JS09.7.A Reirradiation for recurrent high grade glioma (HGG) patients: results of a single arm prospective phase 2 study

Background

Standard of care for recurrent high grade glioma (HGG) is missing. Several treatment options have been investigated including re-irradiation (re-RT). Results are promising but provided by retrospective studies. We designed a single arm prospective phase II study aiming to evaluate efficacy, and toxicity of re-irradiation.

Material and Methods

Adults patients with good performance status, HGG diagnosis reclassified according to the new 2021 fifth edition WHO CNS classification, an interval time (IT) from previous RT ≥ 6 months were included. Outcome was evaluated by MRI imaging at 1 month, and every 3 months thereafter. Toxicities were evaluated in terms of radionecrosis occurrence, and neurocognitive status.

Results

Ninety recurrent HGG patients were treated, 11 oligodendroglioma grade 3, 18 astrocytoma grade 3 and 4, and 61 glioblastoma grade 4. The median age was 54 years, and majority had KPS 90-100. The median IT between first-RT and re-RT was 24 months. Re-surgery has been performed in 56.6%, and chemotherapy in 53.3%. The median follow up time was 64 months; median overall survival (OS) time,1,2,3-year OS rates were 17 months (95%CI 14-19), 66.7%±4.9, 32.6%±5.0, and 22.2 ± 4.7. Prognostic factors impacting on survival were age (p = 0.0154), IT between first RT and re-RT (p = 0.0051), glioma grade (p = 0.0090), and IDH status (p = 0.0001). Radionecrosis grade 2-3 occurred in 9 (10%) patients; neurocognitive functions remained stable until disease progression.

Conclusion

Re-RT proved to be a safe and feasible treatment option with low toxicity. Younger patients with grade 3 IDH mutated gliomas, and a longer IT had the better outcome.

Frontal cortical perfusion abnormalities related to gluten intake and associated autoimmune disease in adult coeliac disease: 99mTc-ECD brain SPECT study

OBJECTIVE

Since brain perfusion abnormalities have been described by single-photon emission computed tomography in some autoimmune diseases, the aim of the present study was to evaluate the incidence of perfusion abnormalities by brain single-photon emission computed tomography in a group of coeliac disease patients, and to investigate whether gluten intake and associated autoimmune diseases may be considered risk factors in causing cerebral impairment.

METHODS

Thirty-four adult coeliac patients (16 on a gluten-free diet and 18 on a gluten-containing diet, 18 (53%) with autoimmune diseases) underwent 99mTc-ethyl cysteinate dimer brain single-photon emission computed tomography and qualitative evaluation of brain perfusion was performed together with a semiquantitative estimation using the asymmetry index. Ten subjects on our database, matched for sex, age and ethnic group, who were proved normal by histology ofjejunal mucosa (four males and six females; median age 39 years, range 27-55 years), were included as control group.

RESULTS

Twenty-four out of 34 patients (71%) showed brain single-photon emission computed tomography abnormalities confirmed by abnormal regional asymmetry index (>5%; range 5.8-18.5%). Topographic comparison of the brain areas showed that the more significant abnormalities were localised in frontal regions, and were significantly different from controls only in coeliac disease patients on unrestricted diet. The prevalence of single-photon emission computed tomography abnormalities was similar in coeliac disease patients with (74%) and without (69%) associated autoimmune disease.

CONCLUSIONS

Abnormalities of brain perfusion seem common in coeliac disease. This phenomenon is similar to that previously described in other autoimmune diseases, but does not appear to be related to associated autoimmunity and, at least in the frontal region, may be improved by a gluten-free diet.

Case control study on health-related quality of life in adult coeliac disease

AIMS

To evaluate whether health-related quality of life in adult coeliac disease is related to: 1) adhesion to gluten-free diet; 2) manifestation of clinical features; and 3) associated diseases.

PATIENTS AND METHODS

A total of 68 coeliac patients (54 female and 14 male) aged between 18 and 74 years, on gluten-free diet for at least two years were studied. The subjective health status was measured by means of the Short Form 36 Health Survey. A series of 136 subjects, matched according to sex, age and ethnic group, were evaluated as control group.

