SABR for Early Non-Small Cell Lung Cancer: Changes in Pulmonary Function, Dyspnea, and Quality of Life

PURPOSE

The aim of this study was to report pulmonary function tests (PFTs) and clinician-reported and patient-reported quality-of-life (QoL) outcomes on a cohort of patients with non-small cell lung cancer (NSCLC) treated with SABR.

METHODS AND MATERIALS

A total of 119 patients with NSCLC were treated with SABR in the prospective cohort SSBROC study of patients with T1-T2N0M0 NSCLC. PFTs and QoL measures were obtained at baseline pretreatment and at 6-month intervals. Here we report on the 6- to 18-month time points. Analysis of covariance (ANCOVA) methods adjusting for baseline analyzed potential predictors on outcomes of PFTs and patient-reported dyspnea at 18 months.

RESULTS

The only statistically significant decline in PFTs was seen in forced expiratory volume in 1 second (FEV1) at 18 months post-SABR, with a decline of -0.11 L (P = .0087; 95% CI, -0.18 to -0.02). Of potential predictors of decline, only a 1-unit increase in smoking pack-years resulted in a -0.12 change in diffusing capacity for carbon monoxide (P = .026; 95% CI, -0.02 to -0.23) and a 0.003 decrease in FEV1 (P = .026; 95% CI, -0.006 to -0.0004). For patient-reported outcomes, statistically significant worsening in both the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (QLQ-C30 Version 3) and the lung module (QLQ-LC13) dyspnea scores occurred at the 18-month time point, but not earlier. No potential predictors of worsening dyspnea were statistically significant. There was no statistically significant decline in clinician-reported outcomes or global QoL scores.

CONCLUSIONS

We found a statistically significant decline in FEV1 at 18 months posttreatment. Smoking pack-years was a predictor for decline in diffusing capacity for carbon monoxide and FEV1 at 18 months. Worsening of patient-reported dyspnea scores was observed, consistent with the expected progression of lung comorbid disease.

A Clinician's Guide to Cancer-Derived Exosomes: Immune Interactions and Therapeutic Implications

Understanding of the role of immunity in the regulation of cancer growth continues to rapidly increase. This is fuelled by the impressive results yielded in recent years by immune checkpoint inhibitors, which block regulatory pathways to increase immune-mediated cancer destruction. Exosomes are cell-secreted membranous nanoscale vesicles that play important roles in regulating physiological and pathophysiological processes. Cancer-derived exosomes (CDEXs) and their biologically-active cargos have been proven to have varied effects in malignant progression, including the promotion of angiogenesis, metastasis, and favorable microenvironment modification. More recently, there is an increasing appreciation of their role in immune evasion. In addition to CDEXs, there are immune-derived exosomes that facilitate communication between immune cells in the non-malignant setting. Investigation of cancer-mediated mechanisms behind interruption or modification of these normal exosomal pathways may provide further understanding of how malignant immune evasion is accomplished. Accumulating evidence indicates that immune-active CDEXs also have the potential to impact clinical oncological management. Whilst immune checkpoint inhibitors have well-established pharmacologically-targeted pathways involving the immune system, other widely used treatments such as radiation and cytotoxic chemotherapies do not. Thus, investigating exosomes in immunotherapy is important for the development of next-generation combination therapies. In this article, we review the ways in which CDEXs impact individual immune cell types and how this contributes to the development of immune evasion. We discuss the relevance of lymphocytes and myeloid-lineage cells in the control of malignancy. In addition, we highlight the ways that CDEXs and their immune effects can impact current cancer therapies and the resulting clinical implications.

Collaborative implementation of stereotactic ablative body radiotherapy: A model for the safe implementation of complex radiotherapy techniques in Australia

INTRODUCTION

Stereotactic ablative radiotherapy (SABR) for lung cancer is a modality of treatment that has improved outcomes for lung cancer patients. However, radiotherapy for lung cancer is underutilized and fewer than half of elderly patients with non-small cell lung cancer (NSCLC) receive active treatment. The purpose of this study is to report on a collaboration in implementing an NSCLC SABR (stereotactic ablative body radiation) program safely, efficiently, and uniformly across several centers, including regional sites. The first aim of this paper is to detail the collaboration and implementation that started in 2013 and is ongoing. The second aim of this paper is to document early toxicities and quality of life outcomes.

