Genomic Predictors of Leptomeningeal Disease Development among Patients with Brain Metastases

PURPOSE/OBJECTIVE(S)

Leptomeningeal disease (LMD) is associated with significant neurologic symptomatology, functional decline, and generally, a very poor prognosis. Clinical characteristics of patients with parenchymal brain metastases have limited potential in predicting who will subsequently develop LMD. We hypothesized that genomic alterations may predict which patients with intracranial disease are at highest risk for developing LMD and sought to identify DNA-based genomic alterations among a targeted panel of cancer-related genes that may increase a patient's risk for LMD.

MATERIALS/METHODS

We identified 810 patients with parenchymal brain metastases secondary to solid tumor primaries without LMD at diagnosis of initial intracranial disease managed at a tertiary cancer center (2003-2020) for whom next-generation sequencing panel data (OncoPanel, 239 genes) were available on at least one extracranial or intracranial tumor specimen. Fine/Gray's competing risks regression was utilized to compare risk for LMD development among patients with vs. without somatic alterations of likely clinical/biological significance, delineated via OncoKB, across 96 genes with a mutational frequency ≥0.5% in the patient cohort. Genes with a q-value<0.10 and hazard ratio (HR)>1 were considered predictive of LMD risk; patients were dichotomized into "high-risk" vs. "low-risk" of LMD development based on the presence or absence of mutations in any one of these predictive genes.

RESULTS

Genomic alterations of potential biological significance in MAPK1 (gain-of-function), CDH1 (loss-of-function), and SF3B1 (switch-of-function) were more common among patients who developed LMD vs. not (MAPK1, 3.6% vs. 0.4%; CDH1, 3.6% vs. 0.8%; SF3B1, 3.6% vs. 0.6%, respectively) and were each associated with an increased risk for LMD development (q-value<0.10 in all cases). On multivariable Fine/Gray's competing risk regression, "high-risk" patients with genomic alterations in any of these three genes (HR 4.32 [1.93-9.67], p<0.001), Karnofsky performance status <90 (HR 1.76 [1.11-2.79], p<0.001), and lack of local, brain-directed therapy as part of intracranial disease management (HR 2.97 [1.48-5.96], p<0.002) were associated with increased risk of LMD; age and primary tumor site were not associated with LMD risk (p>0.05).

CONCLUSION

Utilizing a targeted panel of genes with a known role in cancer pathogenesis, we identified genomic alterations in three genes as being predictive of LMD development. If validated in independent datasets, development of clinical trials exploring inhibition of pathways affected by these genomic alterations may be warranted with the goal of LMD prevention and targeted treatment among particularly high-risk cohorts. To our knowledge, this represents the first study to identify potentially actionable alterations as predictive of leptomeningeal disease development among patients with brain metastases.

A Genomic Score to Predict Local Control among Patients with Brain Metastases Managed with Radiation

PURPOSE/OBJECTIVE(S)

Clinical predictors of local recurrence following radiation among patients with brain metastases (BrM) provide limited explanatory power. As a result, radiation doses and fractionation schemes are relatively homogeneous and prescribed with a "one-size-fits-all" approach. We hypothesized that tumor-specific genomic alterations may underlie radiation sensitivity among patients with BrM and sought to develop a DNA-based signature of radiation-based efficacy in this patient population, utilizing genes that are readily testable in modern-day assays, to identify subpopulations at greater vs. lesser risk of recurrence.

MATERIALS/METHODS

We identified 570 patients with 1,487 distinct BrM managed with whole-brain (WBRT) or stereotactic radiation therapy (SRS/SRT) at a tertiary cancer center (2013-2020) for whom next-generation sequencing panel data (OncoPanel, 239 genes) were available on at least one extracranial or intracranial tumor specimen. Fine/Gray's competing risks regression was utilized to compare local recurrence on a per-metastasis level among patients with vs. without somatic alterations of likely biological significance across 84 OncoPanel genes with a mutational frequency of >0.5%. Genes with a q-value<0.10 were utilized to develop a numeric "Brain-Radiation Prediction Score" ("Brain-RPS") to quantify local recurrence risk.

