Cystic Brain Metastasis Outcomes After Gamma Knife Radiation Therapy

Purpose

The response of cystic brain metastases (BMets) to radiation therapy is poorly understood, with conflicting results regarding local control, overall survival, and treatment-related toxicity. This study aims to examine the role of Gamma Knife (GK) in managing cystic BMets.

Methods and Materials

Volumetric analysis was conducted to measure tumor and edema volume at the time of GK and follow-up magnetic resonance imaging studies. Survival was described using the Kaplan-Meier method, and the cumulative incidence of progression was described using the Aalen-Johansen estimator. We evaluated the association of 4 variables with survival using Cox regression analysis.

Results

Between 2016 and 2021, 54 patients with 83 cystic BMets were treated with GK at our institution. Lung cancer was the most common pathology (51.9%), followed by breast cancer (13.0%). The mean target volume was 2.7 cm3 (range, 0.1-39.0 cm3), and the mean edema volume was 13.9 cm3 (range, 0-165.5 cm3). The median prescription dose of single-fraction and fractionated GK was 20 Gy (range, 14-27.5 Gy). With a median follow-up of 8.9 months, the median survival time (MST) was 11.1 months, and the 1-year local control rate was 75.9%. Gamma Knife was associated with decreased tumor and edema volumes over time, although 68.5% of patients required steroids after GK. Patients whose tumors grew beyond baseline after GK received significantly more whole-brain radiation therapy (WBRT) before GK than those whose tumors declined after GK. Higher age at diagnosis of BMets and pre-GK systemic therapy were associated with worse survival, with an MST of 7.8 months in patients who received it compared with 23.3 months in those who did not.

Conclusions

Pre-GK WBRT may select for BMets with increased radioresistance. This study highlights the ability of GK to control cystic BMets with the cost of high posttreatment steroid use.

Social Media as a Tool to Directly Address Misinformation in Health Care and Promote Patient Education

PURPOSE/OBJECTIVE(S)

Social media plays an important role in the lives of many, including cancer patients. A majority of cancer patients rated the internet as their most important source of information, and many joined social media as a result of their diagnosis. Most online platforms health care information has not been vetted by healthcare professionals. Although readily available and easy to access, the questionable accuracy of this information poses risks for patients. We aim to assess the feasibility of an online platform led by health care professionals to engage cancer patients on social media to directly address misinformation through targeted patient education. We hypothesized that social media-based cancer information will be a well utilized tool that cancer patients could engage with for information and support regarding their diagnosis.

MATERIALS/METHODS

A social media-based campaign called Cancer Real Talk was initiated on Instagram and TikTok, and a corresponding website for the campaign was launched. Topics were identified based on anecdotal experience with patient misconceptions of care and included the role of palliative care, relationship between cancer and sugar, clinical trials, patient radioactivity, cancer screenings, risks associated with excess vitamin intake, and surgery for lung cancer. Video reels were reviewed by two physicians and published with corresponding text on the two social media platforms with the goal of providing factual and relatable information. Metrics including views and "likes" were gathered based on available data on each platform at 1 day, 1 week, 1 month, and long-term (>3 months) data points.

RESULTS

Between July 2022 and January 2023, a total of seven posts were disseminated through both platforms. Views and likes TikTok and Instagram, respectively, are located in Table 1 with Instagram data bolded. At the last check, the Instagram and TikTok accounts had 272 and 231 followers, respectively.

CONCLUSION

Our posts confirmed engagement with social media users and this educational initiative. Variable engagement highlights the need for increased understanding of how and where to engage with patients on social media. Health care outreach and education has the potential to help patients address misinformation and better navigate their cancer care, which is often quite daunting and complex. Future directions include patient collaboration.

Understanding Burnout Among US Radiation Oncology Residents

PURPOSE/OBJECTIVE(S)

Burnout is a significant concern among medical residents in the United States, including those in radiation oncology. This study aims to understand the extent of burnout among radiation oncology residents and identify modifiable factors within program structure and benefits that may help improve overall wellness and reduce burnout.

MATERIALS/METHODS

A Qualtrics-based survey was administered to US radiation oncology program directors and coordinators, utilizing contact information gathered in FREIDA, with a request to forward to all residents. The survey included questions on benefits and program structure as well as the Maslach Burnout Inventory. Data was analyzed using descriptive statistics.

RESULTS

To date, 82 of 736 residents (11.1%) completed the survey with representation from all PGY-levels. Median participant age was 31, and 53% identified as male. 20% of surveyed residents feel emotionally drained from work a few times a week and 6% feel emotionally drained daily. 59% feel burned out from work at least a few times a month, with 6% feeling burned out daily. Despite this, 85% feel they are positively influencing other people's lives through their work at least weekly and 77% feel they have accomplished many worthwhile things in this job at least weekly. 65% have salaries between $60,000-$74,999, and 35% have the opportunity to moonlight for supplemental income. 49% have 3 weeks of vacation and 48% have 4 weeks. 27% reported their department had funded wellness events. 61% reported dual coverage rotations, with 40% requiring coverage of multiple attendings in one day. 65% reported protected academic time on all rotations, and 7% have no protected academic time. 48% of respondents have 12 months of research time. 85% and 36% of those with research and protected academic time, respectively, can complete this off-site. Respondent concerns include the job market (62%), declining personal fertility in residency (46%), and cost of living (40%). The most reported ways to decrease stress and anxiety were exercise (35%), a strong support system (34%), and spirituality (10%). Increased salary was identified as the top benefit that could improve wellness by 41 residents, while retirement matching (32), paid gym memberships (23), a personal wellness stipend (30), and free/subsidized childcare (16) were also ranked among the top 5 benefit changes that could improve wellness. Increased mid-level support (16), more protected academic time during the week (15), and flexibility with work location during academic/research time (13) were the top aspects of program structure that were reported as opportunities to improve wellness.

