Acceleration of Graph Neural Network-Based Prediction Models in Chemistry via Co-Design Optimization on Intelligence Processing Units

Atomic structure prediction and associated property calculations are the bedrock of chemical physics. Since high-fidelity ab initio modeling techniques for computing the structure and properties can be prohibitively expensive, this motivates the development of machine-learning (ML) models that make these predictions more efficiently. Training graph neural networks over large atomistic databases introduces unique computational challenges, such as the need to process millions of small graphs with variable size and support communication patterns that are distinct from learning over large graphs, such as social networks. We demonstrate a novel hardware-software codesign approach to scale up the training of atomistic graph neural networks (GNN) for structure and property prediction. First, to eliminate redundant computation and memory associated with alternative padding techniques and to improve throughput via minimizing communication, we formulate the effective coalescing of the batches of variable-size atomistic graphs as the bin packing problem and introduce a hardware-agnostic algorithm to pack these batches. In addition, we propose hardware-specific optimizations, including a planner and vectorization for the gather-scatter operations targeted for Graphcore's Intelligence Processing Unit (IPU), as well as model-specific optimizations such as merged communication collectives and optimized softplus. Putting these all together, we demonstrate the effectiveness of the proposed codesign approach by providing an implementation of a well-established atomistic GNN on the Graphcore IPUs. We evaluate the training performance on multiple atomistic graph databases with varying degrees of graph counts, sizes, and sparsity. We demonstrate that such a codesign approach can reduce the training time of atomistic GNNs and can improve their performance by up to 1.5× compared to the baseline implementation of the model on the IPUs. Additionally, we compare our IPU implementation with a Nvidia GPU-based implementation and show that our atomistic GNN implementation on the IPUs can run 1.8× faster on average compared to the execution time on the GPUs.

Abstract LB151: Deep learning - based protein therapeutics design to treat HER2+ cancers

Background: HER2 amplification and activation occurs in approximately 15~25% of all breast cancers and is further indicated in other cancer types with high un-met medical needs, such as cholangiocarcinoma, ovarian and esophageal cancer. Further improvement of current HER2 targeting therapeutics on safety and efficacy remains to be desired. Deep learning - based computational approach, such as AlphaFold, has been successfully applied to the understanding of protein structure. However, its applications to protein therapeutic design remain largely underdeveloped. Method: We have developed an end-to-end protein design engine Apollo, which can be used to design target-binding protein therapeutics in silico. Apollo uses recurrent neural networks (RNNs), transformers and graph convolution neural networks (GCNs) to represent proteins, protein structures and protein-protein interactions. This is further improved by multi-head and hierarchical attention layers. Using generative AI, Apollo can either generate putative binding proteins de novo, or to optimize protein lead molecules. Candidate proteins are evaluated in silico for binding affinity and specificity, secondary and tertiary structure, isoelectric point, solubility, and other drug-like properties. Generated designs are iteratively improved by Apollo via a reinforcement learning loop. Results: Apollo has achieved high prediction accuracy by in silico evaluations, using metrics such as AUC and the confusion matrices. Using Apollo, we then designed mini protein binders of 50~100 aa to target HER2 extracellular domain (ECD). These binders can be produced with high yield and purity using mammalian protein expression systems. From de novo generation, the designed candidates are shown to bind to human HER2 with EC50 in the nanomolar range by ELISA. From optimizations based on lead molecules, the designed candidates have shown improved production yield and thermostability while maintaining binding affinity. Conclusions: We have shown the proof-of-concept success of using machine learning to design protein therapeutics.

Citation Format: Ziwei Liang, Tom Murray, Max Bluestone, Chris Zoumadakis, Luke Martin, Alexey Vlasenko, Jeffrey LaFrence, John Lazar, Matthias Denecke, David Longo. Deep learning - based protein therapeutics design to treat HER2+ cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB151.

Assessment of U.S. heart transplantation equity as a function of race: Observational analyses of the OPTN database

Background

Racial disparities in heart transplantation (HT) outcomes are suspected but uncertain. The additional impact of a recent change in donor allocation on disparities in HT in the United States (US) is unknown. We hypothesize racial disparities in HT are present and may be worsened by new allocation practices.

