Efficacy of Laser Interstitial Thermal Therapy (LITT) for Biopsy-Proven Radiation Necrosis in Radiographically Recurrent Brain Metastases

Background

LITT (laser interstitial thermal therapy) in the setting of post-SRS radiation necrosis (RN) for patients with brain metastases has growing evidence for efficacy. However, questions remain regarding hospitalization, local control, symptom control, and concurrent use of therapies.

Methods

Demographics, intraprocedural data, safety, Karnofsky performance status (KPS) and survival data were prospectively collected then analyzed on patients consented between 2016-2020 and who were undergoing LITT for biopsy-proven RN at one of 14 U.S. centers. Data was monitored for accuracy. Statistical analysis included individual variable summaries, multivariable Fine and Gray analysis, and Kaplan Meier estimated survival.

Results

Ninety patients met the inclusion criteria. Four patients underwent two ablations on the same day. Median hospitalization time was 32.5hrs. The median time to corticosteroid cessation after LITT was 13.0 days (0.0, 1229.0) and cumulative incidence of lesional progression was 19% at 1-year. Median post-procedure overall survival was 2.55 years [1.66, infinity] and 77.1% at one year as estimated by Kaplan Meier. Median KPS remained at 80 through 2-year follow-up. Seizure prevalence was 12% within 1-month post-LITT and 7.9% at three months; down from 34.4% within 60-days prior to procedure.

Conclusions

LITT for RN was not only again found to be safe with low patient morbidity but was also a highly effective treatment for RN for both local control and symptom management (including seizures). In addition to averting expected neurological death, LITT facilitates ongoing systemic therapy (in particular immunotherapy) by enabling the rapid cessation of steroids, thereby facilitating maximal possible survival for these patients.

Association of Autologous Tumor Lysate-Loaded Dendritic Cell Vaccination With Extension of Survival Among Patients With Newly Diagnosed and Recurrent Glioblastoma: A Phase 3 Prospective Externally Controlled Cohort Trial

Importance

Glioblastoma is the most lethal primary brain cancer. Clinical outcomes for glioblastoma remain poor, and new treatments are needed.

Objective

To investigate whether adding autologous tumor lysate-loaded dendritic cell vaccine (DCVax-L) to standard of care (SOC) extends survival among patients with glioblastoma.

Design, Setting, and Participants

This phase 3, prospective, externally controlled nonrandomized trial compared overall survival (OS) in patients with newly diagnosed glioblastoma (nGBM) and recurrent glioblastoma (rGBM) treated with DCVax-L plus SOC vs contemporaneous matched external control patients treated with SOC. This international, multicenter trial was conducted at 94 sites in 4 countries from August 2007 to November 2015. Data analysis was conducted from October 2020 to September 2021.

Interventions

The active treatment was DCVax-L plus SOC temozolomide. The nGBM external control patients received SOC temozolomide and placebo; the rGBM external controls received approved rGBM therapies.

Main Outcomes and Measures

The primary and secondary end points compared overall survival (OS) in nGBM and rGBM, respectively, with contemporaneous matched external control populations from the control groups of other formal randomized clinical trials.

Results

A total of 331 patients were enrolled in the trial, with 232 randomized to the DCVax-L group and 99 to the placebo group. Median OS (mOS) for the 232 patients with nGBM receiving DCVax-L was 19.3 (95% CI, 17.5-21.3) months from randomization (22.4 months from surgery) vs 16.5 (95% CI, 16.0-17.5) months from randomization in control patients (HR = 0.80; 98% CI, 0.00-0.94; P = .002). Survival at 48 months from randomization was 15.7% vs 9.9%, and at 60 months, it was 13.0% vs 5.7%. For 64 patients with rGBM receiving DCVax-L, mOS was 13.2 (95% CI, 9.7-16.8) months from relapse vs 7.8 (95% CI, 7.2-8.2) months among control patients (HR, 0.58; 98% CI, 0.00-0.76; P < .001). Survival at 24 and 30 months after recurrence was 20.7% vs 9.6% and 11.1% vs 5.1%, respectively. Survival was improved in patients with nGBM with methylated MGMT receiving DCVax-L compared with external control patients (HR, 0.74; 98% CI, 0.55-1.00; P = .03).

