 35% (range 22-47%). Volumetric-modulated arc (VMAT) photon and PBT adaptive plans for dose escalation to BTVs were created in all cases whilst maintaining OAR tolerances. Both VMAT and PBT provided acceptable target coverage with average BTV-PTV D98% of 73 Gy (range 71.5-73.8 Gy) and average D2% of 76 Gy (range 75.4-77 Gy) while effectively sparing OARs. Sharper dose gradient between DE-BTV and PTV was achieved with VMAT. PBT was particularly advantageous in minimizing the low-dose spillage outside the BTV.

CONCLUSION

We hereby propose a platform for adaptive radiotherapy to GBM tumors with biological-image guidance through the utilization of mpMRI to evaluate the tumor and its microenvironment during CCRT. We identified thresholds for tumor sub volumes showing the most resistant imaging features and created precise BTVs that allowed for dose escalation. PBT represents an additional useful tool for BIGART planning that will be investigated further in our ongoing work.

Pituitary function at presentation and following therapy in patients with non-functional pituitary macroadenomas: a single centre retrospective cohort study

BACKGROUND

Non-functioning pituitary macroadenomas (NFPMs) may present with hypopituitarism. Pituitary surgery and radiotherapy pose an additional risk to pituitary function.

OBJECTIVES

To assess the incidence of hypopituitarism at presentation, the impact of treatment, and the likelihood of endocrine recovery during follow-up.

METHODS

All patients treated surgically with and without radiotherapy for NFPMs between 1987 and 2018 who had longer than six months follow-up were identified. Demographics, presentation, investigation, treatment, and outcomes were collected.

RESULTS

In total, 383 patients were identified. The median age was 57 years, with a median follow-up of 8 years. Preoperatively, 227 patients (227/375; 61%) had evidence of at least one pituitary deficiency. Anterior panhypopituitarism was more common in men (p = 0.001) and older patients (p = 0.005). Multiple hormone deficiencies were associated with large tumours (p = 0.03). Patients treated with surgery and radiotherapy had a higher incidence of all individual pituitary hormone deficiency, anterior panhypopituitarism, and significantly lower GH, ACTH, and TSH deficiencies free survival probability than those treated with surgery alone. Recovery of central hypogonadism, hypothyroidism, and anterior panhypopituitarism was also less likely to be reported in those treated with surgery and radiotherapy. Those with preoperative hypopituitarism had a higher risk of pituitary impairment at latest review than those presented with normal pituitary function (p = 0.001).

CONCLUSION

NFPMs are associated with a significant degree of hypopituitarism at time of diagnosis and post-therapy. The combination of surgery and radiotherapy is associated with a higher risk of pituitary dysfunction. Recovery of pituitary hormone deficit may occur after treatment. Patients should have regular ongoing endocrine evaluation post-treatment to assess changes in pituitary function and the need for long-term replacement therapy.

Non-functioning pituitary macroadenoma following surgery: long-term outcomes and development of an optimal follow-up strategy

Objectives

Recurrence and regrowth of non-functioning pituitary macroadenomas (NFPMs) after surgery are common but remain unpredictable. Therefore, the optimal timing and frequency of follow-up imaging remain to be determined. We sought to determine the long-term surgical outcomes of NFPMs following surgery and develop an optimal follow-up strategy.

Methods

Patients underwent surgery for NFPMs between 1987 and 2018, with a follow-up of 6 months or more, were identified. Demographics, presentation, management, histology, imaging, and surgical outcomes were retrospectively collected.

Results

In total, 383 patients were included; 256 were men (256/383; 67%) with median follow-up of 8 years. Following primary surgery, 229 patients (229/383; 60%) achieved complete resection. Of those, 28 (28/229; 11%) developed recurrence, including six needed secondary surgery (6/229; 3%). The rate of complete resection improved over time; in the last quartile of cases, 77 achieved complete resection (77/95; 81%). Reoperation-free survival at 5, 10 and 15 years was 99%, 94% and 94%, respectively. NFPMs were incompletely resected in 154 patients (154/383; 40%); of those, 106 (106/154; 69%) had regrowth, and 84 (84/154; 55%) required reoperation. Surgical reintervention-free survival at 5, 10 and 15 years was 74%,49% and 35%, respectively. Young age and cavernous sinus invasion were risk factors for undergoing reoperation (P < 0.001 and P < 0.0001, respectively) and radiotherapy (P = 0.003 and P < 0.001, respectively). Patients with residual tumour required reoperation earlier than those underwent complete resection (P = 0.02). Radiotherapy to control tumour regrowth was delivered to 65 patients (65/383; 17%) after median time of 1 year following surgery. Radiotherapy was administered more in patients with regrowth of residual disease (61/106; 58%) than those who had NFPMs recurrence (4/28; 14%) (P ≤ 0.001) Following postoperative radiotherapy, one patient (1/65; 2%) had evidence of regrowth, seven (7/65; 11%) had tumour regression on imaging, and no patients underwent further surgery.

Conclusions

NFPMs recurrence and regrowth are common, particularly in patients with residual disease post-operatively. We propose a follow-up strategy based on stratifying patients as "low risk" if there is no residual tumour, with increasing scan intervals, or "high risk" if there is a residual tumour, with annual scans for at least five years and extended lifelong surveillance after that.

