The Utility of Spectroscopic MRI in Stereotactic Biopsy and Radiotherapy Guidance in Newly Diagnosed Glioblastoma

Current diagnostic and therapeutic approaches for gliomas have limitations hindering survival outcomes. We propose spectroscopic magnetic resonance imaging as an adjunct to standard MRI to bridge these gaps. Spectroscopic MRI is a volumetric MRI technique capable of identifying tumor infiltration based on its elevated choline (Cho) and decreased N-acetylaspartate (NAA). We present the clinical translatability of spectroscopic imaging with a Cho/NAA ≥ 5x threshold for delineating a biopsy target in a patient diagnosed with non-enhancing glioma. Then, we describe the relationship between the undertreated tumor detected with metabolite imaging and overall survival (OS) from a pilot study of newly diagnosed GBM patients treated with belinostat and chemoradiation. Each cohort (control and belinostat) were split into subgroups using the median difference between pre-radiotherapy Cho/NAA ≥ 2x and the treated T1-weighted contrast-enhanced (T1w-CE) volume. We used the Kaplan-Meier estimator to calculate median OS for each subgroup. The median OS was 14.4 months when the difference between Cho/NAA ≥ 2x and T1w-CE volumes was higher than the median compared with 34.3 months when this difference was lower than the median. The T1w-CE volumes were similar in both subgroups. We find that patients who had lower volumes of undertreated tumors detected via spectroscopy had better survival outcomes.

Prospective Longitudinal Assessment of Quality of Life After Stereotactic Ablative Radiotherapy for Oligometastases: Analysis of the Population-based SABR-5 Phase II Trial

AIMS

To evaluate longitudinal patient-reported quality of life (QoL) in patients treated with stereotactic ablative radiotherapy (SABR) for oligometastases.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases, conducted in six regional cancer centres in British Columbia, Canada from 2016 to 2020. Prospective QoL was measured using treatment site-specific QoL questionnaires at pre-treatment baseline and at 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. Patients with bone metastases were assessed with the Brief Pain Inventory (BPI). Patients with liver, adrenal and abdominopelvic lymph node metastases were assessed with the Functional Assessment of Chronic Illness Therapy-Abdominal Discomfort (FACIT-AD). Patients with lung and intrathoracic lymph node metastases were assessed with the Prospective Outcomes and Support Initiative (POSI) lung questionnaire. The two one-sided test procedure was used to assess equivalence between the worst QoL score and the baseline score of individual patients. The mean QoL at all time points was used to determine the trajectory of QoL response after SABR. The proportion of patients with 'stable', 'improved' or 'worsened' QoL was determined for all time points based on standard minimal clinically important differences (MCID; BPI worst pain = 2, BPI functional interference score [FIS] = 0.5, FACIT-AD Trial Outcome Index [TOI] = 8, POSI = 3).

RESULTS

All enrolled patients with baseline QoL assessment and at least one follow-up assessment were analysed (n = 133). On equivalence testing, the patients' worst QoL scores were clinically different from baseline scores and met MCID (BPI worst pain mean difference: 1.8, 90% confidence interval 1.19 to 2.42]; BPI FIS mean difference: 1.68, 90% confidence interval 1.15 to 2.21; FACIT-AD TOI mean difference: -8.76, 90% confidence interval -11.29 to -6.24; POSI mean difference: -4.61, 90% confidence interval -6.09 to -3.14). However, the mean FIS transiently worsened at 9, 18 and 21 months but eventually returned to stable levels. The mean FACIT and POSI scores also worsened at 36 months, albeit with a limited number of responses (n = 4 and 8, respectively). Most patients reported stable QoL at all time points (range: BPI worst pain 71-82%, BPI FIS 45-78%, FACIT-AD TOI 50-100%, POSI 25-73%). Clinically significant stability, worsening and improvement were seen in 70%/13%/18% of patients at 3 months, 53%/28%/19% at 18 months and 63%/25%/13% at 36 months.

CONCLUSIONS

Transient decreases in QoL that met MCID were seen between patients' worst QoL scores and baseline scores. However, most patients experienced stable QoL relative to pre-treatment levels on long-term follow-up. Further studies are needed to characterise patients at greatest risk for decreased QoL.

