The role of postradiotherapy neck dissection in supraglottic carcinoma

PURPOSE

To evaluate our policy of performing neck dissection based on regional response after definitive radiotherapy in patients with supraglottic carcinoma and to identify the prognostic factors in this group of patients.

METHODS AND MATERIALS

Between 1970 and 1995, 121 patients with node-positive squamous cell carcinoma of the supraglottic larynx were treated with definitive radiotherapy. Sixty-nine percent of patients presented with 1997 AJCC Stage IV disease. The N-stage distribution was N1, 49; N2, 62; and N3, 10. The median size of the lymph nodes was 3 cm (range, 0.5-8 cm). Forty-five patients received once-a-day treatment with a median total dose of 65 Gy (range, 58.0-70.8 Gy) in 1.8-2.0 Gy per fraction over 48 days, and 76 patients received split-course accelerated hyperfractionation with a median total dose of 67.2 Gy (range, 63.2-73.6 Gy) in 1.6 Gy twice a day over 43 days. Patients whose lymph nodes were not clinically detectable at 4-6 weeks after the completion of radiotherapy (complete response) were followed without any neck dissection. Patients with persistent neck adenopathy (partial response) underwent neck dissection whenever possible. Mean follow-up of the living patients was 6.5 years.

RESULTS

Regional response was related to the size of lymph nodes at presentation. Eighty-seven percent of patients with nodal size of 3 cm or less had a complete response, whereas 43% of patients with nodal size greater than 3 cm had a partial response. The rate of regional control at 3 years for all patients in the study was 66%. The 3-year ultimate regional control rate after salvage neck dissection was 75%. A relapse in both the primary and regional sites was the most common pattern of relapse, accounting for 39% of all the failures. Local failure was associated with subsequent regional relapse with a relative risk of 4.3. For patients with complete response in whom postradiotherapy neck dissection was withheld, the regional control rates were 75% and 86% for N1 and N2, respectively. The rate of isolated regional relapse in this group of patients was 7.5%. In multivariate analysis, significant favorable factors predictive for regional control were female gender, accelerated hyperfractionation, and complete response; whereas factors predictive for overall survival were Karnofsky Performance Scale score and regional response. The rate of Radiation Therapy Oncology Group (RTOG) Grade 2 or 3 neck fibrosis was 17% and 23% for patients with and without postradiotherapy neck dissection, respectively.

CONCLUSION

Isolated regional relapse is not common in patients with supraglottic carcinoma when a complete response is achieved at 4-6 weeks after definitive radiotherapy and postradiotherapy neck dissection is not performed. Female gender, accelerated hyperfractionation, and complete response are favorable predictors of regional control.

Dosimetric implications of changes in patient repositioning and organ motion in conformal radiotherapy for prostate cancer

PURPOSE

To assess the influence of patient repositioning and organ motion on dose distribution within the prostate and the seminal vesicles (clinical target volume, (CTV)).

MATERIAL AND METHODS

Nine patients were simulated and treated in the supine position, with an empty bladder, and without immobilization devices. While on treatment, patients underwent weekly pelvic computed tomography (CT) scans under conditions identical to those at simulation. Patients were aligned using lasers on anterior and lateral skin tattoos, onto which lead markers were placed. After each CT scan (n=53) the CTV was redefined by contouring, and a new isocenter was obtained. A six-field technique was used. The field margins around the CTV were 20 mm in the cranio-caudal axis, and 13 mm in the other axes, except in the lateral fields where a 10 mm posterior margin was used. Dose-volume histograms (DVHs) for each organ were compared with those determined at simulation, using the notion of the proportional change in the area under the CTV-DVH curve resulting from a change in treatment plan (cDVH).

RESULTS

The reproducibility of the dose distribution was good for the prostate (%cDVH, mean+/-SD: -0.97+/-2.11%) and less than optimal for the seminal vesicles (%cDVH, mean+/-SD: -4.66+/-10.45%). When correlating prostate %cDVH variations with displacements of the isocenter in the Y axis (antero-posterior) the %cDVH exceeded (-)5% in only two dosimetries, both with an isocenter shift of >10 mm. For the seminal vesicles, however, ten out of 53 dosimetries showed a %cDVH exceeding (-) 5%. In nine of these ten dose distribution studies the posterior shift of the isocenter exceeded 8 mm.

