External validation of the Chicago Chiari Outcome Scale in adults with Chiari malformation type I

OBJECTIVE

The Chicago Chiari Outcome Scale (CCOS) serves as a standardized clinical outcome evaluation tool among patients with Chiari malformation type I (CM-I). While the reliability of this scale has been proven for pediatric patients, the literature lacks CCOS validation when used solely in adults. Therefore, this study aimed to determine the validity of the CCOS in an external cohort of adult patients.

METHODS

The authors retrospectively analyzed the medical records of symptomatic patients with CM-I who underwent posterior fossa decompression between 2010 and 2018 in six neurosurgical departments. Each patient was clinically assessed at the latest available follow-up. Gestalt outcome was determined as improved, unchanged, or worsened compared with the preoperative clinical state. Additionally, the CCOS score was calculated for each patient based on the detailed clinical data. To verify the ability of the CCOS to determine clinical improvement, the area under the receiver operating characteristic (AUROC) curve was evaluated. A logistic regression analysis using all four components of the CCOS (pain symptoms, nonpain symptoms, functionality, and complications) was performed to establish predictors of the improved outcome.

RESULTS

Seventy-five individuals with a mean age of 42 ± 15.32 years were included in the study. The mean follow-up duration was 52 ± 33.83 months. Considering gestalt outcome evaluation, 41 patients (54.7%) were classified as improved, 24 (32%) as unchanged, and 10 (13.3%) as worsened. All patients with a CCOS score of 14 or higher improved, while all those with a CCOS score of 8 or lower worsened. The AUROC was 0.986, suggesting almost perfect accuracy of the CCOS in delineating clinical improvement. A CCOS score of 13 showed high sensitivity (0.93) and specificity (0.97) for identifying patients with clinical improvement. Additionally, a meaningful correlation was found between higher CCOS scores in each component and better outcomes. Patient stratification by total CCOS score showed that those categorized as improved, unchanged, and worsened scored prevalently between 13 and 16 points, 10 and 12 points, and 4 and 9 points, respectively.

CONCLUSIONS

In this adult cohort, the CCOS was found to be almost perfectly accurate in reflecting postoperative clinical improvement. Moreover, all four CCOS components (pain symptoms, nonpain symptoms, functionality, and complications) significantly correlated with patient clinical outcomes.

Patient reported causes of fatigue in relation to adjuvant radiotherapy after breast conserving surgery

Abstract #4094

Background: Fatigue is one of the most frequent symptoms experienced by cancer patients, and it adversely affects the quality of life. Fatigue is multidimensional and associated with the malignancy itself, but also with anti-neoplastic treatment and probably with several other causes. The aim of the study was to assess the level of fatigue during and after adjuvant radiotherapy in breast cancer patients and to uncover the kind of factors believed by patients to play a role in the generation of fatigue in relation to radiotherapy.
 Methods: 70 patients (ages 33-76 years, mean 57 years) with early-stage breast cancer were included after breast conserving surgery. Patients were treated with adjuvant radiotherapy (48Gy/24 fractions/5 weeks; 20 patients received boost 10Gy/5 fractions/1 week with tumor-bed). The subjective feeling of fatigue was measured according to the 10-score visual analog scale (VAS). RTOG Acute Radiation Morbidity Scoring Criteria (0-4) were used for the estimation of the acute skin reaction.
 Results: 53% of the patients demonstrated no fatigue (VAS 0-1) before the start of adjuvant postoperative radiotherapy. Patients after adjuvant chemotherapy manifested a little higher level of fatigue; there were no differences between patients with or without anti estrogen therapy. Fatigue intensity increased gradually during radiotherapy, but about 1/3 of the patients felt no fatigue. The majority of the patients reported radiotherapy as a cause of fatigue (33 of 47 patients (70%) with fatigue VAS ≥ 2 at the end of radiotherapy). 25% of the patients believed that their fatigue was still associated with previously given adjuvant chemotherapy, but in fact, the patients after chemotherapy did not demonstrate a higher fatigue level at the end of the radiotherapy course. 5 patients (10%) associated their fatigue with the anti estrogen therapy. There was correlation between fatigue level and intensity of radiotherapy-induced skin toxicity – patients with strong acute skin reaction demonstrated a higher fatigue level. But only 8 patients (17%) indicated the skin reaction as a cause of fatigue. Fatigue level was associated with traveling time to the hospital, especially when the journey took 2 hours or more/day. 45% of the patients gave the transport time to the hospital as a reason for fatigue.
 Conclusion: Fatigue increased over the course of adjuvant radiotherapy of breast cancer patients after breast conserving surgery. Fatigue seems to be multidimensional, but most of the patients indicate radiotherapy treatment as the cause of fatigue.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 4094.