Predictors of Quality of Life Decline in Patients with Oligometastases treated with Stereotactic Ablative Radiotherapy: Analysis of the Population-Based SABR-5 Phase II Trial

AIMS

Most patients experience stable quality of life (QoL) after stereotactic ablative radiotherapy (SABR) treatment for oligometastases. However, a subset of patients experience clinically relevant declines in QoL on post-treatment follow-up. This study aimed to identify risk factors for QoL decline.

MATERIALS AND METHODS

The SABR-5 trial was a population-based single-arm phase II study of SABR to up to five sites of oligometastases. Prospective QoL was measured using treatment site-specific tools at pre-treatment baseline and 3, 6, 9, 12, 15, 18, 21, 24, 30 and 36 months after treatment. The time to persistent QoL decline was calculated as the time from SABR to the first decline in QoL score meeting minimum clinically important difference with no improvement to baseline score on subsequent assessments. Univariable and multivariable logistic regression analyses were carried out to determine factors associated with QoL decline.

RESULTS

One hundred and thirty-three patients were included with a median follow-up of 32 months (interquartile range 25-43). Thirty-five patients (26%) experienced a persistent decline in QoL. The median time until persistent QoL decline was not reached. The cumulative incidence of QoL decline at 2 and 3 years were 22% (95% confidence interval 14.0-29.6) and 40% (95% confidence interval 28.0-51.2), respectively. In multivariable analysis, disease progression (odds ratio 5.23, 95% confidence interval 1.59-17.47, P = 0.007) and adrenal metastases (odds ratio 9.70, 95% confidence interval 1.41-66.93, P = 0.021) were associated with a higher risk of QoL decline. Grade 3 or higher (odds ratio 3.88, 95% confidence interval 0.92-16.31, P = 0.064) and grade 2 or higher SABR-associated toxicity (odds ratio 2.24, 95% confidence interval 0.85-5.91, P = 0.10) were associated with an increased risk of QoL decline but did not reach statistical significance.

CONCLUSIONS

Disease progression and adrenal lesion site were associated with persistent QoL decline following SABR. The development of grade 3 or higher toxicities was also associated with an increased risk, albeit not statistically significant. Further studies are needed, focusing on the QoL impact of metastasis-directed therapies.

Association between acetaminophen use and vitiligo in US women and men

BACKGROUND/OBJECTIVES

Exposure to chemical phenols, which can act as tyrosine analogues and result in anti-melanocyte autoimmunity, has been associated with vitiligo. Acetaminophen (N-acetyl-p-aminophenol) is an over-the-counter analgesic of phenolic origin. The risk of vitiligo with systemic exposure to acetaminophen has not yet been evaluated.

METHODS

We examined the risk of vitiligo with regular use acetaminophen in women, the Nurses' Health Study (NHS) and in men, the Health Professionals Follow-up Study (HPFS). Regular acetaminophen use was asked biennially from 1990 in NHS and from 1986 in HPFS, and the year of clinician-diagnosed vitiligo was asked retrospectively in 2012 in the cohorts.

RESULTS

In NHS, a total of 161 vitiligo cases were identified during a follow-up of 571,724 person-years; in HPFS, a total of 183 vitiligo cases were identified during a follow-up of 680,313 person-years. Regular use of acetaminophen was associated with an increased vitiligo risk in NHS but not HPFS. The multivariable relative risk (RR) was 1.52 (95% confidence interval [CI] 1.03-2.25) in NHS and 1.09 (95% CI 0.76-1.55) in HPFS. The higher risk of vitiligo was similar by duration of acetaminophen use in women; the multivariable RRs were 1.47 (95% CI 0.98-2.21) for acetaminophen use under 5 years, and 1.78 (95% CI 1.11-2.84) for acetaminophen use over 5 years.

CONCLUSIONS

Acetaminophen may be associated with a higher risk of vitiligo in women.