Methods

Cohort: Adults listed for HT before and after a heart allocation policy change (Era 1: Oct 18^th, 2015 - Oct 18^th, 2018, Era 2: Oct 18^th, 2018-June 30, 2021). The primary outcome was the rate of HT by race (Black vs. White), assessed using multivariable competing risk analysis (compete: waitlist removal for death or clinical deterioration). Final adjusted models included co-morbidities, SES and community-level Social Determinants of Health. The secondary outcome was waitlist removal for death or clinical deterioration.

Results

Of 17,384 waitlist candidates (Era 1: 9,150, Era 2: 8,234), Black waitlist candidates had a lower rate of HT compared to White waitlist candidates in Era 1 (adjusted HR 0·90, 95 % CI 0·84-0·97, p = 0·0053) and in Era 2 (adjusted HR 0·81, 95 % CI 0·75-0·88, p <0·0001, era race interaction p=0·056). The rate of waitlist removal for death or deterioration was similar between races in Era 1 (adjusted HR 0·92, 95 % 0·77-1·1, p = 0·38), but increased for Black candidates in Era 2 (adjusted HR 1·34, 95 % CI 1·09-1·65, p = 0·0054, era race interaction p = 0·0051).

Interpretation

Both the measured rate of transplantation and rate of delisting for death or clinical deterioration have worsened for Black compared to White waitlist candidates under the new allocation system. Causes for these disparities require further study.

Funding

University of Minnesota Department of Cardiology funds.

HIF activation enhances FcγRIIb expression on mononuclear phagocytes impeding tumor targeting antibody immunotherapy

BACKGROUND

Hypoxia is a hallmark of the tumor microenvironment (TME) and in addition to altering metabolism in cancer cells, it transforms tumor-associated stromal cells. Within the tumor stromal cell compartment, tumor-associated macrophages (TAMs) provide potent pro-tumoral support. However, TAMs can also be harnessed to destroy tumor cells by monoclonal antibody (mAb) immunotherapy, through antibody dependent cellular phagocytosis (ADCP). This is mediated via antibody-binding activating Fc gamma receptors (FcγR) and impaired by the single inhibitory FcγR, FcγRIIb.

METHODS

We applied a multi-OMIC approach coupled with in vitro functional assays and murine tumor models to assess the effects of hypoxia inducible factor (HIF) activation on mAb mediated depletion of human and murine cancer cells. For mechanistic assessments, siRNA-mediated gene silencing, Western blotting and chromatin immune precipitation were utilized to assess the impact of identified regulators on FCGR2B gene transcription.

RESULTS

We report that TAMs are FcγRIIbbright relative to healthy tissue counterparts and under hypoxic conditions, mononuclear phagocytes markedly upregulate FcγRIIb. This enhanced FcγRIIb expression is transcriptionally driven through HIFs and Activator protein 1 (AP-1). Importantly, this phenotype reduces the ability of macrophages to eliminate anti-CD20 monoclonal antibody (mAb) opsonized human chronic lymphocytic leukemia cells in vitro and EL4 lymphoma cells in vivo in human FcγRIIb+/+ transgenic mice. Furthermore, post-HIF activation, mAb mediated blockade of FcγRIIb can partially restore phagocytic function in human monocytes.

CONCLUSION

Our findings provide a detailed molecular and cellular basis for hypoxia driven resistance to antitumor mAb immunotherapy, unveiling a hitherto unexplored aspect of the TME. These findings provide a mechanistic rationale for the modulation of FcγRIIb expression or its blockade as a promising strategy to enhance approved and novel mAb immunotherapies.

A137 AN ELUSIVE GASTROINTESTINAL BLEED: A CASE OF RUPTURED CYSTIC ARTERY PSEUDOANEURYSM WITH PREVIOUS BILLROTH-II SURGERY

Background

Cystic artery pseudoaneurysm (CAP) is a rare but potentially life-threatening cause of upper gastrointestinal (GI) bleeding and requires urgent intervention.