Correlation between fatigue level and irradiated volume of the whole body, lung and heart in breast cancer patients receiving adjuvant radiotherapy after breast-conserving surgery

19608

Background: Fatigue - an unpleasant, persistent, subjective sense of tiredness - is one of the most common symptoms experienced by cancer patients. It is multidimensional and is associated with both - malignancy itself and the anti-neoplastic treatment. The aim of the study was to assess the level of fatigue during and after adjuvant postoperative radiotherapy in breast cancer patients and evaluate its correlation with the irradiated volume of the whole body, lung and heart. Methods: 48 patients (age 33–76 years, mean 57 years) with early breast cancer after breast-conserving surgery were treated with adjuvant radiotherapy (48Gy/24fractions/5weeks; 12 patients received boost 10Gy/5fractions/1week to the tumor-bed). The patients′ subjective feeling of fatigue intensity was measured according to 10- score visual analog scale (VAS) before the start and weekly during radiotherapy, as well as 14 days and 3 months after radiotherapy. Results: Fatigue intensity increased gradually during radiotherapy (mean fatigue-VAS before and in the last week of treatment was 1.21 and 2.31 respectively; p=0.004). 14 days after the end of radiotherapy, the fatigue intensity was still higher than before treatment (1.88 and 1.21 respectively; p=0.04), but 3 months later, fatigue was lower than at the pretreatment level (n.s.). Irradiation of the large volume of the whole body was correlated with higher fatigue level during and after radiotherapy. If 15% or more of the unilateral lung volume received 20Gy, patients reported higher fatigue level than patients receiving 20Gy for less than 15% of the unilateral lung volume. There were no statistical differences in fatigue level between patients with different percentage of the heart volume receiving irradiation. Patients with boost did not manifest higher fatigue level. Conclusions: Fatigue increased over the course of radiotherapy, but 3 months after the end of therapy it was reduced to lower than at the preliminary level. There was a positive correlation between fatigue level during and after radiotherapy and the irradiated whole body and lung volume, but not heart volume.

No significant financial relationships to disclose.

Fatigue in breast cancer patients during and after radiotherapy

18537

Background: Fatigue—an unpleasant sensation of tiredness, weakness or lack of energy—is one of the most prevalent and profound symptoms caused by malignancy itself and anti-neoplastic treatment. The aim of the study was to assess the level of fatigue during and after adjuvant postoperative radiotherapy of breast cancer patients. Methods: 125 patients with breast cancer were recruited between May 2004 and September 2005 (85 after breast-conserving surgery and 40 after mastectomy). Subjective feeling of fatigue intensity was measured according to 10-score visual analog scale (VAS) before the start and once a week during radiotherapy, 14 days and 3 months after radiotherapy (48 Gy/24 fractions/5 weeks; 25 patients received boost 10 Gy/5 fractions/1 week with tumor-bed). Results: 46% of patients demonstrated non-fatigue before the start of radiotherapy. Patients after breast-conserving surgery and chemotherapy manifested higher lever of fatigue in comparison with patients after lumpectomy but without chemotherapy and patients after mastectomy with and without chemotherapy (p = 0.01). Fatigue intensity increased gradually during radiotherapy (mean fatigue-VAS before and in the last week of treatment was 1.8, 2.75 after lumpectomy and 1.25, 2.95 after mastectomy, respectively). 14 days after the end of radiotherapy fatigue intensity was still higher than before treatment (p = 0.04), but 3 months later it was lower than the pretreatment level. However, 25% of the patients defined their fatigue as 2 or more in VAS three months after radiotherapy. 15% of patients reported non-fatigue during radiotherapy. Older patients (>60 years) estimated their fatigue in the last week of treatment on lower level than younger patients (2.22 vs 2.90, p = 0.065). Patients with boost manifested only a little higher fatigue level in comparison with other patients (2.97 vs 2.52). Conclusions: Increasing fatigue was found in 85% of breast cancer patients during adjuvant radiotherapy. Three months after the end of therapy fatigue was reduced to lover then the preliminary level. There were no significant differences between patients after breast-conserving surgery and mastectomy.

