Prospective Cohort Study to Evaluate Toxicity and Cosmesis between Interstitial APBI and Ultra-Hypo-Fractionated Whole Breast Irradiation in Patients with Early Breast Cancer

PURPOSE/OBJECTIVE(S)

Both interstitial multi-catheter brachytherapy based accelerated partial breast irradiation (APBI) and ultra-hypo-fractionated whole breast irradiation (WBI) with 5 fractions can complete treatment in a short time and result in lower treatment-related costs. Although data are available on their toxicity compared with conventional and hypo-fractionated regimens, there are few data directly comparing these two techniques.

MATERIALS/METHODS

This prospective cohort study enrolled early breast cancer patients with negative ink margin, T1 or T2 stage, and tumor size of 3 cm or less, with 0 to 3 positive lymph nodes after adequate axillary dissection or negative sentinel lymph node biopsy (N0-1), regardless of receptor status (ER, PR, HER2neu). Of the total 31 patients, 15 received APBI with multi-catheter interstitial brachytherapy (35 Gy in10 fractions over 5 days with a minimum interval of 6 hours between fractions) and 16 patients received WBI (27 Gy in 5 fractions over 5 days) with either 3DCRT or VMAT technique. Acute toxicity was assessed using the RTOG toxicity grading and breast cosmesis was assessed using the Harvard breast cosmesis score. Toxicity and cosmesis were assessed immediately after treatment, after one month, and after three months of treatment. Results were compared between groups using the Mann Whitney U test.

RESULTS

All patients completed a 3-month follow-up after completion of treatment. There was no statistically significant difference between the 2 groups in terms of highest grade toxicity (p = 0.97) and acute toxicity immediately after RT (p = 1.0) and after 1 month of RT (p = 0.91). However, at 3 months, more patients in the WBI group had a residual skin reaction than in the APBI group (p = 0.03). There was no statistically significant difference in breast cosmesis scores at any time point. 53.3%, 6.6% had grade 1 and 2 skin toxicities respectively immediately after RT in the APBI group and 62.5% of patients had grade 1 skin toxicity in WBI group. After 1 month 26.6%, 26.6% & 13.3% patients had grade 2, grade 1 and grade 3 toxicities respectively. In the WBI group, at 1 month, 50%, 18.7% and 12.5% patients had grade 1, 3 and 2 skin toxicities respectively. At 3 months, 42.8% and 7.1% of patients in the APBI group had grade 1 and grade 2 toxicities, respectively. In the WBI group, 78.5% and 7.1% of patients had grade 1 and 2 skin toxicities respectively.

CONCLUSION

In this study, no difference in acute toxicity or breast cosmesis was demonstrated between APBI-based interstitial brachytherapy and ultra-hypo-fractionated WBI. Since both regimens can be administered within 5 days, the decision between them is challenging for both physicians and patients. This study can be considered hypothesis-generating and used for further planning of equivalence or noninferiority studies.

Clinical Outcome and Patterns of Failure in Patients with Solitary Plasmacytoma Treated with Radical Radiotherapy

PURPOSE/OBJECTIVE(S)

We intended to assess the patterns of care and failure in patients with solitary plasmacytoma (SP), treated at our institute from 2011-21.

MATERIALS/METHODS

Data pertaining to the management of patients with SP was abstracted by retrospective chart review. Progression free survival (PFS) and overall survival (OS) were defined as the time intervals from the date of diagnosis to the date of progression (local, systemic or both) and death or last follow up, respectively. PFS and OS were analyzed by Kaplan Meier method.