CONCLUSION

Burnout is prevalent among US radiation oncology residents, and changes to residency programs and expanded institutional benefits are strongly perceived as the key components to improved resident wellness. This study highlights the need for further investigation into the root causes of burnout and the development of evidence-based strategies.

Consensus Quality Measures and Dose Constraints for Head and Neck Cancer with an emphasis on Oropharyngeal and Laryngeal Cancer from the Veterans Affairs Radiation Oncology Quality Surveillance Program and American Society for Radiation Oncology Expert Panel

PURPOSE

Safeguarding high-quality care using evidence-based radiation therapy for patients with head and neck cancer is crucial to improving oncologic outcomes, including survival and quality of life.

METHODS AND MATERIALS

The Veterans Administration (VA) National Radiation Oncology Program established the VA Radiation Oncology Quality Surveillance Program (VAROQS) to develop clinical quality measures (QM) in head and neck cancer. As part of the development of QM, the VA commissioned, along with the American Society for Radiation Oncology, a blue-ribbon panel comprising experts in head and neck cancer, to develop QM.

RESULTS

We describe the methods used to develop QM and the final consensus QM, as well as aspirational and surveillance QM, which capture all aspects of the continuum of patient care from initial patient work-up, radiation treatment planning and delivery, and follow-up care, as well as dose volume constraints.

CONCLUSION

These QM are intended for use as part of ongoing quality surveillance for veterans receiving radiation therapy throughout the VA as well as outside the VA. They may also be used by the non-VA community as a basic measure of quality care for head and neck cancer patients receiving radiation.

Definitive chemoradiotherapy +/- induction chemotherapy in esophageal cancer: A real-world experience

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Background: The SEER 5-year overall survival rate for all stages of esophageal cancer (EC) was 25% in 2019. Definitive chemoradiation (CRT) remains the primary treatment approach for locally advanced EC in the US, however, there are data to support use of induction chemotherapy (CT) in addition to CRT, particularly in adenocarcinoma (AC) histology. The purpose of our study was to assess outcomes in EC patients treated with definitive CRT (+/- induction) to determine which prognostic factors predicted for better survival in a recent, real-world cohort of patients, including those with limited stage IV disease. Methods: This retrospective study included Stages II-IVB (AJCC 8th ed.) EC patients treated with definitive CRT (radiation dose of ≥40 Gy and at least two cycles of concurrent CT [+/- induction CT, +/- esophagectomy]) at our institution between 2008 and 2020. To analyze prognostic factors and estimate OS, univariate models (UVA) and a multivariate (MVA) Cox proportional hazards regression model including age, Stage (II, III, IVA, IVB), AC vs. SCC, esophagectomy, ECOG performance status (PS), and induction CT were performed. Results: Of the 183 patients treated with definitive CRT, 18 were stage II, 119 stage III, 21 stage IVA, and 25 stage IVB. There were 45 SCC and 138 AC patients (Table). Prognostic factors associated with prolonged OS on MVA included lower PS (p<0.01) and esophagectomy (p = 0.05). Stage IVA was associated with shorter survival (p<0.01). Induction CT (delivered in 53% of AC, 31% SCC) was associated with improved survival on UVA (p=0.04), but not MVA (p = 0.08). By histology, 5-year survival rate was 42.7% and 18.2% for AC and SCC, respectively. Conclusions: At our institution, those who received an esophagectomy and those with lower ECOG scores had better survival. The 5-year survival rate was higher for AC patients compared to SCC, with more AC patients receiving esophagectomy and induction CT (significant on UVA, but not MVA). The 5-year survival rate for AC in our study was nearly identical to that seen in the CROSS trial (Shapiro et al. 2015) AC cohort but included >25% stage IV patients. This modern cohort also included poor PS (ECOG≥2) patients (9.2% AC and 13.6% SCC), suggesting induction CT, in addition to pre-operative CRT + surgery, may have added benefit in a real-world practice. Thus, further prospective study is needed.[Table: see text]

Comprehensive genomic profiling (CGP) of fibrolamellar oncocytic hepatoma (FLO) and conventional hepatocellular carcinomas (HCC): An observational study

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Background: FLO is a rare variant of liver cancer that disproportionately affects young adults and is frequently progressive and fatal as it is often detected in a clinically advanced stage. It is seldom associated with cirrhosis of liver, viral hepatitis or other risk factors associated with conventional HCC. Treatment options are largely limited to surgical resection, and there is dearth of effective targeted therapies for FLO. Methods: Comprehensive genomic profiling (CGP) was performed using the Foundation Medicine Inc. (FMI) data base on 63 FLO and 1,793 HCC clinically advanced cases between 6/2013-12/2020 using a hybrid capture-based assay of up to 324 genes a to detect genomic alterations (GA), tumor mutational burden (TMB) and microsatellite instability (MSI). PD-L1 expression in tumor cells (Dako 22C3) was measured by IHC and scored using the tumor proportion score (TPS) method. Results: The FLO patients (pts) were significantly younger than HCC pts (median age 20 vs. 64, respectively) and the male preponderance was similar. The HCC group featured significantly more GA/tumor than FLO group (3.74 vs 1.31 p<.0001). In the currently untargetable GA group, CTNNB1, TERT and TP53 GA were significantly more frequent in HCC than FLO. GA in potentially targetable genes were extremely uncommon in both FLO and HCC with HCC featuring slightly more MTOR pathway targets ( PTEN, TSC2, NF1). GA in DNA damage and repair (DDR) pathway including BRCA2 were infrequent in both groups. GA in targetable kinases including EGFR, ERBB2, ALK, RET and PIK3CA were extremely uncommon in both groups. GA associated with intrahepatic cholangiocarcinoma (IDH1, FGFR2) were extremely uncommon in these tumors. Although the mean TMB was significantly higher in HCC than FLO, overall TMB was low with very few cases having TMB > 10 mutations/Mb. PD-L1 expression was relatively low in both groups. GA in genes associated with immune checkpoint inhibitors (ICPI) drug response like PBRM1, CD274, MDM2, STK11 were rarely identified in both groups. Additional details are illustrated in the table. Conclusions: Comparison of CGP of FLO with HCC illustrates the multifarious nature of these cancers. In HCC, there is a high prevalence of GA in TERT, CTNNB1 and TP53. CGP identified certain targetable GA in the MTOR and DDR pathways and TMB was higher in HCC. These findings warrant further evaluation of clinically advanced FLO and HCC pts by CGP to identify possible targetable genomic pathways. [Table: see text]

