Personalized neck irradiation guided by sentinel lymph node biopsy in patients with squamous cell carcinoma of the oropharynx, larynx or hypopharynx with a clinically negative neck: (Chemo)radiotherapy to the PRIMary tumor only. Protocol of the PRIMO study

Background

Elective neck irradiation (ENI) is performed in head and neck cancer patients treated with definitive (chemo)radiotherapy. The aim is to eradicate nodal metastases that are not detectable by pretreatment imaging techniques. It is conceivable that personalized neck irradiation can be performed guided by the results of sentinel lymph node biopsy (SLNB). It is expected that ENI can be omitted to one or both sides of the neck in 9 out of 10 patients, resulting in less radiation side effects with better quality of life.

Methods/design

This is a multicenter randomized controlled trial aiming to compare safety and efficacy of treatment with SLNB guided neck irradiation versus standard bilateral ENI in 242 patients with cN0 squamous cell carcinoma of the oropharynx, larynx or hypopharynx for whom bilateral ENI is indicated. Patients randomized to the experimental-arm will undergo SLNB. Based on the histopathologic status of the SLNs, patients will receive no ENI (if all SLNs are negative), unilateral neck irradiation only (if a SLN is positive at one side of the neck) or bilateral neck irradiation (if SLNs are positive at both sides of the neck). Patients randomized to the control arm will not undergo SLNB but will receive standard bilateral ENI. The primary safety endpoint is the number of patients with recurrence in regional lymph nodes within 2 years after treatment. The primary efficacy endpoint is patient reported xerostomia-related quality of life at 6 months after treatment.

Discussion

If this trial demonstrates that the experimental treatment is non-inferior to the standard treatment in terms of regional recurrence and is superior in terms of xerostomia-related quality of life, this will become the new standard of care.

OP0225 RISK OF COMORBIDITY FOLLOWING OSTEOARTHRITIS DIAGNOSIS: A COHORT STUDY IN THE NETHERLANDS FROM THE FOREUM* INITIATIVE

Background

Osteoarthritis (OA) is a common and disabling disease that places a significant burden on both patients and health care systems. Previous studies have already shown that patients with OA have a higher risk of developing comorbidities. However, many focused on one or a few conditions only, or did not consider the chronology of the disease onset relative to OA.

Objectives

To determine the risk of physician-diagnosed comorbidity following the diagnosis of knee or hip OA, using electronic health records in the Netherlands.

Methods

A cohort study was conducted using the Integrated Primary Care Information (IPCI) database, an electronic health record database with medical records of 2.5 million patients from Dutch general practice. The study population consisted of patients aged 18 years or older, that were at risk for incident OA and comorbidity. Diagnosis of knee or hip OA (i.e. exposure) was defined as the first registration of the corresponding diagnostic code from the International Classification of Primary Care (ICPC) coding system in the medical record. Fifty-eight long-term comorbidities (i.e. outcome) were selected and defined by their corresponding ICPC codes.

Patients’ follow-up started after registration in the database, and ended at the diagnosis date of the comorbidity (i.e. event), or at deregistration, death or at December 31st, 2019 (i.e. censoring), whichever came first. Exposure to knee or hip OA was a time-varying exposure: time between the start of follow-up and diagnosis of OA was defined as unexposed time, and between diagnosis of OA and the end of follow-up as exposed time. Patients’ age was used as time axis to correct for age non-linearly. Sex-adjusted hazard ratios (HRs) comparing exposed and unexposed patient status were estimated with 99.9% confidence intervals (CI).

Results

The study population consisted of 1,890,712 patients. For 11 of the 58 studied comorbidities exposure to knee OA showed a statistically significant HR larger than 1, indicating an increased risk of being diagnosed with these comorbidities after a diagnosis of knee OA. For none of the comorbidities there was a statistically significant negative association (HR<1) with exposure to knee OA. For 7 comorbidities exposure to hip OA showed a statistically significant HR larger than 1. Again, for all other comorbidities the HR of hip OA was non-significant. For an overview of the statistically significant positive associations see Table 1.

Table 1.

