Postoperative C5 Palsy after Anterior or Posterior Decompression for Degenerative Cervical Myelopathy: A Subgroup Analysis of the Multicenter, Prospective, Randomized, Phase III, CSM-Protect Clinical Trial

STUDY DESIGN

Retrospective cohort study of prospectively accrued data.

OBJECTIVE

To evaluate a large, prospective, multicentre dataset of surgically-treated DCM cases on the contemporary risk of C5 palsy with surgical approach.

SUMMARY OF BACKGROUND DATA

The influence of surgical technique on postoperative C5 palsy after decompression for degenerative cervical myelopathy (DCM) is intensely debated. Comprehensive analyses are needed using contemporary data and accounting for covariates.

METHODS

Patients with moderate to severe DCM were prospectively enrolled in the multicenter, randomized CSM-Protect clinical trial and underwent either anterior or posterior decompression between Jan 31, 2012, to May 16, 2017. The primary outcome was the incidence of postoperative C5 palsy, defined as onset of muscle weakness by at least one grade in manual muscle test at the C5 myotome with slight or absent sensory disruption after cervical surgery. Two comparative cohorts were made based on anterior or posterior surgical approach. Multivariate hierarchical mixed-effects logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for C5 palsy.

RESULTS

A total of 283 patients were included, and 53.4% underwent posterior decompression. The total incidence of postoperative C5 palsy was 7.4% and was significantly higher in patients that underwent posterior decompression compared to anterior decompression (11.26% vs. 3.03%, P=0.008). After multivariable regression, posterior approach was independently associated with greater than four times the likelihood of postoperative C5 palsy (P=0.017). Rates of C5 palsy recovery were comparable between the two surgical approaches.

CONCLUSION

The odds of postoperative C5 palsy are significantly higher after posterior decompression compared to anterior decompression for DCM. This may influence surgical decision-making when there is equipoise in deciding between anterior and posterior treatment options for DCM.

LEVEL OF EVIDENCE

Therapeutic Level II.

633 Surveillance for Head and Neck Cancer Recurrences: Is There Scope for A Tailored Approach?

Introduction

Detection of cancer recurrence after treatment of head and neck cancer (HaNC) is vital. Current guidelines stipulate that following primary treatment HaNC patients are followed up for five years with a total of 18-24 appointments. This forms a bulk of the HaNC surgeon’s workload. Asymptomatic recurrences are rare. Patients educated regarding worrying symptoms may institute their own follow up. Such open appointment systems may be as effective at detecting recurrences

Method

At a moderate volume HaNC centre we reviewed 98 patients that had completed their five year follow up. We investigated cancer recurrences and whether these were symptomatic or asymptomatic at time of detection. We analysed each recurrence regarding the time since primary treatment.

Results

23 patients had HaNC recurrences. These recurrences were symptomatic in 17 patients and asymptomatic in 6 patients. Five of the six patients from the asymptomatic group had recurrences within two years of primary treatment. The final patient was of a high-risk histological subtype.

Conclusions

Asymptomatic cancer recurrences are uncommon especially after two years of regular follow up. After two years the frequency of appointments may be tailored on a patient-by-patient basis. Patients educated regarding symptoms of cancer recurrences may institute their own follow up.

RADT-26. LASER INTERSTITIAL THERMAL THERAPY FOR RECURRENT GLIOBLASTOMA: POOLED ANALYSES OF AVAILABLE LITERATURE

INTRODUCTION

Laser Interstitial Thermal Therapy (LITT) is a novel treatment modality that has been used for an array of intracranial pathology. In the current manuscript, we sought to conduct a systematic review and meta-analysis to summarize all available literature to date, on outcomes of patients with recurrent GBM (r-GBM) undergoing LITT, pooling together quantitatively the overall survival and progression-free survival data.

METHODS

A comprehensive literature search was performed to retrieve all studies investigating overall survival, post-procedure survival, and progression-free survival outcomes of patients with r-GBM undergoing LITT. All statistics were pooled together by the meta-analysis of the mean using a weighted random-effects (RE) or fixed-effect (FE) model.

RESULTS

Eleven studies were included in the final cohort, representing a total of 134 patients with rGBM. The pooled mean age of the cohort at the time of recurrence diagnosis was found to be 56.7 ± 4.56 while 41% of the cohort were females. For the delivery of LITT, two studies utilized neodymium-yttrium aluminum-garnet laser (Neodp-YAG Laser), three studies utilized the Visualase system, five studies utilized the Neuroblate system, and one study used both the Neuroblate and the Visualase system. A total of eight studies with 107 patients had available data for overall median survival. The pooled overall survival was found to be 18.6 months (95%CI 16.2-21.1). A total of six studies with 93 patients had available data for post-LITT survival. The pooled post-LITT survival was found to be 10.1 months (95%CI 8.8-11.6). A total of eight studies with 119 patients had available data for progression-free survival. The pooled progression-free survival was found to be 6 months (95%CI 5.3-6.7).