METHOD

A tripartite approach was used to develop the protocol and networks required for the implementation of SABR across multiple sites in NSW. Departments starting the programmes were supported and physics credentialing with central site submission was required before commencing the treatment. Additional ongoing support was available via an email discussion group involving all members of the collaboration.

RESULTS

Between July 22, 2013 and February 22, 2016, 41 patients were enrolled with 34 patients in active follow up. The toxicity profile so far is similar to those of published studies with no appreciable effect on quality of life outcomes.

CONCLUSION

The collaboration formed an effective framework in facilitating the implementation of SABR across several sites in NSW and could be used as a model for the safe and uniform implementation of new technologies in Australia.

Breast irradiation causes pallor in the nipple-areolar complex in women with Celtic skin type (result from the St. George and Wollongong randomised breast boost trial)

INTRODUCTION

The nipple-areolar complex (NAC) has special histological properties with higher melanocyte concentration than breast skin. To date, there are no data describing the late effects on the NAC following breast-conserving therapy (BCT). This study evaluated colour changes in the NAC in patients treated with breast-conserving surgery and adjuvant radiotherapy after 5 years.

METHODS

Digital photographs obtained at 5 years following breast irradiation from the St. George and Wollongong (SGW) trial (NCT00138814) were evaluated by five experts using an iPad® (Apple Inc., Cupertino, CA, USA) application specifically created for this study. The SGW trial randomised 688 patients with Tis-2, N0-1, M0 carcinoma to the control arm of 50 Gy in 25 fractions and boost arm of 45 Gy in 25 fractions and 16 Gy in 8 fractions electron boost.

RESULTS

A total of 141/372 (38%) patients had altered NAC (86% lighter, 10% darker). Patients with Celtic skin type had increased likelihood of having an altered NAC (odds ratio (OR), 1.75 (CI 1.1-2.7, P = 0.011)). On subgroup analysis, those with Celtic skin type receiving biologically equivalent dose (BED) Gy3 ≥ 80 Gy had OR of 3.03 (95% CI 1.2-7.5, P = 0.016) for having altered colour. There was a dose response with more profound changes seen in the NAC compared with irradiated breast skin if BED Gy3 ≥ 80 Gy with OR of 2.42 (95% CI 1.1-5.6, P = 0.036).

CONCLUSION

In this Caucasian BCT population, over 30% of patients developed lighter NAC and more commonly in women with Celtic skin type. The degree of this effect increased with higher radiation dose.

Radiotherapy breast boost with reduced whole-breast dose is associated with improved cosmesis: the results of a comprehensive assessment from the St. George and Wollongong randomized breast boost trial

PURPOSE

To evaluate comprehensively the effect of a radiotherapy boost on breast cosmetic outcomes after 5 years in patients treated with breast-conserving surgery.

METHODS

The St. George and Wollongong trial (NCT00138814) randomized 688 patients with histologically proven Tis-2, N 0-1, M0 carcinoma to the control arm of 50 Gy in 25 fractions (342 patients) and the boost arm of 45 Gy in 25 fractions to the whole breast followed by a 16 Gy in 8 fraction electron boost (346 patients). Five-year cosmetic outcomes were assessed by a panel subjectively in 385 patients and objectively using pBRA (relative breast retraction assessment). A subset of patients also had absolute BRA measurements. Clinician assessment and patient self-assessment of overall cosmetic and specific items as well as computer BCCT.core analysis were also performed.

