CT vs. MRI: Which is More Accurate in Grading Rectal Wall Infiltration after Hydrogel Spacer Placement for Prostate Cancer Patients?

PURPOSE/OBJECTIVE(S)

The purpose of this study was to evaluate the incidence and severity of rectal wall infiltration (RWI) in prostate cancer patients after rectal hydrogel spacer implantation, a commonly used procedure to minimize rectal radiation exposure during prostate radiotherapy. The study aimed to determine correlation of RWI using computed tomography (CT) scans and magnetic resonance imaging (MRI) scans in order to determine the optimal post-placement imaging modality.

MATERIALS/METHODS

This retrospective study was conducted on 370 patients diagnosed with localized prostate cancer who underwent rectal hydrogel spacer placement from 2020 to 2022. CT scans were performed on all patients, with a smaller subset also undergoing MRI scans. The images were independently evaluated by three radiation oncologists to grade RWI levels using a standardized scoring system based on CT and MRI images after hydrogel placement. The levels were categorized as 0 (no RWI), 1 (focal RWI), 2 (moderate RWI), and 3 (significant RWI).

RESULTS

Any grade of RWI was identified in 79.8% of men with the majority (41%) being RWI grade 1. The median time for CT scans was 9 days after hydrogel spacer placement and 14.5 days for MRI scans. For the subset of patients with both CT and MRI scans after spacer (mostly SpaceOAR Vue), RWI was detected in 58.33% of patients based on CT and 61.11% of patients based on MRI. Table 1 shows the mean percentage of patients with each score of RWI for each imaging modality. MRI was more likely to lead to a designation of RWI of any grade compared to CT and more often led to detection of RWI grades 2-3.

CONCLUSION

Our findings demonstrate that the incidence and severity of RWI may be higher than previously reported in clinical trials and that MRI may be a more sensitive imaging modality. Caution is needed in the utilization of rectal spacer gels given the potential for complications with misplacement prior to radiation therapy. Further study is warranted to determine the potential impact of low-grade RWI on the safety of subsequent treatment.

Selected-Lesion SRS as a Novel Strategy in Treatment of Patients with Multiple Brain Metastases

PURPOSE/OBJECTIVE(S)

With the increasing use of intracranial SRS (SRS) for treatment of patients with >10-15 brain metastases treatment; debate remains in the literature about how these patients should be treated. While many advocate for treatment of all lesions with either SRS or whole brain radiation therapy (WBRT), several groups are considering selected-lesion SRS (SL-SRS) where only a subset of intracranial lesions are treated. However, the current practice patterns of SL-SRS are not known.

MATERIALS/METHODS

A survey of 19 questions was created using open-ended and multiple-choice style questions on SL-SRS practices and indications. The survey was distributed to providers in the US and internationally who perform SRS frequently. Ten out of 50 institutions provided responses reflecting the practices of 16 providers. Descriptive statistics was used to compare answers to each question when applicable including percentages and ranges.

RESULTS

SL-SRS was performed at 8/10 institutions, (5 out of 6 US institutions and 3 out of 4 international institutions). Only 2 institutions had established clinical indications for SL-SRS (one in the US and one internationally) and one additional US institution reported clinical trials that require SL-SRS to study efficacy of CNS penetrating targeted therapies. One program reported research protocols for untreated brain metastases that would take priority over SL-SRS (program outside the US). Size of the lesion was cited as the most important factor (90%) when deciding to treat any single lesion. Next, lesion location and focal signs/symptoms were both considered moderately important. 80% ranked distance from prior SRS as the least important factor. Perilesional edema was also less important at most programs (90%). Lesion location and presence of symptoms were also considered important. There were several factors that would encourage providers to consider SL-SRS in a patient. Prior WBRT; progressing systemic disease and CNS-penetrating drug option available; and progressing systemic disease and immunotherapy option available were the most common responses. Most respondents cited "specific request by medical oncology" as well as "cooperative studies in this topic" as factors that might push them towards SL-SRS. Several institutions specified factors beyond the listed options. One institution reported that for patients with >20 lesions, they treated the largest lesions with SRS then follow with WBRT, termed the "pre-WBRT boost." Progression of untreated lesions was the most common reason why providers would bring back patients for additional treatment.

CONCLUSION

The responses to this survey demonstrate that patients with >15-20 intracranial lesions, prior WBRT, and worsening systemic disease with CNS penetrating systemic therapies available are being considered for SL-SRS.