Definitive chemoradiation for oligometastatic esophageal cancer patients

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Background: When esophageal cancer (EC) is metastatic at diagnosis, prognosis is poor, with 5-year survival of ̃5%. NCCN guidelines recommend palliative treatment or best supportive care. However, guidelines do not stratify by the extent of metastatic disease. Oligometastatic (oligo) disease has been shown in some cancers to portend better survival and more aggressive treatment options may be appropriate. Preliminary data has shown this may be the case for oligo EC, however, consensus recommendations remain palliative in intent. This study aims to compare overall survival (OS) in oligo EC patients treated with a definitive approach (chemoradiotherapy [CRT]) to those treated with purely palliative intent. Methods: Patients with oligo (any histology, ≤5 metastatic foci) EC treated in a single academic hospital between 2009-2020 were retrospectively analyzed in 2021. Patients were divided into definitive and palliative treatment groups; definitive CRT was defined as radiation therapy >40 Gy and >2 cycles of chemotherapy (CT) (+/- induction CT). OS was calculated by measuring the time from the date of diagnosis to the date of death or last follow-up. Survival curves between groups and by various prognostic factors were compared using the log rank test. Results: Of 77 Stage IVB patients, 35 met the pre-specified oligo definition. Of these, 18 received definitive CRT, and 17 palliative treatment (Table). With a median follow-up of 60.8 months, median OS for definitive CRT and palliative groups were 91.4 and 8.2 months, (p<0.01), translating into 5-year OS of 57.7% (95%CI: 33.5-82.0%) vs. 7.5% (95%CI: 0.0-21.6%), respectively. Prognostic factors correlated with increased OS included lower ECOG performance status (PS) (p<0.01), induction CT (p<0.01), N stage (p<0.01), adenocarcinoma (vs. squamous cell carcinoma) (p<0.05), diagnosis in 2013 or later (p<0.05), younger age (p<0.05), and > lymphocyte-to-monocyte ratio (p<0.05). Factors not associated with OS included neutrophil-to-lymphocyte ratio (p=0.39), T-stage (p=0.9), primary site (GEJ, distal, mid, or cervical) (p=0.07), tumor grade (p=0.83), type of spread (hematogenous, lymphatic, or local invasion) (p=0.69), sex (p=0.22), and HER2 status (p=0.07). Conclusions: Within our population, oligo EC patients treated with definitive CRT had significantly improved OS as compared to those treated with palliative only intent. These results suggest there may be a sub-population of oligo EC that would benefit from more aggressive treatment paradigms; thus, further evaluation is warranted.[Table: see text]

Clinical Implementation and Initial Experience of Real-Time Motion Tracking With Jaws and Multileaf Collimator During Helical Tomotherapy Delivery

PURPOSE

This work reports the clinical implementation of a real-time motion tracking and correction system using dynamic multileaf collimator and jaws during helical tomotherapy delivery (Synchrony on Radixact; Accuray, Inc).

METHODS AND MATERIALS

The first clinical Synchrony on Radixact system was recently installed and tested at our institution. Various clinical workflows, including fiducial implantation, computed tomography simulation, treatment planning, delivery quality assurance, treatment simulation, and delivery, for both fiducial-free and fiducial-based motion tracking methods were developed. Treatment planning and delivery data from initial patients, including dosimetric benefits, real-time target detection, model building, motion tracking accuracy, delivery smoothness, and extra dose from real-time radiographic imaging, were analyzed.

RESULTS

The Synchrony on Radixact system was tested to be within its performance specifications and has been used to treat 10 lung (fiducial-free) and 5 prostate (fiducial-based) patients with cancer so far in our clinic. The success of these treatments, especially for fiducial-free tracking, depends on multiple factors, including careful selection of the patient, appropriate setting of system parameters, appropriate positioning of the patient and skin markers, and use of treatment simulation. For the lung tumor cases, difficulties in model building, due primarily to the changes of target detectability or respiration patterns, were observed, which led to important system upgrades, including the addition of a treatment delivery simulation capability. Motion tracking metrics for all treated patients were within specifications, for example, (1) delivery quality assurance passing rates >95%; (2) extra dose from radiograph <0.5% of the prescription dose; and (3) average Potential Diff, measured Δ, and Rigid Body were within 6.5, 2.9, and 3.9 mm, respectively.

CONCLUSIONS

Practical workflows for the use of the first clinical motion tracking and correction system in helical tomotherapy delivery have been developed, and the system has now been successfully implemented in our clinic for treating patients with lung and prostate cancer.