RESULTS

The boost arm had improved cosmetic overall outcomes as scored by the panel and BCCT.core software with 79% (p = 0.016) and 81% (p = 0.004) excellent/good cosmesis respectively compared with 68% in no-boost arm. The boost arm also had lower pBRA and BRA values with a mean difference of 0.60 and 1.82 mm, respectively, but was not statistically significant. There was a very high proportion of overall excellent/good cosmetic outcome in 95% and 93% in the boost and no-boost arms using patient self-assessment. However, no difference in overall and specific items scored by clinician assessment and patient self-assessment was found.

CONCLUSION

The results show the negative cosmetic effect of a 16-Gy boost is offset by a lower whole-breast dose of 45 Gy.

The effect of rectal heterogeneity on wall dose in high dose rate brachytherapy

When treating prostate cancer using high dose rate (HDR) brachytherapy, overdosing the rectal wall may lead to post-treatment rectal complications. An area of concern is related to how the rectal wall dose is calculated by treatment planning systems (TPSs). TPSs are used to calculate the dose delivered to the rectal wall, but they assume that the rectum is a water-equivalent homogeneous medium of infinite size and do not consider the effect that an air-filled "empty" rectal cavity would have on the dose absorbed along the rectal wall. The aim of this research is to quantify the effect that an air cavity has on the rectal wall dose, as its presence changes the backscatter conditions in the region. The MO Skin and RADFET dosimeters proved capable of measuring absolute dose with increasing distance from the HDR Ir-192 brachytherapy source. However, the anterior rectal wall doses measured by the MOSkin and RADFET in an empty rectal cavity were 14.7 +/- 0.2% and 13.7 +/- 0.6% lower than the dose measured in a homogeneous rectal phantom. Monte Carlo simulations corroborated the experimentally obtained results, reporting a -13.2 +/- 0.6% difference. The dose measured at the posterior wall of an empty rectal cavity was between 22% and 26% greater than the dose measured in a full rectal cavity. The heterogeneity of the rectal volume appears to have a significant effect on the rectal dose when compared to calculated rectal dose.

Clinical response assessment after 2 cycles of neoadjuvant chemotherapy for primary breast cancer fails to predict for final clinical response, but does predict for pathological complete response

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Background: Neoadjuvant chemotherapy (NC) is increasingly being used for large primary breast carcinomas. Clinical trials have established its role in improving breast-conserving surgery (BCS) rates and have shown that complete pathological response (pCR) is associated with improved survival. Early evaluation of response is important for selecting patients with possible worse outcomes, who may benefit from alternative treatments. Methods: 107 women received NC for large operable breast cancers (T2–4, N1–2, M0). Patients received 6 cycles of FEC chemotherapy (5-FU 500mg/m2, epirubicin 75mg/m2, cyclophosphamide 500mg/m2 every 21 days) prior to a planned operation. Clinical response was recorded at baseline, after 2 cycles of NC and on completion of 6 cycles. Baseline and completion ultrasound and/or mammography were performed and a pathological assessment of response was made in those patients who underwent surgery. Results: Median age was 50 (range= 29–78). Overall clinical response rate after 2 cycles of chemotherapy was 59.8% (64/107) and after 6 cycles was 84.1% (90/107). 56 patients (52.3%) underwent BCS, 37 (34.6%) mastectomy and 14 (13.1%) no operation. Overall pCR rate was 15.0% (16/107). Of the 43 patients who failed to respond clinically after 2 cycles, 27 (62.8%) went on to exhibit a clinical response on completion of chemotherapy. 3 (7.0%) patients went on to have a complete clinical response and 21 (48.8%) underwent BCS. However, none of these 43 patients demonstrated a pCR. Conclusions: Lack of clinical response after 2 cycles of neoadjuvant chemotherapy does not preclude clinical response after further treatment with the same schedule, and many women will have sufficient down-staging to enable breast-conserving surgery. However, a pathological complete response is unlikely if no clinical response is observed after 2 cycles.

No significant financial relationships to disclose.

