Refining Surveillance Guidelines after SBRT for Early-Stage Lung Cancer

PURPOSE/OBJECTIVE(S)

Stereotactic Body Radiation Therapy (SBRT) is a popular treatment for patients with early-stage non-small cell lung cancer (NSCLC). After treatment, NCCN guidelines suggest 3-6-month imaging surveillance up to year 3, every 6 months in years 3-5, and yearly after 5 years. The Delphi Consensus Study recommends annual screening in years 2-5. While patients are more likely to locally recur up to two years after treatment there remains a paucity of data on the benefit of long-term surveillance. We therefore evaluated a cohort of NSCLC patients to evaluate the utility and frequency of both short- and long-term surveillance.

MATERIALS/METHODS

A total of 224 patients with early-stage NSCLC treated with SBRT between 2014-2019 at a single institution were retrospectively evaluated. Patients with nodal disease, treated with >8 fractions, or metastatic disease at time of SBRT were excluded. Any cross-sectional imaging of the chest for each patient after SBRT was reviewed for evidence of recurrence or new malignancy. Recurrence or new malignancy was defined radiographically and/or pathologically. The median scan interval (MSI) was calculated using the time between surveillance scans. The MSI between patients with or without new disease was compared by t-test. Frequency of recurrence between patients with  = T2 disease was compared using chi squared analysis.

RESULTS

A total of 224 patients were reviewed and 168 were included in the analysis. 919 scans were performed, 800 as scheduled surveillance scans and 119 for other indications. Median number of scans per patient was 5 (IQR 3-13), with a max of 15 scans. The MSI was 5 months (IQR 3-6) for up to 3 years after treatment, 8 months (IQR 6-12) between 3-5 years after treatment, and 12 months (IQR 11-13) ≥5 years after treatment. There was no significant difference in MSI between patients that did or did not develop new/recurrent disease. 47% of patients with  = T2 tumors (p = 0.10). All 3 patients with T3 disease recurred or had new malignancy identified on 2, 7, and, 36-month scans. 67 instances of new disease were found on 521 scans (13%) during years 1-3, 12 instances on 70 scans (17%) years 3-4, and 5 found on 11 scans (45%) after 5 years. Of 84 total instances of new disease, representing 50% evaluable patients, 75 were discovered on surveillance scans compared to 9 on non-surveillance scans.

CONCLUSION

The MSI for patients in this cohort aligns with published guidelines. Half of the patients developed new disease with the vast majority discovered on surveillance scans. Higher chance of new disease in larger tumors would suggest not all patients benefit from the same scan interval with some patients receiving up to 15 diagnostic scans during follow up. With patients continuing to recur >5 years after treatment, scan frequency, radiation exposure, and probability of recurrence should all be considered in comprehensive surveillance guidelines.

The Effect of Package Time on Locally Advanced Oral Cavity Cancer Outcomes

PURPOSE/OBJECTIVE(S)

Oral cavity cancer (OCC) with adverse pathologic features is treated with adjuvant radiation (RT) following definitive surgical resection. The 5-year overall survival (OS) in locally advanced OCC patients receiving adjuvant RT has remained stagnant at 60% for over 30 years. Although pathologic risk factors are well-established, the effect of clinical variables such as treatment package time (TPT) in the modern era of radiation and systemic agents is unclear. Examining a large, homogenous cohort of OCC patients, we hypothesized that TPT can predict OS and event free survival (EFS).

MATERIALS/METHODS

A retrospective review of 359 adult patients with OCC treated with surgery and adjuvant RT with or without concurrent chemotherapy from 2012-2022 was performed at a single, high-volume center. Those without definitive surgery, treated to <50 Gy, or with a history of prior RT were excluded. TPT was defined as time from surgery to completion of RT. Other variables considered were sex, race, smoking status, AJCC 8 pathologic stage, perineural invasion (PNI), lymphovascular invasion (LVI), margin positivity, extranodal extension (ENE), and hospitalization between surgery and RT. Log rank tests were performed for OS and EFS where TPT was dichotomized into short (<97.5 days) and long (>97.5 days) groups based on the median TPT of the cohort. Univariate (UVA) and multivariate (MVA) cox regression analyses were performed for OS and EFS.