Abstract P6-02-05: Downstream workup after post-treatment mammography in breast conservation therapy: Is there a significant difference between tomosynthesis and 2-dimensional mammograms?

Introduction:

Emerging data suggest that tomosynthesis mammograms (TS) are considerably superior to two-dimensional (2D) screening mammograms (2DMG) at reducing false positive biopsies for breast cancer screening. However, very little is reported about the comparative efficacy of the two modalities in the post-treatment setting. We compared the rate of downstream workup up after undergoing post-radiation screening 2DMG and TS following breast conservation therapy at our institution.

Methods:

Between the years 2011-2017, 712 breast cancer patients (range 31-91 years) were treated with lumpectomy and adjuvant radiotherapy. As per institutional standard, follow up included either screening 2DMG (n=569) or TS(n=143) and reviewed in this IRB-approved study. The primary endpoint for comparison was the rate of further imaging/workup post-treatment . Comparative analysis was conducted via multivariable binomial regression with propensity matching between the 2DMG and TS groups. Patients with clinical suspicion of recurrence otherwise were excluded.

Results:

The patient cohort in both groups included the following clinical characteristics,: 129 patients with ductal carcinoma in-situ (the remainder were invasive carcinoma; ductal or lobular). A total of 418 patients had T1 lesions, 143 T2, and 22 T3/T4. Eighty-five patients were node positive. Of those, 501 ER+/Her2-, 101 triple negative, and 96 triple positive. Adjuvant radiation included conventional fraction (457) or hypofractionation (153) with boost to the surgical cavity in523Accelerated Partial Breast Irradiation (APBI) was delivered in 106 patients. Post treatment scans occurred within 3 months (166), at 3-6 months (256), or 6+ months (281). The aforementioned characteristics were similarly distributed between 2DMG and TS groups, except for slightly more DCIS in the 2D group.

There was a significantly higher proportion of patients that were recommended for immediate downstream workup in the 2D group (40.7%) compared to in the tomo group (16.8%) (HR = 3.40, P <0.001), leading to 12 biopsies in the 2D group (3 positive) and 4 biopsies in the TS group (0 positive). Upon multivariate analysis, the use of tomo was the lone correlate of reduced downstream workup (p < 0.05), although there was a trend toward significance in patients who were first imaged at a post-treatment interval of 6+ months and in patients not undergoing a radiation boost (P < 0.10).

Conclusion:

Post-breast conservation follow-up with tomo synthesis mammography resulted in significantly less downstream workup as compared to conventional 2D screening mammography. Further investigation is warranted to unveil the absolute and relative cost-effectiveness between the two modalities.

Citation Format: Colosimo BL, Weinberger K, Hasan S, Gresswell S, Anderson S, Wegner RE, Trombetta M. Downstream workup after post-treatment mammography in breast conservation therapy: Is there a significant difference between tomosynthesis and 2-dimensional mammograms? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-02-05.

Re-irradiation with radiosurgery for recurrent glioblastoma multiforme

Local tumor control remains a significant challenge in patients with glioblastoma multiforme (GBM). Despite aggressive radiation therapy approaches, most recurrences are within the high-dose field, limiting the ability to safely re-irradiate recurrence using conventional techniques. Fractionated stereotactic radiosurgery (fSRS) is a technique whose properties make it useful for re-irradiation. We retrospectively reviewed the charts of 14 patients with recurrent GBM treated with salvage radiosurgery. Seven patients were male and seven were female with a median age of 58 (range: 39-76). All patients had prior cranial radiation therapy to a median dose of 60 Gy (58-69). There were 18 lesions treated with a median tumor volume of 6.97 cm3 (0.54-50.0 cm3). fSRS was delivered in 1-3 fractions to a median dose of 24 Gy (18-30 Gy). Median follow-up for the cohort was 8 months (3-22 months). On follow-up MRI, 8 of 18 lesions had a radiographic response. The median time-to-progression following primary irradiation was 8 months (1-28 months) while the median time-to-progression (TTP) following fSRS was 5 months (1-16 months). Median local control following re-irradiation was 5 months and actuarial local control was 21% at 1-year. Overall survival following primary irradiation was 79% at 12 months and 46% at 2 years. Overall survival following re-irradiation was 79% at 6 months and 30% at 1 year. No significant treatment-related toxicity was seen in follow-up. These results indicate that re-irradiation for recurrent GBM using fSRS is well-tolerated and can offer a benefit in terms of progression-free survival (PFS).