Isotoxic dose escalated radiotherapy for glioblastoma based on diffusion-weighted MRI and tumor control probability-an in-silico study

OBJECTIVES

Glioblastoma (GBM) is the most common malignant primary brain tumor with local recurrence after radiotherapy (RT), the most common mode of failure. Standard RT practice applies the prescription dose uniformly across tumor volume disregarding radiological tumor heterogeneity. We present a novel strategy using diffusion-weighted (DW-) MRI to calculate the cellular density within the gross tumor volume (GTV) in order to facilitate dose escalation to a biological target volume (BTV) to improve tumor control probability (TCP).

METHODS

The pre-treatment apparent diffusion coefficient (ADC) maps derived from DW-MRI of ten GBM patients treated with radical chemoradiotherapy were used to calculate the local cellular density based on published data. Then, a TCP model was used to calculate TCP maps from the derived cell density values. The dose was escalated using a simultaneous integrated boost (SIB) to the BTV, defined as the voxels for which the expected pre-boost TCP was in the lowest quartile of the TCP range for each patient. The SIB dose was chosen so that the TCP in the BTV increased to match the average TCP of the whole tumor.

RESULTS

By applying a SIB of between 3.60 Gy and 16.80 Gy isotoxically to the BTV, the cohort's calculated TCP increased by a mean of 8.44% (ranging from 7.19 to 16.84%). The radiation dose to organ at risk is still under their tolerance.

CONCLUSIONS

Our findings indicate that TCPs of GBM patients could be increased by escalating radiation doses to intratumoral locations guided by the patient's biology (i.e., cellularity), moreover offering the possibility for personalized RT GBM treatments.

ADVANCES IN KNOWLEDGE

A personalized and voxel level SIB radiotherapy method for GBM is proposed using DW-MRI, which can increase the tumor control probability and maintain organ at risk dose constraints.

Clinical, Imaging and Neurogenetic Features of Patients with Gliomatosis Cerebri Referred to a Tertiary Neuro-Oncology Centre

INTRODUCTION

Gliomatosis cerebri describes a rare growth pattern of diffusely infiltrating glioma. The treatment options are limited and clinical outcomes remain poor. To characterise this population of patients, we examined referrals to a specialist brain tumour centre.

METHODS

We analysed demographic data, presenting symptoms, imaging, histology and genetics, and survival in individuals referred to a multidisciplinary team meeting over a 10-year period.

RESULTS

In total, 29 patients fulfilled the inclusion criteria with a median age of 64 years. The most common presenting symptoms were neuropsychiatric (31%), seizure (24%) or headache (21%). Of 20 patients with molecular data, 15 had IDH wild-type glioblastoma, with an IDH1 mutation most common in the remainder (5/20). The median length of survival from MDT referral to death was 48 weeks (IQR 23 to 70 weeks). Contrast enhancement patterns varied between and within tumours. In eight patients who had DSC perfusion studies, five (63%) had a measurable region of increased tumour perfusion with rCBV values ranging from 2.8 to 5.7. A minority of patients underwent MR spectroscopy with 2/3 (66.6%) false-negative results.

CONCLUSIONS

Gliomatosis imaging, histological and genetic findings are heterogeneous. Advanced imaging, including MR perfusion, could identify biopsy targets. Negative MR spectroscopy does not exclude the diagnosis of glioma.

Integration of a personalised mobile health (mHealth) application into the care of patients with brain tumours: proof-of-concept study (IDEAL stage 1)

Objectives

Brain tumours lead to significant morbidity including a neurocognitive, physical and psychological burden of disease. The extent to which they impact the multiple domains of health is difficult to capture leading to a significant degree of unmet needs. Mobile health tools such as Vinehealth have the potential to identify and address these needs through real-world data generation and delivery of personalised educational material and therapies. We aimed to establish the feasibility of Vinehealth integration into brain tumour care, its ability to collect real-world and (electronic) patient-recorded outcome (ePRO) data, and subjective improvement in care.

Design

A mixed-methodology IDEAL stage 1 study.

Setting

A single tertiary care centre.

Participants

Six patients consented and four downloaded and engaged with the mHealth application throughout the 12 weeks of the study.

Main outcome measures

Over a 12-week period, we collected real-world and ePRO data via Vinehealth. We assessed qualitative feedback from mixed-methodology surveys and semistructured interviews at recruitment and after 2 weeks.

Results

565 data points were captured including, but not limited to: symptoms, activity, well-being and medication. EORTC QLQ-BN20 and EQ-5D-5L completion rates (54% and 46%) were impacted by technical issues; 100% completion rates were seen when ePROs were received. More brain cancer tumour-specific content was requested. All participants recommended the application and felt it improved care.

Conclusions

Our findings indicate value in an application to holistically support patients living with brain cancer tumours and established the feasibility and safety of further studies to more rigorously assess this.

Early Post-treatment Pseudo-continuous Arterial Spin Labelling Stratifies 12 Month Survival in Gliomas

AIMS

Arterial spin labelling (ASL) is a non-invasive perfusion technique that uses endogenous contrast and is proving to be of value in paediatric neuro-oncology. ASL derived rCBV has been shown to correlate with Dynamic Susceptibility Contrast (DSC) -derived CBV and could be an alternative perfusion technique when DSC is not possible. The aim of the study was to investigate whether early post-treatment tumour ASL can stratify patient survival at 12 months.