RESULTS

Atotal of 72 patients were diagnosed with SP (61-bone plasmacytoma; 11-extramedullary plasmacytoma) in between 2011 and 2021. The median age at diagnosis was 52 years. The male: female ratio was 2.27. The ECOG PS were 0, 1, 2, 3, and 4 in 1, 46, 11, 10, and 3 patients, respectively. The median diameter of the lesion was 6.7 cm (range 2.3-18.4 cm). The median M protein was 0.375 g/dl (range 0.63-5.3 g/dl). On bone marrow examination, 8 and 64 patients had no and minimal marrow involvement, respectively (median bone marrow plasma cells 4%). Radical radiotherapy (RT) was administered in 71 patients, the techniques being 2D-conventional in 35, 3D-conformal in 14, IMRT in 8 and VMAT in 5 patients (details not available in 9). The median RT dose was 45 Gy in 25 fractions over 5 weeks (range 45-50 Gy). In addition, 5(7%) patients underwent surgery prior to RT and 6(8.5%) patients received systemic chemotherapy. After RT, the median quantum of symptom relief was 75% (range 0-100%). The best response to RT was CR, PR, SD and PD in 41(57.7%),18(25.4%),3(4.2%) and 4(5.6%) patients, respectively (response assessment could not be done in 5). Local control with primary RT was achieved in 58(81.7%) patients. No RT related grade 3/4 acute or late toxicity was reported. The median follow up was 48.3 months (range 1.3-141.6 months). A total of 28(39.4%) patients experienced disease progression (systemic in 15, local in 7 and both in 6), out of which 13 could be successfully salvaged with further systemic chemotherapy (mostly bortezomib, lenalidomide/pomalidomide and dexamethasone based) with or without local treatment. On progression to multiple myeloma, 9 patients underwent high dose chemotherapy(melphalan) followed by autologous stem cell transplant. Nine (12.7%) patients died, the causes being COVID-19 infection in 1, surgical complications in 1, PD in 2, second malignancies in 3 and unknown in 2. The actuarial rates of PFS & OS were 58.4% & 92.5% at 3 years and 50.3% & 89.4% at 5 years, respectively. Metachronous second malignancies were noted in 4 patients (B-ALL-1, lung cancer-1, metastatic carcinoma cervix-1, metastatic carcinoma gall bladder-1).

CONCLUSION

In patients with SP, radical RT with a modest dose (45-50 Gy) leads to satisfactory symptom relief, response and local control. Close to 40% patients eventually progress to multiple myeloma, out of which 50% can be successfully salvaged with further systemic chemotherapy. The 5-year OS approaches 90% in this cohort.

Optimum Radiation Dose for Palliation in Head and Neck SCC: A Phase III Randomized Controlled Trial (OPRAH)

PURPOSE/OBJECTIVE(S)

Palliative radiotherapy has been used to alleviate symptoms in locally advanced (T4b) head and neck Squamous cell carcinoma, but optimum dose is still debated. The trial has been designed to determine if high palliative radiation dose (30 Gy/ 5#/ 5 days) improves progression free survival compared to low palliative dose (20 Gy/ 5# 5 days). The secondary objective was to compare toxicity rates profile between the two radiation doses (CTCAE version 5) and compare Quality of life between the two arms with QOL - HN35 questionnaire.

MATERIALS/METHODS

This is a prospective randomized phase III randomized controlled trial. We hypothesized that by increasing the dose per fraction and total dose there would be an improvement in PFS without difference in late toxicity and QOL. The present study will also perform an exploratory analysis of effect of palliative radiotherapy on immune function and its effect on survival. Considering median PFS 2.5 months in 20 Gy arm we assumed that PFS will improve by 1.25 months (total PFS 3.75 months) in 30 Gy arm. To reach the hypothesis with 90% power and alpha error of 0.05, attrition rate of 10% sample size calculated was 286. Patients with cT4b disease of larynx/ Hypopharynx/ Oropharynx/ Oral cavity not amenable to surgery, Carotid encasement > 180 degree, histologically proven squamous cell carcinoma, Age > 18 years and < 75 years ECOG PS 0-2 were eligible.