T-cell receptor v-Beta usage of tumor-infiltrating lymphocyte lines cloned from human breast-tumor and melanoma

A total of forty-one tumor infiltrating T cell lines (TIL) were cloned, in the presence of interleukin-2, from nine breast tumor and five melanoma specimens with limiting dilution in a microculture system. Nineteen (46%) of the lines/clones reacted to autologous tumor targets. The T cell receptor (TcR) V beta gene usage was analyzed using polymerase chain reaction (PCR) technique and a set of oligonucleotide primers specific for 20 V beta families. T cell lines generated from paired peripheral blood lymphocytes (PBL) under similar condition were used as control. Our data revealed a limited heterogeneity in TcR V beta gene usage with a biased expression of V beta 6 in both breast tumor- and melanoma-derived TIL lines/clones. In contrast, a random pattern of TcR V beta usage was observed in 27 control T cell lines derived from PBL of patients with breast cancer and melanoma. The results lend support to oligoclonal expansion of TIL at tumor sites but fail to directly correlate the preferential expression of V beta 6 with the functional property of the TIL in recognition of tumor antigens.

Cellular and molecular analysis of tumor-infiltrating T-lymphocytes from human breast-cancer at clonal level

51 T cell lines/clones were established from tumor-infiltrating lymphocytes of nine breast tumors by limiting dilution. All the lines/clones were exclusively CD3+ and expressed either CD4 (57%) or CD8 (26%) phenotype. In addition, 17% of the lines/clones displayed a dual expression of CD4+CD8+ antigens. No CD3-CD16+ NK clones were obtained. A vast majority of the T cell lines and clones (84%) exhibited cytolytic activity in a lectin-dependent assay which allows the detection of cytolytic T cells of any antigen specificity. 17% of the lines/clones lysed two allogeneic breast tumor cell lines, MCF-7 and HBL-100. 11% of the cells showed NK-like cytolysis by lysing an NK-sensitive cell line K562. Of the 17 lines tested against autologous tumor cells, only two exhibited cytolytic activity via T cell receptor and CD3 molecule in an MHC-restricted manner. Southern blot analysis of T cell receptor of 39 lines/clones revealed a limited heterogeneity of TCR-B chain gene rearrangements, which suggests oligoclonal expansion of T cells infiltrating into the tumor.

[Incidence of nodal involvement of #12u nodes (lymph nodes around the upper lobe bronchus) in cases with right middle lobe, right lower lobe, and left lower lobe carcinoma]

#12u nodes are peribronchial lymph nodes around the upper lobe bronchus which should not be routinely dissected in cases with middle lobe carcinoma or lower lobe carcinoma. In this paper, #12u were examined histologically in 152 lung cancer cases. As a results, 14 of 152 (9.2%) had nodal diseases in #12 nodes. #12u nodes were involved in 3 of 30 N1 diseases (10%), and in 11 of 35 N2 diseases (31.4%). There was a case which had no nodal involvement except for #12u node. And in three cases, we found only one nodal metastasis except for #12u nodes. If we did not dissect #12u nodes, these cases will be relapse in near future. Thus, for curative operation, #12u nodes should be dissected as a standard operation.

Adriamycin, cyclophosphamide and vindesine (ACV) versus mitoxantrone, cyclophosphamide and vindesine (NCV) in advanced breast cancer

The choice of chemotherapy for advanced breast cancer patients is based on both response rates and anticipated side effects. Two polychemotherapy regimens, ACV and NCV, were compared in an open study with 90 patients of whom 69 were evaluable both for efficacy and toxicity. Both ACV and NCV are active in metastatic breast cancer. ACV leads to more remissions in a relatively short time. NCV treatment results in a larger proportion of stable diseases. ACV causes more important alopecia, nausea and vomiting. NCV gives more anemia. The characteristics of both treatment results give the oncologist the opportunity to choose in particular clinical situations.