METHOD

180 consecutive patients diagnosed with glioblastoma and undergoing treatment between 2017-2021 were imaged with an extended MRI protocol that included pseudo-continuous ASL (pCASL). Patients that were imaged with pCASL within 1-3 months of completing radiotherapy were identified retrospectively. Scanner generated Perfusion weighted images were inspected and regions of interest encompassing the tumour were generated and compared with a control region in the contra-lateral grey matter. Overall survival data was collated and a comparison of tumour ASL was assessed with t-test statistics between patients surviving &lt; and &gt;12 months.

RESULTS

43 patients were identified (23 male, median age 58 years, diagnoses: IDHwt-GBM 17, IDHmut-Astrocytoma 13, IDHmut 1p19q co-deleted Oligodendroglioma 13). Tumour ASL was 3.22 (± 2.1) in patients that survived less than 12 months compared to 1.64 (± 1.9) in patients that survived greater than 12 months, p=0.02).

CONCLUSION

Early post-treatment ASL can stratify patient survival at 12 months and show promise as an alternative to DSC perfusion in the prognostication of patients being treated for glioma.

Palliative Carboplatin Chemotherapy in Previously Treated High-Grade Glioma: Real-World Efficacy and Safety

AIMS

Effective third-line chemotherapy options for patients after temozolomide (TMZ) and nitrosourea-based chemotherapy for high-grade glioma (HGG) are not well defined. The use of carboplatin is limited due to uncertainly around its effectiveness and tolerability.

METHOD

Patients with HGG treated with single-agent carboplatin chemotherapy between 2005-2021 were identified from our institutional database. Patient and treatment-related details were acquired from electronic hospital records. SPSS Statistics for Windows, (Version 23.0, IBM Corp.) was used for data analysis.

RESULTS

A total of 16 HGG patients were identified. This included 9 glioblastoma (GBM) and 3 anaplastic astrocytomas (AA). These 12 patients were used for further analysis. The median age was 48 (22-73) years. All patients initially received a flat dose of 450 mg intravenous carboplatin every 3-4 weeks. All had previously received high dose RT (54-60 Gy), and temozolomide and lomustine-based chemotherapy. Carboplatin was used as 3rd or 4th line treatment. The median number of cycles given was 3 (range: 1-12). Five had rapid decline in performance status after 1-3 cycles. Five patients required dose/ cycle length adjustment due to grade 1 or 2 haematological toxicity. Other than cumulative fatigue, no other &gt;/= grade 2 toxicities were reported. None required inpatient management for treatment toxicities. Median progression-free survival on carboplatin was 3 months (range 1-11 months) and overall survival was 8 months (range 1–26 months).

CONCLUSION

Carboplatin is a viable treatment option for HGG with acceptable toxicity rates. However, careful patient selection remains key to attaining maximum benefit.

Clinical Evaluation of Gamma Knife Stereotactic Radiosurgery for Metastatic Disease in Elderly Patients

AIMS

Gamma Knife Stereotactic Radiosurgery (GK-SRS) is an effective treatment option for limited brain metastases (BM); however, there is a paucity of data about its use in the elderly. Our aim is to explore the clinical outcomes of elderly cancer patients treated for BM with GK-SRS at our institution.

METHOD

We identified cancer patients aged ≥80 years at the time of receiving GK-SRS to BM between July 2017 and August 2021 from our electronic institutional database. Descriptive statistics and Kaplan–Meier analysis were performed using SPSS v.22.

RESULTS

A total of 24 patients were identified, with a median age of 83 years (range 80.1-89.9). The most common primary tumours were melanoma (58.4%) and lung (20.8%). In 14 patients (58%), multiple BM were treated simultaneously with a median of 2 lesions (range 2-15). The median target volume was 1.34cc (range 0.03-15.06). Prescribed doses ranged from 18Gy – 25Gy, prescribed to the 41-97% isodose line. After a median follow-up of

6.9 months (range 1.9-49.4 months), the local control rate (LCR) was 91.3% and the median post-GK-SRS overall survival was 9.8 months (95%CI 5.4-14.3). This compares to our previously published data from our wider GK-SRS-treated BM patient cohort, which showed a median survival of 15.6 months and LCR of 94.6%.

CONCLUSION

GK-SRS is an effective treatment modality for selected cancer patients with BM, including those over 80 years of age. Multi-institutional prospective studies are warranted to further explore the safety and functional outcomes of GK-SRS in elderly cancer patients.

Radiation and the nervous system

Radiation therapy is widely used for benign and malignant brain tumours as it is effective and well tolerated. However, damage to the surrounding healthy nervous system tissue leads to a variety of complications both in the short term and long term, ranging from mild and self-limiting to irreversible and fatal. Radiation neurotoxicity is due to a combination of early inflammation and oligodendroglial damage followed later by brain tissue necrosis, white matter damage, accelerated vascular disease and the development of secondary tumours. This article explains the basic principles of radiation physics, the different modalities used in clinical practice, how radiotherapy is planned and delivered and the scientific basis of radiation damage. The main body of the article focuses on the clinical features of radiation toxicity in the brain, spinal cord, cranial and peripheral nerves with an emphasis on the distinction between early and delayed complications.