Comorbidities with significant HRs of exposure to knee or hip OA

Knee OAHip OAComorbidityHR99.9% CIComorbidityHR99.9% CIAnemia1.331.091.64Anemia1.291.021.63Back pain1.281.041.57Atrial fibrillation1.461.141.88Cataract1.271.021.59Fibromyalgia6.091.2529.53Chronic kidney disease1.301.061.59Peripheral vascular disease1.641.092.49Coronary heart disease1.341.031.75Sleeping disorder1.441.101.87Gout1.431.012.03Solid malignancy1.321.111.55Hearing loss1.341.001.79Spinal disc herniation2.031.462.83Neck pain1.581.162.16Obesity2.021.063.83Sleeping disorder1.331.041.69Thromboembolic disease1.401.011.94

Conclusion

This study showed that certain comorbidities were diagnosed more often in patients exposed to knee or hip OA, and none were less frequently diagnosed in patients exposed OA. This suggests that the management of OA should consider the risk of other long-term-conditions and that further research on causality between OA and comorbidity is needed.

References

[1]*https://www.foreum.org/projects.cfm?projectid=159

Acknowledgements

We thank the Patient Research Participants members Jenny Cockshull, Stevie Vanhegan, and Irene Pitsillidou for their involvement in the project. We would like to thank the FOREUM for financially supporting the research.

Disclosure of Interests

None declared

The impact of vestibular schwannoma and its management on employment

BACKGROUND

Employment is an important factor in quality of life. For vestibular schwannoma (VS) patients, employment is not self-evident, because of the sequelae of the disease or its treatment and their effects on daily life.

OBJECTIVES

This study assessed employment status, sick leave (absenteeism) and being less productive at work (presenteeism) in the long-term follow-up of VS patients, and evaluated the impact of treatment strategy (active surveillance, surgery or radiotherapy).

METHODS

A cross-sectional survey study was performed in a tertiary university hospital in the Netherlands. Patients completed the iMTA-post productivity questionnaire (iPCQ). Employment status was compared to that of the general Dutch population. Employment, absenteeism and presenteeism were compared between patients under active surveillance, patients after radiotherapy and post-surgical patients.

RESULT

In total 239 patients participated, of which 67% were employed at the time of the study. Only 14% had a disability pension, which was comparable to the age-matched general Dutch population. The proportion of patients with absenteeism was 8%, resulting in a 4% reduction of working hours. Presenteeism was reported by 14% of patients, resulting in a 2% reduction of working hours. The median number of working hours per week was 36, and since the diagnosis, these hours had been reduced by 6%. There were no significant differences between treatment modalities.

CONCLUSION

On average, long-term employment status and working hours of VS patients are comparable to the age-matched general population. Treatment strategies do not seem to differentially impact on long-term employment of VS patients.

Variation in head and neck cancer care in the Netherlands: A retrospective cohort evaluation of incidence, treatment and outcome

BACKGROUND

To explore variation in numbers and treatment between hospitals that treat head and neck cancer (HNC) in the Netherlands.

MATERIAL AND METHODS

Patient, tumor and treatment characteristics were collected from the Netherlands Cancer Registry, while histopathological features were obtained by linkage to the national pathology record register PALGA. Inter-hospital variation in volume, stage, treatment, pathologically confirmed loco-regional recurrence and overall survival rate was evaluated by tumor site.

RESULTS

In total, 2094 newly diagnosed patients were included, ranging from 65 to 417 patients in participating hospitals treating HNC in 2008. Oral cavity cancer was mainly treated by surgery only, ranging from 46 to 82% per hospital, while the proportion of surgery with (chemo)radiotherapy ranged from 18 to 40%. Increasing age, male sex, and high stage were associated with a higher hazard of dying. In oropharynx cancer, the use of (chemo)radiotherapy varied from 31 to 82% between hospitals. We found an indication that higher volume was associated with a lower overall hazard of dying for the total group, but not by subsite. Low numbers, e.g. for salivary gland, nasopharynx, nasal cavity and paranasal sinus, did not permit all desired analyses.

CONCLUSION

This study revealed significant interhospital variation in numbers and treatment of especially oropharyngeal and oral cavity cancer. This study is limited because we had to rely on data recorded in the past for a different purpose. To understand whether this variation is unwanted, future research should be based on prospectively collected data, including detailed information on recurrences, additional case-mix information and cause of death.