RESULTS

Until December 2022, we completed accrual of 239 patients. Median age: 53 years (Range: 29-70 years); Gender: Male: Female = 9: 1 (214: 25). 145 patients had history of smoking, 87 had additional history of tobacco chewing. 67 patients had history of alcohol consumption, 13 patients had history of smoking, tobacco and alcoholism. All patients had stage IVA or Stage IVB disease. Primary site was oral cavity in 58%, Oropharynx in 19%, larynx in 10% and hypopharynx in 8% cases. 72.3% patients had a PS of 1, 21.7% had PS 2 at presentation. Prior to RT requirement of analgesic was: No pain medicine: 5; WHO step I:173, WHO step II: 52, WHO step III:14. All patients received conformal radiation with 6 MV linear accelerator. Target volume was GTV plus 1 cm margin to form CTV and 5 mm expansion to generate PTV. Out of 239 patients 67 patients had a disease progression. Mucositis is the commonest side effect affecting most of the patients and improve with best supportive care.

CONCLUSION

High dose palliation appears to be equally well tolerated. However, the impact of such dose escalation will be established if final analysis reaches the pre-defined endpoint.

A Peptide-PNA Hybrid Beacon for Sensitive Detection of Protein Biomarkers in Biological Fluids

Specific and rapid detection of proteins in biological fluids poses a challenging problem. In biological fluids, many proteins are present at low concentrations, requiring high affinity and specificity of the beacon-protein interaction. We report the design of a peptide-PNA hybrid beacon that exploits the dimeric nature of a target protein, S100B, a biomarker for brain trauma, to enhance binding affinity and specificity. The complementary base-pairing of the PNA bases brings the two arms of the beacon, one carrying an Alexa tag and the other carrying a Dabcyl moiety, into proximity, thus quenching Alexa fluorescence. Each of the arms carries a sequence that binds to one of the subunits. Binding to the target separates the quencher from the probe lifting the quenching of fluorescence. Enhanced affinity and specificity resulting from simultaneously binding to two sites allowed specific detection of S100B at low-nanomolar concentrations in the presence of serum. The design can be easily adapted for the detection of proteins containing multiple binding sites and could prove useful for rapid and sensitive biomarker detection.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Modelling the water-plant cuticular polymer matrix membrane partitioning of diverse chemicals in multiple plant species using the support vector machine-based QSAR approach

In this study, a support vector machine (SVM) based multi-species QSAR (quantitative structure-activity relationship) model was developed for predicting the water-plant cuticular polymer matrix membrane (MX) partition coefficient, K_MXw of diverse chemicals using two simple molecular descriptors derived from the chemical structures and following the OECD guidelines. Accordingly, the Lycopersicon esculentum Mill. data were used to construct the QSAR model that was externally validated using three other plant species data. The diversity in chemical structures and end-points were verified using the Tanimoto similarity index and Kruskal-Wallis statistics. The predictive power of the developed QSAR model was tested through rigorous validation, deriving a wide series of statistical checks. The MLOGP was the most influential descriptor identified by the model. The model yielded a correlation (r²) of 0.966 and 0.965 in the training and test data arrays. The developed QSAR model also performed well in another three plant species (r² > 0.955). The results suggest the appropriateness of the developed model to reliably predict the plant chemical interactions in multiple plant species and it can be a useful tool in screening the new chemical for environmental risk assessment.

Interferon Regulatory Factor 6 Is Necessary for Salivary Glands and Pancreas Development

Interferon regulatory factor 6 ( IRF6) acts as a tumor suppressor and controls cell differentiation in ectodermal and craniofacial tissues by regulating expression of target genes. Haploinsufficiency of IRF6 causes Van der Woude and popliteal pterygium syndrome, 2 syndromic forms of cleft lip and palate. Around 85% of patients with Van der Woude express pits on the lower lip that continuously or intermittently drain saliva, and patients with the common cleft lip and palate have a higher prevalence of dental caries and gingivitis. This study aims to identify the role of IRF6 in development of exocrine glands, specifically the major salivary glands. Our transgenic mouse model that expresses LacZ reporter under the control of the human IRF6 enhancer element showed high expression of IRF6 in major and minor salivary glands and ducts. Immunostaining data also confirmed the endogenous expression of IRF6 in the developing ductal, serous, and mucous acinar cells of salivary glands. As such, we hypothesized that Irf6 is important for proper development of salivary glands and potentially other exocrine glands. Loss of Irf6 in mice causes an increase in the proliferation level of salivary cells, disorganized branching morphogenesis, and a lack of differentiated mucous acinar cells in submandibular and sublingual glands. Expression and localization of the acinar differentiation marker MIST1 were altered in Irf6-null salivary gland and pancreas. The RNA-Seq analysis demonstrated that 168 genes are differentially expressed and confer functions associated with transmembrane transporter activity, spliceosome, and transcriptional regulation. Furthermore, expression of genes involved in the EGF pathway-that is, Ereg, Ltbp4, Matn1, Matn3, and Tpo-was decreased at embryonic day 14.5, while levels of apoptotic proteins were elevated at postnatal day 0. In conclusion, our data report a novel role of Irf6 in exocrine gland development and support a rationale for performing exocrine functional tests for patients with IRF6-damaging mutations.