In vivo distribution of radio-labeled tumor infiltrating lymphocytes in cancer patients

Tumor-infiltrating lymphocytes have proven effective in murine tumor models and preliminary clinical trials. To evaluate the efficacy of these lymphocytes in treatment attempts were made to study the in vivo migration and distribution of these lymphocytes. Tumor-infiltrating lymphocytes isolated from five patients with malignant metastatic breast cancer or melanoma cultured and expanded in vitro with low-dose of recombinant interleukin-2 were labeled with 111Indium-oxine and infused to the patients. A large view gamma camera was used to evaluate the distribution and localization of the infused TIL. Localization of 111In-labeled TIL in the lungs was seen within two hours after infusion and high levels of radioactivity were observed at 24 hours in lungs, liver and spleen. The activity in the lungs diminished after 72 hours. No specific localization of 111In-labeled TIL was observed in the metastatic sites.

Phenotypic analysis of tumor-infiltrating lymphocytes from human breast cancer

Suspensions of fresh tumor-infiltrating lymphocytes (TIL) were prepared from 30 human breast ductal adenocarcinomas. To evaluate the phenotypic pattern of the isolated TIL, lymphocyte surface markers including CD19, CD3, CD4, CD8, CD16 and HLA-DR were examined by flow cytometry. Lymphocyte recovery ranged from 1.1% to 44%, independent of tumor size. TIL most often scored high for CD3+ with a varying number of CD4+ and CD8+ cells. Three samples out of 30 expressed up to 44% of CD19+ B cells, while CD3-CD16+ NK cells were rare. CD4 and CD8 expression was significantly different between the lymph node metastases group and the lymph node negative group (p < 0.01). 67% of the TIL with a CD4/CD8 ratio greater than 1 showed lymph node metastases. Furthermore, the CD4 expression of TIL and CD4/CD8 ratio correlated with tumor size (p < 0.01), but not with tumor differentiation and hormone receptor expression. Although there was considerable diversity of TIL among breast tumors, our data suggest that a high expression of CD4+ T cells may imply progression of the tumor, and an increased CD4/CD8 ratio of the TIL isolated from human breast adenocarcinoma may indicate development of metastases.

Myelin basic protein-specific T lymphocytes in multiple sclerosis and controls: precursor frequency, fine specificity, and cytotoxicity

A panel of 90 myelin basic protein (MBP)-specific T-cell lines were derived from peripheral blood of eight patients with multiple sclerosis and four normal subjects. The precursor frequency of MBP-reactive T cells in peripheral blood mononuclear cells ranged from 10(-7) to 9 x 10(-7) (mean, 6.7 x 10(-7)) in the group of patients with multiple sclerosis and from 0.5 x 10(-7) to 9.8 x 10(-7) (mean, 5.6 x 10(-7)) in the control subjects. This difference between the two groups was not statistically significant (p greater than 0.1). These T-cell lines expressed exclusively CD3+CD4+CD8- phenotypes and were restricted predominantly by HLA-DR molecules. When tested with fragments and synthetic peptides of human MBP, these MBP-specific T-cell lines (45 lines for each group) displayed a limited heterogeneous pattern with a biased recognition to peptide 84-102 and the C-terminal peptide 149-171. The reactivity to the 84-102 region of MBP was associated with the HLA-DR2, DRw15 (DRw15,2) haplotype, whereas the recognition to peptide 149-171 did not correlate with a particular HLA-DR allele(s). Furthermore, the majority of T-cell lines (greater than 75%) were found to exhibit substantial cytotoxic activity against MBP-coated target cells, but showing no significant difference between these two groups. This MBP-dependent cytotoxicity was not associated with epitope specificities of the T-cell lines tested.