Salivary gland pleomorphic adenoma in the Netherlands: A nationwide observational study of primary tumor incidence, malignant transformation, recurrence, and risk factors for recurrence

INTRODUCTION

Whereas salivary gland pleomorphic adenoma (SGPA) is the most common type of salivary gland tumor, little is known about its epidemiology because national cancer registries do not register this disease.

OBJECTIVES

To establish SGPA incidence trends, rates of secondary malignant transformation and recurrence and associated factors in the Netherlands.

MATERIALS AND METHODS

Data on incidence, epidemiology, secondary malignant transformation and recurrence were retrieved from the Dutch pathology registry (PALGA) for the years 1992, 1997, 2002, 2007, and 2012. Multivariate analysis was performed to discover the risk factors for recurrence.

RESULTS

3506 cases of SGPA were recorded implying an overall European standardized rate of 4.2-4.9 per 100,000 person-years. Our figures showed a female preponderance (1:1.43) with an annual 1% rise in female incidence (95% confidence interval [CI]: 0.2-1.8) and a bimodal age distribution in women (p<0.0001). The overall 20-year recurrence rate was 6.7%, and median time to first recurrence was 7years. Positive and uncertain resection margins and younger age at diagnosis were risk factors for recurrence, with odds ratios (ORs) of 4.62 (95%CI 2.84-7.51), 4.08 (95%CI 2.24-7.43), and 0.42 (95%CI 0.29-0.63) respectively. Tumor locations in the minor salivary glands had lower odds of recurrence than tumors in the parotid (OR 0.24; 95% CI: 0.07-0.77; p<0.016). Malignant transformation occurred in 0.15% of SGPAs (3.2% of recurrences).

CONCLUSION

This first nationwide study clearly showed sex differences in SGPA epidemiology, possibly suggesting some underlying hormonal mechanism. Long-term recurrence risks were low, and secondary malignant transformation risks were very low.

Recurrent oropharyngeal cancer after organ preserving treatment: pattern of failure and survival

The objectives is to thoroughly analyze the pattern of failure and oncologic outcome in recurrent oropharyngeal cancer (OPC) after (chemo)radiotherapy and correlate the site of failure to the planned radiation dose. Between January 2010 and April 2014, 57 patients with recurrent OPC after (chemo)radiotherapy were analyzed. Endpoints were pattern of failure and overall survival (OS). Local (LF) and regional failure (RF) were classified as in-field [>50% within gross tumor volume (GTV)], marginal [<50% within GTV but >50% within clinical target volume (CTV)], or out-of-field (>50% outside CTV) recurrences. In the whole group, 70 recurrences were reported. Of the 31 LF, 29 (93.5%) were in-field and 2 (6.5%) were marginal. No out-field LF was reported. Of the 21 RF, 13 RF (62%) were in-field, 6 (28.5%) marginal, and 2 (9.5%) out-of-field recurrences. Forty-three percent of RF was developed in an electively treated neck level, and 2 of them were contralateral. OS at 2 years in recurrent HPV positive, compared to HPV-negative OPC, were 66 and 18%, respectively (p = 0.011). OS was also significantly better in patients that were salvage treatment which was possible (70 vs. 6%, p < 0.001). Median survival after distant failure was 3.6 months. The great majority of LFs were located within the GTV and 43% of RFs developed in an electively treated neck level. The currently used margins and dose recipe and the indication for bilateral nodal irradiation need to be reevaluated. OS was significantly better in recurrent HPV-positive OPC and in patients, where salvage treatment was possible.

Risk of cardiac valvulopathy with use of bisphosphonates: a population-based, multi-country case-control study

Analyses of healthcare data from 30 million individuals in three countries showed that current use of bisphosphonates may be associated with a small increased risk of cardiac valvulopathy (vs. those not exposed within the previous year), although confounding cannot be entirely ruled out. The observed tendency for decreased valvulopathy risk with cumulative duration of bisphosphonate use >6 months may even indicate a protective effect with prolonged use. Further studies are still needed to evaluate whether bisphosphonates increase or decrease the risk of valvulopathy.

INTRODUCTION

A signal of cardiac valve disorders with use of bisphosphonates was identified in the literature and EudraVigilance database, which contains reports of suspected adverse drug reactions from worldwide sources. The aim of this study was to evaluate the association using population-based healthcare data.

