Outcomes of Gamma Knife Radiosurgery for Brain Metastases in the Motor Cortex

BACKGROUND AND OBJECTIVES

To study the clinical, imaging, and survival outcomes in patients with motor cortex brain metastases treated with stereotactic radiosurgery (SRS).

METHODS

Imaging and clinical data were obtained from our prospective patient registry. Tumor volumes were obtained from serial imaging data.

RESULTS

The outcomes of 208 patients with metastases involving the motor cortex who underwent SRS between 2012 and 2021 were analyzed. A total of 279 metastases (0.01 cm 3 -12.18 cm 3 , mean 0.74 cm 3 ) were irradiated. The SRS margin dose varied from 10 to 20 Gy (mean 16.9 Gy). The overall tumor control rate was 97.8%. Perilesional edema was noted in 69 (25%) tumors at presentation. Adverse radiation effects (ARE) were noted in 6% of all tumors but were symptomatic in only 1.4%. Median time to appearance of symptomatic ARE was 8 months. Edema without ARE was observed in 13%. New focal seizures were noted in 5 patients (2%) and new generalized seizures in 1 patient (0.3%). Thirty-six patients (17%) presented with motor deficits. At final follow-up, 32 (85%) were improved or unchanged, 13 (41%) had a normal examination, 10 (31%) had mild deficits, and 9 (28%) still had moderate deficits. New remote brain metastases were found in 31% of patients at a median of 8 months. After treatment, the Karnofsky performance score distribution of the population showed an overall right shift and a median survival of 10 months. Patients with incidentally found brain metastases had significantly better survival than those presenting with deficits (median 13 vs 9 months) ( P = .048). Absence of a neurological deficit, recursive partitioning analysis Class I and II, and dose >18 Gy were each associated with a significant survival advantage.

CONCLUSION

SRS for motor cortex metastases is safe in most patients and effective in providing tumor control. Patients treated before neurological deficits develop show better outcomes.

Volumetric growth rate of incidentally found meningiomas on immunotherapy

PURPOSE

The expression of PD-L1 in high-grade meningiomas made it a potential target for immunotherapy research in refractory cases. Several prospective studies in this field are still on going. We sought to retrospectively investigate the effects of check-point inhibitors (CI) on meningiomas that had been naïve to either surgical or radiation approaches by following incidental meningiomas found during treatment with CI for various primary metastatic cancers.

METHODS

We used the NYU Perlmutter Cancer Center Data Hub to find patients treated by CI for various cancers, who also had serial computerized-tomography (CT) or magnetic-resonance imaging (MRI) reports of intracranial meningiomas. Meningioma volumetric measurements were compared between the beginning and end of the CI treatment period. Patients treated with chemotherapy during this period were excluded.

RESULTS

Twenty-five patients were included in our study, of which 14 (56%) were on CI for melanoma, 5 (20%) for non-small-cell lung cancer and others. CI therapies included nivolumab (n = 15, 60%), ipilimumab (n = 11, 44%) and pembrolizumab (n = 9, %36), while 9 (36%) were on ipilimumab/nivolumab combination. We did not find any significant difference between tumor volumes before and after treatment with CI (1.31 ± 0.46 vs. 1.34 ± 0.46, p=0.8, respectively). Among patients beyond 1 year of follow-up (n = 13), annual growth was 0.011 ± 0.011 cm3/year. Five patients showed minor volume reduction of 0.12 ± 0.10 cm3 (21 ± 6% from baseline). We did not find significant predictors of tumor volume reduction.

CONCLUSION

Check-point inhibitors may impact the natural history of meningiomas. Additional research is needed to define potential clinical indications and treatment goals.

Low-Dose Radiosurgery for Brain Metastases in the Era of Modern Systemic Therapy

BACKGROUND AND OBJECTIVES

Dose selection for brain metastases stereotactic radiosurgery (SRS) classically has been based on tumor diameter with a reduction of dose in the settings of prior brain irradiation, larger tumor volumes, and critical brain location. However, retrospective series have shown local control rates to be suboptimal with reduced doses. We hypothesized that lower doses could be effective for specific tumor biologies with concomitant systemic therapies. This study aims to report the local control (LC) and toxicity when using low-dose SRS in the era of modern systemic therapy.

METHODS

We reviewed 102 patients with 688 tumors managed between 2014 and 2021 who had low-margin dose radiosurgery, defined as ≤14 Gy. Tumor control was correlated with demographic, clinical, and dosimetric data.

RESULTS

The main primary cancer types were lung in 48 (47.1%), breast in 31 (30.4%), melanoma in 8 (7.8%), and others in 15 patients (11.7%). The median tumor volume was 0.037cc (0.002-26.31 cm 3 ), and the median margin dose was 14 Gy (range 10-14). The local failure (LF) cumulative incidence at 1 and 2 years was 6% and 12%, respectively. On competing risk regression analysis, larger volume, melanoma histology, and margin dose were predictors of LF. The 1-year and 2-year cumulative incidence of adverse radiation effects (ARE: an adverse imaging-defined response includes increased enhancement and peritumoral edema) was 0.8% and 2%.

CONCLUSION

It is feasible to achieve acceptable LC in BMs with low-dose SRS. Volume, melanoma histology, and margin dose seem to be predictors for LF. The value of a low-dose approach may be in the management of patients with higher numbers of small or adjacent tumors with a history of whole brain radio therapy or multiple SRS sessions and in tumors in critical locations with the aim of LC and preservation of neurological function.