Aims

To describe the clinical enigma of CAP in the context of distorted anatomy and discuss management.

Methods

Case report and review of literature

Results

Case Report

A healthy 91-year-old man with a remote history of gastric ulcer perforation leading to Billroth-II surgery 40 years ago presented to a community hospital with melena. He had no abdominal pain and liver enzymes were normal. His hemoglobin was 97 g/L (from 137 g/L the month prior) with a BUN:Cr ratio of 50.6 mg/dL and white cell count of 14.4 x109/L. Upper endoscopy identified a large adherent clot in the stomach that could not be dislodged and was suspected to obscure the culprit lesion. Afferent and efferent limbs from previous Billroth-II surgery were identified but not intubated. He was managed supportively with acid suppression and blood transfusion, but his hemoglobin continued decreasing, leading to transfer to a tertiary centre. Upon arrival he had new-onset abdominal pain, rigors, and diaphoresis with a heart rate of 175 beats/minute and blood pressure of 75/40 mmHg. After resuscitation, emergent CT angiogram demonstrated acute contrast extravasation into the gallbladder in keeping with a ruptured CAP. He underwent successful coiling of the cystic artery. Following this, his abdominal pain resolved, and hemoglobin stabilized. Repeat endoscopy demonstrated Billroth-II anatomy without bleeding lesion. He was treated with antibiotics for presumed cholecystitis and discharged home for outpatient cholecystectomy.

Literature Review

CAP is a rare cause of hemobilia, described only in case reports. The complete hemobilia triad of jaundice, right upper quadrant pain, and GI bleeding is absent in the majority of cases, requiring endoscopic evaluation of the ampulla of Vater or contrast CT. The most common causes of CAP are iatrogenic from cholecystectomy, cholecystitis, gallstones, and malignancy. These mechanisms, whether through trauma or inflammation, lead to damage of the gallbladder wall and the cystic artery. Contained CAP can lead to intermittent bleeding whereas ruptured CAP causes brisk arterial bleeding, necessitating arterial embolization or emergent cholecystectomy. In cases of biliary obstruction, either from the original process or subsequent blood clot at the ampulla, ERCP can lead to successful decompression.

Conclusions

We present a case of ruptured CAP which eluded diagnosis due to diagnostic rarity, lack of clinical clues, and distorted anatomy. CAP should be considered with a history of recent cholecystectomy, acute cholecystitis, or gallstones. Maintaining an index of suspicion for rare causes of GI bleeding can ensure timely diagnosis and escalation to the appropriate level of care.

Funding Agencies

None

Accuracy of Point-of-Care-Ultrasonography in Confirming Shoulder Reduction in Emergency Departments

Aims Accurate identification of the successful reduction of a dislocated shoulder could avoid additional episodes of procedural sedation and repeated performance of X-rays. The objective of this study was to assess the diagnostic accuracy of point-of-care-ultrasound (POCUS) in the confirmation of a successful joint reduction in patients with shoulder dislocation. Methods This was a single-centre, prospective observational study set in an urban academic ED in Ireland, with a convenience sample of adult patients with shoulder dislocation on X-ray. Ultrasound was performed on participants before and after joint reduction using a posterior approach technique. The operator's confidence levels were recorded after image acquisition. Results Thirty-three subjects were recruited. All dislocations were correctly identified on pre-reduction US, indicating a sensitivity of 100% (CI 89.42 - 100). Post-reduction US confirmed successful reduction in 30 subjects that were subsequently reported as such on X-Ray, giving it a specificity of 100% (CI 88.43 - 100). Failure to achieve reduction was correctly identified on US in three cases, resulting in post-reduction US Sensitivity of 100% (CI 29.24 - 100) and 100% accuracy (CI 89.42 - 100). Conclusion This study has shown that POCUS, with a posterior approach technique, has 100% sensitivity and specificity in confirming successful shoulder reduction in the ED.

