Prevention of cisplatin nephrotoxicity (CN) in head and neck cancer patients receiving concurrent chemoradiation (CCRT) by adding oral rehydration solution (ORS) to short hydration regimen: A randomized open-label controlled trial

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Background: CN remains a frequent occurrence despite receiving standard fluid hydration, particularly for head and neck cancer patients undergoing CCRT. We aimed to investigate whether adding ORS to short hydration regimen can reduce CN. Methods: We conducted a randomized open-label controlled trial in patients with head and neck cancer receiving CCRT with 3-weekly cisplatin (≥ 60 mg/m²). Eligible patients were randomly assigned to receive short hydration regimen (2000 mL of normal saline on day 1) alone or in combination with 2000 mL of ORS on days -1, 2 and 3 of each cycle. All patients were instructed to drink at least 2000 mL of fluid. The primary end point was the incidence of ≥ gr 1 creatinine (Cr) elevation on day 8. The planned sample size was 160 (80 patients each arm). Results: Thirty-five patients in ORS group and 34 patients in control group (43% of planned sample size) were enrolled. Baseline characteristics were balanced between the two groups, except more patients in ORS group underwent surgery (35.3% vs. 22.9%), and had less feeding tube prophylaxis (76.5% vs. 88.6%), although there were not statistically significant. The mean dose of cisplatin on day 1 was significantly higher in ORS group (91.2 mg/m2 vs. 85.1 mg/m2, p=0.01). There was no difference of volume of total fluid intake and toxicities between the two groups. Less percentage of patients in ORS group developed ≥ gr 1 Cr elevation as shown in the Table, although there were not statistically significant. Conclusions: Although our interim analysis showed no significant difference of CN between the groups, there was a trend that addition of ORS might prevent acute and chronic kidney injury secondary to cisplatin. The completed enrollment is warranted to confirm this early findings. Clinical trial information: TCTR20200207005 . [Table: see text]

Cancer care through the fire and flames: Three-year experience in utilizing of oncologic electronic consultation and referral system in the red zone of Thailand

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Background: “The South Thailand Insurgency” is burning violence in the deep south of Thailand. The insurgency which has been ongoing since 2004 has played out in the three southernmost districts of the country Pattani, Yala and Narathiwat and some area of Songkhla, so-called the “Red Zone”. The chronic terrorism had major affected on cancer service. Many cancer patients gave up on their lives due to struggle with the disease itself, financial constraints due to longstanding economic downturn and security concerns during travelling led to high loss to follow-up rate and treatment delay. We, an oncology service team working at Songklanagarind hospital, the only one cancer center served this area together with primary doctors and nurses in the Red Zone created a network and utilized an oncology-specific electronic consultation and referral system to make more efficient care. We reported its performance in 3 years period. Methods: Electronic consultation system (E-consult) was a web-based program developed to provide advice and facilitate the referral process in cancer care. Since October 2015, we prospectively surveyed the impact of this pilot project on the quality of service by counting waiting time, number of center visit until treatment, unnecessary referral avoidance, patient and potential cost saving compared to normal referral system. Results: E-consult reached out to 7 hospitals and 589 cancer patients successfully referred through E-consult. Among patients from the Red Zone, without E-consult, their average waiting time was 56.4 days, number of visit was 6.5 visits. The estimated financial burden was $758.8 per patient. After implementation of E-consult in 259 patients, average time to treatment was 41.5 days (p = 0.006) and a number of the counter visit was 2.3 visits (p < 0.001). Estimated financial burden could be reduced to $358.7(p < 0.001). Ultimately, we prevented 28 patients from unnecessary referral. Conclusions: In this special context the electronic referral system was helpful to improve medical access, timeliness to specialist care, saving the patients’ family time and resources. This model is widely applicable to oncology referral chain.