Implementation of the Vinehealth application, a digital health tool, into the care of patients living with brain cancer

e13582

Background: Cancers of the brain lead to significant neurocognitive, physical and psychological morbidities. Digital technologies provide a novel platform to capture and evaluate these needs. Mobile health (mHealth) applications typically focus on one aspect of care rather than addressing the multimodal needs of the demographic of these patients. The Vinehealth application aims to address this by tracking symptoms, delivering machine learning-based personalised educational content, and facilitating reminders for medications and appointments. Where mHealth interventions traditionally lack the evidence-based approach of pharmaceuticals, this study acts as an initial step in the rigorous assessment of a new digital health tool. Methods: A mixed methodology approach was applied to evaluate the Vinehealth application as a care delivery adjunct. Patients with brain cancer were recruited from the day of their procedure ± 7 days. Over a 12-week period, we collected real-world and ePRO data via the application. We assessed qualitative feedback from mixed-methodology surveys and semi-structured interviews at onboarding and after two weeks of application use. Results: Six participants enrolled of whom four downloaded the application; four completed all interviews. One patient set up their device incorrectly and so couldn't receive the questionnaires; excluding this patient, the EQ-5D-5L and EORTC QLQ-BN20 completion rates were 100% and 83% respectively. Average scores (±SD) at onboarding and offboarding were EQ-5D-5L: 2.07±1.28 and 1.73±1.22, and QLQ-BN20: 13.33 and 22.5. In total: 212 symptoms, 174 activity, and 47 medication data points were captured, and 113 educational articles were read. Participants were generally optimistic about application use. All users stated they would recommend Vinehealth and expressed subjective improvements in care. Accessibility issues in the ePRO delivery system which impacted completion rate were identified and have subsequently been fully addressed. Conclusions: This feasibility study showed acceptable patient use, led to a subjective improvement in care, and demonstrated effective collection of real-world and validated ePRO data. This provides a strong basis to further explore the integration of the Vinehealth application into brain cancer care. This study will inform the design of a larger, more comprehensive trial continuing to evaluate improvements in care delivery through data collection, educational support and patient empowerment.

Comparison of Whole-Body MRI, CT, and Bone Scintigraphy for Response Evaluation of Cancer Therapeutics in Metastatic Breast Cancer to Bone

Background CT and bone scintigraphy have limitations in evaluating systemic anticancer therapy (SACT) response in bone metastases from metastatic breast cancer (MBC). Purpose To evaluate whether whole-body MRI enables identification of progressive disease (PD) earlier than CT and bone scintigraphy in bone-only MBC. Materials and Methods This prospective study evaluated participants with bone-only MBC between May 2016 and January 2019 (ClinicalTrials.gov identifier: NCT03266744). Participants were enrolled at initiation of first or subsequent SACT based on standard CT and bone scintigraphy imaging. Baseline whole-body MRI was performed within 2 weeks of entry; those with extraosseous disease were excluded. CT and whole-body MRI were performed every 12 weeks until definitive PD was evident with one or both modalities. In case of PD, bone scintigraphy was used to assess for bone disease progression. Radiologists independently interpreted images from CT, whole-body MRI, or bone scintigraphy and were blinded to results with the other modalities. Systematic differences in performance between modalities were analyzed by using the McNemar test. Results Forty-five participants (mean age, 60 years ± 13 [standard deviation]; all women) were evaluated. Median time on study was 36 weeks (range, 1-120 weeks). Two participants were excluded because of unequivocal evidence of liver metastases at baseline whole-body MRI, two participants were excluded because they had clinical progression before imaging showed PD, and one participant was lost to follow-up. Of the 33 participants with PD at imaging, 67% (22 participants) had PD evident at whole-body MRI only and 33% (11 participants) had PD at CT and whole-body MRI concurrently; none had PD at CT only (P < .001, McNemar test). There was only slight agreement between whole-body MRI and CT (Cohen κ, 0.15). PD at bone scintigraphy was reported in 50% of participants (13 of 26) with bone progression at CT and/or whole-body MRI (P < .001, McNemar test). Conclusion Whole-body MRI enabled identification of progressive disease before CT in most participants with bone-only metastatic breast cancer. Progressive disease at bone scintigraphy was evident in only half of participants with bone progression at whole-body MRI. © RSNA, 2020 Online supplemental material is available for this article.

Assessment of the Spatial Heterogeneity of Breast Cancers: Associations Between Computed Tomography and Immunohistochemistry

BACKGROUND

Tumour heterogeneity is considered an important mechanism of treatment failure. Imaging-based assessment of tumour heterogeneity is showing promise but the relationship between these mathematically derived measures and accepted 'gold standards' of tumour biology such as immunohistochemical measures is not established.

METHODS

A total of 20 women with primary breast cancer underwent a research dynamic contrast-enhanced computed tomography prior to treatment with data being available for 15 of these. Texture analysis was performed of the primary tumours to extract 13 locoregional and global parameters. Immunohistochemical analysis associations were assessed by the Spearman rank correlation.