Evaluating the performance of the GeneXpert HIV-1 qualitative assay as a consecutive test for a new early infant diagnosis algorithm in South Africa

BACKGROUND

The proportion of HIV-exposed infants and young children infected with HIV in South Africa (SA) has declined markedly over the past decade as a result of the country's comprehensive prevention of mother-to-child transmission programme. This decrease has in turn reduced the positive predictive value (PPV) of diagnostic assays, necessitating review of early infant diagnosis (EID) algorithms to ensure improved accuracy.

OBJECTIVES

To evaluate the performance of the GeneXpert HIV-1 qualitative assay (Xpert EID) as a consecutive test for infants with an 'HIV-detected' polymerase chain reaction screening test at birth.

METHODS

We retrospectively analysed a longitudinal cohort of HIV-exposed infants on whom birth testing was performed, using whole-blood ethylenediaminetetra-acetic acid samples, from four tertiary sites in Gauteng Province between June 2014 and December 2019. Birth samples from all infants with a Cobas AmpliPrep/Cobas TaqMan HIV-1 Qualitative Test v2.0 (CAP/CTM v2.0) HIV-detected screening test, a concurrent Xpert EID test and a subsequent confirmatory CAP/CTM v2.0 test on a separate specimen were included. Performance of the Xpert EID in predicting final HIV status was determined as proportions with 95% confidence intervals (CIs). A comparison of indeterminate CAP/CTM v2.0 results, as per National Health Laboratory Service resulting practice, with discordant CAP/CTM v2.0 v. Xpert EID results was performed.

RESULTS

Of 150 infants who met the inclusion criteria, 6 (3.9%) had an Xpert EID result discordant with final HIV status: 5 (3.3%) were false negatives and 1 (0.7%) was false positive. As a consecutive test, the Xpert EID yielded a sensitivity of 96.5% (95% CI 92 - 98.9), specificity of 85.7% (95% CI 42.1 - 99.6), PPV of 99.3% (95% CI 95.7 - 99.9), negative predictive value of 54.5% (95% CI 32.5 - 74.9) and overall accuracy of 96.1% (95% CI 91.5 - 98.5). Using discordant CAP/CTM v2.0/Xpert EID results as criteria to verify indeterminate results instead of current practice would have reduced the number of indeterminate screening results by 42.1%, from 18 (12.6%) to 11 (7.2%), without increasing the false-positive rate.

CONCLUSIONS

Addition of the Xpert EID as a consecutive test for specimens with an HIV-detected PCR screening result has the potential to improve the PPV and reduce the indeterminate rate, thereby reducing diagnostic challenges and time to final status, in SA's EID programme.

Remote Musculoskeletal Assessment Framework: A Guide for Primary Care

Introduction

Remote consulting has exploded into primary care following the initial COVID-19 surge as a measure to reduce potential cross-infection (staff-patient or patient-patient). Musculoskeletal (MSK) conditions comprise up to 21% of the annual primary care caseload in England. Established techniques for MSK examination, however, rely on face-to-face attendance. Evidence-based guidance for remote MSK assessment is required to ensure the quality of care is maintained with the move from face-to-face to virtual consultations.

Method

A literature review of published evidence and current guidelines was conducted. The most appropriate remote consultation techniques and MSK examinations were identified and where there was no evidence, modified examination tests were developed from established face-to-face examination techniques. A concise, accessible framework for remote MSK assessment in primary care was then created and tested on a non-medically trained volunteer.

Results

Over 2232 papers and articles were identified by search headings, reducing to 28 sources that had relevant content. At the time of searching, there was no published evidence relating to MSK remote consultation in a primary care setting. However, evidence was found in the physiotherapy and rehabilitation literature for the efficacy and practicality of MSK teleconsultation.

MSK remote examination framework

From this literature and with the addition of modified established examinations, an MSK assessment framework was constructed. This framework provides pre-consultation guidance and step-by-step remote examination instructions. Patient and clinician resources (including a patient information leaflet and photographic examples of examinations) were created as supplementary material.

