Multicenter evaluation of left ventricular assist device implantation with or without ECMO bridge in cardiogenic shock

BACKGROUND

The efficacy of extracorporeal membrane oxygenation (ECMO) as a bridge to left ventricular assist device (LVAD) remains unclear, and recipients of the more contemporary HeartMate 3 (HM3) LVAD are not well represented in previous studies. We therefore undertook a multicenter, retrospective study of this population.

METHODS AND RESULTS

INTERMACS 1 LVAD recipients from five U.S. centers were included. In-hospital and one-year outcomes were recorded. The primary outcome was the overall mortality hazard comparing ECMO versus non-ECMO patients by propensity-weighted survival analysis. Secondary outcomes included survival by LVAD type, as well as postoperative and one-year outcomes. One hundred and twenty-seven patients were included; 24 received ECMO as a bridge to LVAD. Mortality was higher in patients bridged with ECMO in the primary analysis (HR 3.22 [95%CI 1.06-9.77], p = 0.039). Right ventricular assist device was more common in the ECMO group (ECMO: 54.2% vs non-ECMO: 11.7%, p < 0.001). Ischemic stroke was higher at one year in the ECMO group (ECMO: 25.0% vs non-ECMO: 4.9%, p = 0.006). Among the study cohort, one-year mortality was lower in HM3 than in HeartMate II (HMII) or HeartWare HVAD (10.5% vs 46.9% vs 31.6%, respectively; p < 0.001) recipients. Pump thrombosis at one year was lower in HM3 than in HMII or HVAD (1.8% vs 16.1% vs 16.2%, respectively; p = 0.026) recipients.

CONCLUSIONS

Higher mortality was observed with ECMO as a bridge to LVAD, likely due to higher acuity illness, yet acceptable one-year survival was seen compared with historical rates. The receipt of the HM3 was associated with improved survival compared with older generation devices.

Outcomes of Children Diagnosed with Unilateral Retinoblastoma: Retrospective Audit

PURPOSE/OBJECTIVE(S)

To evaluate treatment outcomes of children diagnosed with unilateral retinoblastoma.

MATERIALS/METHODS

Retrospective study of children diagnosed with unilateral retinoblastoma registered at the Tata Memorial Hospital (TMH), Mumbai from January 2013 to December 2018 and completed the planned curative treatment protocol.

RESULTS

For the 98 cases that were analyzed, the median age of presentation was 24 months. The majority of patients had the intraocular disease (n = 72), whereas orbital retinoblastoma was in 26 patients. At the time of presentation, on imaging extra scleral spread was observed in 16 patients whereas 18 patients had optic nerve involvement, 11 patients had both extra scleral invasion and optic nerve involvement. We used the International Classification of Retinoblastoma for grouping. Out of 98 patients, 71 patients were in Group E, 21 were in Group D and 4 were in Group B and 2 were in Group C. For Staging of Retinoblastoma, we used International Retinoblastoma Staging System (IRSS) in our study and 14 patients had Stage 0 disease, 52 patients had Stage I disease, 10 patients had Stage II, 21 patients had Stage III A and 1 patient had Stage III B disease. High-risk features on surgical specimen histopathology were optic nerve cut margin positive in 6 patients, optic nerve involvement in 21 patients, extra scleral spread in 3 patients, Choroidal invasion in 38 and Iris involvement in 10 patients. Primary enucleation was offered in 52 patients whereas 26 patients underwent secondary enucleation. Systemic chemotherapy was received by the patient in the neoadjuvant setting in 17 patients as a form of chemo-reduction and 51 patients received systemic chemotherapy in the adjuvant setting. Intra-arterial chemotherapy was offered to 27 patients as a primary treatment or in conjugation with focal therapy (n = 11). Definitive radiotherapy was offered to only 2 patients and 22 patients received adjuvant radiotherapy. At a median follow-up of 62 months, 2patients had local relapse, which was salvaged by focal therapy in one and enucleation in the other. Ten patients who had leptomeningeal relapse had died. The 5-year local control (LC) is 97.6%, event-free survival (EFS) is 88% and overall survival (OS) is 89.5%. Globe was salvaged in only 16 cases. On univariate analysis, we observed a significant association between overall survival and extraocular and intraocular disease (p-value 0.0), Extra scleral spread (p-value 0.0), optic Nerve involvement (imaging), and an optic nerve cut margin positive (p-value 0.045), ICRB Groups (p-value 0.0) and IRSS stage (p- value 0.024).