RESULTS

Hypoxia-inducible factor-1α was correlated with first-order kurtosis (r = -0.533, P = .041) and higher order neighbourhood grey-tone difference matrix coarseness (r = 0.54, P = .038). Vascular maturity-related smooth muscle actin was correlated with higher order grey-level run-length long-run emphasis (r = -0.52, P = .047), fractal dimension (r = 0.613, P = .015), and lacunarity (r = -0.634, P = .011). Micro-vessel density, reflecting angiogenesis, was also associated with lacunarity (r = 0.547, P = .035).

CONCLUSIONS

The associations suggest a biological basis for these image-based heterogeneity features and support the use of imaging, already part of standard care, for assessing intratumoural heterogeneity.

The impact of route of diagnosis on survival in patients with glioblastoma

INTRODUCTION

The standard of care for glioblastoma is maximal debulking surgery followed by chemo-radiotherapy (CRT). Published data show worse outcomes for patients who present with GBM as an emergency. This study investigates prognostic factors in a cohort of GBM patients treated with postoperative CRT, and compares outcomes in patients who present via emergency pathways with those who present through outpatient clinics.

METHODS

Patients with GBM operated on between 1 April 2010 and 5 October 2015 and then treated with postoperative CRT were included in the study. Data were collected from electronic patient records and radiotherapy planning systems. Survival data were censored on 22 March 2016. Univariate and multivariate analyses of prognostic factors were performed.

RESULTS

104 patients were studied; mean age 51.6 years (range 19 to 70 years). Median overall survival (OS) was 16.5 months, with 68.2% and 37.8% alive at 12 and 24 months respectively. On multivariate analysis, improved OS was associated with ECOG Performance Status of 0 (vs ≥1; p = .012), patient age <60 years (vs ≥60 years; p < .001), and surgical debulking or macroscopic complete resection (vs biopsy; p < .001). Patients who presented through emergency medical pathways had worse survival (p = .005).

CONCLUSION

This study supports published data that initial presentation through emergency pathways is associated with worse outcomes in GBM, even in patients who remain fit enough to receive post-operative CRT.

Splenic Enlargement and Bone Marrow Hyperplasia in Patients Receiving Trastuzumab-Emtansine for Metastatic Breast Cancer

BACKGROUND

An association between trastuzumab-emtansine (T-DM1) and splenic enlargement is reported in preclinical data, and has been noted anecdotally in patients receiving T-DM1 at our institution. Use of whole-body MRI examinations (WB-MRI) allows for detailed bone marrow assessment and semi-automated splenic volume calculations.

OBJECTIVE

To retrospectively evaluate changes in splenic volume versus evidence of bone marrow hyperplasia and/or changes in portal venous pressure in patients receiving T-DM1 for metastatic breast cancer.

PATIENTS AND METHODS

Twelve metastatic breast cancer patients underwent 29 WB-MRIs before and during T-DM1 therapy. Splenic volume, portal vein diameter, bone marrow diffusion-weighted normalised signal intensity (nSI), quantitative water diffusivity (apparent diffusion coefficient, ADC) and fat fraction (rF%) were measured and correlated.

RESULTS

Splenic volume increases were observed in 92% of patients. Mean splenic volume increased from 144 cm³ (95% CI 110-177 cm³) to 209 cm³ (95% CI 161-257 cm³) on T-DM1 therapy (p = 0.006). Splenic volume increases correlated with treatment duration (r² = 0.43). Bone marrow hyperplasia was evidenced by an increase in bone marrow nSI (3.5 to 4.8, p = 0.12), and decreases in rF% (64.3% to 57.3%, p = 0.12) and ADC (655 μm²/s to 543 μm²/s, p = 0.11). No changes to portal vein diameter were seen.

CONCLUSIONS

Previously unreported increases in splenic volume and bone marrow hyperplasia are observed on WB-MRI in patients on T-DM1 therapy. Caution must be applied to avoid misinterpreting T-DM1-induced bone marrow hyperplasia as diffuse disease progression in bone.

Spatial heterogeneity of MRI response to first-line hormonal therapy to predict progression-free survival in metastatic breast cancer

e12544

Background: Whole-body magnetic resonance imaging (WB-MRI) can positively identify response to systemic therapy in metastatic breast cancer (MBC) by the analysis of water diffusivity, cellularity and cell variability. We adapted a novel methodology that captures patient-level, spatial response heterogeneity using the METastasis Response Assessment Diagnostic System (MET-RADS) using WB-MRI. This study evaluated whether spatial heterogeneity seen at the first response assessment is predictive of duration of treatment (i.e. progression-free survival, PFS) in patients on first line hormonal therapy for MBC. Methods: Patients on first line hormonal therapy for MBC had baseline and on-treatment response assessment WB-MRI scans. All patients had a primary breast mass in situ. Patients showing unequivocal disease progression at their first response assessment scans were excluded from further analysis. Criteria for response assessment utilised the methodology described by MET-RADS. A Likert five-point response assessment category (RAC) score (1 = response highly likely, 5 = progression highly likely) was applied to 14 anatomic regions (7 bone & 7 soft tissue). Two scores reflecting the dominant and next most common response per region were recorded, capturing inter- and intra-region response heterogeneity. A novel Response Heterogeneity Index (RHI) summarised the response heterogeneity at the patient level. RHI and depth of response (mean RAC score for all involved regions) and therapy duration were analysed. Results: Twenty-one patients with primary breast mass in situ were analysed. Patients with higher levels of response heterogeneity (defined as RHI > 5; n = 11) had significantly shorter PFS than those with RHI ≤5 (n = 10; median PFS: 11 vs 27 months; log rank test p = 0.011). The depth of response and PFS were unrelated (mean RAC ≤2.5 vs mean RAC > 2.5; median PFS: 21 vs 18 months; log rank test p = 0.46). There were no correlations between RHI score and mean RAC (r2= 0.007). Conclusions: A low spatial heterogeneity of response is predictive of improved PFS in patients receiving first line hormonal therapy for MBC.