Association of total neoadjuvant therapy with favorable clinical outcomes in patients with locally advanced esophageal and gastroesophageal junction adenocarcinomas (LA-GEJ CA)

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Background: Both peri-operative chemotherapy and neoadjuvant chemoradiation have been shown to improve outcomes in patients (pts) with LA-GEJ CA compared to surgery alone. Rates of post-operative chemotherapy delivery remain suboptimal. Total neo-adjuvant therapy (TNT) in LA-GEJ CA - induction chemotherapy (IC) followed by concurrent chemoradiation (CRT) - may improve systematic delivery of neoadjuvant therapy and result in favorable clinical outcomes. Methods: We retrospectively reviewed medical records of 135 pts with LA-GEJ CA at our institution between 2/2007 and 11/2019; pertinent clinical data were abstracted with Institutional Review Board approval. Patients treated with IC and curative-intent CRT with ≥40 Gy dose of radiation for adenocarcinoma were included in this analysis (N = 59). Doublet or triplet IC regimens utilizing 5-Flurouracil(5-FU), Cisplatin/Oxaliplatin and Docetaxel were commonly administered while combinations of Carboplatin +Paclitaxel or 5-FU + Oxaliplatin were used in CRT. Clinical complete response (CCR) was defined as metabolic imaging and endoscopic biopsies negative for residual malignancy after completion of TNT. Patients were followed from diagnosis to recurrence and overall survival. Survival probabilities were estimated using the Kaplan-Meier method and compared between groups using a log-rank test. Results: Out of 59 evaluable pts, 69% were clinical stage T3, 71% were node positive. 37 pts (63%) underwent surgery, R0 resection rate was 89% (33/37), pathologic complete response (pCR) rate was 19% (7/37). Among the pts who did not undergo surgery, 41% (9/22) opted to forego surgery since they attained a CCR. For the entire cohort, median Disease-Free Survival (mDFS), median Overall Survival (mOS), and 3-yr OS were 2.4 yrs, 4.7 yrs, and 67% respectively. Pts who did not undergo surgery had a mDFS, mOS, and 3-yr OS of 1.5 yrs, 4.2 yrs, and 59% respectively. Median DFS, mOS, and 3-yr OS of patients who underwent surgery were 3.5 yrs, 5.8 yrs and 72% respectively. Patients who achieved a CCR and opted to forego surgery (N = 9) had a 3 -yr DFS of 42% vs 83% for pts (N = 7) who demonstrated a pCR after curative intent tri-modality therapy. (P = 0.0099) Interestingly, the same group that achieved CCR and opted out of surgery had 3yr OS of 89% vs 83% of those who demonstrated a pCR (p = 0.0042). Conclusions: TNT for pts with LA-GEJ CA is associated with high rates of R0 resection as well as excellent DFS and OS compared to historical controls, warranting prospective evaluation. The remarkable DFS and OS in patients who opted to forego surgery due to achieving CCR is reflective of the local and systemic control rendered by this approach. Careful characterization and close longitudinal follow-up of patients who achieve CCR may help identify a subgroup of LA-GEJ CA pts who may benefit from surgery sparing approaches.

Lactation challenges of resident physicians- results of a national survey

Background

There are unique challenges to parenting in residency and there is limited data to guide policy regarding lactation facilities and support for female physicians-in-training. We aimed to assess issues surrounding breast-feeding during graduate medical training for current residents or recent graduates from United States (US) residency programs.

Methods

A national cross-sectional survey was sent to current and recently graduated (2017 and later) female residents in June 2020. This questionnaire was administered using the Qualtrics Survey tool and was open to each participating woman’s organization for 4 weeks. Summary statistics were used to describe characteristics of all respondents and free-text responses were reviewed to identify common themes regarding avenues for improvement.

Results

Three hundred twelve women responded to the survey, representing a 15.6% response rate. The median duration of providing breastmilk was 9 months (IQR 6–12). 21% of residents reported access to usable lactation rooms within their training hospital, in which 12% reported a computer was present. 60% of lactating residents reported not having a place to store breast milk. 73% reported residency limited their ability to lactate, and 37% stopped prior to their desired goal. 40% reported their faculty and/or co-residents made them feel guilty for their decision to breastfeed, and 56% reported their difficulties with breastfeeding during residency impacted their mental health.

Conclusion

Residents who become mothers during training face significant obstacles to meeting their breastfeeding/pumping needs and goals. With these barriers defined, informed policy change can be instituted to improve the lactation experience for physicians-in-training.

QOLP-01. OUTCOME ASSESSMENT OF MULTIDISCIPLINARY BRAIN TUMOR BOARD MEETING RECOMMENDATIONS FOR BRAIN METASTASIS: IS THERE A GAP?

BACKGROUND

Brain metastasis (BM) is the most common form of brain cancer affecting 20-40% of cancer patients. Advancements in cancer therapy has prolonged survival but BM incidence has increased. BM management requires a multidisciplinary approach to individualize care via an ever-growing sum of surgical, radiation, and systemic therapy options. Consensus is achieved by multidisciplinary tumor board meeting (MTBm). Nevertheless, BM diagnosis predicts poor prognosis. Palliative Care (PC) is essential for proper BM management. Yet, formal PC assessment may not be available for MTBm. We evaluated whether MTBm consensus recommendations were followed.

RESULTS

Our weekly MTBm discussed 157 BM cases during 2019 (median age: 64 years [range 28-91], male/female: 82/75). The most common primary diagnosis was lung (n=49, 31%), breast (n=24, 15%), melanoma (n=16, 10%). The majority was newly diagnosed BM (n=143, 91%). MTBm recommendations were divided into three not-mutually-exclusive categories: surveillance/workup (n=78, 50%), BM-directed treatment (n=101, 64%) and GOC discussion (n=7, 4%). MTBm recommendations were fully followed in 113 cases (72%), partially in 13(8%), and not followed in 25(16%). Of the 38 patients whose recommendations were partially/not followed, the main reason was transition to hospice/death (n=26, 68%). Of the 101 patients recommended treatment, 68% (n=68) fully followed it, yet 31% (n=21) of them died within 3 months; for those living longer than 3 months (n=47, 69%), median KPS at 3 months was 70 (range 30-90). Of the entire cohort (n=157), only 20 (13%) established consistent PC follow-up (&gt;1 outpatient visit) and 69 cases (44%) transitioned to hospice/died within 6 months, 30 of which (43%) still completed surgery (n=6) or radiotherapy (n=24) within this period.