EGFR-mutated non-small lung cancer brain metastases and radiosurgery outcomes with a focus on leptomeningeal disease

PURPOSE

Patients with EGFR-mutated NSCLC represent a unique subset of lung cancer patients with distinct clinical and molecular characteristics. Previous studies have shown a higher incidence of brain metastases (BM) in this subgroup of patients, and neurologic death has been reported to be as high as 40% and correlates with leptomeningeal disease (LMD).

METHODS

Between 2012 and 2021, a retrospective review of our prospective registry identified 606 patients with BM from NSCLC, with 170 patients having an EGFR mutation. Demographic, clinical, radiographic, and treatment characteristics were correlated to the incidence of LMD and survival.

RESULTS

LMD was identified in 22.3% of patients (n = 38) at a median follow-up of 19 (2-98) months from initial SRS. Multivariate regression analysis showed targeted therapy and a cumulative number of metastases as significant predictors of LMD (p = 0.034, HR = 0.44), (p = .04, HR = 1.02). The median survival time after SRS of the 170 patients was 24 months (CI 95% 19.1-28.1). In a multivariate Cox regression analysis, RPA, exon 19 deletion, and osimertinib treatment were significant predictors of overall survival. The cumulative incidence of neurological death at 2 and 4 years post initial stereotactic radiosurgery (SRS) was 8% and 11%, respectively, and correlated with LMD.

CONCLUSION

The study shows that current-generation targeted therapy for EGFR-mutated NSCLC patients may prevent the development and progression of LMD, leading to improved survival outcomes. Nevertheless, LMD is associated with poor outcomes and neurologic death, making innovative strategies to treat LMD essential.

Extended Survival in Patients With Non-Small-Cell Lung Cancer-Associated Brain Metastases in the Modern Era

BACKGROUND

Brain metastases (BM) have long been considered a terminal diagnosis with management mainly aimed at palliation and little hope for extended survival. Use of brain stereotactic radiosurgery (SRS) and/or resection, in addition to novel systemic therapies, has enabled improvements in overall and progression-free (PFS) survival.

OBJECTIVE

To explore the possibility of extended survival in patients with non-small-cell lung cancer (NSCLC) BM in the current era.

METHODS

During the years 2008 to 2020, 606 patients with NSCLC underwent their first Gamma Knife SRS for BM at our institution with point-of-care data collection. We reviewed clinical, molecular, imaging, and treatment parameters to explore the relationship of such factors with survival.

RESULTS

The median overall survival was 17 months (95% CI, 13-40). Predictors of increased survival in a multivariable analysis included age <65 years ( P < .001), KPS ≥80 ( P < .001), absence of extracranial metastases ( P < .001), fewer BM at first SRS (≤3, P = .003), and targeted therapy ( P = .005), whereas chemotherapy alone was associated with shorter survival ( P = .04). In a subgroup of patients managed before 2016 (n = 264), 38 (14%) were long-term survivors (≥5 years), of which 16% required no active cancer treatment (systemic or brain) for ≥3 years by the end of their follow-up.

CONCLUSION

Long-term survival in patients with brain metastases from NSCLC is feasible in the current era of SRS when combined with the use of effective targeted therapeutics. Of those living ≥5 years, the chance for living with stable disease without the need for active treatment for ≥3 years was 16%.

Stereotactic Radiosurgery for Intraventricular Metastases: A Multicenter Study

BACKGROUND

Intraventricular metastases (IVMs) are uncommon, and their optimal management remains debatable.

OBJECTIVE

To define the safety and efficacy of stereotactic radiosurgery (SRS) in the treatment of IVMs.

METHODS

This retrospective, multicenter study included patients managed with SRS for IVMs. SRS-induced adverse events, local tumor or intracranial progression, and the frequency of new-onset hydrocephalus or leptomeningeal spread were documented. Analyses of variables related to patient neuroimaging or clinical outcomes were also performed.

RESULTS

The cohort included 160 patients from 11 centers who underwent SRS for treatment of 1045 intracranial metastases, of which 196 were IVMs. The median survival from SRS was 10 months. Of the 154 patients and 190 IVMs with imaging follow-up, 94 patients (61%) experienced distant intracranial disease progression and 16 IVMs (8.4%) progressed locally. The 12- and 24-month local IVM control rates were 91.4% and 86.1%, respectively. Sixteen (10%) and 27 (17.5%) patients developed hydrocephalus and leptomeningeal dissemination post-SRS, respectively. Adverse radiation effects were documented in 24 patients (15%). Eleven patients (6.9%) died because of intracranial disease progression.

CONCLUSION

SRS is an effective treatment option for IVMs, with a local IVM control rate comparable with SRS for parenchymal brain metastases. Leptomeningeal spread and hydrocephalus in patients with IVM occur in a minority of patients, but these patients warrant careful follow-up to detect these changes.

Up-front single-session radiosurgery for large brain metastases-volumetric responses and outcomes

BACKGROUND

Patients presenting with large brain metastases (LBM) pose a management challenge to the multidisciplinary neuro-oncologic team. Treatment options include surgery, whole-brain or large-field radiation therapy (WBRT), stereotactic radiosurgery (SRS), or a combination of these.

OBJECTIVE

To determine if corticosteroid therapy followed by SRS allows for efficient minimally invasive care in patients with LBMs not compromised by mass effect.