METHODS

This was a case-control study among users of bisphosphonates and other drugs for osteoporosis in six healthcare databases covering over 30 million individuals in Italy, Netherlands and the UK from 1996 to 2012. Prescriptions/dispensations were used to assess drug exposure. Newly diagnosed cases of cardiac valvulopathy were identified via disease codes/free-text search. Controls were matched to each case by age, sex, database and index date. Adjusted odds ratios (ORs) were estimated using conditional logistic regression for the pooled data and meta-analysis of individual database risk estimates.

RESULTS

A small but statistically significant association was found between exposure to bisphosphonates as a class and risk of valvulopathy. Overall risk was 18 % higher (95 % CI 12-23 %) in those currently exposed to any bisphosphonate (mainly alendronate and risedronate) vs. those not exposed within the previous year. Risk of valve regurgitation was 14 % higher (95 % CI 7-22 %). Decreased valvulopathy risk was observed with longer cumulative duration of bisphosphonate use, compared to use of less than 6 months. Meta-analyses of database-specific estimates confirmed results from pooled analyses.

CONCLUSIONS

The observed increased risks of cardiac valvulopathy with bisphosphonate use, although statistically significant, were quite small and unlikely to be clinically significant. Further studies are still needed to evaluate whether bisphosphonates increase or decrease the risk of valvulopathy and to investigate possible mechanisms for the association.

The influence of nodal yield in neck dissections on lymph node ratio in head and neck cancer

OBJECTIVES

Recent studies suggest that lymph node ratio (LNR) is a strong prognostic factor in head and neck cancer. This study aims to determine if the yield of harvested lymph nodes (LNs) influences the LNR.

METHODS

The study included 522 head and neck cancer patients, undergoing 638 primary and salvage (selective) neck dissections between 2002 and 2012. Before 2007 the neck dissection specimens were macroscopically and microscopically examined by pathologists and after 2007 the macroscopic examination was performed by pathology technicians. For comparison of mean LN yields, univariate and multivariate analyses were performed.

RESULTS

The mean number of LNs among 374 specimens examined by pathologists was 24 (range 0-89) vs. 32 (range 2-89) among 264 specimens examined by pathology technicians (P<.001). This caused the mean LNR in the non pre-treated patient group to drop from 11.4% to 8.7%. The counts of LNs per type of neck dissection were significantly different and increased with the number of levels involved. However, there was no linear relationship and the higher yields could be mostly ascribed to LNs in level V. The LNR varied from 8.1% to 18.4% among the different types of neck dissections.

CONCLUSIONS

A significant increase in the number of harvested LNs, but a decrease in LNR was observed after introducing pathology technicians for macroscopic examination. A clear association between the extent of the dissection and the number of harvested LNs was observed. LNR appears to be strongly dependent on the harvesting protocol and the extent of the dissection.

Durable remission of inoperable liver metastasis from rectal cancer after hepatic arterial infusion of oxaliplatin and 5-fluorouracil in combination with intravenous cetuximab

At diagnosis of a cT3N0M1 adenocarcinoma of the rectum with synchronous inoperable liver metastases, a 59-year-old man was treated with preoperative radiotherapy (5×5 Gy), followed by laparoscopy-assisted anterior resection of the rectum with total mesorectal excision. At the first postoperative evaluation, a new lung metastasis was detected. First-line chemotherapy with folfiri (5-fluorouracil, irinotecan, leucovorin) resulted in transient stabilization of the metastatic liver disease. At progression, oxaliplatin and 5-fluorouracil-folinic acid were administered by intrahepatic arterial infusion, in combination with intravenous cetuximab. A partial radiologic response was obtained, with complete metabolic response on fluorodeoxyglucose positron-emission tomography, and normalization of carcinoembryonic antigen values. The solitary lung metastasis was sequentially treated with radiotherapy and resection. Five years after the initial diagnosis, this patient remains free from progression, with residual cystic remnants of the liver metastases visible on conventional computed tomography imaging, but not enhancing with fluorodeoxyglucose positron-emission tomography.