Abstract P5-01-01: Adding whole-body MRI to body CT scans when evaluating response to systemic anti-cancer therapies alters treatment decisions in metastatic breast cancer

Introduction

Accurate evaluation of disease extent and response to systemic anti-cancer therapy (SACT) is key to the clinical management of patients with metastatic breast cancer. By identifying disease distribution and response (particularly progression prior to symptomatic deterioration), imaging aids therapy choices and may maximise quality of life. Whole body MRI (WB-MRI) has increased accuracy for detecting liver and bone disease in breast cancer; however, its potential impact on patient management is largely unexplored. Thus, the purpose of this study was to evaluate the added value of WB-MRI with standard of care CT scans for clinical decision making in routine practice for patients with metastatic breast cancer.

Methods

All patients with metastatic breast cancer who had undergone WB-MRI between 1st April 2009 and 31st March 2016 were screened for this study. Those who had undergone a CT scan of the chest, abdomen and pelvis (CT-CAP) within 14 days of a WB-MRI date were eligible. Original radiology reports for the WB-MRI and CT-CAP were reviewed to establish the extent of reported disease and the SACT response assessment. Contemporaneous medical notes were reviewed to establish the impact of the paired imaging findings (and clinical review) with regard to therapy decisions per time point.

Results

210 pairs of WB-MRI and CT-CAP scans in 101 patients were eligible for analysis. The median age of the studied patients was 56 years (range 23 to 84 years). 46 examination pairs were baseline studies; 164 were undertaken for response assessments (1st line SACT = 46; 2nd line = 27; ≥3rd line = 58; no information = 33).

In 140 cases (66.7%) there were differences between the extent of disease reported by the WB-MRI and CT-CAP. Of these, 112 (80.0%) were due to the WB-MRI reporting additional sites of disease not evident on CT-CAP, mostly skeletal lesions. CT-CAP showed more disease in 10.0%, mostly lung lesions. 10.0% had some lesions evident only on WB-MRI and other lesions evident only on CT-CAP.

Of the 164 scan pairs performed for SACT response assessment, there were differences in the reported response to therapy in 46 cases (28.0%). 89.1% of disagreements were due to WB-MRI showing evidence of either disease progression (67.4%) or partial response (21.7%) that was reported as stable disease on CT-CAP.

Decisions to change SACT in response to disease progression reported by either/both imaging methods were made in 80 cases. Of these, treatment changes were made due to progression reported only on WB-MRI in 23 (28.8%) cases.

Discussion

This is a retrospective analysis of the real world use of WB-MRI and CT-CAP in the clinical practice of metastatic breast cancer, evaluating their impact on clinical care on a per time point basis. WB-MRI identified additional sites of disease (mostly bone) in over half of patients, which affected SACT decisions in a significant proportion of cases. In many cases, SACT changes would not have been made at the same time point without WB-MRI information. Further research is required to test the hypothesis that earlier identification of disease progression by WB-MRI leads to improved quality of life and patient outcomes.

Citation Format: Kosmin M, Makris A, Joshi PV, Ah-See M-L, Padhani AR. Adding whole-body MRI to body CT scans when evaluating response to systemic anti-cancer therapies alters treatment decisions in metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-01-01.

Abstract P4-21-36: Splenic enlargement and bone marrow hyperplasia in patients receiving trastuzumab-emtansine for metastatic breast cancer

Introduction

Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate used for treatment of human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer. An association between T-DM1 and splenic enlargement was noted anecdotally on sequential whole-body MRI (WB-MRI) examinations. A retrospective analysis of WB-MRI examinations of patients on T-DM1 was undertaken to investigate the hypothesis that an increase in splenic volume is due to either a generalised hyperplasia of the bone marrow and reticulo-endothelial system and/or an increase in portal venous pressure.

Methods

12 patients underwent 29 serial WB-MRIs before and during T-DM1 therapy. Splenic volume, portal vein diameter, bone marrow muscle-normalised signal intensity (nSI), water diffusivity (apparent diffusion coefficient, ADC) and fat fraction were measured. Changes in splenic volume were analysed, and correlations between the measured variables were obtained.

Results

An increase in splenic volume was observed in 92% of patients. Mean splenic volume increased from 144cm3 (95%CI 110-177cm3) to 209cm3 (95%CI 161-257cm3) on T-DM1 therapy (p=0.006). Increase in splenic volume correlated with treatment duration (r2=0.71). Increase in normal bone marrow signal was seen (nSI 3.5 to 4.8, p=0.12), along with a decrease in fat fraction (64.3% to 57.3%, p=0.12), and reduced ADC (655µm2/s to 543µm2/s, p=0.11). No consistent changes to portal vein diameter were seen.