CONCLUSION

Retinoblastoma is curable if detected early. Extra ocular disease and high-risk features are associated with inferior outcomes and poor globe salvage rates.

Brachytherapy for Organ and Function Preservation in Soft-Tissue Sarcomas in Adult and Paediatric Patients

Adjuvant radiotherapy is an integral component in the management of soft-tissue sarcomas. Brachytherapy is a very convenient and conformal way of delivering adjuvant radiotherapy in such tumours, which spares the surrounding normal tissue. Randomised studies have established the efficacy of brachytherapy in the adjuvant setting, with a 5-year local control of 80-85%. High dose rate, low dose rate and pulsed dose rate have shown equivalent local control, but high dose rate has gained popularity owing to patient convenience, radiation safety and flexibility in dose optimisation. Freehand insertion perioperative brachytherapy (intraoperative placement and postoperative treatment) is the most commonly used technique in soft-tissue sarcomas, with intraoperative radiotherapy and radioactive seed placement being the less commonly used techniques. Brachytherapy can be used as monotherapy or in combination with external beam radiotherapy, such as in cases of close/positive margins for safe dose escalation. Although the quantum of side-effects with external beam radiotherapy has considerably reduced with the evolution of technology and the introduction of intensity modulation (intensity-modulated radiotherapy), brachytherapy still scores better in terms of dose conformality, especially in recurrent tumours (previously irradiated) and when used to treat paediatric and geriatric patients.

The Practice of Paediatric Radiation Oncology in Low- and Middle-income Countries: Outcomes of an International Atomic Energy Agency Study

AIMS

Childhood cancer survival is suboptimal in most low- and middle-income countries (LMICs). Radiotherapy plays a significant role in the standard care of many patients. To assess the current status of paediatric radiotherapy, the International Atomic Energy Agency (IAEA) undertook a global survey and a review of practice in eight leading treatment centres in middle-income countries (MICs) under Coordinated Research Project E3.30.31; 'Paediatric radiation oncology practice in low and middle income countries: a patterns-of-care study by the International Atomic Energy Agency.'

MATERIALS AND METHODS

A survey of paediatric radiotherapy practices was distributed to 189 centres worldwide. Eight leading radiotherapy centres in MICs treating a significant number of children were selected and developed a database of individual patients treated in their centres comprising 46 variables related to radiotherapy technique.

RESULTS

Data were received from 134 radiotherapy centres in 42 countries. The percentage of children treated with curative intent fell sequentially from high-income countries (HICs; 82%) to low-income countries (53%). Increasing deficiencies were identified in diagnostic imaging, radiation staff numbers, radiotherapy technology and supportive care. More than 92.3% of centres in HICs practice multidisciplinary tumour board decision making, whereas only 65.5% of centres in LMICs use this process. Clinical guidelines were used in most centres. Practice in the eight specialist centres in MICs approximated more closely to that in HICs, but only 52% of patients were treated according to national/international protocols whereas institution-based protocols were used in 41%.

CONCLUSIONS

Quality levels in paediatric radiotherapy differ among countries but also between centres within countries. In many LMICs, resources are scarce, coordination with paediatric oncology is poor or non-existent and access to supportive care is limited. Multidisciplinary treatment planning enhances care and development may represent an area where external partners can help. Commitment to the use of protocols is evident, but current international guidelines may lack relevance; the development of resources that reflect the capacity and needs of LMICs is required. In some LMICs, there are already leading centres experienced in paediatric radiotherapy where patient care approximates to that in HICs. These centres have the potential to drive improvements in service, training, mentorship and research in their regions and ultimately to improve the care and outcomes for paediatric cancer patients.