CONCLUSIONS

Precise targeting of prostate radiotherapy is primarily dependent on careful daily set-up and on random changes in rectal geometry. Margins no less than 10 mm around the prostate and at least 15 mm around the seminal vesicles are probably necessary to insure adequate target coverage with a six-field technique.

A comprehensive dataset of annotated brain metastasis MR images with clinical and radiomic data

Brain metastasis (BM) is one of the main complications of many cancers, and the most frequent malignancy of the central nervous system. Imaging studies of BMs are routinely used for diagnosis of disease, treatment planning and follow-up. Artificial Intelligence (AI) has great potential to provide automated tools to assist in the management of disease. However, AI methods require large datasets for training and validation, and to date there have been just one publicly available imaging dataset of 156 BMs. This paper publishes 637 high-resolution imaging studies of 75 patients harboring 260 BM lesions, and their respective clinical data. It also includes semi-automatic segmentations of 593 BMs, including pre- and post-treatment T1-weighted cases, and a set of morphological and radiomic features for the cases segmented. This data-sharing initiative is expected to enable research into and performance evaluation of automatic BM detection, lesion segmentation, disease status evaluation and treatment planning methods for BMs, as well as the development and validation of predictive and prognostic tools with clinical applicability.

[Utility of the PET/CT in vulvar cancer management]

OBJECTIVE

To describe the clinical impact of PET/CT in the management of patients with vulvar cancer.

MATERIAL AND METHODS

Retrospective analysis of 13 PET/CT studies with (18)F-FDG (6 staging and 7 suspected recurrence) corresponding to 10 patients diagnosed with vulvar cancer by biopsy, with a mean age of 64.5 years. The preoperative PET/CT study was analyzed qualitatively according to the lesion region. Surgical excision was carried out, covering all the suspected areas according to the PET/CT study. This was compared with the histopathologic analysis.

RESULTS

Abnormal vulvar PET/CT uptake was found in 9 out of the 13 studies and invasion of adjacent structures in 5 of them (urethra, perineal, vagina). The inguinal-femoral lymph nodes were considered as affected in 3 studies and one pelvic lymph node was also affected. Four of the studies had extralymphatic involvement: 3 in lung and 1 in ischiorectal fossa. The PET/CT showed a 100% sensitivity for the detection of the vulvar lesion in squamous cell carcinomas and 60% in non-squamous cell ones. There was a false positive result for local invasion due to urine contamination. One of the studies with lung metastases was related to a synchronous breast tumor. All the pathological lymph node levels detected in the PET/CT study were confirmed in the histopathology study. No new lesions were identified by surgery. PET/CT changed the therapeutic management in 8/13 studies (61.5%).

CONCLUSIONS

PET/CT is postulated as a useful imaging test for the management of vulvar cancer, mainly in the identification of nodal metastases. It may affect both surgical planning and clinical management. Larger series are needed to confirm our findings.

Growth exponents reflect evolutionary processes and treatment response in brain metastases

Tumor growth is the result of the interplay of complex biological processes in huge numbers of individual cells living in changing environments. Effective simple mathematical laws have been shown to describe tumor growth in vitro, or simple animal models with bounded-growth dynamics accurately. However, results for the growth of human cancers in patients are scarce. Our study mined a large dataset of 1133 brain metastases (BMs) with longitudinal imaging follow-up to find growth laws for untreated BMs and recurrent treated BMs. Untreated BMs showed high growth exponents, most likely related to the underlying evolutionary dynamics, with experimental tumors in mice resembling accurately the disease. Recurrent BMs growth exponents were smaller, most probably due to a reduction in tumor heterogeneity after treatment, which may limit the tumor evolutionary capabilities. In silico simulations using a stochastic discrete mesoscopic model with basic evolutionary dynamics led to results in line with the observed data.

Growth dynamics of brain metastases differentiate radiation necrosis from recurrence

Background

Radiation necrosis (RN) is a frequent adverse event after fractionated stereotactic radiotherapy (FSRT) or single-session stereotactic radiosurgery (SRS) treatment of brain metastases (BMs). It is difficult to distinguish RN from progressive disease (PD) due to their similarities in the magnetic resonance images. Previous theoretical studies have hypothesized that RN could have faster, although transient, growth dynamics after FSRT/SRS, but no study has proven that hypothesis using patient data. Thus, we hypothesized that lesion size time dynamics obtained from growth laws fitted with data from sequential volumetric measurements on magnetic resonance images may help in discriminating recurrent BMs from RN events.