Discussion

An increase in splenic volume was consistently observed in patients on T-DM1 therapy. This was unrelated to portal vein changes but correlated with bone marrow hyperplasia. Caution should be applied when assessing metastatic disease in bone to avoid incorrectly attributing T-DM1-related changes in normal bone marrow to disease progression.

Citation Format: Kosmin M, Makris A, Jawad N, Miles D, Padhani AR. Splenic enlargement and bone marrow hyperplasia in patients receiving trastuzumab-emtansine for metastatic breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-21-36.

A systematic review of the prognostic value of lymph node ratio, number of positive nodes and total nodes examined in pancreatic ductal adenocarcinoma

BACKGROUND Pancreatic ductal adenocarcinoma is the most common pancreatic cancer. Five-year overall survival is currently 3.3-6.0%. The aim of this review was to evaluate the prognostic value of lymph node ratio, number of positive nodes and total nodes examined on overall survival rate following pancreatic resection. MATERIALS AND METHODS A literature search was conducted of MEDLINE, EMBASE, the Cochrane Library and Central Register of Controlled Trials and the Cochrane Database of Systematic Review databases, from January 1996 to January 2016. RESULTS Overall, 19 studies including 4,883 patients examined the relationship between lymph node ratio and overall survival. A high lymph node ratio was associated with decreased overall survival in 17 studies. A total of 12 studies examined the relationship between the number of positive nodes and overall survival, and 11 studies revealed that an increase in the number of positive nodes was associated with decreased overall survival. In 15 studies examining the relationship between the total nodes examined and overall survival, there was no association with overall survival in 12 studies. CONCLUSIONS Lymph node ratio and number of positive nodes are factors associated with overall survival in pancreatic ductal adenocarcinoma, but not total nodes examined.

Case-control studies show that a non-conservative amino-acid change from a glutamine to arginine in the P2RX7 purinergic receptor protein is associated with both bipolar- and unipolar-affective disorders

Three linkage studies of bipolar disorder have implicated chromosome 12q24.3 with lod scores of over 3.0 and several other linkage studies have found lods between 2 and 3. Fine mapping within the original chromosomal linkage regions has identified several loci that show association with bipolar disorder. One of these is the P2RX7 gene encoding a central nervous system-expressed purinergic receptor. A non-synonymous single nucleotide polymorphism, rs2230912 (P2RX7-E13A, G allele) and a microsatellite marker NBG6 were both previously found to be associated with bipolar disorder (P=0.00071 and 0.008, respectively). rs2230912 has also been found to show association with unipolar depression. The effect of the polymorphism is non-conservative and results in a glutamine to arginine change (Gln460Arg), which is likely to affect P2RX7 dimerization and protein-protein interactions. We have confirmed the allelic associations between bipolar disorder and the markers rs2230912 (P2RX7-E13A, G allele, P=0.043) and NBG6 (P=0.010) in a London-based sample of 604 bipolar cases and 560 controls. When we combined these data with the published case-control studies of P2RX7 and mood disorder (3586 individuals) the association between rs2230912 (Gln460Arg) and affective disorders became more robust (P=0.002). The increase in Gln460Arg was confined to heterozygotes rather than homozygotes suggesting a dominant effect (odds ratio 1.302, CI=1.129-1.503). Although further research is needed to prove that the Gln460Arg change has an aetiological role, it is so far the most convincing mutation to have been found with a role for increasing susceptibility to bipolar and genetically related unipolar disorders.

The cost-effectiveness of autologous transfusion revisited: implications of an increased risk of bacterial infection with allogeneic transfusion

BACKGROUND

Previous analyses have found autologous transfusion to be very expensive but have not considered avoidance of postoperative bacterial infections as one of its benefits.

STUDY DESIGN AND METHODS

A cost-utility analysis using a Markov cohort simulation model compared autologous blood transfusion to allogeneic transfusion in a hypothetical cohort of patients undergoing elective total hip replacement with respect to discounted quality-adjusted life years (QALYs) and health-care system costs.

RESULTS

Assuming a base case rate of serious infection of 3.7 percent, a relative risk of infection of 1.85, and additional costs of $12,980 per infection, autologous transfusion has a cost-effectiveness of $2,470 per QALY. If the relative risk of bacterial infection following allogeneic transfusion exceeds 1.1, the cost-effectiveness of autologous transfusion is less than $50,000 per QALY and if the relative risk exceeds 2.4, autologous transfusion is dominant, resulting in both lower costs and greater QALYs. If there were no increased risk of transfusion, the cost-effectiveness of autologous transfusion would be $3,400,000 per QALY.

CONCLUSIONS

If there is only a modest increase in the risk of bacterial infection following allogeneic transfusion, autologous transfusion would result in improved outcomes at a cost of less than $50,000 per QALY. Autologous transfusion would be dominant above a relative risk of infection that is within the range of values observed in randomized controlled trials. However, if there is no increased risk of bacterial infection, autologous transfusion would be a very expensive strategy. Until more definitive data are available on the magnitude and costs of this risk, we advise against prematurely closing the debate about the cost-effectiveness of autologous transfusion.