A Fully Automated Post-Surgical Brain Tumor Segmentation Model for Radiation Treatment Planning and Longitudinal Tracking

Glioblastoma (GBM) has a poor survival rate even with aggressive surgery, concomitant radiation therapy (RT), and adjuvant chemotherapy. Standard-of-care RT involves irradiating a lower dose to the hyperintense lesion in T2-weighted fluid-attenuated inversion recovery MRI (T2w/FLAIR) and a higher dose to the enhancing tumor on contrast-enhanced, T1-weighted MRI (CE-T1w). While there have been several attempts to segment pre-surgical brain tumors, there have been minimal efforts to segment post-surgical tumors, which are complicated by a resection cavity and postoperative blood products, and tools are needed to assist physicians in generating treatment contours and assessing treated patients on follow up. This report is one of the first to train and test multiple deep learning models for the purpose of post-surgical brain tumor segmentation for RT planning and longitudinal tracking. Post-surgical FLAIR and CE-T1w MRIs, as well as their corresponding RT targets (GTV1 and GTV2, respectively) from 225 GBM patients treated with standard RT were trained on multiple deep learning models including: Unet, ResUnet, Swin-Unet, 3D Unet, and Swin-UNETR. These models were tested on an independent dataset of 30 GBM patients with the Dice metric used to evaluate segmentation accuracy. Finally, the best-performing segmentation model was integrated into our longitudinal tracking web application to assign automated structured reporting scores using change in percent cutoffs of lesion volume. The 3D Unet was our best-performing model with mean Dice scores of 0.72 for GTV1 and 0.73 for GTV2 with a standard deviation of 0.17 for both in the test dataset. We have successfully developed a lightweight post-surgical segmentation model for RT planning and longitudinal tracking.

Spectroscopic MRI-Based Biomarkers Predict Survival for Newly Diagnosed Glioblastoma in a Clinical Trial

Despite aggressive treatment, glioblastoma has a poor prognosis due to its infiltrative nature. Spectroscopic MRI-measured brain metabolites, particularly the choline to N-acetylaspartate ratio (Cho/NAA), better characterizes the extent of tumor infiltration. In a previous pilot trial (NCT03137888), brain regions with Cho/NAA ≥ 2x normal were treated with high-dose radiation for newly diagnosed glioblastoma patients. This report is a secondary analysis of that trial where spectroscopic MRI-based biomarkers are evaluated for how they correlate with progression-free and overall survival (PFS/OS). Subgroups were created within the cohort based on pre-radiation treatment (pre-RT) median cutoff volumes of residual enhancement (2.1 cc) and metabolically abnormal volumes used for treatment (19.2 cc). We generated Kaplan-Meier PFS/OS curves and compared these curves via the log-rank test between subgroups. For the subgroups stratified by metabolic abnormality, statistically significant differences were observed for PFS (p = 0.019) and OS (p = 0.020). Stratification by residual enhancement did not lead to observable differences in the OS (p = 0.373) or PFS (p = 0.286) curves. This retrospective analysis shows that patients with lower post-surgical Cho/NAA volumes had significantly superior survival outcomes, while residual enhancement, which guides high-dose radiation in standard treatment, had little significance in PFS/OS. This suggests that the infiltrating, non-enhancing component of glioblastoma is an important factor in patient outcomes and should be treated accordingly.

Mutant Isocitrate Dehydrogenase 1 Expression Enhances Response of Gliomas to the Histone Deacetylase Inhibitor Belinostat

Histone deacetylase inhibitors (HDACis) are drugs that target the epigenetic state of cells by modifying the compaction of chromatin through effects on histone acetylation. Gliomas often harbor a mutation of isocitrate dehydrogenase (IDH) 1 or 2 that leads to changes in their epigenetic state presenting a hypermethylator phenotype. We postulated that glioma cells with IDH mutation, due to the presence of epigenetic changes, will show increased sensitivity to HDACis. This hypothesis was tested by expressing mutant IDH1 with a point alteration-converting arginine 132 to histidine-within glioma cell lines that contain wild-type IDH1. Glioma cells engineered to express mutant IDH1 produced D-2-hydroxyglutarate as expected. When assessed for response to the pan-HDACi drug belinostat, mutant IDH1-expressing glioma cells were subjected to more potent inhibition of growth than the corresponding control cells. Increased sensitivity to belinostat correlated with the increased induction of apoptosis. Finally, a phase I trial assessing the addition of belinostat to standard-of-care therapy for newly diagnosed glioblastoma patients included one patient with a mutant IDH1 tumor. This mutant IDH1 tumor appeared to display greater sensitivity to the addition of belinostat than the other cases with wild-type IDH tumors based on both standard magnetic resonance imaging (MRI) and advanced spectroscopic MRI criteria. These data together suggest that IDH mutation status within gliomas may serve as a biomarker of response to HDACis.