RESULTS

A total of 234 patients met inclusion criteria. Median OS was 81.6 months. Median EFS was 50.0 months. Median OS was 51.1 months in the longer TPT group and was not reached in the shorter TPT group. Median EFS was greater with shorter TPT (72.6 vs 31.3 months). The longer TPT group had worse OS and EFS probabilities than the shorter TPT group (p = 0.006 and p = 0.059, respectively). On UVA, factors significantly associated with OS were TPT (p = 0.006), former/current smoker status (p = 0.003 and p = 0.011, respectively), pathologic stage IV (p<0.001), positive PNI (p<0.001) or LVI (p = 0.005), and ENE (p<0.001). On MVA for OS, shorter TPT (p = 0.026), former smoker status (p = 0.009), pathologic stage IV (p = 0.026), positive PNI (p = 0.009), and ENE (p = 0.05), remained significant. On UVA, factors significantly associated with EFS were former/current smoker status (p = 0.01/p = 0.04), pathologic stage IV (p<0.001), pT1/T2 (p = 0.018), positive PNI (p = 0.011) or ENE (p<0.001), and concurrent chemotherapy (p = 0.001). On MVA, former smoker status (p = 0.035) and positive PNI (p = 0.018) remained significant. Notably, of the 130 patients requiring hospitalization between surgery and radiation, 101 (78%) were prior/current smokers.

CONCLUSION

In this large cohort of locally advanced OCC patients, TPT <97.5 days is associated with improved OS and EFS. Smoking history should be further explored for its potential contribution to treatment delay. Multidisciplinary coordination should be encouraged to minimize TPT.

Novel computational biology modeling system can accurately forecast response to neoadjuvant therapy in early breast cancer

BACKGROUND

Generalizable population-based studies are unable to account for individual tumor heterogeneity that contributes to variability in a patient's response to physician-chosen therapy. Although molecular characterization of tumors has advanced precision medicine, in early-stage and locally advanced breast cancer patients, predicting a patient's response to neoadjuvant therapy (NAT) remains a gap in current clinical practice. Here, we perform a study in an independent cohort of early-stage and locally advanced breast cancer patients to forecast tumor response to NAT and assess the stability of a previously validated biophysical simulation platform.

METHODS

A single-blinded study was performed using a retrospective database from a single institution (9/2014-12/2020). Patients included: ≥ 18 years with breast cancer who completed NAT, with pre-treatment dynamic contrast enhanced magnetic resonance imaging. Demographics, chemotherapy, baseline (pre-treatment) MRI and pathologic data were input into the TumorScope Predict (TS) biophysical simulation platform to generate predictions. Primary outcomes included predictions of pathological complete response (pCR) versus residual disease (RD) and final volume for each tumor. For validation, post-NAT predicted pCR and tumor volumes were compared to actual pathological assessment and MRI-assessed volumes. Predicted pCR was pre-defined as residual tumor volume ≤ 0.01 cm³ (≥ 99.9% reduction).

RESULTS

The cohort consisted of eighty patients; 36 Caucasian and 40 African American. Most tumors were high-grade (54.4% grade 3) invasive ductal carcinomas (90.0%). Receptor subtypes included hormone receptor positive (HR+)/human epidermal growth factor receptor 2 positive (HER2+, 30%), HR+/HER2- (35%), HR-/HER2+ (12.5%) and triple negative breast cancer (TNBC, 22.5%). Simulated tumor volume was significantly correlated with post-treatment radiographic MRI calculated volumes (r = 0.53, p = 1.3 × 10^-7, mean absolute error of 6.57%). TS prediction of pCR compared favorably to pathological assessment (pCR: TS n = 28; Path n = 27; RD: TS n = 52; Path n = 53), for an overall accuracy of 91.2% (95% CI: 82.8% - 96.4%; Clopper-Pearson interval). Five-year risk of recurrence demonstrated similar prognostic performance between TS predictions (Hazard ratio (HR): - 1.99; 95% CI [- 3.96, - 0.02]; p = 0.043) and clinically assessed pCR (HR: - 1.76; 95% CI [- 3.75, 0.23]; p = 0.054).