Built-in mechanical stress in viral shells

Mechanical properties of biological molecular aggregates are essential to their function. A remarkable example are double-stranded DNA viruses such as the φ29 bacteriophage, that not only has to withstand pressures of tens of atmospheres exerted by the confined DNA, but also uses this stored elastic energy during DNA translocation into the host. Here we show that empty prolated φ29 bacteriophage proheads exhibit an intriguing anisotropic stiffness which behaves counterintuitively different from standard continuum elasticity predictions. By using atomic force microscopy, we find that the φ29 shells are approximately two-times stiffer along the short than along the long axis. This result can be attributed to the existence of a residual stress, a hypothesis that we confirm by coarse-grained simulations. This built-in stress of the virus prohead could be a strategy to provide extra mechanical strength to withstand the DNA compaction during and after packing and a variety of extracellular conditions, such as osmotic shocks or dehydration.

Regional Variability in the Prevalence of Cerebral White Matter Lesions: An MRI Study in 9 European Countries (CASCADE)

White matter lesions (WML) on MRI of the brain are common in both demented and nondemented older persons. They may be due to ischemic events and are associated with cognitive and physical impairments. It is not known whether the prevalence of these WML in the general population differs across European countries in a pattern similar to that seen for coronary heart disease. Here we report the prevalence of WML in 1,805 men and women drawn from population-based samples of 65- to 75-year-olds in ten European cohorts. Data were collected using standardized methods as a part of the multicenter study CASCADE (Cardiovascular Determinants of Dementia). Centers were grouped by region: south (Italy, Spain, France), north (Netherlands, UK, Sweden), and central (Austria, Germany, Poland). In this 10-year age stratum, 92% of the sample had some lesions, and the prevalence increased with age. The prevalence of WML was highest in the southern region, even after adjusting for differences in demographic and selected cardiovascular risk factors. Brain aging leading to disabilities will increase in the future. As a means of hypothesis generation and for health planning, further research on the geographic distribution of WML may lead to the identification of new risk factors for these lesions.

Growth and body composition in preterm infants with bronchopulmonary dysplasia

OBJECTIVE

To compare growth and body composition in preterm infants with bronchopulmonary dysplasia (BPD) with normal healthy term infants during the first year of life.

DESIGN

Twenty nine preterm infants with BPD (mean (SD) gestational age 27.1 (1.6) weeks; birth weight 852 (173) g) were followed prospectively. Anthropometry and body composition determined by total body electrical conductivity were measured and compared with those of healthy term infants at the same post-term age.

RESULTS

In infants with BPD, the mean weight standard deviation scores (SD scores) 6 weeks after term were significantly lower (-1.44 and -2.68, boys and girls respectively) than in healthy term infants of the same age and did not improve during the first year. The mean length SD score was significantly lower in infants with BPD 6 weeks after term than in healthy term infants of the same age, and, although it improved significantly during the first year, the mean length SD score in girls with BPD was significantly below 0 12 months after term. In infants with BPD, the mean free fat mass (FFM) SD score and the mean total body fat (TBF) SD score at 6 weeks post-term age were significantly below 0. The mean FFM SD scores (-1.01 and -2.56, boys and girls respectively) and the mean TBF SD scores (-1.14 and -2.40, boys and girls respectively) 12 months after term were significantly lower than in healthy term infants of the same age.

CONCLUSIONS

Preterm infants with BPD have impaired growth, with a deficit in TBF and FFM already 6 weeks after term; FFM and TBF remain low compared with healthy term infants during the first year of life. Nutritional intervention studies in infants with BPD are needed to evaluate if nutrition is the major determinant of growth and body composition or if this pattern of growth in preterm infants with BPD is the result of disturbed endocrine control.

Standards for total body fat and fat-free mass in infants

Data on body composition in conjunction with reference centiles are helpful in identifying the severity of growth and nutritional disorders in infancy and for evaluating the adequacy of treatment given during this important period of rapid growth. Total body fat (TBF) and fat-free mass (FFM) were estimated from total body electrical conductivity (TBEC) measurements in 423 healthy term Caucasian infants, aged 14-379 days. Cross sectional age, weight, and length related centile standards are presented for TBF and FFM. Centiles were calculated using Altman's method, based on polynomial regression and modelling of the residual variation. The TBF percentage steeply increased during the first half year of life, and slowly declined beyond this age. Various simple TBEC derived anthropometric prediction equations for TBF and FFM are available to be used in conjunction with these standards. Regression equations for the P50 and the residual SD, depending on age, weight, or length, are provided for constructing centile charts and calculating standard deviation scores.