Spectroscopic MRI-Guided Proton Therapy in Non-Enhancing Pediatric High-Grade Glioma

Radiation therapy (RT) is a critical part of definitive therapy for pediatric high-grade glioma (pHGG). RT is designed to treat residual tumor defined on conventional MRI (cMRI), though pHGG lesions may be ill-characterized on standard imaging. Spectroscopic MRI (sMRI) measures endogenous metabolite concentrations in the brain, and Choline (Cho)/N-acetylaspartate (NAA) ratio is a highly sensitive biomarker for metabolically active tumor. We provide a preliminary report of our study introducing a novel treatment approach of whole brain sMRI-guided proton therapy for pHGG. An observational cohort (c1 = 10 patients) receives standard of care RT; a therapeutic cohort (c2 = 15 patients) receives sMRI-guided proton RT. All patients undergo cMRI and sMRI, a high-resolution 3D whole-brain echo-planar spectroscopic imaging (EPSI) sequence (interpolated resolution of 12 µL) prior to RT and at several follow-up timepoints integrated into diagnostic scans. Treatment volumes are defined by cMRI for c1 and by cMRI and Cho/NAA ≥ 2x for c2. A longitudinal imaging database is used to quantify changes in lesion and metabolite volumes. Four subjects have been enrolled (c1 = 1/c2 = 3) with sMRI imaging follow-up of 4-18 months. Preliminary data suggest sMRI improves identification of pHGG infiltration based on abnormal metabolic activity, and using proton therapy to target sMRI-defined high-risk regions is safe and feasible.

A91 INTERACTIONS BETWEEN PREGNANCY, DELIVERY, AND ILEAL POUCH-ANAL ANASTOMOSIS FOR INFLAMMATORY BOWEL DISEASE: A RETROSPECTIVE CHART REVIEW

Background

Ulcerative colitis (UC) is a type of inflammatory bowel disease (IBD) that affects people in their reproductive years of life. Surgical treatment for medically refractory UC involves surgery over 2-3 stages, which includes a subtotal colectomy followed by creation of an ileal pouch-anal anastomosis (IPAA), known as a “J pouch”. The IPAA allows preservation of fecal continence and avoids the psychosocial impacts of a stoma. The IPAA procedure is a deep pelvic surgery, which may impact pregnancy outcomes. Caesarean section (C-section) delivery is often performed to avoid anal sphincter and J pouch damage from vaginal delivery. However, literature demonstrates conflicting results regarding the risks of C-section compared to vaginal delivery, including the impact on pouch function. Surveys of clinicians also report varying delivery recommendations.

Purpose

To describe the delivery methods, pregnancy outcomes and postpartum course of IBD patients with IPAA at Mount Sinai Hospital.

Method

A retrospective chart review is being performed for female patients at Mount Sinai Hospital (Toronto, Ontario) with a diagnosis of IBD and an IPAA. Eligible patients completed a pregnancy from January 1, 2002-February 1, 2021 post-IPAA surgery and had variables of interest accessible in their electronic medical record. Variables of interest include demographics, pregnancy history, IBD characteristics, IPAA surgery details, pregnancy outcomes, mode of delivery and characteristics, and postpartum complications. Clinical data will be presented as means, medians and frequencies. Differences between variables of interest will be evaluated with Student’s t-test or chi-squared test.

Result(s)

Three avenues of patient identification yielded 1113 patients to be screened. Inclusion criteria were met for 71 patients and chart review is complete for 36 patients who had a total of 53 pregnancies and delivered 56 babies. Most patients (49%) had a two-stage IPAA surgery, 21% required a three-stage surgery and 30% were undocumented. Most patients’ (55%) IPAA was created through laparotomy, while 13% was through laparoscopic procedure and 32% was undocumented. Seventy-four percent of deliveries were through C-section (75% of primiparous), 69% of which were indicated to protect the patient’s J pouch and 31% for an obstetrical indication. The remaining 26% of deliveries were vaginal, 29% of which were assisted with forceps or vacuum, 57% had tears (37.5% first-, 37.5% second-, and 25% third-degree) and 50% had an episiotomy.