CONCLUSION

LITT is a novel minimally invasive procedure which, when used with optimal adjuvant therapy, may confer survival benefit for patients with r-GBM.

RARE-53. THE ROLE OF RADIATION AND CHEMOTHERAPY IN ADULT PATIENTS WITH HIGH-GRADE BRAINSTEM GLIOMAS

BACKGROUND

High-grade gliomas (HGGs) of the brainstem represent a rarer subtype of central nervous system tumors compared to their supratentorial counterpart. Predictors of survival and patterns of care have not yet been established on a national, multi-institutional scale.

METHODS

The National Cancer Database was queried for adult cases surgically diagnosed with brainstem high-grade glioma. An array of patient demographics, comorbidities, tumor characteristics and treatment parameters were captured. Predictors of survival were investigated using multivariable Cox proportional hazards regression analysis adjusting for age, insurance status, Charlson comorbidity score, tumor grade, tumor size and type of treatment.

RESULTS

A total of 422 patients (median 51 years, 60% males) were analyzed. Two hundred eighty one received postoperative radiation with chemotherapy (66.6%), thirty-nine had radiation alone (9.2%), while the remaining had no adjuvant treatment (24.2%). Median radiation dosage was 54Gy. Overall median survival was 9.8 months (95% CI 8.8–12). Survival was significantly longer (p< .001) in the chemotherapy+radiation group (median: 14.2 months, 95% CI 11.7–17.1) compared to radiation alone (median: 5.7 months, 95% CI 3.7–12) and no adjuvant treatment (median:1.8 months, 95% CI 1.4–4). In multivariable analysis, increasing age (HR 1.87, 95% CI 1.47–2.37, p< .001) was associated with worse survival, whereas radiation with chemotherapy (HR 0.67, 95% CI 0.46–0.98, p=0.038) were associated with lower hazards of death compared to radiation alone. In subgroup analysis, the effect of adjuvant chemotherapy with radiation remained significant for grade IV (HR 0.46, 95% CI 0.28–0.76, p=0.003), but not for grade III tumors (HR 0.87, 95% CI 0.48–1.58, p=0.65).

CONCLUSION

Findings of the present analysis demonstrate the effectiveness of radiation with chemotherapy for adult patients with high-grade brainstem gliomas, particularly grade IV. Further research should aim on identifying specific patient profiles and molecular subgroups that are more likely to benefit from multimodality therapy.

Abstract 2091: Lysosomal targeting of doxorubicin induces different membrane permeabilization and cytotoxicity in two breast cancer cell lines

Background: Lysosomal targeting has been investigated for the treatment of cancer but details of the resulting cytotoxicity remain unclear. The induced lysosomal membrane permeabilization (LMP) has been shown to induce apoptosis and cytotoxicity. The purpose of this study is to elucidate details of doxorubicin (DOX) induced LMP in breast cancer cells and identify correlations with cytotoxicity.

Methods: A gelatin – doxorubicin conjugate (GDOX) to target lysosomes was synthesized by EDC chemistry in formamide and purified by precipitation and desalting. GDox and free Dox uptake studies at 10 µM or its equivalent were conducted in MCF7 and MDA-MB-231 (triple negative breast cancer-TNBC) cells in growth media. Intracellular localization was followed by fluorescent markers. LMP was shown by cytosolic release of 10 kD Dextran-Alexa Fluor 488 previously loaded into lysosomes. Intra-lysosomal release of Dox from GDOX was examined by rupture of lysosomes and nuclear accumulation of released Dox followed by fluorescent microscopy and ImageJ. Released Dox accumulation in the nucleus without lysosome rupture was analyzed by UHPLC. Viability, growth inhibition profiles, and IC50 values were determined by the MTT procedure and GraphPad Prism 7.

Results: GDox localized substantially to the lysosomes in both MCF7 and TNBC cells while free DOX localized to the nucleus, as expected. GDOX induced LMP by 24 hrs in 100% of the TNBC cells but only 20% of the MCF7 cells even up to 48 hrs. Intra-lysosomal DOX release in the MCF7 cells was notable only by 24 hrs and was estimated by fluorescent intensity (300,000 integrated density units per cell) at one-half the amount of free DOX accumulation in the nucleus. Nuclear accumulation of released DOX escaping intact lysosomes in MCF7 cells by 24 hrs was one-half that at 48 hrs which reached 0.13 µg Dox per 106 cells by 48 hrs representing only one-tenth that achieved by free DOX. MCF7 cell viability in GDOX was reduced to 62±3% of controls by 24 hr but reached 19±4% by 48 hrs compared to 11±1% for free Dox. The IC50 values of GDOX after 48 hr were 1.3±0.7 µM and 4.5±2 µM in TNBC and MCF7 cells, respectively.