CONCLUSION

Periodic assessment of MTBm recommendations is relevant for sensible BM management. Balancing treatment while focusing on QoL in a patient population with limited survival is challenging. PC assessment at MTBm could close this gap.

A Pilot Study of Cardiac MRI in Breast Cancer Survivors After Cardiotoxic Chemotherapy and Three-Dimensional Conformal Radiotherapy

PURPOSE/OBJECTIVES

Node-positive breast cancer patients often receive chemotherapy and regional nodal irradiation. The cardiotoxic effects of these treatments, however, may offset some of the survival benefit. Cardiac magnetic resonance (CMR) is an emerging modality to assess cardiac injury. This is a pilot trial assessing cardiac damage using CMR in patients who received anthracycline-based chemotherapy and three-dimensional conformal radiotherapy (3DCRT) regional nodal irradiation using heart constraints.

MATERIALS AND METHODS

Node-positive breast cancer patients (2000-2008) treated with anthracycline-based chemotherapy and 3DCRT regional nodal irradiation (including the internal mammary chain nodes) with heart ventricular constraints (V25 < 10%) were invited to participate. Cardiac tissues were contoured and analyzed separately for whole heart (pericardium) and for combined ventricles and left atrium (myocardium). CMR obtained ventricular function/dimensions, late gadolinium enhancement (LGE), global longitudinal strain (GLS), and extracellular volume fraction (ECV) as measures of cardiac injury and/or early fibrosis. CMR parameters were correlated with dose-volume constraints using Spearman correlations.

RESULTS

Fifteen left-sided and five right-sided patients underwent CMR. Median diagnosis age was 50 (32-77). No patients had baseline cardiac disease before regional nodal irradiation. Median time after 3DCRT was 8.3 years (5.2-14.4). Median left-sided mean heart dose (MHD) was 4.8 Gy (1.1-11.2) and V25 was 5.7% (0-12%). Median left ventricular ejection fraction (LVEF) was 63%. No abnormal LGE was observed. No correlations were seen between whole heart doses and LVEF, LV mass, GLS, or LV dimensions. Increasing ECV did not correlate with increased heart or ventricular doses. However, correlations between higher LV mass and ventricular mean dose, V10, and V25 were seen.

CONCLUSION

At a median follow-up of 8.3 years, this cohort of node-positive breast cancer patients who received anthracycline-based chemotherapy and regional nodal irradiation had no clinically abnormal CMR findings. However, correlations between ventricular mean dose, V10, and V25 and LV mass were seen. Larger corroborating studies that include advanced techniques for measuring regional heart mechanics are warranted.

38. INNOVATIVE USE OF A CUSTOM MOBILE APPLICATION (APP) BY A BRAIN METASTASES PROGRAM FACILITATES MULTIDISCIPLINARY MANAGEMENT OF PATIENTS AND DECREASED LENGTH OF HOSPITAL STAY (LOS)

INTRODUCTION

Patients with Brain Metastases (BM) are complex, mandating multidisciplinary care. Our BM patients are discussed at in-person, weekly Brain Tumor Boards (BTB). However, BM patients diagnosed outside weekly BTBs wait several days for the next BTB, causing delays in generating multidisciplinary plans-of-care, prolonging LOS. We created a custom mobile app for our Brain Metastases Program to have a ‘Brain Metastases Virtual Tumor Board’ (BMVTB) discussion, in real-time, resulting in faster plans-of-care, decreasing LOS.

METHODS

The current pathway for navigating multidisciplinary discussions for patients with BM was examined by members of our Brain Metastases Program. We identified the need for all disciplines to participate in a BMVTB, outside of our in-person, weekly BTB. We developed a secure app that can be downloaded on any provider’s mobile device. The app includes a digital BM treatment algorithm for providers to understand comprehensive, data-driven, BM management. The app also gives our multidisciplinary Brain Metastases Program access to a BMVTB messenging tool to securely communicate and generate real-time consensus plans-of-care. Using a Vizient Clinical Database, we retrospectively calculated LOS index (observed LOS/expected LOS) for 184 BM patients over 21 months, creating a baseline. After launching our app and BMVTB workflow we prospectively evaluated LOS index in 45 BM patients over 6 months.

RESULTS

Over 21-months, 184 patients demonstrated baseline LOS index of 1.073. After launching our mobile app and BMVTB workflow, 45 patient admissions over 6-months demonstrated LOS index of 0.850. Using Levene’s test for equal variances, LOS variance with the app and BMVTB was lower than LOS variance at baseline (p = 0.049). This demonstrates a 38% reduction in LOS when the app and BMVTB generated real-time plans-of-care.

CONCLUSION

We demonstrated utility of a custom BM app coupled with a BMVTB to generate real-time plans-of-care for BM patients, reducing LOS.

P6388Effects of Interleukin-1 blockade with anakinra in patients with ST-segment elevation acute myocardial infarction on recurrent ischemic events: results from the VCUART3 study

Background

ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of recurrent ischemic events. Prior studies of IL-1 blockade have shown conflicting results regarding the risk of future events.