Hepatitis B screening rates and reactivation in solid organ malignancy patients undergoing chemotherapy in Southern Thailand

Background/Aims

Hepatitis B virus reactivation (HBVr) following chemotherapy (CMT) is well-known among hematologic malignancies, and screening recommendations are established. However, HBVr data in solid organ malignancy (SOM) patients are limited. This study aims to determine hepatitis B surface antigen (HBsAg) screening rates, HBV prevalence, and the rate of significant hepatitis caused by HBVr in SOM patients undergoing CMT.

Methods

Based on the Oncology unit’s registration database from 2009–2013, we retrospectively reviewed records of all SOM patients ≥18 years undergoing CMT at Songklanagarind Hospital who were followed until death or ≥6 months after CMT sessions. Exclusion criteria included patients without baseline liver function tests (LFTs) and who underwent CMT before the study period. We obtained and analyzed baseline clinical characteristics, HBsAg screening, and LFT data during follow-up.

Results

Of 3,231 cases in the database, 810 were eligible. The overall HBsAg screening rate in the 5-year period was 27.7%. Screening rates were low from 2009–2012 (7.8–21%) and increased in 2013 to 82.9%. The prevalence of HBV among screened patients was 7.1%. Of those, 75% underwent prophylactic antiviral therapy. During the 6-month follow-up period, there were three cases of significant hepatitis caused by HBVr (4.2% of all significant hepatitis cases); all were in the unscreened group.

Conclusions

The prevalence of HBV in SOM patients undergoing CMT in our study was similar to the estimated prevalence in general Thai population, but the screening rate was quite low. Cases of HBVr causing significant hepatitis occurred in the unscreened group; therefore, HBV screening and treatment in SOM patients should be considered in HBV-endemic areas.

Serum S100β as a predictor of severity and outcomes for mixed subtype acute ischaemic stroke

INTRODUCTION

Serum S100β levels are mostly used for predicting outcomes of large-vessel stroke. Its application to mixed subtypes of acute ischaemic stroke (AIS) has been limited.

METHODS

Patients with mixed subtypes of AIS who were aged over 18 years and presented within 24 hours of stroke onset were consecutively enrolled. Serum S100β levels at presentation (S100β_b) and 72 hours (S100β_72hrs), and corresponding National Institutes of Health Stroke Scale (NIHSS_b and NIHSS_72hrs, respectively) scores were assessed. Stroke outcomes were evaluated using the modified Rankin Scale (mRs) at 30 days (mRs₃₀) and 90 days (mRs₉₀). Correlations between S100β_b and S100β_72hrs, as well as differences between the two (∆S100β) and the corresponding NIHSS, mRs₃₀ and mRs₉₀ scores, were evaluated (p < 0.05).

RESULTS

35 patients were eligible for analysis. On univariate analysis, stroke outcomes had a significant association with S100β_b, S100β_72hrs, NIHSS_b, NIHSS_72hrs and ∆S100β. Both S100β_b and S100β_72hrs correlated with corresponding NIHSS values (ρ_b = 0.51, p < 0.001; ρ_72hrs = 0.74, p < 0.001), mRs₃₀ (ρ_b = 0.58, p < 0.001; ρ_72hrs = 0.72, p < 0.001) and mRs₉₀ (ρ_b = 0.51, p = 0.002; ρ_72hrs = 0.68, p < 0.001). Correlations existed between ∆S100β and mRs₃₀ (ρ = 0.74, p < 0.001) and mRs₉₀ (ρ = 0.71, p < 0.001). Practical cut-off points for unfavourable outcomes (mRs 3-6) were S100β_72hrs > 0.288 µg/L (sensitivity 92.3%, specificity 86.4%) and ∆S100β > 0.125 µg/L (sensitivity 100%, specificity 81.8%).

CONCLUSION

High serum S100β is associated with unfavourable outcomes for mixed subtype AIS. Cut-off values of S100β_72hrs and ∆S100β were optimal for predicting unfavourable stroke outcomes.