Conclusions: Taken together these results indicate that LMP is not induced by pooling of released DOX in MCF7 lysosomes nor does LMP contribute to cytotoxicity in these cells. The lysosomal accumulation of GDOX in MDA cells, in contrast to MCF7 cells, leads to extensive LMP which may contribute to the greater cytotoxicity in these cells compared to the MCF7 cells. The small amount of released DOX accumulating in the MCF7 nuclei may induce a nuclear pathway of cytotoxicity in these cells.

Acknowledgements: Financial support is appreciated from the Agnes Varis Trust for Women’s Leadership and Health, King Abdul-Aziz University, and NIH R15 CA135421.

Citation Format: Mohammed Alvi, Rachel Nicoletto, Bayan A. Eshmawi, Clyde M. Ofner. Lysosomal targeting of doxorubicin induces different membrane permeabilization and cytotoxicity in two breast cancer cell lines [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2091.

Effect of teriparatide use on bone mineral density and spinal fusion: a narrative review of animal models

Purpose of the study: Teriparatide (Human recombinant Parathyroid Hormone 1-34) is an anabolic agent that is frequently used in patients with osteoporosis and has been extensively investigated with animal model and clinical studies in current literature. The purpose of the study was to evaluate the impact of teriparatide on bone mineral density and fusion. Materials and methods: The findings from preclinical studies that have investigated the role of teriparatide in animal models are summarized in presented review. Results: Overall, the studies show an improvement in bone mineral density and increased fusion rates for osteoporotic animals undergoing spine fusion with teriparatide use. Conclusion: Further studies should be conducted for unanswered questions, such as teriparatide use before surgery, the effect on cervical fusion and surgery related complications.

Abstract 4663: Lysosomal targeting from a gelatin-doxorubicin conjugate produces evidence of both nuclear and lysosomal cytotoxcity pathways in mcf-7 breast cancer cells

Background: Intra-lysosomal targeting has been investigated for the treatment of cancer but details of the cytotoxicity pathways remain unclear. A high molecular weight gelatin - doxorubicin conjugate (GDox) has been synthesized to target acidic lysosomes for intra-lysosomal drug release. The purpose of this investigation was to explore GDox feasibility for drug delivery and to make a preliminary determination of a cytotoxic pathway. Methods: GDox was synthesized in formamide using the carbodiimide, EDC. Drug load was determined spectroscopically, drug release at pH 4.8 was determined by HPLC, and molecular weight and its reduction in FBS was determined by HPSEC. Cellular localization was determined for free Dox and GDox at 10 µM or its equivalent Dox concentration using fluorescence microscopy with appropriate subcellular stains. Three to four independent trials (n=3-4) were examined with 200 to 700 cells per time point. Cytotoxicity was determing by the MTT procedure (n=3). Viabilities, growth inhibition profiles and their IC50 values were calculated with GraphPad Prism 7. The nucleus content of free Dox or Dox released from GDox after incubation was determined by UHPLC using fluorescent detection (n=3-4). Results: A typical GDox contained 5.6% w/w Dox, had a molecular weight of ~ 160 kDa, and released 58+2.3% Dox at pH 4.8 representing lysosomal pH. After incubation in FBS at 37°C for 24 hr the low molecular weight species increased a relatively small 16%. Fluorescent images with LysoTracker Green confirmed GDox localization to the lysosome which was detectable by 2 hr but substantial in swollen lysosomes by 24 and 48 hrs. No released Dox was observed in the nucleus, but a slight red nucleus haze at later times suggested this possibility. Cell debri from GDox was not observed from free Dox. As expected, free Dox rapidly accumulated in the nucleus by 2 hr. Viability determinations at 0.1, 1, and 10 µM for 2 to 48 hr showed no effect from either agent before 24 hr. By 48 hr at 10 µM, the viability of Dox (30+12%) and GDox (36+13%) were indistinguishable (p=0.68). However, by 72 hr, IC50 values varied 10-fold at 0.094 and 0.96 µM, respectively. The nucleus drug content after incubation at 10 µM for 2 to 48 hr was 0.27+0.07 to 1.39+0.6 µg/106 cells (p&lt0.01) for free Dox, and 0.014+0.01 to 0.11+0.06 µg/106 cells (p&lt0.01) for released Dox. Conclusions: Taken together these results suggest good feasibility of GDox lysosomal targeting and Dox release in MCF7 breast cancer cells. Of note, after 48 hr incubation GDox produced the same cytotoxicity as the free drug but with 13-fold less Dox in the nucleus. This striking nucleus difference and the substantial lysosomal GDox content suggest a lysosomal pathway of GDox cytotoxicity in addition to a nuclear pathway. Support: NIH/NCI R15CA135421 and the Agnes Varis Trust for Women's Leadership and Health.

Citation Format: Mohammed Alvi, Bayan Eshmawi, Rachel Nicoletto, Hyun Kate Kim, Christopher Cammarata, Clyde Ofner. Lysosomal targeting from a gelatin-doxorubicin conjugate produces evidence of both nuclear and lysosomal cytotoxcity pathways in mcf-7 breast cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4663.