Methods

A total of 101 BMs from different institutions, growing after FSRT/SRS (60 PDs and 41 RNs) in 86 patients, displaying growth for at least 3 consecutive MRI follow-ups were selected for the study from a database of 1031 BMs. The 3 parameters of the Von Bertalanffy growth law were determined for each BM and used to discriminate statistically PDs from RNs.

Results

Growth exponents in patients with RNs were found to be substantially larger than those of PD, due to the faster, although transient, dynamics of inflammatory processes. Statistically significant differences (P < .001) were found between both groups. The receiver operating characteristic curve (AUC = 0.76) supported the ability of the growth law exponent to classify the events.

Conclusions

Growth law exponents obtained from sequential longitudinal magnetic resonance images after FSRT/SRS can be used as a complementary tool in the differential diagnosis between RN and PD.

POS1416 THE IMPACT OF NON-PERSISTENCE ON RESOURCE UTILIZATION COSTS IN IMMUNE-MEDIATED RHEUMATIC DISEASES

Background:

Rheumatoid arthritis (RA), psoriatic arthritis (PsA) and ankylosing spondylitis (AS) are chronic progressive immune-mediated rheumatic diseases (IMRD) that can cause a progressive disability and joint deformation and thus can impact in healthcare resource utilization (HCRU) and costs.

Objectives:

To describe the HCRU and treatment costs in IMRD patients initiating subcutaneous tumour necrosis factor-alpha inhibitors (SC-TNFi) therapy, based on treatment persistence.

Methods:

Retrospective cohort study including all naïve patients initiating SC-TNFi therapy for IMRD from 2015-2018 in a tertiary university hospital.

Patients were divided into two cohorts: persistent and non-persistent. Treatment persistence was estimated as the duration of time from SC-TNFi therapy initiation to discontinuation during one year of follow-up.

SC-TNFi therapy and HCRU costs (outpatient care, rheumatology specialized outpatient care, inpatient care, emergency care, laboratory testing and other non- biological therapies) were calculated one year before and after initiation of SC-TNFi and compared between persistence and non-persistence groups.

Results:

110 patients were identified.

Baseline characteristics: Non-persistent cohort (n=25) versus Persistent cohort (n=85): median age 48.6(12.7) vs 47.3(15.4) (p=0.692). Female (n=12;48%) vs (n=49;57.6%) (p=0.493). Race: Caucasian (n=22;88%), Asiatic (n=3;12%), Other (n=0;0%) vs Caucasian (n=75;88.2%), Asiatic (n=5;5.9%), Other (n=5;5.9%) (p=0.351).IMRD: RA (n=14;56%),PsA (n=2;8%), AS (n=4;16%), other spondyloarthropathy (n=5;20%) vs RA (n=34;40%),PsA (n=11;12.9%), AS (n=24;28.3%), other spondyloarthropathy (n=16;18.8%) (p=0.470). SC-TNFi therapy: adalimumab (n=4;16%), etanercept commercial (n=4;16%), etanercept biosimilar1 (n=5;20%), etanercept biosimilar2 (n=5;20%), golimumab (n=5;20%), certolizumab (n=2;8%) vs adalimumab (n=22;25.9%), etanercept commercial (n=11;12.9%), etanercept biosimilar1 (n=7;8.3%), etanercept biosimilar2 (n=10;11.8%), golimumab (n=24;28.2%), certolizumab (n=11;12.9%) (p=0.398).

Overall cost of SC-TNFi treatment: Non-persistent 11218.81€ (6444.32), persistent 10470.19€ (3465.48); p= 0.658.

Table 1.