Cervical cancer screening in incarcerated women: An experience from the first cervical cancer screening campaign in a southern Thailand correctional facility

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Background: Cervical cancer is one of the most preventable cancers, not only presence of effective HPV vaccination but also simple and robust screening methods such as Pap test. Nevertheless, there were some women at risk whom were unable to access screening cause of incarceration. Hence, in 2018, together with Songkhla Woman Correctional Institute, we launched a cancer screening campaign including clinical breast exam, mobile mammography and Pap test. This is the first report of cervical cancer screening result demonstrated the essential of cervical cancer screening in these disadvantaged women. Methods: Due to the regulation of the jail, we had to limited bring-in tools, allowed staffs and operating-time, therefore we used a pre-screening questionnaire, included 5 items: HIV infection, number of partner, parity, age at first sexual intercourse and number of term baby and each of them scored as 2 for “high-risk” and 1 for “low-risk”, total score ranged from 5 to 10. We ranked and chose the volunteer participants, who have HIV infection and/or with highest risk score, to undergo Pap test. Results: Of the 1328 questionnaire responders, Their mean risk score was 7.3 (SD= 1.3). HIV infected participants number were 34 (2.5%). Of the 200 screened-participants, None of them had ever received HPV vaccination before, and all participant did not have Pap test since imprisonment. (mean 53.8 m, range 13-236 m, SD 36.7). Their score ranged between 8 to 10, 42.5% of them had score level 8, 54.5% had score level 9 and 3% had score level 10. Mean age was 37.7 years. 10 (5%) of them had abnormal Pap test; 1 of them showed ASC-US, 1 was LSIL, 1 was ASC-H, 5 of them showed HSIL and 2 of them showed squamous cell carcinoma and small round cell carcinoma. Final histopathological test resulted in 6 of cervical intraepithelial neoplasia (CIN) I, metaplasia and cervicitis, 3 were diagnose CIN III and 1 diagnosed microinvasive carcinoma. Incidence of cervical cancer was higher than normal population in this region. (0.5% vs 0.02%). Conclusions: Incarcerated women were at high risk of cervical cancer compared to normal population. Unfortunately, in many places, they were unconditionally inaccessible to the cervical cancer preventive healthcare system for years. Social should increase awareness to decrease this health disparity.

Comparing programmed death ligand-1 expression on tumor cells before and after acquiring resistance to tyrosine kinase inhibitor in EGFR harbouring non-small cell lung cancer

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Background: Although anti-PD1/PD-L1-targeting immunotherapy has been successful in the treatment of non-small cell lung cancer (NSCLC) patients, the benefit is unclear in EGFR mutation(mEGFR) NSCLC. To date, there are several clones of anti-PD-L1 antibody which provide different predictive values and the level of expression also dynamically changed after treatment. The study examined changes of PD-L1 expression in mEGFR harbouring NSCLC tissues, comparing between before and after treatment with tyrosine kinase inhibitors(TKIs) using an FDA-approved PD-L1 assay. Methods: We retrospectively reviewed tumor specimen from 24 patients with mEGFR NSCLC who had been treated with gefitinib, erlotinib, afatinib and received second tissue biopsy after acquiring resistance to TKIs. The collected FFPE specimens were stained with commercial anti-PD-L1 22C3 assay monoclonal antibody. Tumor proportion score(TPS) and H-score were measured before and after TKIs. Results: Of the study patients,54.2% patients were exon 19 deletion(n = 13), 41.7% were exon 21 point mutation(L858R) (n = 10), and 1 case was L858R/S761I. After TKIs resistance 10/13 (76.9%) of exon 19del and 8/10 (80%) of L858R revealed presence of +T790M. Pretreatment PD-L1 expression was positive(TPS≥1%) in 6 cases (25%). Mean TPS of positive cases was 34.0% and H-score was 78.2, All except 2 of 6 positive cases had adequate specimens from second biopsy(n = 22). Among 4 positive cases,PD-L1 expression tended to be higher after TKIs; mean TPS changed from 23.9 to 40.9 (p = 0.171) and H-score were from 49.3 to 91.1 (p = 0.172). 18/24 patients with TPS and H-score zero at the beginning remained zero after progression. Median TTP were similar in patients with positive PD-L1 expression and negative,13.8 m vs 14.5 m (n = 24,p = 0.644) with TKIs and 3.9 m vs 2.5 m (n = 14, p = 0.560) with chemotherapy. Conclusions: Prevalence of PD-L1 expression in mEGFR NSCLC was low. PD-L1 expression tended to be higher after TKIs for this with positive cases which may guide the sequences of treatment. Nevertheless no changes of PD-L1 expression for those with negative, hence re-biopsy may not be necessary.