Conclusion

Due to the frameshift away from face-to-face consultation, primary care clinicians have found themselves lacking an evidence base or practical guidance to support remote MSK assessment. This paper is a systematic literature review of MSK telemedicine from which practical advice and evidence-based MSK tests have been developed. Where there is no evidence, modified traditional tests are suggested to allow a complete framework for remote MSK examination - using a system approach of ‘look, point, move’ followed by modified special tests, for use in a primary care setting as a ‘ready-to-use’ practical guide to remote MSK assessment, presented in a downloadable format.

What did this add?

With 21% of primary care consultations relating to MSK conditions and limited means of performing face-to-face MSK examination due to COVID-19, there needs to be a recognised framework for assessing the MSK system remotely. To the best of our knowledge, this evidence does not exist for primary care remote MSK examination. This paper demonstrates evidence-based practical advice (from non-primary care settings) and modified MSK examinations to be used in a primary care MSK remote consultation.

Cutaneous Eccrine Adenolipoma with a Spindle Cell Component

Introduction/Objective

Cutaneous adenolipoma is a rare, benign variant of solitary lipoma characterized by a mature adipocytic proliferation with entrapped eccrine or apocrine sweat glands. It is found predominately in middle-aged females, with a predilection for lower extremities including the thigh and gluteal regions. Cutaneous adenolipoma is presumed to be a hamartomatous process. Herein, we report a unique case of a cutaneous eccrine adenolipoma with a spindle cell component, namely, an early evolving spindle cell adenolipoma.

Methods

A 43-year-old female with a recurrent history of hidradenitis presented with a 2.7 cm x 1.5 cm x 0.7 cm soft, mobile nodule on the right posterior thigh. It had been present for at least four months and clinically resembled a lipoma. An excisional punch biopsy was performed for pathological evaluation. A concurrent nevus lipomatosus superficialis was diagnosed from the right perineum.

Results

Gross examination of the thigh nodule revealed fragments of a tan-yellow, lobulated, fatty lesion. Microscopic examination demonstrated a benign lipomatous proliferation with entrapped eccrine glands associated with a surrounding spindle cell stroma. Initial differential diagnosis included a cutaneous eccrine adenolipoma variant and a cutaneous mixed solitary hamartoma composed of admixed neural, eccrine and lipomatous components.

Immunohistochemical staining showed uptake for CD34 and CD10 in the spindle cell stromal component, but negative for desmin and S100. Based on our histopathological findings, our diagnosis of an eccrine cutaneous adenolipoma with a spindle cell component was rendered. This unique lesion displayed features of an evolving spindle cell lipoma with entrapped sweat glands, which may be viewed as an early stage of a dermal spindle cell adenolipoma.

Conclusion

Cutaneous eccrine adenolipoma is a rare, benign lipomatous neoplasm with entrapped sweat glands that can also show a spindle cell component. We share this rare lesion exemplifying the histomorphological spectrum of a lipomatous hamartoma and to highlight the recognition of a cutaneous adenolipoma.

The validation of a new scoring method for assessing ego development based on three dimensions of language

We describe research on the validity of a new theoretical framework and scoring methodology, called STAGES, for sentence completion tests of meaning-making maturity or complexity (also called ego development or perspective-taking capacity). STAGES builds upon research on the substantially validated Washington University Sentence Completion Test of Jane Loevinger as updated by Susanne Cook-Greuter. STAGES proposes an underlying structural explanation for the Cook-Greuter system based on three dimensions. Two of these are polar factors: individual/collective, and passive/active; and the third is a categorization of the sophistication of the types of objects referred to (i.e. as concrete, subtle/abstract, or "metaware"). We describe two validation studies for the STAGES scoring method and model. The first is a replication study of concurrent validity, using 73 inventories to test the hypothesis that the STAGES scoring method replicates the Cook-Greuter scoring method. Using the weighted Kappa statistic, we demonstrate a very strong match between the two methods, confirming the first hypothesis. This study includes levels up to and including Strategist (i.e. a substantial percentage of test-takers from most populations). Levels above Strategist were validated using another method because (1) there is less Cook-Greuter data available at these levels, and (2) the two scoring methods diverge sufficiently, making comparison difficult. The second study, of 71 inventories, attempts to validate the STAGES scoring method at levels above Strategist by testing the inter-rater reliability among four scorers. The inter-rater reliability above Strategist, using the weighted Kappa statistic, was found to be moderate to substantial, indicating that the instrument and scoring method has internal validity for these four, rare higher levels. Additionally, the inter-rater reliability over all STAGES levels were found to be very strong.