METHODS

We analyzed the change in tumor volume to determine the efficacy of single-session SRS in the treatment of LBM in comparison to other treatment modalities. Twenty-nine patients with systemic cancer and brain metastasis (≥ 2.7 cm in greatest diameter) who underwent single-session SRS were included.

RESULTS

Among 29 patients, 69% of patients had either lung, melanoma, or breast cancer. The median initial tumor size (maximal diameter) was 32 mm (range 28-43), and the median initial tumor volume was 9.56 cm³ (range 1.56-25.31). The median margin dose was 16 Gy (range 12-18). The average percent decrease in tumor volume compared to pre-SRS volume was 55% on imaging at 1-2 months, 58% at 3-5 months, 64% at 6-8 months, and 57% at > 8 months. There were no adverse events immediately following SRS. Median corticosteroid use after SRS was 21 days. Median survival after radiosurgery was 15 months.

CONCLUSION

Initial high-dose corticosteroid therapy followed by prompt single-stage SRS is a safe and efficacious method to manage patients with LBMs (defined as ≥ 2.7 cm).

Modern Hearing Preservation Outcomes After Vestibular Schwannoma Stereotactic Radiosurgery

BACKGROUND

For patients with vestibular schwannoma (VS), stereotactic radiosurgery (SRS) has proven effective in controlling tumor growth while hearing preservation remains a key goal.

OBJECTIVE

To evaluate hearing outcomes in the modern era of cochlear dose restriction.

METHODS

During the years 2013 to 2018, 353 patients underwent Gamma knife surgery for VS at our institution. We followed 175 patients with pre-SRS serviceable hearing (Gardner-Robertson Score, GR 1 and 2). Volumetric and dosimetry data were collected, including biological effective dose, integral doses of total and intracanalicular tumor components, and hearing outcomes.

RESULTS

The mean age was 56 years, 74 patients (42%) had a baseline GR of 2, and the mean cochlear dose was 3.5 Gy. The time to serviceable hearing loss (GR 3-4) was 38 months (95% CI 26-46), with 77% and 62% hearing preservation in the first and second years, respectively. Patients optimal for best hearing outcomes were younger than 58 years with a baseline GR of 1, free canal space ≥0.041 cc (diameter of 4.5 mm), and mean cochlear dose <3.1 Gy. For such patients, hearing preservation rates were 92% by 12 months and 81% by 2 years, staying stable for >5 years post-SRS, significantly higher than the rest of the population.

CONCLUSION

Hearing preservation after SRS for patients with VS with serviceable hearing is correlated to the specific baseline GR score (1 or 2), age, cochlear dose, and biological effective dose. Increased tumor-free canal space correlates with better outcomes. The most durable hearing preservation correlates with factors commonly associated with smaller tumors away from the cochlea.

Preoperative flow analysis of arteriovenous malformations and obliteration response after stereotactic radiosurgery

OBJECTIVE

Morphological and angioarchitectural features of cerebral arteriovenous malformations (AVMs) have been widely described and associated with outcomes; however, few studies have conducted a quantitative analysis of AVM flow. The authors examined brain AVM flow and transit time on angiograms using direct visual analysis and a computer-based method and correlated these factors with the obliteration response after Gamma Knife radiosurgery.

METHODS

A retrospective analysis was conducted at a single institution using a prospective registry of patients managed from January 2013 to December 2019: 71 patients were analyzed using a visual method of flow determination and 38 were analyzed using a computer-based method. After comparison and validation of the two methods, obliteration response was correlated to flow analysis, demographic, angioarchitectural, and dosimetric data.

RESULTS

The mean AVM volume was 3.84 cm3 (range 0.64-19.8 cm3), 32 AVMs (45%) were in critical functional locations, and the mean margin radiosurgical dose was 18.8 Gy (range 16-22 Gy). Twenty-seven AVMs (38%) were classified as high flow, 37 (52%) as moderate flow, and 7 (10%) as low flow. Complete obliteration was achieved in 44 patients (62%) at the time of the study; the mean time to obliteration was 28 months for low-flow, 34 months for moderate-flow, and 47 months for high-flow AVMs. Univariate and multivariate analyses of factors predicting obliteration included AVM nidus volume, age, and flow. Adverse radiation effects were identified in 5 patients (7%), and 67 patients (94%) remained free of any functional deterioration during follow-up.

CONCLUSIONS

AVM flow analysis and categorization in terms of transit time are useful predictors of the probability of and the time to obliteration. The authors believe that a more quantitative understanding of flow can help to guide stereotactic radiosurgery treatment and set accurate outcome expectations.

LOCL-11 EGFR-MUTATED NON-SMALL CELL LUNG CANCER (NSCLC) LEPTOMENINGEAL DISEASE (LMD) IN A LARGE STEREOTACTIC RADIOSURGERY PATIENT COHORT: INCIDENCE AND OUTCOME

AIM

Patients with EGFR-mutated NSCLC brain metastases (BM) treated with targeted agents +/- radiosurgery (SRS) have increasing life expectancies. Systemic treatment may become less effective in preventing CNS progression as survival is prolonged. We sought to identify subsequent LMD in patients with EGFR-mutated NSCLC treated initially with SRS for BM and describe the associated features, treatment, and outcome.

METHODS

Review of our prospective Gamma Knife registry identified 177 patients with EGFR-mutated NSCLC between 2005 and 2021 treated with SRS. The EMR was queried for development of LMD, and type of LMD was recorded (focal/nodular or diffuse).