HCRU costs

Non-persistent(n=25)Persistent(n=85)Total(n=110)PHCRU costs 12 months prior to SC-TNFi initiation,€(SD)Outpatient care243.48(828.86)87.17(293.61)122.70(471.20)0.204Rheumatology outpatient care216.39(169.88)174.79(101.06)184.24(120.55)0.224Inpatient care500.41(1542.93)170.34(846.47)245.36(1046.74)0.571Emergency care37.77(66.00)39.30(83.16)38.95(79.31) 0.850Laboratory testing376.12(195.59)388.20(207.07)385.46(203.70)0.458Other non-biological therapies10.77(39.83)36.79(250.55)30.88(221.01) 0.803Total1384.94(1816.17)896.60(1247.60)1007.59(1402.87)0.299HCRU costs 12 months post SC-TNFi initiation,€(SD)Outpatient care106.11 (172.85)76.67 (112.90)83.36 (128.67) 0.682Rheumatology outpatient care327.29(170.10)195.58(100.05)225.52(130.99)<0.001Inpatient care89.35(446.77)80.86(466.54)82.79(460.11) 0.969Emergency care89.14(171.89)36.06(106.23)48.12(125.31) 0.198Laboratory testing182.14(128.62)146.86(141.48)154.88(138.89) 0.061Other non-biological therapies3859.80(4043.86)25.89(116.05)897.24(2493.21)<0.001Total4653.84(4269.61)561.93(682.14)1491.91(2709.23)<0.001

Conclusion:

- Non-persistence was observed in less than a quarter of the patients.

- No differences in the costs of SC-TNFi treatment were observed between the persistent and non-persistent groups, leading us to believe that persistence may not be associated with SC-TNFi costs offsets for patients with IMRD.

- During the period post SC-TNFi initiation, the costs of rheumatologic outpatient care and treatment with other non-biological therapies as well as total costs were statistically significantly lower in the persistent cohort. These results suggest that persistence may be associated with HCRU cost savings for IMRD patients.

Disclosure of Interests:

None declared

AB0212 NON-ADHERENCE IN RHEUMATOLOGIC IMMUNE-MEDIATED DISEASES

Background:

Patient adherence is a key determinant of treatment success in rheumatologic immune-mediated diseases. Available data about adherence to biological treatments and factors associated to non-adherence is limited in Spain. Moreover, no studies compare adherence between subcutaneous and oral drugs.

Objectives:

To evaluate non-adherence to prescribed subcutaneous biologicals and oral drugs in patients with rheumatologic immune-mediated diseases and to assess possible predictor factors associated to treatment non-adherence.

Methods:

Retrospective observational study including all patients with oral and subcutaneous treatment for rheumatologic immune-mediated diseases from 2017 to 2019 in the outpatient pharmaceutical care area from a tertiary university hospital. Non-adherence was evaluated by reviewing all scheduled drug-dispensing visits in the computerized application. We considered non-adherent every time that a patient missed at least one drug administration.

Data collected: demographic, total patients and patient-treatments, total dispensing visits and route of administration for drug dispensed in every visit.

We classified patients in adherent and non-adherent considering dispensing visits. Non-adherent group: number of dispensing visits, reasons for non-adherence, number of missed administrations per patient and drug and predictor factors for non-adherence.

Results:

783 patients included: 52.4(13.7) years; 427(54.5%) female; 164 (20.9%) smoker; 697 (89%) Caucasian.

A total of 79 (10.1%) of 783 patients received more than one treatment.

869 patient-treatments: 294 adalimumab (33.8%), 236 etanercept (27.2%), 78 golimumab (8.9%), 47 apremilast (5.4%), 39 certolizumab (4.5%), 34 secukinumab (3.9%), 30 tocilizumab (3.5%).

9,197 dispensing visits. Route of administration: 6,406 subcutaneous (93.2%), 374 oral (6.8%).

Non-adherence analysis: 2417 (26.3%) dispensing visits, reasons for non-adherence/ dispensing visits: 92 unjustified (97.5%), 33 infection (1.4%), 18 (surgery) 0.7%, 3 pregnancy (0.1%), 6 others (0.3%).

Number of missed administrations/patient treatment: 675 patients missed at least one administration (77.7%).Mean 2.5 (±12.9) missed administrations.

Number of missed administrations/drug: 9.9 baricitinib (±20.8), 15.8 tofacitinib (±31.2), 25.4 apremilast (±53.2).

Predictor factors for non-adherence: ethnicity (p=0.015), treatment with golimumab (p=0.006), and tocilizumab (p=0.036). Age (p=0.072).

Conclusion:

- Non-adherence to the prescribed drug occurred in 77.7% of patients with rheumatologic immune-mediated diseases

- Demographic factors such as ethnicity as well as golimumab and tocilizumab treatment, despite their different frequency of administration, were predictors for non-adherence

- Route of administration did not influence non-adherence.