CONCLUSION

We demonstrated TS ability to simulate and model tumor in vivo conditions in silico and forecast volume response to NAT across breast tumor subtypes.

Abstract 749: SimBioSys TumorScope accurately models and predicts response to neoadjuvant therapy in breast cancer - Validation study

Neoadjuvant Therapy (NAT) for breast cancer results in higher rates of breast conservation surgery. Importantly, there is data supporting the use of multiple NAT regimens, with little guidance as to which one would be most effective for a given patient. Thus, tools that can accurately predict patient outcome before cancer treatment can provide guidance during treatment planning and increase the chances of therapy success.

Here we present the first biophysical modelling platform, TumorScope (TS), capable of constructing a 3D model of the tumor microenvironment by integrating models for tumor morphology, metabolism, drug delivery and behavior, and vascularity. Thereby allowing visualization of response to multiple NATs for a given tumor. TS integrates patient data to create an in-silico tumor model capturing the tumor response trajectory, volume, dimensions, pathological complete response (pCR), residual cancer burden and tumor morphology, and risk of recurrence (ROR). To illustrate the clinical applicability and to validate TS we performed a single center validation study.

Previously acquired pre-treatment standard of care (SOC) diagnostic data (demographics, drug regimen, imaging (DCE MRI), and pathology) was used as TS inputs. Using this baseline data only, TS predicted weekly volumetric response through the treatment time and used simulated residual volume to predict pCR and assessed the ROR. The validation was performed using ground truth from post treatment assessment of pCR, radiographic volumes extracted from MRIs and ROR information.

A chart review was performed to identify consecutive patients who had received NAT and had a corresponding pre-treatment MRI at University of Cincinnati. A validation set was generated from this list and data processed through TS (n=81, after excluding 9 patients with poor quality DCE-MRIs).

TS predicted pCR was predefined as a residual tumor volume &lt; 0.01 cm3 or a 99.9% or greater reduction in tumor volume. Performance metrics of TS were calculated. TS response (pCR vs. residual) prediction accuracy had an area under the curve (AUC) =0.912 with sensitivity and specificity of 88.9% and 92.5%, respectively. The performance was robust across all subtypes. Using SOC diagnostic data TS predicted the reduction in tumor volume with a median absolute volumetric error of 3.4% vs radiographic volume from pre-surgery DCE MRIs (n=59). TS prognostic ROR (High vs Low) had a hazard ratio [HR] 12.705, p=0.01 which was comparable as a prognostic indicator to actual pCR which had a [HR] 5.81, p=0.08.

In summary, TS accurately predicts patient-specific response to NAT in early breast cancer using only baseline SOC pre-treatment data. This approach to a comprehensive view of the tumor represents a major step-forward in personalized clinical decision making. The results from this study will be used in a multi-center meta-analysis of TS performance characteristics.

Citation Format: Gregory H. Norris, John Pfeiffer, Yuhan Zhang, Hope R. Esslinger, The SimBioSys Team, Vinita Takiar. SimBioSys TumorScope accurately models and predicts response to neoadjuvant therapy in breast cancer - Validation study [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 749.

Genetics of pain perception, COMT and postoperative pain management in children

BACKGROUND

Effective perioperative analgesia is lacking for children owing to interindividual variations and underdosing of opioids caused by fear of adverse effects. We investigated the role of COMT SNPs on postoperative pain management in children.

METHODS

One hundred and forty nine children undergoing adenotonsillectomy were enrolled. The associations of four COMT SNPs (rs6269, rs4633, rs4818 and rs4680) with postoperative pain were analyzed and outcome measures included maximum pain scores, need for postoperative opioid interventions and postoperative morphine requirements.

RESULTS

We detected an association of postoperative opioid intervention need with all four COMT SNPs. Minor allele carriers of COMT SNPs were approximately three-times more likely to require analgesic interventions than homozygotes of major alleles (p-value range: 0.0031-0.0127; odds ratio range: 2.6-3.1). In addition, significant association was detected between maximum Face, Leg, Activity, Consolability, Cry (FLACC) pain scores and three COMT SNPs (rs6269, rs4633 and rs4680). Haplotype 1 (ATCA: 51.3%) and Haplotype 2 (GCGG: 36.2%) are more frequent. Haplotype 2 was associated with higher odds of intravenous analgesic intervention need in postanesthesia recovery unit with an odds ratio of 2.6 (95% CI: 1.2-5.4; p-value = 0.022).