RESULTS

38 (21%) of the 177 patients developed LMD at a median of 10 months (range 1-25 IQR) following SRS. 27 (71%) of these were on tyrosine kinase inhibitors (TKI) at time of LMD diagnosis. Median overall survival (OS) from initial SRS for the entire cohort was 21 months (18-27 95%CI). Median OS after LMD diagnosis was 5 months (2-32 95%CI). LMD was diagnosed radiographically in 35 patients (92%); 20 patients had diffuse, 15 had focal/nodular, and 3 had positive CSF cytology. 26 (68%) had systemic progression synchronously with LMD. 33 (87%) had treatment for LMD including 19 with whole brain radiation therapy, 16 with the addition of or increased dosing of TKI, 6 with SRS for nodular disease, and 9 with intraventricular chemotherapy. The one- and two-year survival rates following the diagnosis of LMD was 21% and 3%, respectively.

CONCLUSION

LMD developed in a substantial subset of our patients, and despite the use of a variety of salvage therapies, survival was poor. Investigation to identify factors correlating with the development of LMD and those related to outcome are ongoing. The development of LMD on TKI in several of our patients supports efforts to pursue development of therapeutic agents with long-lasting CNS efficacy.

Volumetric growth rates of untreated cavernous sinus meningiomas

OBJECTIVE

Meningiomas that arise primarily within the cavernous sinus are often believed to be more indolent in their growth pattern. Despite this perceived growth pattern, disabling symptoms can arise even with small tumors. While research has been done on cavernous sinus meningiomas (CSMs) and their treatment, very little is known about their natural growth rates. With a better understanding of the growth rate of CSM, patient treatment and guidance can be can optimized and individualized. The goal of this study was to determine volumetric growth rates of untreated CSMs.

METHODS

Thirty-seven patients with 166 MR images obtained between May 2004 and September 2019 were reviewed, with a range of 2-13 MR images per patient (average of 4.5 MR images per patient). These scans were obtained over an average follow-up period of 45.9 months (median 33.8, range 2.8-136.9 months). All imaging prior to any intervention was included in this analysis. Volumetric measurements were performed and assessed over time.

RESULTS

The estimated volumetric growth rate was 23.3% per year (95% CI 10.2%-38.0%, p < 0.001), which is equivalent to an estimated volume doubling time (VDT) of 3.3 years (95% CI 2.1-7.1 years). There was no significant relationship between growth rate and patient age (p = 0.09) or between growth rate and patient sex (p = 0.78). The median absolute growth rate was 41% with a range of -1% to 1793%. With a definition of "growth" as an increase of greater than 20% during the observed period, 65% of tumors demonstrated growth within their observation interval. Growth rates for each tumor were calculated and tumors were segmented based on growth rate. Of 37 patients, 22% (8) demonstrated no growth (< 5% annual growth, equivalent to a VDT > 13.9 years), 32% (12) were designated as slow growth (annual growth rate 5%-20%, VDT 3.5-13.9 years), 38% (14) were found to have medium growth (annual growth rate 20%-100%, VDT 0.7-3.5 years), and 8% were considered fast growing (annual growth rate > 100%, VDT < 0.7 years).

CONCLUSIONS

This study evaluated CSM volumetric growth rates. A deeper understanding of the natural history of untreated CSMs allows for better counseling and management of patients.

Enumeration of Total Bacteria and Coliforms in Milk by Dry Rehydratable Film Methods: Collaborative Study

Eleven laboratories participated in a collaborative study to compare the dry rehydratable film (Petrifilm® SM and Petrifilm® VRB) methods, respectively, to the standard plate count (SPC) and violet red bile agar (VRBA) standard methods for estimation of total bacteria and coliform counts in raw and homogenized pasteurized milk. Each laboratory analyzed 16 samples (8 different samples in blind duplicate) for total count by both the SPC and Petrifilm SM methods. A second set of 16 samples was analyzed by the VRBA and Petrifilm VRB methods. The repeatability standard deviations (the square root of the between-replicates variance) of the SPC, Petrifilm SM, VRBA, and Petrifilm VRB methods were 0.0S104, 0.0444, 0.14606, and 0.13806, respectively; the reproducibility standard deviations were 0.7197, C.06380, 0.15326, and 0.13806, respectively. The difference between the mean Iog10 SPC and the mean logio Petrifilm SM results was 0.027. For the VRBA and Petrifilm VRB methods, the mean log10 difference was 0.013. These results generally indicate the suitability of the dry rehydratable film methods as alternatives to the SPC and VRBA methods for milk samples. The methods have been adopted official first action.