Clinical outcome of patients with primary gliosarcoma treated with concomitant and adjuvant temozolomide: A single institutional analysis of 27 cases

CONTEXT AND AIM

The prognosis of primary gliosarcoma (PGS) remains dismal with current treatment modalities. We analyzed the outcome of PGS patients treated with concurrent and adjuvant temozolomide (TMZ).

SETTINGS AND DESIGN

Retrospective single institutional analysis.

MATERIALS AND METHODS

We retrospectively evaluated 27 patients of PGS treated with radiotherapy (RT) and TMZ during 2007-2012.

STATISTICAL ANALYSIS USED

Overall survival (OS) was estimated by the use of Kaplan Meier method and toxicities were evaluate using common terminology criteria for adverse events version 2.0 (National Cancer Institute, USA).

RESULTS

Median age at presentation and Karnofsky performance status was 45 years and 90 respectively and male: female ratio was 20:7. Patients received adjuvant RT to a total dose of 60 Gy at 2 Gy/fraction. All patients except 5 received adjuvant TMZ to a median number of 6 cycles. Grade 2 and 3 hematological toxicity was seen in 8% and 4% of patients respectively during concurrent RT. During adjuvant chemotherapy, 13.6% had Grade 3 thrombocytopenia and 9.5% had Grade 3 neutropenia. Median OS was 16.7 months (1 year and 2 year actuarial OS was 70.8% and 32.6% respectively). Adjuvant TMZ was associated with a better survival (median survival 21.21 vs. 11.93 months; P = 0.0046) on univariate analysis and also on multivariate analysis (hazard ratio 1.82, 95% confidence interval: 1.503-25.58; P = 0.012).

CONCLUSIONS

The results of our study, largest series of patients with PGS treated with concurrent and adjuvant TMZ shows an impressive survival with acceptable toxicity. We suggest TMZ be included in the "standard of care" for this tumor.

Simultaneous inhibition of key growth pathways in melanoma cells and tumor regression by a designed bidentate constrained helical peptide

Protein-protein interactions are part of a large number of signaling networks and potential targets for drug development. However, discovering molecules that can specifically inhibit such interactions is a major challenge. S100B, a calcium-regulated protein, plays a crucial role in the proliferation of melanoma cells through protein-protein interactions. In this article, we report the design and development of a bidentate conformationally constrained peptide against dimeric S100B based on a natural tight-binding peptide, TRTK-12. The helical conformation of the peptide was constrained by the substitution of α-amino isobutyric acid--an amino acid having high helical propensity--in positions which do not interact with S100B. A branched bidentate version of the peptide was bound to S100B tightly with a dissociation constant of 8 nM. When conjugated to a cell-penetrating peptide, it caused growth inhibition and rapid apoptosis in melanoma cells. The molecule exerts antiproliferative action through simultaneous inhibition of key growth pathways, including reactivation of wild-type p53 and inhibition of Akt and STAT3 phosphorylation. The apoptosis induced by the bidentate constrained helix is caused by direct migration of p53 to mitochondria. At moderate intravenous dose, the peptide completely inhibits melanoma growth in a mouse model without any significant observable toxicity. The specificity was shown by lack of ability of a double mutant peptide to cause tumor regression at the same dose level. The methodology described here for direct protein-protein interaction inhibition may be effective for rapid development of inhibitors against relatively weak protein-protein interactions for de novo drug development.