Differential diagnosis of lung cancer, its metastasis and chronic obstructive pulmonary disease based on serum Vegf, Il-8 and MMP-9

Chronic obstructive pulmonary disease (COPD) patients are at higher risk of developing lung cancer and its metastasis, but no suitable biomarker has been reported for differential diagnosis of these patients. Levels of serum biomarkers (VEGF, IL-8, MMP-9 and MMP-2) were analyzed in these patients, which were compared with healthy donors (HD). Levels of VEGF (P < 0.005) and MMP-9 (P < 0.05) were significantly higher in COPD patients than HD. Compared to HD, a decrease in IL-8 (~8.1 folds; P < 0.0001) but an increase in MMP-9 (~1.6 folds; P < 0.05) levels were observed in the lung cancer patients. Cancer patients showed significantly (P < 0.005) lower levels of serum VEGF (1.9 folds) and IL-8 (~9 folds) than the COPD patients. VEGF level was significantly higher (2.6 folds; P < 0.0005) in metastatic than non-metastatic cancer patients. However, MMP-2 didn't show significant variation in these patients. The Youden's index (YI) values for lung cancer diagnosis in HD using IL-8 was 0.55 with 83.3% overall accuracy. VEGF was able to diagnose COPD in HD with better YI (0.38) and overall accuracy (70.6%). IL-8 was able to diagnose cancer in COPD patients and HD with YI values of 0.35, 0.55 with 71% and 83.3% overall accuracy, respectively.

Treatment results in advanced stage Hodgkin's lymphoma: a retrospective study

BACKGROUND

Hodgkin's lymphoma displays distinct epidemiological attributes in Asian population thus making it relevant to study whether there are any differences in treatment outcomes too when treated with current standard of care.

AIM

To evaluate the treatment outcomes of de-novo advanced stage HL in adults.

MATERIALS AND METHODS

This retrospective study included de-novo advanced stage HL patients (≥15 years) registered at our center from January 2004 to December 2007. Treatment outcomes were measured in terms of response rates, overall survival (OS) and progression-free survival (PFS). Overall and PFS were calculated with Kaplan-Meier methodology and Cox-proportional hazards model was used for multivariate analysis to identify prognostic factors.

RESULTS

There were 125 patients (males 77%) who received minimum one cycle of chemotherapy with median age of 32 years (Range 15-65 years). Stage IV disease was seen in (46 patients) 37%; 75% (94 patients) patients had B symptoms. International prognostic score (IPS) ≤4 was seen in 95/112 (85%) patients. ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) chemotherapy was given to 94%. Radiation to residual/bulky sites was given to 36% (45 patients). Response data was available for 112 patients; complete response in 76%; partial response in 10 % and progressive disease in 3 patients. Nineteen deaths (progressive disease-7, toxicity-8, unrelated cause-4) were observed. At median follow-up of 28 months, estimated 5-year OS and PFS were 60% and 58%, respectively. On multivariate analysis, IPS and response to treatment were significant factors for both OS and PFS.

CONCLUSIONS

The treatment outcomes in this study are comparable with the published literature with limited follow-up data.

Local therapy in non-metastatic primary Ewing sarcoma of the mandible and maxilla in children

Ewing sarcoma (ES) of the jaw bones comprises a small fraction of ES at all sites. Due to their rarity, a specific policy for local treatment is lacking. The aim of this study was to evaluate the local therapy for ES and recommend measures to individualize treatment options. Patients with primary non-metastatic ES of the jaw bones treated between August 2005 and February 2015 were analyzed. All patients received primary induction chemotherapy, following which lesions amenable to resection based on specific radiological criteria were resected; those with unresectable lesions were offered definitive radiotherapy. The maxilla was the primary site in 13 patients and the mandible in eight. The median age of patients was 11.6 years (range 5-17 years). Overall, surgery was performed in 17 patients and definitive radiotherapy was used in four patients. Postoperative radiotherapy was administered to 12 patients and was avoided in five patients with 100% tumour necrosis. The 3-year overall survival, event-free survival, and local control were 68.1%, 63.6%, and 80.2%, respectively. Mandible primary and a histological response to chemotherapy were significant prognostic factors. The stratification of patients based on radiological criteria aids in selecting local therapy. In eligible patients, surgery with contemporary reconstruction results in optimal oncological and functional outcomes. Surgery also has the added advantage of identifying patients who may not need radiotherapy.