CONCLUSION

COMT SNPs may play a significant role in interindividual variation in postoperative pain perception and postoperative morphine requirements in children. Original submitted 16 August 2013; Revision submitted 13 December 2013.

OCT1 genetic variants influence the pharmacokinetics of morphine in children

AIM

Large interindividual variability in morphine disposition could contribute to unpredictable variability in morphine analgesia and adverse events. Caucasian children have more adverse effects and slower morphine clearance than African-American children. To study variations in intravenous morphine pharmacokinetics in children, we examined the influence of genetic polymorphisms in OCT1.

METHODS

In 146 children undergoing adenotonsillectomy, 146 concentration-time profiles (2-4 measurements per patient) were available. Population pharmacokinetic analysis characterized the profiles in NONMEM(®) and tested OCT1 variants as covariates.

RESULTS

Allometrically scaled post hoc Bayesian morphine clearance in homozygotes of loss-of-function OCT1 variants (n = 9, OCT1*2-*5/*2-*5) was significantly lower (20%) than in wild-type (n = 85, OCT1*1/*1) and heterozygotes (n = 52, OCT1*1/*2-*5; p < 0.05).

CONCLUSION

Besides bodyweight, OCT1 genotypes play a significant role in intravenous morphine pharmacokinetics. Relatively high allelic frequencies of defective OCT1 variants among Caucasians may explain their lower morphine clearance and possibly higher frequencies of adverse events compared with African-American children. Original submitted 21 December 2012; Revision submitted 7 May 2013.

Codeine-related adverse drug reactions in children following tonsillectomy: a prospective study

OBJECTIVES/HYPOTHESIS

To prospectively determine factors associated with codeine's adverse drug reactions (ADRs) at home in a large homogenous population of children undergoing outpatient tonsillectomy.

STUDY DESIGN

Prospective, genotype blinded, observational study with a single group and repeated ADR measures documented by parents at home.

METHODS

A total of 249 children 6 to 15 years of age scheduled for tonsillectomy were enrolled. The primary outcome was number of daily codeine-related ADRs. We examined the number and type of ADR by race and by days and further modeled factors potentially associated with ADR risk in a subcohort of white children. Sedation following a dose of codeine was a secondary outcome measure. Parents recorded their children's daily ADRs and sedation scores during postoperative days (POD) 0 to 3 at home.

RESULTS

Diaries were returned for 134 children, who were given codeine. A total of 106 (79%) reported at least one ADR. The most common ADRs were nausea, lightheadedness/dizziness for white children and nausea, and vomiting for African American children. In a subcohort of white children ≤ 45 kg, increased ADR risk was associated with the presence of one or more full function CYP2D6 alleles (P < 0.001), POD (P < 0.001), and sex (P = 0.027). Increased pain intensity (P = 0.009) and PODs 0 and 1 (P = 0.001) contributed to a higher sedation risk. Neither obstructive apnea nor predicted CYP2D6 phenotype were associated with sedation risk.

CONCLUSIONS

Our results provide evidence that multiple factors are associated with codeine-related ADRs and support the FDA recommendation to avoid codeine's routine use following tonsillectomy in children.

Propofol clearance in morbidly obese children and adolescents: influence of age and body size

BACKGROUND AND OBJECTIVE

Given the alarming increase in obesity among children undergoing surgery, the main aim of this study was to characterize propofol clearance in a cohort of morbidly obese children and adolescents in relation to their age and body weight characteristics.

METHODS

A prospective pharmacokinetic study in morbidly obese children and adolescents undergoing elective surgery was conducted. Serial blood samples were collected and nonlinear mixed-effects modelling using NONMEM(®) was performed to characterize propofol pharmacokinetics with subsequent evaluation of age and body size descriptors.