Methods

We enrolled patients with STEMI within 12 hours of presentation at 3 sites in the United States of America. After revascularization, patients were randomly assigned to receive anakinra 100 mg twice daily, anakinra 100 mg once daily (standard dose) alternated with placebo once daily every 12 hours, or placebo every 12 hours for 14 days in 1:1:1 ratio. Prespecified exploratory endpoints for recurrent ischemic events, adjudicated by an independent committee, evaluated the composite risk of subsequent acute myocardial infarction (AMI, World Health Organization classification Type 1), unstable angina, or urgent revascularization. Data are expressed as median and interquartile range or number and percentage. Cox regression analysis was used to generate unadjusted hazard ratios and confidence intervals. (ClinicalTrials.gov number, NCT01950299)

Results

Of 311 patients screened, 99 subjects (81% males, 58% Caucasians, 55 [49–62] years of age) were randomly assigned to anakinra twice daily (N=31), anakinra once daily (N=33) or placebo (N=35). The cohort included patients with hypertension (57%), tobacco use (55%), diabetes mellitus (30%), and prior diagnosis of coronary artery disease (21%) without statistically significant imbalances in the demographic characteristics between groups (all P>0.05). Discharge medications for the index STEMI admission, in addition to the study medication, included aspirin (100%), statins (100%), P2Y12 inhibitors (100%), beta-blockers (90%), and angiotensin converting enzyme inhibitor/angiotensin receptor blocker (84%), without statistically significant imbalances between the 3 groups. Over the 1-year follow-up, recurrent ischemic events occurred in 5/35 (14.3%) patients treated with placebo and 6/64 (9.1%) patients treated with anakinra (hazard ratio = 0.68 [0.20–2.24], P=0.53). No differences were observed between high- and low-dose anakinra treatment groups.

Conclusions

A two week treatment with IL-1 receptor antagonist, anakinra, did not significantly decrease or increase recurrent ischemic events over the course of a 1-year follow-up in patients with STEMI.

Acknowledgement/Funding

Funded by NHLBI 1R34HL121402; Drug supply by Swedish Orphan Biovitrum

The CAROLE (CArdiac Related Oncologic Late Effects) Study: A Phase II, single-arm feasibility trial

11569

Background: Long-term breast cancer survivors are at risk of late effects from cardiotoxic (tox) radiation (RT) and chemotherapy (chemo). However, there is a paucity of data to recommend appropriate cardiac screening for those ~10 years (yrs) after diagnosis (dx). This phase II, single arm study assessed multimodality screening in a heterogeneous cohort of long-term survivors. Methods: Our prospective, single center pilot study enrolled 201 (of 200 planned) eligible patients (pts): age 18-65 at dx, with treatment (tx) for breast cancer (any stage/tx) in 2004-2011 (≥6 yrs prior), with no cardiac disease (dz) at dx. The primary endpoint was presence of any cardiac dz (preclinical or clinical) on electrocardiogram (EKG), echocardiogram (echo), or coronary artery calcium CT (CAC CT); secondary endpoint included clinical (clin) dz alone. Subgroups assessed were: no tox chemo or RT (no tox), tox RT (left-sided) alone, tox chemo (anthracycline) alone, and both tox chemo and tox RT (tox chemoRT). Results: After enrollment (6/2017-7/2018), 200 pts had sufficient data for analysis. Median age was 50 (29-65) at dx, 63 (37-77) at imaging, and interval (dx to imaging) was 11.5 (6.7-14.5) yrs. There were 44% no tox, 31.5% tox RT, 16% tox chemo, and 8.5% tox chemoRT pts. Among all pts, 77.6% displayed evidence of any cardiac dz, 51.5% had clin dz. Per modality, rates of any and clin dz were: 27.1%/10% EKG, 50.0%/25.3% echo, and 50.8%/45.8% CAC CT. Among subgroups, these rates were: 73.9%/53.4% no tox, 82.5%/58% tox RT, 75%/38.7% tox chemo, and 82.4%/35.3% tox chemoRT (NS on χ2 test, p = .58/p = .15). Multivariable logistic regression with tox RT, tox chemo, and age as covariates, showed no significant tox RT (NS) or tox chemo effect (NS), however, increasing age was significantly associated with higher incidence of cardiac dz (p < 0.01; OR = 1.12 per yr, 95% CI: 1.07-1.18). Conclusions: Among pts with a median of > 10 yrs post breast cancer tx, multimodality CAROLE screening was feasible and showed high rates of cardiac dz (any/clin = 77.6%/51.5%) among all subgroups, including those without tox tx. This study provides evidence for long-term cardiac screening in a diverse group of breast cancer survivors and provides a novel pathway for evaluation. Clinical trial information: NCT03235427.

#WomenWhoCurie: Leveraging Social Media to Promote Women in Radiation Oncology

The proportion of female trainees in radiation oncology has generally declined despite increasing numbers of female medical students; as a result, radiation oncology is among the bottom 5 specialties in terms of the percentage of female applicants. Recently, social media has been harnessed as a tool to bring recognition to underrepresented groups within medicine and other fields. Inspired by the wide-reaching social media campaign of #ILookLikeASurgeon to promote female physicians, members of the Society for Women in Radiation Oncology penned a new hashtag and launched the #WomenWhoCurie social media campaign on Marie Curie's birthday November 7th, as part of their strategy to raise public awareness. From November 6, 2018 until November 10, 2018, the #WomenWhoCurie hashtag delivered 1,135,000 impressions, including 408 photos from all over the world including United States, Spain, Canada, France, Australia, Ireland, the United Kingdom, Mexico, Japan, the Netherlands, India, Ecuador, Panama, Brazil, and Nigeria. Alongside continued gender disparity research, social media should continue to be used as a tool to engage the community and spur conversations to formulate solutions for gender inequity.