Role of ATF-2 in regulation of epithelial–mesenchymal transition and radio-sensitivity of A549 cells mediated by secreted soluble factors

Introduction

Epithelial–mesenchymal transition (EMT) is known to be a crucial event whereby cancer cells acquire the traits needed to execute multiple steps of metastasis [ 1 ]. Intriguingly, epithelial cancer cells undergoing EMT also exhibit increased radioresistance [ 2 ]. EMT is a dynamic process and is triggered by various micro-environmental stimuli, out of which secreted soluble factors play a major role [ 3 ]. Herein, we have investigated the effect of self-conditioned medium (CM) on the human lung carcinoma A549 cells and the underlying mechanism.

Material and methods

A549 cells were obtained from National Centre for Cell Sciences, Pune, and cultured in DMEM with 10% FCS and antibiotics at 37°C in 5% CO2/air. To get CM, 1 × 106 A549 cells were grown in complete medium. After 48 h of incubation, media were harvested referred as CM. Media alone without cells were incubated under the same conditions served as control termed as plain medium (PM) [ 4 ]. A549 cells grown in PM/CM subjected to immunofluorescence staining for E-cadherin, vimentin and actin. Motility scratch assay and matrigel invasion assay were performed to study the invasiveness of A549 cells in PM/CM. In some cases, cells were pretreated with inhibitors against MAPKs. To pinpoint the soluble factor(s) in CM responsible for initiating the invasiveness in A549 cells, CM was pretreated with neutralizing antibodies against IL-8, VEGF and IL-1β.

Results and discussion

We found that CM induced a series of changes associated with EMT in A549 cells such as change in shape from cuboidal to elongated spindle shape, decrease in E-cadherin, increase in vimentin and enhanced actin polymerization with decreased cell–cell contact. CM also promoted motility, invasion and anchorage-independent growth in A549 cells. Neutralizing IL-8, IL-1β and VEGF in CM significantly inhibited motility and invasion. Moreover, JNK and p38 activated by CM in A549 cells played important role in invasiveness. In downstream signalling, CM activated ATF-2 by phosphorylating it at Thr69 and 71. Knockdown of ATF-2 using siRNA abrogated the CM-enhanced motility and invasion. It has been reported that EMT not only accelerates cancer metastasis but may also result in resistance against therapeutic agents [ 2 , 5 ]. We therefore investigated the effect of CM on radioresistance of A549 cells. Our results showed that A549 cells grown in CM followed by gamma irradiation exhibited higher clonogenic survival and lower DNA damage measured in terms of gamma-H2AX foci. Interestingly, these CM-treated A549 cells in response to radiation showed phosphorylation of ATF-2 at Ser 490/498 (not at Thr69/71), which was co-localized with gamma-H2AX foci. These studies suggest the dual role of ATF-2, i.e. as EMT potentiating transcription factor and DNA damage response protein in lung cancer cells stimulated with soluble factors, which can be exploited as potential therapeutic target for cancer radiotherapy.

A retrospective audit of clinicopathological attributes and treatment outcomes of adolescent and young adult non-Hodgkin lymphomas from a tertiary care center

Background:

The uniqueness of adolescent and young adult (AYA) non-Hodgkin lymphomas (NHL) with respect to biology and treatment have largely remained unanswered due to marked heterogeneity in treatment, paucity of prospective, or retrospective studies and poor representation of AYA in clinical trials. This audit attempts to put forward the clinicopathological attributes and treatment outcomes of AYA NHL treated with both pediatric and adult protocols from a single centre in a developing country.

Patients and Methods:

Hospital records of all consecutive NHL patients registered in lymphoma clinic from January 2007 to May 2010 were reviewed for information on demography, clinical features, histology subtype, staging, treatment regimen, response rates, toxicities, and follow up. Two-year progression-free (PFS) and overall survival (OS) were calculated with Kaplan-Meier method.

Results:

AYA NHL constituted 4% of all lymphomas. Diffuse large B-cell (DLBL) was the most frequent subtype. Following were the 2-year PFS and OS - DLBL 64%, 76.9%, Burkitt's lymphoma: 56%, 56%, lymphoblastic lymphoma: 33.2%, 44%. Our results did not show any improvement in outcome of DLBL with the use of Burkitt's lymphoma like regimen.

Conclusions:

This study highlights some of the key features of AYA NHL occurring in developing world.