Paraneoplastic pemphigus as a first sign of metastatic retroperitoneal inflammatory myofibroblastic tumor: (18)F-FDG PET/CT findings

A 30-year-old female presented with a 3-month history of erosive stomatitis and bullous lesions, along with recurrent episodes of abdominal pain. She was found to have a retroperitoneal lump in left lumbar region. Skin biopsy revealed bullous disorder. CT guided biopsy of the retroperitoneal mass was suggestive of inflammatory myofibroblastic tumor (IMT). She was started on oral steroids and supportive care, and surgery was being planned when she developed respiratory failure. CT chest revealed vertebral metastases. PET/CT for whole body work up revealed a left para-aortic mass along with multiple skeletal metastases. The patient was kept on conservative management. After 3 months, the patient has shown clinical improvement, and an exploratory laparotomy is now being planned for the excision of the tumor, followed by chemotherapy. This case of retroperitoneal IMT is rare in terms of skeletal metastases with paraneoplastic pemphigus.

Abstract P1-11-12: Religion-related factors and breast cancer screening among American Muslims

Background: Cancer disparities research often overlooks the influence a shared religion may have across race and ethnicity, and thereby misses opportunities to leverage shared religious networks to promote screening. While American Muslims have low rates of mammography and their health behaviors are strongly influenced by religion, a description of such relationships is lacking in the literature. Our study fills this gap.

Methods: We conducted a mixed-methods exploration of how religion-related factors impact breast cancer screening practices. We sampled an ethnically and racially diverse group of Muslim women frequenting mosques and community sites. A survey incorporated measures of fatalism, religiosity, religious discrimination, and Islamic modesty, while subsequent focus groups elicited perspectives on how religious beliefs, values and identity impact breast cancer screening intentions. Survey analyses involved logistic regression models, while focus groups were analyzed using a team-based framework content analysis approach.

Results: Of 240 survey respondents, 72 were Arabs, 71 S. Asians and 59 African Americans. Seventy-five percent had insurance, while 85% had a PCP. 77% reported ever having a mammogram while only 37% a mammogram within the past 2 years. In multivariate models, positive religious coping (OR= 0.21;P &lt;.05) and perceived religious discrimination in healthcare (OR=0.74;P &lt;.05) were negatively associated with having a mammogram in the past two years, while having a primary care physician (OR=20;P&lt;.01) was positively associated. Ever having a mammogram was positively associated with increasing age (OR=1.1;P&lt;.05), years of US residency (10-20 yrs OR=11; 20 yrs OR=4.3;P&lt;.05) and knowing someone with breast cancer (OR=3.5;P&lt;.01). Importantly, ethnic/racial affiliation did not influence mammography rates.

Of 50 focus group participants there were nearly equal numbers of S. Asians, Arabs, and African Americans, 74% reported ever having a mammogram, with 56% having a mammogram within the past two years. Focus group data revealed that family support and encouragement strongly impacted screening intentions, and that obtaining screening in a way that accommodated notions of religious modesty was paramount and prior experiences with such accommodations influenced subsequent intentions. Focus group participants believed that the mosque is a critical community venue for setting religious mores but is underutilized for health education and for motivating theological responses to illness. Participants expressed the need for mosque administration and religious leaders to openly discuss breast health and mammography screening among the Muslim community.

Conclusions: Aspects of religion appear to influence cancer screening behaviors similarly across the socioeconomic, ethnic, and racial diversity of American Muslims. Promoting biennial mammography screening among American Muslims requires addressing ideas about religious coping as related to preventive cancer screening and empowering women to combat perceived religious discrimination. Mosques are underutilized in breast cancer screening interventions but are a ripe setting for religiously-tailored programming that can address barriers to screening and promote a culture of health in this community.

Citation Format: Aasim Padela, S Murrar, S Mallick, Z Hosseinain, C Liao, C Ajax, F Marfani, M Peek. Religion-related factors and breast cancer screening among American Muslims [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-12.