RESULTS

Genomic alterations of potential biological relevance in 11 (ATM, MYCL, PALB2, FAS, PRDM1, PAX5, CDKN1B, EZH2, NBN, DIS3, MDM4) and two genes (FBXW7 and AURKA) were associated with a decreased or increased risk of local recurrence, respectively (q-value<0.10). Weighted scores corresponding to the strength of association with local failure for each gene were summed to calculate a patient-level Brain-RPS. On multivariable Fine/Gray's competing risks regression, Brain-RPS [1.66 (1.44-1.92, p<0.001)], metastasis-associated edema [1.89 (1.38-2.59), p<0.001], and receipt of WBRT without SRS/SRT or neurosurgical resection [2.73 (1.78-4.20), p<0.001] were independent predictors of local failure.

CONCLUSION

Utilizing a targeted panel of genes with a known role in cancer pathogenesis, we developed a genomic score that can be calculated from an extracranial or intracranial site to quantify local recurrence risk following brain-directed radiation. Prior attempts to develop a biomarker-based radiation response signature have not focused on patients with BrM and have primarily relied on RNA-based measures of radiosensitivity, limiting their utility in real-world clinical practice for this patient population. To our knowledge, this represents the first study to systemically correlate DNA-based alterations with radiation-based outcomes among patients with BrM. If validated, Brain-RPS has potential to facilitate clinical trials aimed at genome-based personalization of radiation treatment among patients with BrM.

Adjuvant Radiotherapy in Atypical Meningioma: Are the Risks Worth the Benefit?

PURPOSE/OBJECTIVE(S)

Adjuvant radiotherapy (RT) improves progression-free survival (PFS) in atypical meningiomas. Herein, we assess whether the treatment-related acute and long-term toxicity of upfront RT in atypical meningioma patients versus surveillance merits the PFS benefit.

MATERIALS/METHODS

In our prior single institution retrospective study of 230 patients with resected intracranial atypical meningiomas between 2000-2015, adjuvant RT was associated with a significantly lower risk of progression/recurrence compared to surveillance (HR = 0.21 [95% CI 0.11-0.41]; p<0.01), with 36% of surveillance patients eventually requiring salvage RT. In the current study, the acute (≤6 months) and long term (>6 months) RT-related toxicities from the same patient cohort for those who received adjuvant RT (n = 51) were evaluated and compared to those who received salvage RT (n = 64) in the surveillance group. Additionally, overall treatment-related toxicity at time of last follow up was obtained for comparison between the adjuvant RT (n = 51) vs surveillance (n = 179) group. All toxicities were graded per CTCAE v5.0. Kaplan-Meier analysis was used to calculate the cumulative incidence of toxicities; Pearson's chi-squared and log-rank test were used for comparison.

RESULTS

Adjuvant RT as compared to salvage RT was generally associated with greater RT-related toxicities both in the acute (90% vs 69%, p = 0.006) and long term (57% vs 33%, p = 0.010). While there was no significant difference in grade 3-4 acute toxicities, long term grade 3-4 toxicities (including headache, seizure, vision loss, neuromotor deficit, and neurocognitive deficit) were present in 14% of adjuvant vs 3% of salvage RT group (p = 0.035). Radionecrosis occurred in 18% of adjuvant RT vs 8% of salvage RT group (p = 0.11). Between adjuvant RT vs surveillance groups, any-treatment related toxicity at last follow up was greater with adjuvant RT (31% vs 15%; p = 0.006), with trend towards greater grade 3-4 toxicities (including headache, vision loss, neuromotor deficit, neurocognitive deficit, and cerebral edema) as well (8% vs 3%; p = 0.101). Cumulative incidence of treatment-related neuromotor deficit (any grade) was significantly greater in the adjuvant RT vs surveillance group with 14% vs 2% at 10 years (p = 0.004). There was no difference in rate of cerebrovascular accident between adjuvant RT (6%) vs surveillance (4%) groups (p = 0.83).

CONCLUSION

Adjuvant RT for patients with atypical meningioma was associated with greater acute and long-term treatment toxicities. Potential RT-related toxicity and impact on quality-of-life should thus be carefully weighed against the tumor control benefit of RT in deciding the optimal use and timing of RT.

Unconventional Hall response in the quantum limit of HfTe5

Interacting electrons confined to their lowest Landau level in a high magnetic field can form a variety of correlated states, some of which manifest themselves in a Hall effect. Although such states have been predicted to occur in three-dimensional semimetals, a corresponding Hall response has not yet been experimentally observed. Here, we report the observation of an unconventional Hall response in the quantum limit of the bulk semimetal HfTe5, adjacent to the three-dimensional quantum Hall effect of a single electron band at low magnetic fields. The additional plateau-like feature in the Hall conductivity of the lowest Landau level is accompanied by a Shubnikov-de Haas minimum in the longitudinal electrical resistivity and its magnitude relates as 3/5 to the height of the last plateau of the three-dimensional quantum Hall effect. Our findings are consistent with strong electron-electron interactions, stabilizing an unconventional variant of the Hall effect in a three-dimensional material in the quantum limit.