RESULTS

Patients obtained worse scores with respect to healthy controls at all domains of Short Form 36 Health Survey (p<0.05); compliers showed better results than non-compliers. The lowest scores were obtained in patients with more than six symptoms, mostly in non-compliers, the highest in compliers with less than six symptoms. Patients with two or more associated diseases presented significantly worse scores than patients with only one associated disease.

CONCLUSIONS

The importance of gluten-free diet in clinical management of coeliac disease is confirmed by results of the present study; moreover, the results seem to indicate that a complex interplay of factors should be taken into account in evaluating health-related quality of life in adult coeliac disease. Accordingly, our data show that health-related quality of life of coeliac patients is impaired not only by poor compliance but also by different negative factors such as severity of illness (in terms of number of symptoms) at diagnosis and comorbidity.

Transesophageal Doppler ultrasonography evaluation of hemodynamic changes during videolaparoscopic cholecystectomy

BACKGROUND

The aim of this study was to assess the changes of hemodynamic and oxyphoretic parameters induced by pneumoperitoneum in a series of patients undergoing laparoscopic cholecystectomy, by using the transesophageal Doppler ultrasonography (TEDU).

METHODS

DESIGN

prospective study.

SETTING

a medico-surgical intensive care unit of an University Hospital.

PATIENTS

11 patients who underwent laparoscopic cholecystectomy because of gallbladder stones.

INTERVENTIONS

a central venous line, a radial artery line were placed before the induction of anesthesia. End expiratory CO2 (EtCO2) was monitored by using a capnometer (Dräger, Germany). Cardiac output (CO) was measured using the transesophageal Doppler system Abbott ODM II (Abbott Critical Care Systems, Ireland), which was positioned in the esophagus after stabilization of anesthesia.

MEASUREMENTS

hemodynamic parameters, including CO, central venous pressure, mean arterial pressure, measurement of EtCO2 and arterial and central venous samples were performed: after reaching a stable anesthesia but before any surgical manipulation (T0); after induction of pneumoperitoneum (T1); 15 min after T1 (T2); 30 min after T1 (T3).

RESULTS

SVR increased significantly at T1 and T2 compared to T0; PaCO2 and PvCO2 at T2 and T3. HR and MAP increased significantly at T1, and CVP significantly at all the times.

CONCLUSIONS

Laparoscopic surgery is a mini-invasive technique of increasing success among both surgeons and patients. The widening of candidate patients raises the question of eligibility for individuals with known cardiopulmonary disease. In these patients, only a careful and thorough anesthesiologic monitoring allows the prompt identification and treatment of any relevant hemodynamic and/or ventilatory changes.

Nutritional assessment in head injured patients through the study of rapid turnover visceral proteins

BACKGROUND & AIMS

Nutritional monitoring of rapid turnover visceral protein is important in the recognition of malnutrition in patients admitted to the Intensive Care Unit (ICU). We studied prealbumin and retinol-binding protein in patients who received three different kinds of artificial nutrition in order to evaluate the appropriateness of artificial nutrition.

METHODS

45 consecutive head injury patients received enteral (Group A), parenteral (Group B) or both enteral and parenteral nutrition (Group C) at random. We considered these parameters: prealbumin, retinol binding protein and nitrogen balance before (T1), after 3 (T2), 7 (T3) and 11 (T4) days after the beginning of study. Statistical analysis was performed with Kruskal-Wallis test and Bonferroni's t -test.

RESULTS

Plasma prealbumin and Retinol binding protein (RBP) showed an increasing of basal values during the study period in all groups (<< 0.0001) and more significantly in group A (Enteral nutrition P < 0. 001 vs Total parenteral nutrition (TPN) and Enteral P<< 0.01 vs Enteral and parenteral nutrition).

CONCLUSION

Data obtained in the present study indicate that a laboratory is essential for monitoring nutritional assessment and for checking the appropriateness of nutritional therapy. We found prealbumin to be the most sensitive measure and found it to be the test of choice for early assessment and intervention.