Palliative treatment directives for bone metastases: A quality-directed approach to guiding institutional practice

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Background: The efficacy of single fraction (fx) radiation treatment (RT) has proven to have equipoise for palliation of bone metastases when compared to courses of 10 fx or more. Despite these data, there has been a slow adoption of this practice in the US and worldwide. Examination of our multicenter practice from 2004 - 2016 showed that single fx RT utilization has remained at 17% and hypofractionationed (HFX) courses (1 or 5 fx) have remained at 71% since 2009. We hypothesized that evidence-based, treatment-guiding directives could improve HFX utilization in this population. Methods: Institutionally, palliative bone metastasis treatments are routinely tracked by a Quality Assurance committee. In 2/2016, two consensus-driven and evidence-based clinical directives were created within our electronic health system for use with either simple or complicated bone metastasis, irrespective of primary histology. The simple and complex directives had default prescriptions of 8 Gy/1fx or 20 Gy/5fx, respectively. The directives were reviewed with physician staff to improve compliance; directives were allowed to be edited at the physician’s discretion if an alternative fx was indicated. The chi-square test was used for analysis. Results: From 1/2009-5/2016, there were 1,781 treatment courses of palliative external beam RT. Following implementation in 2/2016, the new clinical directives were used for 96% of cases and were modified in 12 cases (n = 72). Single fx use increased from 17% to 36% among palliative bone metastasis treatments (p ≤ 0.001) and HFX (1 or 5 fx) utilization increased from 71% to 92% compared to other fractionation schemes (10 fx or other) (p = 0.001). Conclusions: The institution-wide adoption of evidence-based, treatment directives proved to be a straightforward and successful intervention which allowed for rapid adoption and increased utilization of the standard of care. Our early data suggests that this may be a useful approach in the setting of reticence to new treatment paradigms. Further examination of evidence based directives is warranted to address issues of overtreatment in palliation and in standardizing oncologic care.

Evolutionarily conserved recognition and innate immunity to fungal pathogens by the scavenger receptors SCARF1 and CD36

Receptors involved in innate immunity to fungal pathogens have not been fully elucidated. We show that the Caenorhabditis elegans receptors CED-1 and C03F11.3, and their mammalian orthologues, the scavenger receptors SCARF1 and CD36, mediate host defense against two prototypic fungal pathogens, Cryptococcus neoformans and Candida albicans. CED-1 and C03F11.1 mediated antimicrobial peptide production and were necessary for nematode survival after C. neoformans infection. SCARF1 and CD36 mediated cytokine production and were required for macrophage binding to C. neoformans, and control of the infection in mice. Binding of these pathogens to SCARF1 and CD36 was β-glucan dependent. Thus, CED-1/SCARF1 and C03F11.3/CD36 are β-glucan binding receptors and define an evolutionarily conserved pathway for the innate sensing of fungal pathogens.

A nasal proteosome adjuvant activates microglia and prevents amyloid deposition

OBJECTIVE

We assessed whether peripheral activation of microglia by a nasal proteosome-based adjuvant (Protollin) that has been given safely to humans can prevent amyloid deposition in young mice and affect amyloid deposition and memory function in old mice with a large amyloid load.

METHODS

Amyloid precursor protein (APP) transgenic (Tg) J20 mice received nasal treatment with Protollin weekly for 8 months beginning at age 5 months. Twenty-four-month-old J20 mice were treated weekly for 6 weeks.

RESULTS

We found reduction in the level of fibrillar amyloid (93%), insoluble beta-amyloid (Abeta; 68%), and soluble Abeta (45%) fragments in 14-month-old mice treated with Protollin beginning at age 5 months. Twenty-four-month-old mice treated with nasal Protollin for 6 weeks had decreased soluble and insoluble Abeta (1-40) and (1-42) and improved memory function. Activated microglia (CD11b+ cells) colocalized with Abeta fibrils in the 24-month-old animals, and microglial activation correlated with the decrease in Abeta. No microglial activation was observed in 14-month-old mice, suggesting that once Abeta is cleared, there is downregulation of microglial activation. Both groups had reduction in astrocytosis. Protollin was observed in the nasal cavity and cervical lymph node but not in the brain. Activated CD11b+SRA+ (scavenger receptor A) cells were found in blood and cervical lymph node and increased interleukin-10 in cervical lymph node. No toxicity was associated with treatment.

INTERPRETATION

Our results demonstrate a novel antibody-independent immunotherapy for both prevention and treatment of Alzheimer's disease that is mediated by peripheral activation of microglia with no apparent toxicity.

Reversal of axonal loss and disability in a mouse model of progressive multiple sclerosis

Axonal degeneration is an important determinant of progressive neurological disability in multiple sclerosis (MS). Thus, therapeutic approaches promoting neuroprotection could aid the treatment of progressive MS. Here, we used what we believe is a novel water-soluble fullerene derivative (ABS-75) attached to an NMDA receptor antagonist, which combines antioxidant and anti-excitotoxic properties, to block axonal damage and reduce disease progression in a chronic progressive EAE model. Fullerene ABS-75 treatment initiated after disease onset reduced the clinical progression of chronic EAE in NOD mice immunized with myelin-oligodendrocyte glycoprotein (MOG). Reduced disease progression in ABS-75-treated mice was associated with reduced axonal loss and demyelination in the spinal cord. Fullerene ABS-75 halted oxidative injury, CD11b+ infiltration, and CCL2 expression in the spinal cord of mice without interfering with antigen-specific T cell responses. In vitro, fullerene ABS-75 protected neurons from oxidative and glutamate-induced injury and restored glutamine synthetase and glutamate transporter expression in astrocytes under inflammatory insult. Glutamine synthetase expression was also increased in the white matter of fullerene ABS-75-treated animals. Our data demonstrate the neuroprotective effect of treatment with a fullerene compound combined with a NMDA receptor antagonist, which may be useful in the treatment of progressive MS and other neurodegenerative diseases.