Clinical Characteristics and Treatment Outcomes of Patients with Primary Mediastinal Germ Cell Tumors: 10-Years' Experience at a Single Institution with a Bleomycin-Containing Regimen

BACKGROUND

Cisplatin-based chemotherapy followed by surgical resection of the residual tumor remains the standard of care for patients with mediastinal germ cell tumors (MGCTs). To prevent pulmonary complications, a non-bleomycin-containing regimen is generally preferred. This study aims to review the clinical characteristics and outcomes of these patients.

METHODS

A retrospective chart review was undertaken in patients treated for MGCTs between 2003 and 2013.

RESULTS

A total of 40 patients were enrolled; 7 patients were diagnosed with seminoma, while 33 patients had non-seminoma. 92% of patients received chemotherapy as a first treatment modality: 87% bleomycin, etoposide and cisplatin; 13% etoposide and cisplatin, with an objective response rate of 61.3%. Among these, 44% achieved a complete serological response. 17 patients underwent surgical resection of the residual tumor. No patient suffered from pulmonary complications after surgery. The 5-year overall survival (OS) was 71.4 and 27.3% in seminoma and non-seminoma patients, respectively (p = 0.051). For those who received chemotherapy followed by surgical resection with no viable tumor or only mature teratoma detected, the 5-year OS was 72.7% compared with 20.7% in patients not treated with surgery (p = 0.02).

CONCLUSION

Our study confirmed the importance of a multimodality approach with primary chemotherapy followed by surgical resection of the residual tumor. A bleomycin-containing regimen can be safely used in this setting.

Clinical characteristics and outcomes of patients with primary mediastinal germ cell tumors

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Background: Mediastinal germ cell tumors (MGCTs) account for 20% of all mediastinal tumors. Cisplatin-based chemotherapy followed by surgical resection of residual tumor remains the standard of care. To prevent pulmonary complications secondary to extensive thoracic surgery, non-bleomycin containing regimen is generally preferred. This study aims to review clinical characteristics and outcomes of these patients. Methods: A retrospective chart review was undertaken in patients with MGCTs treated in our institution between 1993 and 2013. Results: A total of 40 patients were enrolled with a median age of 24. Only one patient is female. Stratified by histology; eight patients (20%) had pure seminoma, 25 patients (62.5%) had pure non-seminoma, four patients (10%) had mixed seminoma and non-seminoma, and three patients (7.5%) had malignant transformation (two adenocarcinoma, one sarcoma). Median tumor size was 13 centimeters. Ninety-two percent of patients received chemotherapy as a first treatment modality, whereas 8% underwent upfront surgery. All patients received cisplatin-based chemotherapy: Eighty seven percent bleomycin, etoposide and cisplatin; 13% etoposide and cisplatin. Seventy-two percent of patients completed four planned cycles of chemotherapy. Thirty-one patients were able to assess radiological response: 3.2% complete response, 58.1% partial response, 29.0% stable disease, and 9.7% progressive disease. Forty-four percent of patients achieved completely serological response with chemotherapy. Seventeen patients underwent surgical resection of residual tumor. Among these, viable tumor was seen in 35% (6 out of 17 patients). No patients complicated with clinically significant pulmonary complications after thoracic surgery. The five year overall survival (OS) of patients with seminoma was 72.9% as compared with 19.9% in those with non-seminoma (p=0.012). For those who received chemotherapy followed by surgical resection with no viable tumor or only mature teratoma detected (N=11), the five year OS was 64.9%. Conclusions: Our study confirmed the importance of multi-modality approaches with primary chemotherapy followed by surgical resection of residual tumor. Bleomycin-containing regimen can be safely used in this setting.