Institutionalized older adults' perceptions of nurse caring behaviors. A pilot study

The purpose of this article is to identify which behaviors performed by nursing staff were important indicators of caring as perceived by older adults residing in institutional settings. Using Watson's Theory of Transpersonal Care as the framework for the study, the Caring Behavior Assessment (CBA) instrument, which is congruent with Watson's carative factors, was used to interview residents. A convenience sample of 21 residents residing in long-term care and assisted-living facilities answered the 63-item CBA. Descriptive statistics were used to analyze the importance of each identified behavior. The analyses revealed that the highest indicator of nurse caring focused on the nurses' technical competency (instrumental activities). This study noted a significant gender-specific perception of caring. This may reflect differences in gender communication styles and interpersonal processes which may affect connotations of caring expressions. Humanistic caring (expressive activities) was the second most important indicator of care. Older adults desired care which preserved and enhanced individual dignity.

Recurrent external ophthalmoparesis during hormonal therapy after thyroid ablation. Case report

We here report the case of a patient who had undergone total thyroid ablation for Graves' disease. After the beginning of oral therapy with 1-thyroxine, she developed a left external ophthalmoparesis that remitted with the discontinuation of the drug and recurred whenever the replacement therapy (1-thyroxine or tri-iodothyronine) was reintroduced.

Testicular germ cell tumors and human immunodeficiency virus infection: a report of 26 cases. Italian Cooperative Group on AIDS and Tumors

PURPOSE

Besides tumors that are diagnostic of AIDS, such as non-Hodgkin's lymphoma, Kaposi's sarcoma, and invasive carcinoma of the cervix, other tumors have been described in the human immunodeficiency virus (HIV) setting. Some case reports on testicular cancer in HIV-infected patients have appeared in the literature. We present a retrospective study on 26 cases of testicular germ cell tumors (TGCTs) observed within the Italian Cooperative Group on AIDS and Tumors (GICAT) between November 1986 and September 1994.

PATIENTS AND METHODS

Twenty-six patients with TGCT and HIV-infection from the GICAT were retrospectively analyzed.

RESULTS

Fourteen patients had seminoma and 12 had nonseminoma. Four patients underwent only orchidectomy, one patient received only chemotherapy, nine patients were treated with postsurgical chemotherapy, 10 patients (38%) received postsurgical radiotherapy, one patient received postsurgical chemotherapy plus radiotherapy, and one patient was lost for follow-up evaluation immediately after diagnosis. The complete response (CR) rate was 95%. Relapse occurred in 32% of patients. The median follow-up time was 33 months. The mortality rate was 37%. Causes of death were neoplasia in three of nine patients, AIDS in five of nine patients, and fortuitous event in one of nine patients. The overall 3-year survival rate was 65%, and the 3-year disease-free survival rate was 65%. Severe hematologic toxicity was observed in seven of 15 patients.

CONCLUSION

HIV-infected patients with testicular cancer should be offered standard oncologic therapy, irrespective of their HIV status, since the majority can be cured of their tumor and have a good quality of life. Use of concomitant prophylaxis for opportunistic infections is recommended.

[Idiopathic cupulolithiasis: vasomotor reactivity evaluation of the vertebro-basilar artery by transcranial doppler ultrasonography and acetazolamide test]

Benign paroxysmal positional vertigo (BPPV) or cupulolithiasis is one of the more common peripheral vestibular disorders. Diagnosis is made on the observation of typical positioning nystagmus brought about by the Hallpike manoeuver. In most cases of BPPV, etiology is unknown. Microcirculatory disorders have often been considered responsible for idiopathic BPPV. Few reports have been published on this specific aspect of the problem. In our study we evaluated vertebro-basilar haemodynamics and vasomotory reactivity after Acetazolamide administration in 12 patients with idiopathic BPPV. The results obtained reveal the absence of macrocirculatory impairment in the vertebro-basilar district in basal conditions, but significative vasoreactivity variation after acetazolamide, both in vertebral and basilar arteries. Poor vasomotor reactivity in one vertebral artery was observed in 5 patients and, in two cases, in the basilar artery. Altered vasoreactivity in the middle cerebral arteries was not observed in any case. In the light of these findings, we suggest that a possible inadequate response if microcirculation in the labyrinth, in some particular haemodynamic situations, might cause otolithic damage.