Conclusions and Relevance

In this study, adding DCVax-L to SOC resulted in clinically meaningful and statistically significant extension of survival for patients with both nGBM and rGBM compared with contemporaneous, matched external controls who received SOC alone.

Trial Registration

ClinicalTrials.gov Identifier: NCT00045968.

Research quality and transparency, outcome measurement and evidence for safety and effectiveness in robot-assisted surgery: systematic review

BACKGROUND

Robot-assisted surgery (RAS) has potential panspecialty surgical benefits. High-quality evidence for widespread implementation is lacking. This systematic review aimed to assess the RAS evidence base for the quality of randomized evidence on safety and effectiveness, specialty 'clustering', and outcomes for RAS research.

METHODS

A systematic review was undertaken according to PRISMA guidelines. All pathologies and procedures utilizing RAS were included. Studies were limited to RCTs, the English language and publication within the last decade. The main outcomes selected for the review design were safety and efficacy, and study purpose. Secondary outcomes were study characteristics, funding and governance.

RESULTS

Searches identified 7142 titles, from which 183 RCTs were identified for data extraction. The commonest specialty was urology (35·0 per cent). There were just 76 unique study populations, indicating significant overlap of publications; 103 principal studies were assessed further. Only 64·1 per cent of studies reported a primary outcome measure, with 29·1 per cent matching their registration/protocol. Safety was assessed in 68·9 per cent of trials; operative complications were the commonest measure. Forty-eight per cent of trials reported no significant difference in safety between RAS and comparator, and 11 per cent reported RAS to be superior. Efficacy or effectiveness was assessed in 80·6 per cent of trials; 43 per cent of trials showed no difference between RAS and comparator, and 24 per cent reported that RAS was superior. Funding was declared in 47·6 per cent of trials.

CONCLUSION

The evidence base for RAS is of limited quality and variable transparency in reporting. No patterns of harm to patients were identified. RAS has potential to be beneficial, but requires continued high-quality evaluation.

SURG-12. PREDICTORS OF SURVIVAL AND UTILITY OF INTRAOPERATIVE MRI FOR RESECTION OF GRADE II ASTROCYTOMAS AND OLIGODENDROGLIOMAS: A MULTICENTER ANALYSIS

BACKGROUND

Few studies use large, multi-institutional patient cohorts to examine the role of intraoperative MRI (iMRI) in the resection of grade II gliomas. We assessed the impact of iMRI and other factors on overall survival (OS) and progression-free survival (PFS) for newly-diagnosed grade II astrocytomas and oligodendrogliomas.

METHODS

Retrospective analyses of a multicenter database assessed the impact of patient-, treatment-, and tumor-related factors on OS/PFS.

RESULTS

232 resections (112 astrocytomas, 120 oligodendrogliomas; 135 males; mean age 36.2 ± 0.9 years) were analyzed. Oligodendrogliomas had longer OS (p&lt; 0.001) and PFS (p=0.009) than astrocytomas. Multivariate regression showed that extent of resection (EOR), including gross-total (GTR) versus near-total (NTR) resection (p=0.02, HR: 0.64, 95% CI: 0.25-.79) and GTR versus subtotal resection (STR) (p=0.006, HR: 0.23, 95% CI: 0.08-0.66), was associated with longer OS. GTR versus NTR (p=0.04, HR: 0.49, 95% CI: 0.29-.85), GTR versus STR (p=0.02, HR: .54, 95% CI: .32-.91) and iMRI use (p=0.02, HR: 0.54, 95% CI: 0.32-0.92) were associated with longer PFS. Frontal (p=0.048, HR: 2.11, 95% CI: 1.01-4.43) and occipital/parietal (p=0.003, HR: 3.59, 95% CI: 1.52-8.49) locations were associated with shorter PFS (versus temporal). Kaplan-Meier analyses showed longer OS with increasing EOR (p=0.03) and 1p/19q gene deletions (p=0.02). PFS improved with increasing EOR (p=0.01), GTR versus NTR (p=0.02), and resections above STR (p=0.04). Factors influencing adjuvant treatment (35.3% of patients) included age (p=0.002, OR: 1.04) and EOR (p=0.037, OR: 0.41 for NTR versus STR; p=0.003, OR: 0.39 for GTR versus STR), but not glioma subtype or location, as determined by logistic regression. Additional tumor resection after iMRI was performed in 105/159 (66%) iMRI cases, yielding GTR in 54.5% of these cases.