5 year retrospective follow-up of new cases of Charcot neuroarthropathy-A single centre experience

BACKGROUND

Few data describe the natural history of Charcot neuroarthropathy treated with a total contact plaster cast (TCC).

METHODS

A 5 year retrospective analysis of 50 patients presenting with an acute CN, Assessing time to clinical resolution into appropriate footwear and assessing if initial immobilisation device influenced resolution time.

RESULTS

During the study period 42 patients (84%) of patients went into remission, 2 died during their treatment, 4 had major amputations, in 2 patients treatment was ongoing. 36 patients were treated with combination offloading devices, 6 were treated with one modality only. Median time to resolution for patients initially treated with a TCC was not significantly shorter than for those treated with a removable below knee boot. 34.9% required re-casting due to clinical deterioration in the removable device.

CONCLUSIONS

More precise measures of resolution of CN are needed to assess the impact of initial treatment modality on time to resolution.

Intracerebral haemorrhage and hemiplegia with heterotopic ossification of the affected hip

We present the case of a 72-year-old woman who developed right hemiparesis following a left frontal intraparenchymal haemorrhage. Three months following initial presentation, the patient noted poorly localised right lower quadrant pain. Following extensive investigations, a diagnosis of heterotopic ossification of the hip was made. We discuss the aetiology and pathogenesis of this uncommon entity, and discuss its relationship to ipsilateral neurological injury. The link with neurological injury can result in a delayed and atypical presentation. Early recognition and treatment are important for those caring for patients with acquired neurological deficits, and permit improved patient outcomes.

Ice sheets. Reverse glacier motion during iceberg calving and the cause of glacial earthquakes

Nearly half of Greenland's mass loss occurs through iceberg calving, but the physical mechanisms operating during calving are poorly known and in situ observations are sparse. We show that calving at Greenland's Helheim Glacier causes a minutes-long reversal of the glacier's horizontal flow and a downward deflection of its terminus. The reverse motion results from the horizontal force caused by iceberg capsize and acceleration away from the glacier front. The downward motion results from a hydrodynamic pressure drop behind the capsizing berg, which also causes an upward force on the solid Earth. These forces are the source of glacial earthquakes, globally detectable seismic events whose proper interpretation will allow remote sensing of calving processes occurring at increasing numbers of outlet glaciers in Greenland and Antarctica.

Glyco-engineered anti-EGFR mAb elicits ADCC by NK cells from colorectal cancer patients irrespective of chemotherapy

Background:

The epidermal growth factor receptor (EGFR) is overexpressed in colorectal cancer (CRC), and is correlated with poor prognosis, making it an attractive target for monoclonal antibody (mAb) therapy. A component of the therapeutic efficacy of IgG1 mAbs is their stimulation of antibody-dependent cellular cytotoxicity (ADCC) by natural killer (NK) cells bearing the CD16 receptor. As NK cells are functionally impaired in cancer patients and may be further compromised upon chemotherapy, it is crucial to assess whether immunotherapeutic strategies aimed at further enhancing ADCC are viable.

Methods:

CRC patients before, during and after chemotherapy were immunophenotyped by flow cytometry for major white blood cell populations. ADCC-independent NK cell functionality was assessed in cytotoxicity assays against K562 cells. ADCC-dependent killing of EGFR⁺ A431 cancer cells by NK cells was measured with a degranulation assay where ADCC was induced by GA201, an anti-EGFR mAb glyco-engineered to enhance ADCC.

Results:

Here, we confirm the observation that NK cells in cancer patients are dysfunctional. However, GA201 was able to induce robust NK cell-dependent cytotoxicity in CRC patient NK cells, effectively overcoming their impairment.

Conclusions:

These findings support the evaluation of the therapeutic potential of GA201 in combination with chemotherapy in CRC patients.