RADI-28. UP-FRONT SINGLE SESSION RADIOSURGERY FOR LARGE BRAIN METASTASES - VOLUMETRIC RESPONSES AND OUTCOMES

OBJECTIVE: Patients presenting with large brain metastases (LBM), described in the literature as ≥2.5 cm in maximum diameter or ≥10cm³in volume, pose a management challenge. For patients not compromised by mass effect, corticosteroid therapy followed by SRS allows for efficient, minimal access care that facilitates immediate institution of systemic therapy. METHODS: We performed a volumetric-based analysis in order to determine the efficacy of single-session SRS in the treatment of LBM in comparison to other treatment modalities. Thirty patients over the age of 18 with systemic cancer and brain metastases (≥2.7cm in greatest diameter or ≥10cm³in volume) who underwent single session SRS were included. Serial tumor volumes, clinical outcomes, and medication requirements were studied. RESULTS: Among 30 patients, 70% of patients had either lung, melanoma, or breast cancer. Median initial tumor size (maximum diameter) was 32mm (range 28–43) and median initial tumor volume was 9.32cm³ (range 1.09–25.31). Median marginal dose was 16Gy (range 12–18). Average percent decrease in tumor volume was 50% on imaging at 4–8 weeks, 60% at 4–6 months, 48% at 6–8 months, and 67% at >8 months compared to initial imaging. Only one patient required a subsequent craniotomy 4 years after SRS for an enlarging cyst which was granulation tissue consistent with radiation effects on pathology. There were no adverse events immediately following SRS. Median corticosteroid use after SRS was 21 days. There was no statistically significant difference in KPS score between treatment day and last follow up, suggesting relative safety and maintenance of function. CONCLUSION: Initial high dose corticosteroid therapy followed by prompt single session SRS is a safe and efficacious method of managing patients with large brain metastases (defined in our study as ≥2.7cm or ≥10cm³), if the clinical condition of the patient is acceptable at presentation.

Abstract P3-03-33: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Blackhall VI, Bugelli M, Abbott NA, Mullen R. Withdrawn [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 P3-03-33.

Perception of equivalent doses of neuroleptic drugs

An anonymous questionnaire was sent to 67 senior and junior psychiatrists enquiring about their perception of equivalent antipsychotic dosages of three commonly used neuroleptic drugs. Thirty-one questionnaires were returned and revealed a wide variation in perceived potencies for the specific drugs. Increased experience in psychiatry was not associated with a decreased variation. On average clinicians saw haloperidol and flupenthixol decanoate as substantially less potent, relative to chlorpromazine, than the available literature would suggest.

Gastric Schwannoma or GIST: accuracy of preoperative diagnosis?

Mesenchymal cell tumours of the gastrointestinal tract are rare in western society. Gastrointestinal stromal tumour (GIST) is the most common of this group of tumours. Gastric schwannoma is rarer, accounting for only 0.2% of all gastric tumours and 4% of all benign gastric neoplasms. Indeed, schwannoma has only been recognized as a primary gastrointestinal tumour in the last 20 years through advances in pathological techniques. We report a rare case of gastric schwannoma, the endoscopic and radiological features of which were indistinguishable from a GIST. Due to the diagnostic uncertainty, surgical resection is the treatment of choice. Development of more reliable diagnostic methods, such as endoscopic core biopsy, may help the accuracy of preoperative diagnosis.

P3-12-04: Involved Anterior Margins after Breast Conserving Surgery: Is Re-Excision Required?

Background: Complete tumour excision in breast conserving surgery (BCS) is critical for successful treatment; involved circumferential resection margins are associated with increased disease recurrence. However, the importance of an involved anterior margin is less clear. The purpose of this study was to audit an aggressive approach to involved anterior margins and hence assess whether anterior margin re-excision yields clinical benefit.

Material and Methods: A retrospective case note and pathology review was performed for all patients who underwent BCS between 2006 and 2010 through a single cancer centre. An involved margin was defined as &lt;1mm clearance of invasive or in situ breast cancer. Results: 1667 patients underwent BCS for invasive and/or in-situ disease, of whom 114 (6.8%) underwent re-excision, most commonly for mixed invasive and in-situ pathology. The annual re-excision rate rose significantly (p&lt;0.001), with no change in whole tumour diameter, specimen weight or specimen volume. A total of 170 involved margins were identified: most commonly the anterior margin (59 margins, 30.6%) followed by the posterior (39 22.9%) or inferior (31, 18.3%) margin. Patients with anterior margin involvement were more likely to have grade 3 invasive disease (p=0.0323) but less likely to have residual disease found at re-excision (2/49 vs. 32/101 margins, p=0.0033); there were no differences when in-situ characteristics were compared.

Conclusions: Re-excision of involved anterior margins rarely excises residual disease and may be unnecessary. Multidisciplinary teams should consider whether further therapy for an involved anterior margin is required on a patient by patient basis.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-12-04.

MR imaging of fistula in ano: indications and contribution to surgical assessment

BACKGROUND

Magnetic Resonance Imaging (MRI) is the imaging modality of choice for fistula in ano. The purpose of this study was to analyse the use of MRI, and to assess its contribution towards the assessment of this sometimes difficult condition.

METHODS

A retrospective analysis of all patients with fistula in ano between January 2003 and December 2007 was performed, focussing on those who had MRI assessment. The primary pathology, indication for MRI and the contribution of this investigation to assessment of fistula in ano were analysed.

RESULTS

MRI was performed in 40 patients. The primary pathologies included: perianal sepsis in 20 (50%), Crohn's disease in 11 (27.5%), primary fistula in ano in 6 (15%) and others in 3 (7.5%) patients. Indications for MRI were to assess the fistula anatomy in 17 (42.5%), to assess a clinically suspected fistula in 12 (30%), to assess a complex fistula found at Examination Under Anaesthesia (EUA) in 6 (15%) and to exclude a fistula in 5 (12.5%). MRI was considered helpful in 34 (85%) of all cases. MRI established the fistula anatomy and guided further surgery in 47.1%, correlated with EUA findings in 38.2% and excluded a suspected fistula in 14.7% of these.

CONCLUSIONS

This study further supports the benefit of using MRI to assess fistula in ano. When used in selected patients, it was of benefit in 85% of cases, by establishing fistula anatomy and guiding further surgery, correlating EUA findings or excluding a clinically suspected fistula.