CONCLUSIONS

EOR significantly improves OS and PFS for patients with grade II astrocytomas and oligodendrogliomas. Intraoperative MRI may improve EOR and was associated with increased PFS.

The effects of introducing artemether-lumefantrine malaria treatment and insecticide-impregnated bed nets to an elective surgical hospital

Malaria and anaemia in patients admitted for elective orthopaedic operations commonly cause delays to surgery. Our hospital has introduced artemether-lumefantrine as the standard treatment for malaria in accordance with the national policy, replacing sulphadoxine-pyrimethamine. Insecticide-impregnated bed nets were also introduced throughout our wards. A retrospective audit of all new elective surgical admissions over a 12-month period was performed in order to assess the effect of these changes. The study was designed to follow an identical audit performed before their introduction. Of the 435 patients admitted, 75 (17.2%) had malaria parasites present on blood film. In these patients, surgery was significantly delayed, by a mean of 9.9 days more than the group without malaria ( P < 0.001). Before the changes to malaria treatment, the mean delay was 2.2 days ( P < 0.05). Six patients (1.7%) developed malaria during admission, significantly fewer than the 16 (4.3%) before the introduction of bed nets ( P = 0.036). The average haemoglobin level on admission in patients with malaria parasites was 11.8 g/dL (95% confidence interval [CI] 11.4–12.2) and in those without 13.1 g/dL (95% CI: 12.9–13.3). Seventeen patients (3.9%) were admitted with a haemoglobin concentration of <10 g/dL and two (0.5%) of <8 g/dL. There were no significant delays to surgery in these patients compared to those without anaemia. The adoption of artemether-lumefantrine by our hospital significantly increased delays to surgery. The introduction of insecticide-impregnated bed nets significantly reduced the number of patients developing malaria during their hospital stay.

Stereotactic radiation techniques in the treatment of acoustic schwannomas. 2007

Medical decision-making is based on benefit-to-cost analysis. Optimally, treatment obtains a high degree of benefit while minimizing the physical, social, and financial costs. The goals of the treatment of acoustic schwannomas are prohibiting tumor growth and alleviation of symptoms caused by damage to local structures. These symptoms-tinnitus, ataxia, and hearing loss-secondary to eighth nerve dysfunction, as well as symptoms arising from damage to adjacent structures such as the facial nerve, trigeminal nerve, or pons, can be caused by tumor growth or treatment. Determination of optimal therapy must also take into account an understanding of the natural history of the disease, because acoustic schwannomas are slow-growing benign tumors that when left untreated, usually enlarge over time and cause problems.

Stereotactic radiation techniques in the treatment of acoustic schwannomas

Medical decision-making is based on benefit-to-cost analysis. Optimally, treatment obtains a high degree of benefit while minimizing the physical, social, and financial costs. The goals of the treatment of acoustic schwannomas are prohibiting tumor growth and alleviation of symptoms caused by damage to local structures. These symptoms-tinnitus, ataxia, and hearing loss--secondary to eighth nerve dysfunction, as well as symptoms arising from damage to adjacent structures such as the facial nerve, trigeminal nerve, or pons, can be caused by tumor growth or treatment. Determination of optimal therapy must also take into account an understanding of the natural history of the disease, because acoustic schwannomas are slow-growing benign tumors that when left untreated, usually enlarge over time and cause problems.

Accuracy in equianalgesic dosing. conversion dilemmas

The clinical benefit and increased application of opioid rotation has focused attention on efficacy differences between opioids and their respective equianalgesic dose ratios. Understanding the differences between the opioids is critical to understanding their equianalgesic dose ratios and for adjusting therapy following rotation to a new analgesic. The purpose of this article is to describe controversies regarding the relative potencies of these agents as presented in current equianalgesic charts and to provide pharmacologic information to assist the clinician with opioid rotation.

Technetium mixed-ligand complexes containing bidentate phosphines and monodentate thiol ligands. Preparation, in vitro data and detection of a certain heart affinity

TcO-4 is reduced by a mixture of phosphine and thiol ligands to yield cationic complexes in which both ligands are coordinated. Polar and lipophilic properties of the products can easily be controlled by variation of either of the ligands. The yields are always high. Potential heart affinity of the compounds was screened by means of the isolated perfused rat heart. Some of the complexes show significant heart uptake and good retention in the myocardial tissue.