Large scale expansion of human tumor infiltrating lymphocytes with surface-modified stimulator cells for adoptive immunotherapy

Expansion of tumor infiltrating lymphocytes (TIL) in vitro is hampered by several factors, including a limited amount of lymphocytes obtained from different tumors, unknown target antigens and limited supply of antigen-presenting cells (APC) which are generally believed to be essential in the classical way of T cell stimulation and expansion. In approaching these difficulties, we have recently used surface-oxidized allogeneic PBL to stimulate the TIL periodically in the presence of a low dose of rIL-2 (200 IU/ml). TIL derived from 22 (out of 23) tumor specimens could be expanded with 20 -10(7) fold increases over 6-16 weeks to a sufficient amount of 10(9) -10(11) cells for adoptive immunotherapy. In contrast, only 2-100 fold increase were observed in six tumor specimens (out of 23) when 200 IU/ml rIL-2 was used only. The phenotypes, autologous tumor reactivity and cytolytic capability of TIL propagated with surface-oxidized stimulators were similar to those expanded in the presence of IL-2 alone. These data suggest that expanding TIL with surface-modified stimulator cells could be a useful alternative method to obtain a large amount of tumor specific cytolytic T cells for clinical immunotherapeutic use, irrespective of tumor-antigen stimulation and MHC restriction.

A team approach to patient care in the medical intensive care units at Robert Wood Johnson University Hospital

The MICU offers the pharmacist and the pharmacy technician an exciting opportunity to participate meaningfully in direct patient care. Cost containment will continue to be an important issue in the 1990s. The pharmacist must promote optimal therapeutic decision making and decrease the incidence of adverse drug reactions to get the patient better and out of the unit as quickly as possible. The pharmacist will ensure that patients receive the safest, most cost-effective therapy without compromising the quality of care. The pharmacist and pharmacy technician can collaborate with MICU nurses to create a safe and efficient flow of medications. Time management by nurses becomes much more efficient when they are able to benefit from the interactions of pharmacists and pharmacy technicians as described in this article.

A murine monoclonal antibody to human breast cancer cells associated with DNA ploidy status

A murine monoclonal antibody, 5D10, raised against the human breast cancer cell line MCF7 reacted preferably with mammary carcinomas and weakly with normal epithelial cells. The antigens recognised by the antibody had molecular weights of about 28 and 90 kD. The reactivity of the antibody to human breast carcinomas correlated with the DNA ploidy status of the tumour cells. Upon analysis of 54 breast carcinoma specimens, the percentage of antibody positive cells was significantly higher in tumours with an aneuploid stemline than in those with a diploid DNA content (P less than 0.001). This antibody therefore could be a useful tool in evaluating the prognosis of breast carcinomas.

Antibodies to myelin basic protein and measles virus in multiple sclerosis: precursor frequency analysis of the antibody producing B cells

Antibody-producing B lymphocytes were polyclonally activated and transformed, by Epstein-Barr virus (EBV), into multiple B lymphoblastoid cell lines in a microculture system. The frequencies of B precursor cells producing antibodies to myelin basic protein (MBP) and measles virus were analyzed in peripheral blood of patients with multiple sclerosis (MS) and control subjects. Measles virus-specific B cells were detected at a significantly higher frequency in MS patients (n = 10, P less than 0.005) than patients with other neurological diseases (n = 10) and normal subjects (n = 10). In contrast, the frequencies of B cells producing anti-MBP antibodies and natural antibodies did not differ statistically among the three groups tested (P greater than 0.05). In addition, the anti-MBP antibodies produced by a panel of stable B cell lines obtained were found to react selectively with an epitope(s) within the C-terminal half fragment 90-171 of the human MBP molecule. In our experiments, no antibody cross-reactivity between MBP and measles virus could be detected in a total of 2760 B cell cultures.

Lysosomal naphthylamidase activity as a possible aid in cytological screening

Lysosomal naphthylamidase activity has been measured microdensitometrically in cells in samples obtained by cervical and vaginal irrigation from 22 cases cytologically graded I and II, 28 graded III (moderate to severe dysplasia), 22 graded IV (carcinoma in situ), and 15 cases (grade V) of invasive carcinoma. There was a statistically significant difference in this activity in the cells from cases of grade V as against those in the relatively normal samples (grades I and II; p < 0.001) and as against those of grade IV (p < 0.005). The method is sufficiently robust for routine use provided that it is recognised that elevated activities can be found as a consequence of other factors such as previous surgical intervention and infection with herpes simplex.