Proposed regulations for research with biospecimens: responses from stakeholders at CTSA consortium institutions

Secondary research with biospecimens acquired through clinical care and through research is often conducted without the informed consent of individuals from whom the specimens were acquired. While such uses are consistent with the current federal regulations, surveys of the general public suggest that many individuals would prefer more information and choice regarding research use of biospecimens. The federal government issued an Advance Notice of Proposed Rulemaking (ANPRM) in 2011 that proposed a number of potential changes in the regulations governing human subjects. These proposed regulations are particularly pertinent to institutions committed to research involving human subjects-including institutions in the NIH-funded Clinical and Translational Science Awards (CTSA) consortium. In this study, we reviewed public responses by CTSA-funded institutions and CTSA-affiliated organizations and groups regarding the proposed changes in the ANPRM with respect to research with biospecimens. Our results indicate that the majority of responses to the ANPRM from CTSA institutions were not supportive of the proposed changes. While many responses acknowledge a need to change current research practices regarding biospecimens, the proposed changes in the ANPRM received only limited support from this subgroup of academic research institutions.

Androgen deprivation therapy (ADT) use in Medicare beneficiaries with nonmetastatic (M0) prostate cancer (PC) in the United States

e15169

Background: ADT is well-established for metastatic PC but is also used in men with less advanced PC. Patterns of ADT use in the M0 PC setting have not been well-described. Methods: Medicare claims in 2005 for men aged ≥66 years (yrs) were assessed for use of gonadotropin-releasing hormone agonists or bilateral orchiectomy. The cohort was limited to men who, during the 15 months (mos) prior to their first 2005 ADT claim, had continuous Parts A + B coverage, a diagnosis code for PC, no claims for metastases (except lymph nodes), and no claims for ADT. Follow-up (f/u) was from ADT initiation to 3 yrs, death, or change in Medicare coverage. Regimen duration was defined by combining claim service count and dosage with FDA label dosing. Because ADT has biologic activity beyond the recommended regimen duration, active dose time was calculated by adding 3 and 6 mos to claims for regimens <6 mos and ≥6 mos, respectively. Interruption was defined as ≥180 days from end of active dose time to next ADT claim. Results: We identified 3246 M0 PC patients aged ≥66 yrs who initiated ADT in 2005 but describe results in the 2161 who had 3 full yrs of f/u (data for the entire cohort were similar). Nearly 70% received only 1 type of ADT agent during f/u (25% had 2 types, 5% had 3 or 4 types), and 73% started on a 3-or 4-month regimen. The distribution of patients by first ADT type (and by type received at any point) was: leuprolide injection: 54% (67%); goserelin implant: 36% (43%); triptorelin injection: 6% (19%); leuprolide implant: 2% (4%); orchiectomy: <1% (1%); and histrelin implant: 0% (3%). Use of >1 type of ADT agent was more common in men who began with goserelin (45%) or triptorelin (53%) versus leuprolide (≤24%). At three years after ADT initiation, 36% received ADT for the entire 36-month period, 15% for 24-35 mos, 17% for 12-23 mos, and 32% for <12 mos. Interruption in active therapy occurred in only 13%. Conclusions: Most elderly men with M0 PC initiating ADT in 2005 started on a 3- or 4-month leuprolide or goserelin regimen. Though these agents remained the most commonly used throughout f/u, switching was common (30% used >1 type during f/u). ADT was continued for at least 2 yrs in nearly half and extended to 3 yrs in over one-third of the cohort.

Rare cerebellar metastases from oesophageal carcinoma

BACKGROUND

Metastatic oesophageal carcinoma to the brain is an uncommon diagnosis that may cause abnormal neurological findings.

AIMS

The case of a 56-year-old man who presented with brain secondaries as an initial manifestation of carcinoma of oesophagus is presented and the unique characteristics highlighted.

RESULTS

Patient survival was for 12 months after initial presentation and treatment.

CONCLUSION

Oesophageal carcinoma is a recognised cause of intracerebral metastatic tumours, though this is an uncommon occurrence.