Comparison of doxorubicin and mitoxantrone in the treatment of elderly patients with advanced diffuse non-Hodgkin's lymphoma using CHOP versus CNOP chemotherapy

PURPOSE AND METHODS

A prospective, randomized, multicenter phase III trial was performed to investigate the feasibility of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy in elderly patients ( > or = 60 years) with advanced non-Hodgkin's lymphoma (NHL) of intermediate- and high-grade malignancy, and to compare the tolerance and efficacy of doxorubicin versus mitoxantrone (CHOP v CNOP).

RESULTS

Of 157 enrolled patients, 148 were eligible and 145 were assessable for response. Thirty-one percent of CNOP and 45% of CHOP patients completed six cycles without dose reduction. The cumulative normalized dose-intensity (NDI) was 92% with CHOP and 90% with CNOP after six cycles. The overall complete response (CR) rates were 49% and 31% in CHOP- and CNOP-treated patients, respectively (P = .03). Survival with CNOP was significantly worse as compared with CHOP (P = .03). Lymphoma-specific survival was significantly better in CHOP-treated patients (P = .034) At 3 years, 42% of CHOP and 26% of CNOP patients were alive. Additional unfavorable prognostic factors at diagnosis were high serum lactate dehydrogenase (LDH) level, bulky mass, and low performance status, but not age. The median disease-free intervals of complete responders were 27 (CHOP) and 15 (CNOP) months, respectively. Considering the complete group of patients, at 3 years 17% of CHOP and 13% of CNOP patients were alive and disease-free (P = .12). Common toxicity criteria (CTC) grade > or = 2 with CNOP and CHOP was not different.

CONCLUSION

CHOP is well tolerated in elderly patients with advanced intermediate- or high-grade NHL and its NDI is not seriously impaired. Treatment with CHOP (doxorubicin) results in better CR and survival rates than CNOP (mitoxantrone). CHOP should be recommended for elderly patients with high-risk NHL.

Is range of motion of the hip and ankle joint related to running injuries? A case control study

This study concerns a case-control study on the relation between range of motion (ROM) of the hip and ankle joints and running injuries. Sixteen male runners who had sustained a medically treated running injury during the year prior to the ROM measurements were matched for weekly running distance and age with sixteen male runners who had not sustained such an injury. All subjects were fit at the time of measurement. ROM was measured by standardized goniometry after a warm-up on a cycle-ergometer. Within non-injured subjects all goniometric measurements showed no significant (p > 0.05) differences between the left and right side of the body. Within injured subjects all goniometric measurements showed no significant (p > 0.05) differences between the injured and non-injured side of the body. Runners who had sustained a running injury showed a significant (p > 0.001) more restricted ROM of the hip joints (average ROM value 59.4 degrees +/- 8.0 degrees) in comparison to runners who had no been injured during the same period (average value ROM 68.1 degrees +/- 5.2 degrees). No such differences (p > 0.05) were found with regard to ankle ROM (average ROM value injured 12.8 degrees +/- 3.4 degrees and average ROM value non injured 14.0 degrees +/- 2.7 degrees). These findings suggest that ROM can be characterized as a more or less stable anthropometric trait.(ABSTRACT TRUNCATED AT 250 WORDS)

[2 cases of death following cell therapy]

Fresh-cell therapy is a paramedical procedure whose claimed therapeutic success has not been proven by customary clinical tests (randomized, double-blind trials). In addition, the qualitatively and quantitatively non-standardized parenteral application of heterologous antigens presents considerable danger for the recipient in the form of fatal immune reactions. Two cases are reported in which history, clinical findings and autopsy provided evidence of a causal relationship between cell therapy and death. In one instance, a 75-year-old woman died 30 days after an intramuscular injection of quick-frozen fresh cells from the effects of an immune-complex vasculitis; in the other, a 60-year-old woman died 14 days after "original fresh-cell treatment after Prof. Niehans" from perivenous leucoencephalitis.