Outcome of right- and left-sided colonic and rectal cancer following surgical resection

AIM

To determine the outcome of surgery for colorectal cancer from a single region and to see whether location of the primary cancer influences prognosis.

METHOD

Patients with colorectal cancer diagnosed from January 2002 to December 2006, entered into a prospective database were followed until death or to December 2008. Right-sided (caecum to transverse colon) and left-sided (splenic flexure to rectosigmoid junction) colonic cancers and rectal cancers (distal to rectosigmoid junction to the anus) were identified. Statistical analysis was performed using Pearson's chi-square test, Kaplan-Meier (log-rank statistic) and Cox regression analysis with a P-value < 0.05 denoting significance.

RESULTS

Of 841 patients with solitary colorectal cancers identified (median age 72 [30-101] years; 53% male), 283 (33.7%) were right-sided colonic, 330 (39.2%) were left-sided colonic and 228 (27.1%) were rectal. Respective resection rates were 82.7%, 77.9% and 91.6%, and curative resection rates were 79.9%, 82.9.0% and 85.7%, respectively. There was no significant difference in recurrence rates between right- (16.1%), left-sided (23.0%) colonic and rectal (20.7%) cancers (P = 0.207). Respective mean survival rates were 54.4, 59.8 and 63.6 months (P = 0.007).

CONCLUSION

Right-sided colorectal cancers had a worse prognosis than left-sided and rectal cancers, possibly because of more advanced staging and fewer curative resections.

Workforce mobility in the pharmacy profession

Focal points

Personality disorder and competence to refuse treatment

The traditional view that having a personality disorder, unlike other mental disorders, is not usually reason enough to consider a person incompetent to make healthcare decisions is challenged. The example of a case in which a woman was treated for a physical disorder without her consent illustrates that personality disorder can render a person incompetent to refuse essential treatment, particularly because it can affect the doctor-patient relationship within which consent is given.

Somatic characteristics and cardiovascular risk factors in growth hormone deficiency: A randomized, double-blind, placebo-controlled study of the effect of treatment with recombinant human growth hormone

The purpose of the present study was to identify the effect of treatment with recombinant human growth hormone (rhGH) on seven somatic characteristics and eight clinical cardiovascular risk factors. Twenty-seven male and 24 female patients between the ages of 21 and 60 years were examined. The investigation was a double-blind, placebo-controlled study of 12 months duration. Patients were assigned randomly to treatment (T) and placebo (P) groups. In the first 6 months group T received rhGH and group P placebo. In the second 6 months both groups received rhGH. Complete data were available for 23 males and 20 females. Increments were calculated between 6 months -BL (increment 1) and 12-6 months (increment 2) in both T and P groups. Apart from the somatotype, data were analysed with a 2 x 2 mixed analysis of variance (ANOVA) using treatment (rhGH and placebo) and time (increments 1 and 2). Somatotype data were analysed using a 2 x 3 multivariate ANOVA. Three significant interactions were identified in males: waist circumference (P = 0.006), trunk fat (P = 0.0001), and conicity index (P = 0.001). The only significant interaction in females was trunk fat (P = 0.006). In general, treatment and placebo groups responded differently by time and treatment. Responses were similar in males and females. In the first 6 months when group P was on placebo, waist circumference, trunk fat, and conicity index increased slightly; with group T on rhGH somatic variables declined markedly. In the second 6 months when both groups received rhGH there was a marked decline in group P and a continued decline (but less steeply) in group T. In males there were significant decreases in endomorphy in group T and increases in mesomorphy in group P. In females the somatotype remained stable. There were no significant interactions in clinical cardiovascular risk factors in either males or females. Favourable responses occurred in male and female lipid profiles, although these were not significant. It was concluded that in males waist circumference, trunk fat, conicity index, and somatotype responded significantly to treatment with rhGH; in females the only significant response was trunk fat.

Adhesion Failure in Bonded Rubber Cylinders Part 2: Fatigue Life Prediction of External Ring-Shaped Cracks Using Tearing Energy Approach

Rubber disks bonded between flat parallel metal plates are often used as adhesion test specimens; for example, ASTM D 429 1999, Method A. However, the mechanics of adhesion failure (debonding) for this geometry have not previously been fully analyzed. Therefore, a study was conducted to determine the strain energy release rate (tearing energy) for bonded rubber disks having external ring cracks at the rubber-to-metal bond and to develop a method for predicting the fatigue life.

Finite element analysis was used to determine the tearing energy as a function of crack length for disks of various dimensions (shape factors). The crack configurations considered were an external-ring-shaped crack located at the outside circumference of either one or both rubber-to-metal bonds. The fatigue crack propagation (FCP) behavior was characterized for a generic filled natural rubber material.

The tearing energy was found to be a non-linear function of crack length. For small cracks, the tearing energy was small and approached zero as the crack length decreased. The tearing energy then increased as the crack grew, indicating accelerating growth, until it passed through a maximum value. The peak tearing energy was found to depend on the height of the disk. Finally at large cracks, the tearing energy decreased or was essentially constant as the crack grew.

The fatigue life of the rubber cylinders at different shape factors was determined experimentally. An empirical model coupled with the fatigue crack propagation behavior (FCP) for the material at different tearing energies was used to predict the fatigue life. The experimental and predicted fatigue life showed excellent agreement at low and moderate shape factors. However at high shape factors, fatigue life was not well predicted. From the experimental results, it was found that, at high shape factors, cavitation occurs causing a series of “dimples” to form, which leads to the development of an internal penny-crack, thereby violating the assumed model of an external ring-shaped crack.