RESULTS

Twenty obese and morbidly obese children and adolescents with a mean age of 16 years (range 9-18 years), a mean total body weight (TBW) of 125 kg (range 70-184 kg) and a mean body mass index of 46 kg/m(2) (range 31-63 kg/m(2)) were available for pharmacokinetic modelling using a two-compartment pharmacokinetic model (n = 294 propofol concentration measurements). Compared with lean body weight and ideal body weight, TBW proved to be the most predictive covariate for clearance [CL (L/min) = 1.70 × (TBW/70)(0.8)]. Central volume of distribution, peripheral volume and intercompartmental clearance were 45.2 L, 128 L and 1.75 L/min, respectively, with no predictive covariates identifiable.

CONCLUSION

In the population pharmacokinetic model for propofol in morbidly obese children and adolescents, TBW proved to be the most significant determinant for clearance. As a result, it is anticipated that dosage of propofol for maintenance of anaesthesia in morbidly obese children and adolescents should be based on TBW using an allometric function.

Morphine clearance in children: does race or genetics matter?

OBJECTIVE

Interindividual variability in analgesic response and adverse effects of opioids because of narrow therapeutic indices are major clinical problems. Morphine is an opioid commonly used in children to manage perioperative pain. Al-though size and age often are considered primary covariates for morphine pharmacokinetic models, the impact of other factors important in personalizing care such as race and genetic variations on morphine disposition is not well documented.

DESIGN

Genotype blinded clinical observational pharmacokinetic study. One hundred forty-six African American and Caucasian children scheduled for elective outpatient adenotonsillectomy were enrolled in our prospective genotype blinded observational study with standard perioperative clinical care.

SETTING

Tertiary care pediatric institution.

INTERVENTIONS

Morphine bolus for intraoperative analgesia in children and pharmacokinetic analyses in different races.

MAIN OUTCOME MEASURES

Pharmacokinetics and pharmacogenetics of intravenous morphine in a homogeneous pediatric outpatient surgical pain population were evaluated.

RESULTS

The authors observed that African American children have higher morphine clearance than Caucasian children. The increased clearance is directed toward the formation of morphine-3-glucuronide formation, rather than the formation of morphine-6-glucuronide. Common uridine diphosphate glucuronosyl transferase (UGT) 2B7 genetic variations (2161C>T and 802C>T) were not associated with observed racial differences in morphine's clearance although the wild type of the UGT2B7 isozyme is more prevalent in the African Americans.

CONCLUSIONS

Race of the child is an important factor in perioperative intravenous morphine's clearance and its potential role in personalizing analgesia with morphine needs further investigation.

Race and unequal burden of perioperative pain and opioid related adverse effects in children

BACKGROUND

Interindividual variability in pain perception and analgesic response is a major problem in perioperative practice. Adult studies suggest pain management is influenced by patient's race. The objective of this study is to evaluate the influence of race on perioperative pain treatment in children.

METHODS

Prospective observational study evaluating effect of race on analgesia and opioid related adverse effects after tonsillectomy in African American and Caucasian children. A sample of 194 healthy children between 6 and 15 years of age were included. Race was self-identified by parents. All participants received standard perioperative care with a standard anesthetic and an intraoperative dose of morphine. Analgesia outcomes included maximum postoperative pain scores, postoperative opioid requirement, and analgesic interventions. Safety outcomes included incidences of opioid related adverse effects.

RESULTS

African American children experienced significantly more postoperative pain than Caucasian children as measured by postoperative opioid requirement (P = .0011), maximum postoperative pain scores (P < .0001), and analgesic interventions (P < .0001) in the recovery room. Although Caucasian children received relatively less opioids perioperatively, they had significantly higher opioid related adverse effects (P = .039). African American children with obstructive sleep apnea were more likely to have prolonged post anesthesia recovery unit stay due to inadequate pain control.

CONCLUSIONS

After similar uses of intraoperative morphine for tonsillectomy, there was an unequal burden of increased pain in African American children and increased opioid adverse effects in Caucasian children in the recovery room. Though Caucasian children received relatively less opioids perioperatively, they had higher incidences of opioid related adverse effects than African American children.