Outpatient total shoulder arthroplasty: A cost-identification analysis

Background

As demand for total shoulder arthroplasty (TSA) rises, containing costs will become increasingly important. We hypothesize that performing ambulatory TSA procedures results in significant cost savings.

Methods

A model was created to evaluate cost savings. Hospital stay length and cost, pain control method and cost, and number of annual outpatient TSA procedures were estimated based on literature.

Results

Estimated cost savings per patient were $747 to $15,507 (base case $5594), total annual savings of $4.1M to $349M (base case $82M), and ten-year savings of $51M to $5.4B (base case $1.1B).

Conclusion

Ambulatory TSA procedures result in significant cost savings.

The psychological well-being and prenatal bonding of gestational surrogates

STUDY QUESTION

How does the psychological well-being and prenatal bonding of Indian surrogates differ from a comparison group of mothers?

SUMMARY ANSWER

Surrogates had higher levels of depression during pregnancy and post-birth, displayed lower emotional connection with the unborn baby, and greater care towards the healthy growth of the foetus, than the comparison group of mothers.

WHAT IS ALREADY KNOWN

Studies in the West have found that surrogates do not suffer long-term psychological harm. One study has shown that surrogates bond less with the foetus than expectant mothers.

STUDY, DESIGN, SIZE, DURATION

This study uses a prospective, longitudinal and cross-sectional design. Surrogates and a matched group of expectant mothers were seen twice, during 4-9 months of pregnancy and 4-6 months after the birth.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Semi-structured interviews and standardized questionnaires were administered to 50 surrogates and 69 expectant mothers during pregnancy and 45 surrogates and 49 expectant mothers post-birth. All gestational surrogates were hosting pregnancies for international intended parents.

MAIN RESULTS AND THE ROLE OF CHANCE

Surrogates had higher levels of depression compared to the comparison group of mothers, during pregnancy and post-birth (P < 0.02). Low social support during pregnancy, hiding surrogacy and criticism from others were found to be predictive of higher depression in surrogates post-birth (P < 0.05). Regarding prenatal bonding, surrogates interacted less with and thought less about the foetus but adopted better eating habits and were more likely to avoid unhealthy practices during pregnancy, than expectant mothers (P < 0.05). No associations were found between greater prenatal bonding and greater psychological distress during pregnancy or after relinquishment.

LIMITATIONS, REASONS FOR CAUTION

All surrogates were recruited from one clinic in Mumbai, and thus the representativeness of this sample is not known. Also, the possibility of socially desirable responding from surrogates cannot be ruled out.

WIDER IMPLICATIONS OF THE FINDINGS

As this is the first study of the psychological well-being of surrogates in low-income countries, the findings have important policy implications. Providing support and counselling to surrogates, especially during pregnancy, may alleviate some of the psychological problems faced by surrogates.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by the Wellcome Trust [097857/Z/11/Z] and Nehru Trust, Cambridge. K.K. is the Medical Director of Corion Fertility Clinic. All other authors have no conflict of interest to declare.

Indian egg donors' characteristics, motivations and feelings towards the recipient and resultant child

This is the first study to examine characteristics, motivations and experiences of Indian egg donors. In-depth interviews were conducted with 25 egg donors who had donated during the previous 8 months at a fertility clinic in Mumbai. The semi-structured interviews were conducted in Hindi and English. In addition to demographic information, data were collected on donors' motivations for donating, with whom they had discussed donation, and feelings towards the recipients. The response rate was 66%. All participants were literate and had attended school. Twenty (80%) egg donors had children and five (20%) did not. The most common motivation (19, 76%) for donating was financial need. Egg donors had discussed their donation with their husband or with close family/friends, with almost all mentioning that wider society would disapprove. The majority (20, 80%) had no information about the recipients and 11 (44%) preferred not to. The findings highlight the similarities and differences between egg donors from India and those from other countries and that egg donors are of a more varied demographic background than surrogates in India. Given that India has been a popular destination for fertility treatment, the findings have important implications for regulation and practice within India and internationally.