Disclosure of Interests:

None declared

Drug-related problems in patients admitted for SARS-CoV-2 infection during the COVID-19 pandemic

Introduction: Drug-related problems (DRP) are events or circumstances in which drug therapy does or could interfere with desired health outcomes. In December 2019, a new coronavirus, SARS-CoV-2, appeared. Little knowledge about this type of infection resulted in the administration of various drugs with limited use in other pathologies. Evidence about DRP in patients with COVID-19 is lacking. Objective: The aim of the present study is to describe identified cases of DRP and those drugs involved in the first wave of patients with COVID-19, and evaluate associated risk factors. Material and methods: Observational, retrospective study performed in a tertiary university hospital between 14th March 2020 and 31 May 2020 (corresponding to the first COVID-19 wave). We recruited patients admitted during the study period. Exclusion criteria included age < 18 years; admission to critically ill units; and care received either in the emergency room, at-home hospitalization or a healthcare center. Results: A total of 817 patients were included. The mean age was 62.5 years (SD 16.4) (range 18-97), and 453 (55.4%) were male. A total of 516 DRP were detected. Among the patients, 271 (33.2%) presented at least one DRP. The mean DRP per patient with an identified case was 1.9. The prevailing DRPs among those observed were: incorrect dosage (over or underdosage) in 145 patients (28.2%); wrong drug combination in 131 (25.5%); prescriptions not in adherence to the then COVID-19 treatment protocol in 73 (14.1%); prescription errors due to the wrong use of the computerized physician order entry in 47 (9.2%); and incorrect dosage due to renal function in 36 (7%). The logistic regression analysis showed that patients who received only prescriptions of antibacterials for systemic use (J01 ATC group) faced a higher likelihood of experiencing a DRP (OR 2.408 (1.071-5.411), p = 0.033). Conclusion: We identified several factors associated with an increased risk of DRPs, similar to those reported in other pre-pandemic studies, including a prolonged length of stay, higher number of prescribed drugs and antimicrobial administration. The relevance of pharmacists and tools like pharmacy warning systems can help prevent, identify and resolve DRP efficiently.

Is a blood sample for hemoglobins in the transfusional range reliable?

OBJECTIVE

To evaluate the correlation and agreement in our unit and population of hemoglobin in gasometry versus hematology analyzer, to evaluate errors in transfusion or lack thereof.

RESULTS

strong association between Point-of-care (POC) and hematimetry, with P<.001, with a coefficient of determination r² of 0.56, an intraclass correlation coefficient of 0.63 and a Lin's concordance correlation coefficient of 0.65. For hemoglobins less than 7g/dL, a success rate of 29.41% was obtained.

CONCLUSIONS

Low-moderate agreement of POC hemoglobin with standard haemothymetry. High probability of errors in the indication of transfusion based on gasometer hemoglobins, especially in low hemoglobins.

Morphological MRI features as prognostic indicators in brain metastases

BACKGROUND

Stereotactic radiotherapy is the preferred treatment for managing patients with fewer than five brain metastases (BMs). However, some lesions recur after irradiation. The purpose of this study was to identify patients who are at a higher risk of failure, which can help in adjusting treatments and preventing recurrence.

METHODS

In this retrospective multicenter study, we analyzed the predictive significance of a set of interpretable morphological features derived from contrast-enhanced (CE) T1-weighted MR images as imaging biomarkers using Kaplan-Meier analysis. The feature sets studied included the total and necrotic volumes, the surface regularity and the CE rim width. Additionally, we evaluated other nonmorphological variables and performed multivariate Cox analysis.

RESULTS

A total of 183 lesions in 128 patients were included (median age 61 [31-95], 64 men and 64 women) treated with stereotactic radiotherapy (57% single fraction, 43% fractionated radiotherapy). None of the studied variables measured at diagnosis were found to have prognostic value. However, the total and necrotic volumes and the CE rim width measured at the first follow-up after treatment and the change in volume due to irradiation can be used as imaging biomarkers for recurrence. The optimal classification was achieved by combining the changes in tumor volume before and after treatment with the presence or absence of necrosis (p <  < 0.001).

CONCLUSION

This study demonstrated the prognostic significance of interpretable morphological features extracted from routine clinical MR images following irradiation in brain metastases, offering valuable insights for personalized treatment strategies.