Concurrent presentation of erythrocytic and megakaryocytic aplasia

A case of a patient presenting with idiopathic concurrent erythrocytic and megakaryocytic aplasia is reported. The patient's response to immunosuppressive therapy and her bone marrow pathology clearly suggest an immune mechanism. Based on the lack of suppression of erythroid colony growth, several mechanisms are postulated. Well-established molecular and genetic evidence, along with clinical observations, suggests that a relationship exists between the erythrocytic and megakaryocytic cell lines. This may be related to a common bipotential stem cell or common cell surface markers. This case provides strong clinical evidence to support this relationship.

Hemolytic anemia associated with lead poisoning from shotgun pellets and the response to Succimer treatment

Symptomatic lead poisoning with severe hemolytic anemia was observed in a patient with retained shot gun pellets. Surgical resection of the retained pellets and the use of a newer chelating agent, Succimer (2,3-dimercaptosuccinic acid) successfully lowered blood lead level. Hemolytic anemia was associated with deficient erythrocyte pyrimidine 5'-nucleotidase, and lowering of the lead level corrected the deficiency, suggesting that the enzyme deficiency is responsible for the hemolysis associated with lead poisoning. This case illustrates that retained lead pellets from shotgun wounds can cause severe lead poisoning.

Neonatal thrombosis with anticardiolipin antibody in baby and mother

The anticardiolipin antibody is associated with increased risk of thrombosis, which is manifested with various clinical presentations, including vascular thrombosis, recurrent fetal wastage, and neurologic defects. We report a case of neonatal thrombosis occurring in the renal vein and inferior vena cava associated with moderate positive anticardiolipin antibody titer in the baby while the maternal serum showed even stronger anticardiolipin antibody of immunoglobulin G class. Subsequent follow-up over the 4 months postpartum period showed a disappearance of the antibody in the baby, whereas the mother's antibody persisted. This case illustrates the fact that the maternal anticardiolipin antibody can be transferred to the fetus and may be a risk factor for thrombosis in the neonates. Anticardiolipin antibody syndrome should be considered in the differential diagnosis of neonatal thrombosis.

Increased preoperative collection of autologous blood with recombinant human erythropoietin therapy

To study whether the administration of recombinant human erythropoietin increases the amount of autologous blood that can be collected before surgery, we conducted a randomized, controlled trial of erythropoietin in 47 adults scheduled for elective orthopedic procedures. The patients received either erythropoietin (600 units per kilogram of body weight) or placebo intravenously twice a week for 21 days, during which time up to 6 units of blood was collected. Patients were excluded from donation when their hematocrit values were less than 34 percent. All patients received iron sulfate (325 mg orally three times daily). The mean number of units collected per patient (+/- SE) was 5.4 +/- 0.2 for the erythropoietin group and 4.1 +/- 0.2 for the placebo group. The mean red-cell volume donated by the patients who received erythropoietin was 41 percent greater than that donated by the patients who received placebo (961 vs. 683 ml, P less than 0.05). Only 1 of the 23 patients treated with erythropoietin was unable to donate greater than or equal to 4 units (4 percent) as compared with 7 of the 24 patients who received placebo (29 percent). No adverse effects were attributed to erythropoietin. We conclude that recombinant human erythropoietin increases the ability of patients about to undergo elective surgery to donate autologous blood.

Natural history of acquired immunodeficiency syndrome in hemophilic patients

During the 5-year period from 1981 to 1985, we have observed 8 cases of acquired immunodeficiency syndrome (AIDS) among our 85 patients with hemophilia A. Thus, the prevalence of AIDS with hemophilia A is 9.4% in our patient population. By utilizing stored serum or plasma samples dating back to 1978, antibody against HTLV-III was detected in all 8 cases with AIDS. Based on the time interval from the appearance of antibody to HTLV-III to the diagnosis of AIDS in these patients, the incubation period ranged from 27 months to 60 months, with a median of 36 months. Before the diagnosis of full-blown AIDS, all patients exhibited a variety of prodromal manifestations of non-specific nature, including weight loss, oral candidiasis, unexplained non-productive chronic cough, generalized lymphadenopathy, and thrombocytopenia lasting several months to several years. Serial T-lymphocyte subset studies were available in some patients during the HTLV-III seropositive period and showed progressive lymphopenia, depletion of T4 cells with an average absolute count of 94 +/- 128 per mm3 (mean +/- 1 S.D.), and a markedly reversed T4/T8 ratio of 0.26 +/- 0.19 (mean +/- 1 S.D.). These findings suggest that the incubation period of AIDS is considerably long and that prospective study of serial immunologic markers and HTLV-III markers may be warranted in hemophilic patients at risk.

Clinical trial of a new disposable bleeding-time device

A new disposable bleeding time device (Hemalet) was tested in 20 normal individuals and 11 patients with various bleeding disorders. The results were compared with those of Simplate II. The mean bleeding time for normal individuals was 5.4 +/- 1.5 (mean +/- 1 SD) minutes by Hemalet and 5.8 +/- 1.4 (mean +/- 1 SD) minutes by Simplate II, with good correlation between the results by the two devices (r = 0.81). The bleeding time in patients with various bleeding disorders were also comparably prolonged between the two devices. The new disposable bleeding time device with a disposable blade has quick release (penetration) into skin and retraction, and offers an alternative means of a bleeding time test.