Parents' perspectives on the MMR immunisation: a focus group study

BACKGROUND

The uptake of the combined measles, mumps and rubella immunisation (MMR) in Britain has fallen since 1998, when a link was hypothesised with the development of bowel disorders and childhood autism. Despite reassurances about the safety of MMR, uptake levels remain lower than optimal. We need to understand what influences parents' decisions on whether to accept MMR or not so that health professionals can provide a service responsive to their needs.

AIM

To investigate what influences parents' decisions on whether to accept or refuse the primary MMR immunisation and the impact of the recent controversy over its safety.

DESIGN

Qualitative study using focus group discussions.

SETTING

Forty-eight parents, whose youngest child was between 14 months and three years old, attended groups at community halls in six localities in Avon and Gloucestershire.

METHODS

Purposive sampling strategy was used to include parents from a variety of socioeconomic backgrounds. Three groups comprised parents who had accepted MMR and three groups comprised parents who had refused MMR. Data analysis used modified grounded theory techniques incorporating the constant comparative method.

RESULTS

All parents felt that the decision about MMR was difficult and stressful, and experienced unwelcome pressure from health professionals to comply. Parents were not convinced by Department of Health reassurances that MMR was the safest and best option for their children and many had accepted MMR unwillingly. Four key factors influenced parents' decisions: (a) beliefs about the risks and benefits of MMR compared with contracting the diseases, (b) information from the media and other sources about the safety of MMR, (c) confidence and trust in the advice of health professionals and attitudes towards compliance with this advice, and (d) views on the importance of individual choice within Government policy on immunisation.

CONCLUSIONS

Parents wanted up-to-date information about the risks and benefits of MMR to be available in advance of their immunisation appointment. Many parents did not have confidence in the recommendations of health professionals because they were aware that GPs needed to reach immunisation targets. Most parents would, however, welcome more open discussion about immunisation with health professionals.

Effect of task-relevant cues and state anxiety on motor performance

12 experienced, female trampolinists participated in a field study designed to test the conscious processing hypothesis, which predicts that the combination of task-relevant knowledge and high state anxiety will impair motor performance. Results supported the hypothesis; however, an alternative attentional explanation of the data was also identified.

State anxiety and motor performance: testing the conscious processing hypothesis

Previous research has argued that skills acquired explicitly are more likely to fail under stressful conditions than skills that have been learned implicitly. The present study addressed an alternative explanation for the robustness under stress of implicit task performance. As implicit learners acquired the skill of golf putting while generating random letters, it is possible that they became desensitized to self-generated verbalizations and thus immune to the effects of competitive anxiety. We tested this interpretation while controlling for a further rival hypothesis generated by Eysenck's Processing Efficiency Theory. We also examined the effect of increased state anxiety on the kinematic processes underlying performance breakdowns. For task performance, we found evidence that partially supported the conscious processing hypothesis, while the results of the kinematic analysis of the putting stroke were equivocal. Analysis of self-reported effort scores provided partial support for processing efficiency theory.

Intensity and direction of competitive state anxiety as interpreted by rugby players and rifle shooters

This study reports the findings of part of an ongoing research program examining sports performers' interpretations of competitive anxiety prior to competition. The notion of 'directional perceptions' has questioned the limited utility of examining only the intensity of competitive anxiety responses as has Jones. The purpose of this study was to examine intensity and direction, i.e., interpretation of intensity as facilitative or debilitative, of anxiety symptoms as a function of two types of sport. The types of sport were explosive (rugby league) versus fine motor skills (target rifle shooting). The sample comprised 50 male rugby league participants and 50 target rifle shooters who completed a modified version of the Competitive State Anxiety Inventory-2 prior to competition. Contingency analysis yielded a significant difference in the number of rugby players who reported somatic anxiety as facilitative and the number of rifle shooters who reported somatic states as debilitative. No such differences were evident for cognitive anxiety. Analysis of variance indicated no differences between the two groups on the intensity of cognitive and somatic anxiety, but the performers competing in rugby league interpreted both states as being more facilitative to performance; the rugby league players also had higher scores on self-confidence than the shooters. These findings provide continuing support for the measurement of directional perceptions of competitive anxiety and highlight the importance of examining individual sports.

A Jamaican psychiatrist evaluates diagnoses at a London psychiatric hospital

BACKGROUND

Authors have suggested that the high rate of schizophrenia reported for African-Caribbeans living in the UK is due to misdiagnosis by British psychiatrists.

AIMS

To compare the diagnoses made by a Black Jamaican psychiatrist with those of White British psychiatrists.

METHOD

All in-patients on four wards at the Maudsley hospital were approached for the study; 66 participated: 24 White, 29 Black African-Caribbeans and 13 Blacks from other countries of origin. F.W.H., a Black Jamaican psychiatrist, conducted his standard clinical assessment and performed the Present State Examination (PSE) on these patients. His diagnoses were compared with the case note diagnoses made by British psychiatrists, and with the PSE CATEGO diagnoses.

RESULTS

Of 29 African and African-Caribbean patients diagnosed with schizophrenia, the diagnoses of the British and the Jamaican psychiatrists agreed in 16 instances (55%) and disagreed in 13 (45%). Hence, interrater reliability was poor (kappa = 0.45). PSE CATEGO diagnosed a higher proportion of subjects as having schizophrenia than the Jamaican psychiatrist did (chi 2 = 3.74, P = 0.052).