[Solid tumors associated with HIV infection]

Between December 1986 and December 1991, the Italian Cooperative Group on AIDS-related tumours documented 94 HIV related solid tumours. Of 21 germinal testicular tumours collected, ten were seminomas. Cervical carcinoma was observed observed in 28 IVDAs (intraepithelial in 8 and advanced, with rapid progression, in one). Lung cancer associated with HIV infection was reported in 14 patients. Also reported were two cases of colorectal carcinoma, one anorectal carcinoma, one pancreatic carcinoma, one carcinoid, one oral carcinoma. Of the central nervous system tumours, were diagnosed 3 cases of glioblastomas, one medulloblastoma and one meningioma. This retrospective study shows that while oral and anorectal tumours were very rarely observed, a wide spectrum of other HIV-related solid tumours were found in this series. The required therapeutic approaches may not necessarily be influenced by the HIV infection, in contrast with the observed pattern for treatment of EKS and lymphomas in HIV infected subjects.

Association of large granular lymphocyte/natural killer cell proliferative disease and second hematologic malignancy

We describe the first three patients with a large granular lymphocytosis/lymphocytic leukemia and another blood malignancy. In two, a myeloproliferative disorder developed soon after the diagnosis of abnormal proliferation of large granular lymphocytes-natural killer (LGL-NK) cells, a myelodysplastic syndrome evolving to acute leukemia and a Philadelphia-positive chronic myelogenous leukemia. In these cases, LGLs expressed the phenotype of CD3+ NK and CD3- NK cells, respectively, and were clonal in the first patient as demonstrated by T-cell receptor gene rearrangement study. In the third case, a similarly clonal excess of LGLs, phenotypically CD3+ NK cells, was detected following a diagnosis of B-cell hairy-cell leukemia. Clinically, the concurrence of LGL proliferation and other leukemia did not seem to confer a worse prognosis on the patients. Although an association by chance remains a possible explanation, a common origin from an altered precursor cell for both myeloid and LGL proliferations in the first two cases is discussed, whereas in the third it might be related to the severe immune derangement frequently observed in hairy-cell leukemia.

Therapeutic efficacy of danazol in myelodysplastic syndromes

Sixteen unselected untreated patients with primary myelodysplastic syndromes (MDS) and various combinations of blood cytopenia were treated with danazol, an attenuated androgen reported to be of some value in these conditions. After a 12 week trial (danazol 600 mg/day/p.o.), anaemia improved in 4/14 patients, with transfusional requirements being reduced by 50% or more in four other cases (response 57%). An enhanced reticulocyte production was documented in 6/13 cases (46%), and thrombocytopenia resolved in 5/8 (62%). Results of the granulocyte count were less satisfactory, with only one partial response obtained among five cases. A normalization of the monocyte count was seen in 3/5 patients with chronic myelomonocytic leukaemia, with one of them achieving a complete haematological and clinical remission lasting 6 months. Circulating blast cells decreased significantly (50% or more) in 4/6 cases. Although clinical symptoms from anaemia and bleeding disappeared in responsive cases, four patients developed acute non-lymphocytic leukaemia. Danazol was well tolerated and produced no acute or chronic toxicity. The drug appears useful in the management of anaemic and thrombocytopenic MDS patients.

Investigation of chronic lymphocytosis in adults

Thirteen cases of idiopathic chronic lymphocytosis are the subject of this report. Patients showed a lymphocyte count between 4 and 15 X 10(9)/L for at least six months, marrow lymphocytosis not exceeding 25%, absence of lymphomegaly and hepatosplenomegaly, and no associated infections, immune, or neoplastic disease. Morphologic examination of smears revealed a lymphocytosis of large granular lymphocytes in five. A selected battery of polyclonal and monoclonal antisera to antigens commonly found on B-, T-, and natural killer cells allowed the identification of six cases of early B-cell chronic lymphocytic leukemia, two cases of T-cell lymphocytosis with a suppressor or helper T-cell phenotype, and five cases of large granular lymphocyte/natural killer cell proliferative disease. The results demonstrate the usefulness of combining morphologic and phenotype studies for the investigation of chronic lymphocytosis, which often appears as an early leukemia or a benign clonal proliferative disorder of lymphocyte subsets.