Effect of difluoromethylornithine treatment on regional ornithine decarboxylase activity and edema formation after experimental brain injury

This study examined the effect of difluoromethylornithine (DFMO) on regional activities of ornithine decarboxylase (ODC) and edema formation in bilateral cerebral cortex and hippocampus after a unilateral controlled cortical-impact (CCI) injury in rats. To measure the activity of ODC, the brains of injured and control rats were frozen in situ at 30 min, 3, 6, and 24 h after CCI brain injury of moderate severity. The specific gravity, an indicator of edema formation, was examined in decapitated animals at corresponding time points. Brain injury induced significant increases of ODC in the ipsilateral hippocampus, adjacent and injury-site cortices, and in the contralateral cortex and hippocampus at 3 and 6 h after injury. No significant edema formation was found in any brain region at 30 min after injury. A significant edema formation was first found only in the injury-site cortex at 3 h after injury. At 6 and 24 h after injury, significant edema was found in all regions ipsilateral to the injury-site. At 24 h after injury, significant but less severe edema was also found in the contralateral cortex and hippocampus. DFMO, an irreversible inhibitor of ODC, abolished the increase in ODC in all regions. It also attenuated edema formation in the adjacent cortex and in the contralateral cortex and hippocampus. These findings indicate that polyamines may play a role in posttraumatic brain edema formation, particularly in important brain regions remote from the injury-site.

Differential assay of zidovudine and its glucuronide metabolite in serum and urine with a radioimmunoassay kit

We developed an ancillary procedure for the ZDV-Trac RIA (Incstar) to allow simultaneous determination of both zidovudine (3'-azido-3'-deoxythymidine, ZDV, AZT, Retrovir) and its metabolite, the glucuronide of ZDV (3'-azido-3'-deoxy-5'-O-beta-D-glucopyranuronosylthymidine, ZDVG, GAZT), in human serum and urine. Using the ZDV-Trac RIA, we measured ZDV concentrations before and after ZDVG in samples was hydrolyzed to ZDV by beta-glucuronidase (EC 3.2.1.31); ZDVG concentration was calculated as the difference between the two results. This method enables rapid evaluation of a large number of samples with a total turn-around time of 6 h. The lower detection limit of the RIA was 0.27 micrograms/L; the measurements varied linearly with ZDV concentrations from 0.27 to 217 micrograms/L, with the 50% inhibitory concentration being approximately 10 micrograms/L. Analytical recoveries of inhouse serum and urine controls for both ZDV and ZDVG exceeded 90%. Coefficients of variation (CVs) of serum controls were less than 6% for ZDV and less than 11% for ZDVG; for urine controls, CVs for both ZDV and ZDVG were less than 6%. Results for ZDVG concentrations obtained by HPLC and by the ZDV-Trac RIA system compared well: r = 0.978, slope 1.0, for serum samples, and r = 0.993, slope 1.09, for urine samples.

Differential assay of zidovudine and its glucuronide metabolite in serum and urine with a radioimmunoassay kit

We developed an ancillary procedure for the ZDV-Trac RIA (Incstar) to allow simultaneous determination of both zidovudine (3'-azido-3'-deoxythymidine, ZDV, AZT, Retrovir) and its metabolite, the glucuronide of ZDV (3'-azido-3'-deoxy-5'-O-beta-D-glucopyranuronosylthymidine, ZDVG, GAZT), in human serum and urine. Using the ZDV-Trac RIA, we measured ZDV concentrations before and after ZDVG in samples was hydrolyzed to ZDV by beta-glucuronidase (EC 3.2.1.31); ZDVG concentration was calculated as the difference between the two results. This method enables rapid evaluation of a large number of samples with a total turn-around time of 6 h. The lower detection limit of the RIA was 0.27 micrograms/L; the measurements varied linearly with ZDV concentrations from 0.27 to 217 micrograms/L, with the 50% inhibitory concentration being approximately 10 micrograms/L. Analytical recoveries of inhouse serum and urine controls for both ZDV and ZDVG exceeded 90%. Coefficients of variation (CVs) of serum controls were less than 6% for ZDV and less than 11% for ZDVG; for urine controls, CVs for both ZDV and ZDVG were less than 6%. Results for ZDVG concentrations obtained by HPLC and by the ZDV-Trac RIA system compared well: r = 0.978, slope 1.0, for serum samples, and r = 0.993, slope 1.09, for urine samples.

Essential factors in the kinetic analysis of RNA synthesis in HeLa cells

Further evidence of mRNA in HeLa cells with a half-life two hours or less is given. A kinetic model of RNA synthesis in HeLa cells is described in which equilibration of label occurs first into the acid soluble pool (evidence is given that this pool feeds RNA synthesis) and thence in nuclear and cytoplasmic molecules. The measured accumulation of label in nuclear and cytoplasmic poly (A) is examined with the model and parameters were found which are consistent with the quantitative transfer of nuclear poly(A) to the cytoplasm. The strengths and limitations of the model are discussed.

Possible relationship of poly(A) shortening to mRNA turnover

Whereas the original size of poly(A) in HeLa cells is about 200 nucleotides, at steady state most of the poly(A) in mRNA contains less than 50 nucleotides. An endonucleolytic attack on poly(A) is suggested as the most likely method to accumulate short pieces of poly(A). Both poly(A) shortening and mRNA turnover appear to be inhibited by emetine, a drug that stops translation. It is possible that a random endonucleolytic attack leads to scission of poly(A) to a size below which the mRNA is unstable.

Short-lived messenger RNA in HeLa cells and its impace on the kinetics of accumulation of cytoplasmic polyadenylate

Accumulation of [3H]adenine in the acid-soluble pool and in nuclear and cytoplasmic poly(A) of HeLa cells shows that the nuclear poly(A) rises along a curve similar to that of the acid-soluble pool. By use of a [3H]guanosine pulse-chase experiment in adenine-grown cells, at least 35-50% of the pulse-labeled mRNA was found to have a half-life of about 1-2 hr. A mathematical model involving nuclear poly(A) synthesis and conservative transport to the cytoplasm has been derived from the new information about mRNA with a short half-life. This model predicts curves similar to those found for nuclear and cytoplasmic accumulation of poly(A). Thus, there is no necessity on kinetic grounds to invoke either nuclear turnover or cytoplasmic synthesis of poly(A).