CONCLUSIONS

Agreement between the Jamaican psychiatrist and his UK counterparts about which patients had schizophrenia was poor. PSE CATEGO may overestimate rates of schizophrenia.

Knowledge and conscious control of motor actions under stress

A recent study by Masters (1992) investigated the effect of stress upon the performance of a well-learned motor skill, golf putting, acquired under implicit and explicit learning conditions. Masters found that stress had a detrimental effect on performance for the explicit learning group but not for the implicit learning group. However, the implicit learning group was required to perform articulatory suppression during the learning trials but not during the stress trials. As such, it is possible that the subjects in the implicit learning group continued to improve during the stress session simply because they were performing an easier task. This paper reports an experiment which re-examines Masters' (1992) conclusions by replicating and extending his method. An additional implicit learning group was included which was required to carry out articulatory suppression during both the learning trials and the stress trials. It was hypothesized that this 'new' implicit learning group would suffer the same disruption to performance as the explicit learning group, providing evidence which would contradict Masters' explanation. Thirty-two subjects were allocated to one of four groups. Performance measures were analysed using two-factor analysis of variance (4 x 5: groups x sessions) with repeated measures on the sessions factor. The main dependent variable was the number of putts successfully completed. The analysis revealed that both the implicit learning groups continued to improve their performance under stress whilst the explicit learning group did not. Despite limitations to both Masters' (1992) and the present study, these results add support to Masters' explicit knowledge hypothesis.

White matter signal hyperintensities in the brains of patients with late paraphrenia and the normal, community-living elderly

We determined the prevalence and anatomical location of areas of white matter hyperintensity visualized by magnetic resonance imaging in the brains of 38 late paraphrenic patients with an onset of psychotic illness after the age of 60 and 31 healthy aged community volunteers. All degrees of white matter signal hyperintensity were very common in both groups, and there was no excess of such changes in the brain of patients. Periventricular white matter and subcortical grey matter hyperintensities were significantly associated with both measured diastolic and systolic blood pressure in patients and control subjects. Periventricular and deep white matter, together with subcortical grey matter hyperintensities, were significantly associated with increased age. The excess of such presumed brain-imaging abnormalities previously reported in patients with an onset of psychosis late in life may be a consequence of earlier authors' failure to include examination of appropriate community control populations and to carefully exclude patients with evidence of stroke.

A double-blind comparison of moclobemide and fluoxetine in the treatment of depressive disorders

Moclobemide and fluoxetine were tested in a six-week trial involving 122 patients with major depressive illness. Patients initially received moclobemide, 150 mg three times daily, or fluoxetine 20 mg/day, but during weeks 3, 4, 5 and 6 the doses could be altered, giving a range of 300-600 mg/day for moclobemide or 20-40 mg/day for fluoxetine. No dietary restrictions were imposed on the patients. The trial was completed by 49 patients receiving moclobemide, and 43 patients receiving fluoxetine. The efficacies of these two agents, as determined on the Hamilton Depression Rating Scale and from Clinical Global Assessments, were found not to differ significantly. The frequencies of occurrence of adverse reactions were also similar, but sedation, nausea and vomiting were reported more frequently with fluoxetine, and insomnia was experienced with moclobemide. Tolerance of both drugs was judged to be high.

Bacillus stearothermophilus Disc Assay for Detection of Inhibitors in Milk: Collaborative Study

A 2-part (A and B) collaborative study was conducted on a Bacillus stearothermophilus paper disc (12.7 mm) method to detect residual inhibitors in milk. The 18 participating collaborators assayed raw milk samples spiked with a beta-lactam (penicillin G). Of the 18 collaborators, 14 participated in part A and 16 in part B. Part A demonstrated that either Antibiotic Medium No. 4 or PM Indicator Agar is suitable for use in the assay. The lowest concentration detectable, not significantly different from 100% at the α = 0.05 level, was 0.008 unit/mL with either medium. Part B demonstrated that the sensitivity of the method is equal to that of the current AOAC method (16.131- 16.136). The concentration of beta-lactam detected by 50% of the analysts was 0.003-0.005 unit/mL in this study, compared with 0.005 unit/mL reported in an earlier collaborative study on the current AOAC method. No false positive results were reported in part A or part B. All samples found positive by the confirmatory test in part B were correctly identified as a beta-lactam with commercial Penase discs. The lowest concentration detectable by the method, not significantly different from 100% at the α = 0.05 level, was 0.008 unit/mL. The method was adopted official first action.

Determination of Alkaline Phosphatase in Casein: Collaborative Study

A collaborative study was made to determine alkaline phosphatase in casein samples by the rapid colorimetric test. Six to eight collaborators tested 10 unknown casein samples containing various amounts of residual phosphatase with and without the addition of magnesium acetate. Results indicated that magnesium acetate significantly increased phosphatase activity. The collaborators correctly analyzed 95% of the samples with the added magnesium acetate. The method has been adopted official first action.

Determination of alkaline phosphatase in casein: collaborative study

A collaborative study was made to determine alkaline phosphatase in casein samples by the rapid colorimetric test. Six to eight collaborators tested 10 unknown casein samples containing various amounts of residual phosphatase with and without the addition of magnesium acetate. Results indicated that magnesium acetate significantly increased phosphatase activity. The collaborators correctly analyzed 95% of the samples with the added magnesium acetate. The method has been adopted official first action.