Aufgaben des ÖGD im Rahmen der Kinder- und Jugendgesundheit

Children and adolescents increasingly show health-related problems which may not be considered as diseases to be treated but nevertheless severely affect academic performance and social behaviour. Regarding the consequences, e.g. from the PISA study, the significance of health problems and their negative impact on academic success are still not sufficiently taken into account. The tasks of paediatric public health services include: (1) health promotion in schools and kindergartens, (2) preventive and other medical checkups in kindergartens and schools to detect the individual needs of children and adolescents for support, (3) reducing the risk of long-term damage in handicapped or retarded children and adolescents by seeking out these children where necessary, and (4) advising the political decision makers by reporting on the population's health and social situation. The main aim is to provide children with special needs with what they need in order to prevent them, especially those whose parents cannot ensure this support themselves, developing a deeper disturbance, or to make sure that these young people are able to participate in social life and to integrate into society in spite of health problems or handicaps. To achieve these goals and to improve the health of children and adolescents, a community-based paediatric public health service has to cooperate with other institutions such as youth authorities, social welfare, education authorities, schools and other local institutions with an input into the health of children and adolescents.

Deciding on radical prostatectomy: a patient's perspective

This article provides a review of one patient's experience with prostate cancer. It examines the various aspects of the decision-making process-the discovery of the disease, the research undertaken to learn about the disease and the treatment options, the decision as to course of action, the resultant radical prostatectomy, and the short- and long-term follow-up. Throughout the analysis, both the emotional aspects of dealing with the disease and the lessons that can be learned by both the patient and the physician are analyzed and discussed along with the information resources available. The concluding section discusses the critical role of the physician in the decision-making process, especially in the age of information technology and the resultant information overload.

Factor analysis of exercise capacity, dyspnoea ratings and lung function in patients with severe COPD

In this study we aimed to determine the relationship between exercise capacity, clinical ratings of dyspnoea and lung function parameters in patients with severe chronic obstructive pulmonary disease (COPD) by means of the statistical method of factor analysis. Sixty two patients (mean age +/- SD, 66 +/- 9 yrs) in stable clinical condition, with a forced expiratory volume in one second (FEV1) < 65% of predicted were investigated. Before the study, therapy was optimized, including inhaled bronchodilators, theophylline and steroids. Exercise capacity was determined from the best 6 min walking distance achieved in five self-paced treadmill walks performed on consecutive days. Lung function testing comprised spirometry and body plethysmography. Four different tools were chosen to rate dyspnoea and quality of life: the Baseline Dyspnoea Index (BDI), the Oxygen Cost Diagram (OCD), a modified Medical Research Council (MRC) Scale, and the Chronic Respiratory Disease Questionnaire (CRQ). Principal component factor analysis revealed that the data could be reduced to three hypothetical underlying variables (factors), which accounted for 79% of the total variance. BDI, MRC, OCD, CRQ and walking distance were attributed to the first factor, forced expiratory volume in one second and airway resistance to the second factor, and lung volumes to the third factor. Thus, our data suggest that the pathophysiological condition of severe COPD is characterized by three statistically independent entities: 1) exercise capacity, dyspnoea and quality of life ratings; 2) airway obstruction; and 3) pulmonary hyperinflation.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of theophylline withdrawal in severe chronic obstructive pulmonary disease

To determine the value of theophylline in the maintenance therapy of patients with severe chronic obstructive pulmonary disease (COPD), we conducted a trial of theophylline therapy withdrawal in 38 clinically stable patients with severe COPD (FEV1 < 60 percent) predicted. Symptoms, lung function, blood gases, and 6-min walking distance were assessed on days 1 and 2. Quality of life and overall dyspnea were scored using four different clinical rating scales. Theophylline therapy was continued in 20 patients and replaced by placebo from day 3 on in the remainder; measurements were repeated on days 5 and 6. Withdrawal of theophylline therapy resulted in significant (p < 0.05) deterioration in lung function, exercise performance, and two indices of overall dyspnea, and a significant increase in scoring of symptoms and auscultation findings. Individual analysis revealed a clinically relevant deterioration in 72 percent of patients from whom theophylline therapy was withdrawn, while only 15 percent of patients receiving theophylline exhibited deterioration. No major side effects were observed. Our data show that about half of the patients with severe COPD can be considered as theophylline responders. The response of these patients to withdrawal of theophylline therapy suggests that the clinical effectiveness of this drug cannot be explained exclusively by bronchodilation. Due to the inherent difficulties in predicting response to theophylline, its effectiveness in patients with severe COPD should be determined individually, including assessment of exercise performance and ratings of dyspnea.