No significant financial relationships to disclose.

Loss of heterozygosity on chromosomes 2p, 3p, 18q21.3 and 11p15.5 as a poor prognostic factor in stage II and III (FIGO) cervical cancer treated by radiotherapy

Loss of heterozygosity (LOH) has been shown to be an important prognostic factor in a variety of malignant neoplasm's. Cervical cancer develops as result of multiple genetic alterations. The aim of this study was to analyze presence of LOH in cervical cancer and to identify the correlation between LOH and survival and relapse-free survival time in patients treated with radiotherapy. Studies were performed on tumor specimens and venous blood from 20 patients with cervical cancer (squamous cell carcinoma G2 and G3) in stage II and III (FIGO) treated with radiotherapy. DNA was isolated using organic extraction. Additional microcolumn purification was performed. The fluorescent multiplex polymerase chain reaction (PCR) was used to amplify 10 microsatellite loci included in commercially available human identification kits. Microsatellite marker BAT 26 was amplified in separate PCR reactions. 75% cervical cancers manifested LOH. LOH in BAT 26 analysis (chromosome 2) was present in all these specimens. 60% of the cases showed LOH at one or more of other examined loci (mostly on 3p, 18q21.3, and 11p15.5). Eight of nine cervical cancers in clinical stage III showed LOH. All cases of G3 squamous cell carcinoma of the cervix manifested LOH on 2p. Patients with LOH have worse prognosis for survival and relapse-free survival compared to patients without LOH.

Localization of blood coagulation factors in situ in pancreatic carcinoma

Blood coagulation is activated commonly in pancreatic carcinoma but the role of the tumor cell in this activation is undefined. Immunohistochemical procedures were applied to fixed sections of 22 cases of resected adenocarcinoma of the pancreas to determine the presence of components of coagulation and fibrinolysis pathways in situ. Tumor cell bodies stained for tissue factor: prothrombin: and factors VII, VIIIc, IX, X, XII, and subunit "a" of factor XIII. Fibrinogen existed throughout the tumor stroma, and tumor cells were surrounded by fibrin. Staining for tissue factor pathway inhibitor, and plasminogen activators was minimal and inconsistent. Plasminogen activator inhibitors -1, -2, and -3 were present in the tumor stroma, and on tumor cells and vascular endothelium. Extravascular coagulation activation exists associated with pancreatic carcinoma cells in situ that is apparently unopposed by naturally occurring inhibitors or the plasminogen activator-plasmin system. We postulate that such local coagulation activation may regulate growth of this malignancy. These findings provide a rationale for testing agents that modulate the blood coagulation/fibrinolytic system (that inhibit tumor growth in other settings) in pancreatic carcinoma.

Expression of prothrombin fragment 1+2 in cancer tissue as an indicator of local activation of blood coagulation

Immunohistochemistry was applied to AMeX-fixed tissue sections of 12 adenocarcinomas of the stomach (seven intestinal adenocarcinomas and five diffuse carcinomas), 12 adenocarcinomas of the pancreas (nine ductal adenocarcinomas and three signet ring carcinomas), and 12 squamous cell carcinomas of the larynx obtained at surgical resection to examine the possibility of extravascular activation of blood coagulation in cancer tissues by exploring the in loco patterns of distribution of fibrinogen, a final product of blood coagulation, fibrin, and a by-product of coagulation reactions (prothrombin fragment 1+2). Gastric, pancreatic, and laryngeal cancers exhibited fibrinogen antigen in abundance throughout the tumor stroma. Fibrin was detected along the edges of nests of carcinoma cells and at the host-tumor interface. Prothrombin fragment 1+2 was present in the blood vessels in areas of neoangiogenesis at the host-tumor interface (gastric and pancreatic cancer tissues) and on the tumor cell bodies (pancreatic and laryngeal cancer tissues). The presence of prothrombin fragment 1+2 in cancer tissues appears to be a good indicator of coagulation activation and thrombin generation at the tumor burden.