Conclusion(s)

At Mount Sinai Hospital, most IBD patients with an IPAA who completed a pregnancy had a history of laparotomy to create their IPAA. Most patients (74%) with IBD and an IPAA are delivering through C-section, and mainly to protect their J pouch, which is in line with reports in the literature. Most patients had a tear or episiotomy during vaginal delivery. Rates of third-degree tears may be higher than in the general population. Trends will be further elucidated with advancement of the study.

Disclosure of Interest

None Declared

A214 WOMEN WITH INFLAMMATORY BOWEL DISEASE HAVE INCREASED HEALTH-CARE UTILIZATION DURING PREGNANCY AND POSTPARTUM COMPARED TO THOSE WITHOUT INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED COHORT STUDY

Background

Compared to those without inflammatory bowel disease (IBD), women with IBD may have increased health-care utilization during pregnancy and postpartum. This may lead to significant morbidity and decrease in quality of life. Characterizing this health-care use is important for health-policy purposes to determine methods to shift care to the ambulatory setting.

Purpose

We aimed to compare health-care utilization of women with and without IBD during preconception, pregnancy and postpartum.

Method

We accessed administrative databases and validated algorithms at the Institute of Clinical Evaluative Services (ICES) in Ontario to identify women (age 18-55) with and without IBD who had a completed live, singleton pregnancy between 2003 and 2018. The primary outcome was to characterize differences in emergency department (ED) visits and hospitalizations between women with and without IBD during the 12 months preconception, pregnancy, and in the 12 months postpartum. The secondary outcome was to assess differences in prenatal care between women with and without IBD. Multivariable negative binomial regression with generalizing estimating equations, accounting for multiple pregnancies for each patient, was performed to report incidence rate ratios (IRR) with 95% confidence intervals (95% CI). Covariates included maternal age at conception, location of residence at conception (rural vs. urban), socioeconomic status (using surrogate marker of neighborhood income quintile), and maternal comorbidity.

Result(s)

9158 pregnancies in 6163 women with IBD and 1,729,411 pregnancies in 1,091,013 women without IBD were included. Women with IBD were older at time of delivery and had greater pre-pregnancy comorbidities. During pregnancy, women with IBD were more likely to visit the ED (IRR 1.13, 95% CI,1.08-1.18) and be hospitalized (IRR 1.11, 95% CI,1.01-1.21) for non-IBD specific reasons. Similarly, during postpartum, women with IBD were more likely to visit the ED (IRR 1.21, 95% CI, 1.15-1.27) and be hospitalized (IRR 1.18, 95% CI, 1.05-1.32) for non-IBD specific reasons. Venous thromboembolic events accounted for 7.0% of all postpartum hospitalizations in women with IBD compared to 2.7% in those without IBD (p<0.0001). There was no difference in ED visits and hospitalizations between women with and without IBD in preconception. Finally, women with IBD had greater number of prenatal visits with obstetricians during pregnancy and were more likely to receive a first trimester prenatal visit compared to those without IBD.

Conclusion(s)

Compared to those without IBD, women with IBD are more likely to visit the ED and be hospitalized during pregnancy and postpartum, particularly for venous thromboembolic events. Efforts should be made from a health policy perspective to increase access to ambulatory care for patients with IBD during the peripartum period which in turn may reduce acute setting health-services utilization.

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CCC

Disclosure of Interest

None Declared

A85 ASSESSING THE IMPACT OF A DEDICATED RAPID INTERDISCIPLINARY IBD CLINIC ON PATIENT WAIT TIMES, REPORTED OUTCOMES, AND SATISFACTION OF CARE

Background

Inflammatory bowel disease (IBD) is a chronic fluctuating condition where patients can experience periods of active disease and remission. Timely access to care has been shown to be impactful on important disease outcomes. In January 2020, we implemented a rapid assessment IBD program consisting of expedited access to interdisciplinary care and close monitoring of patients.

Purpose

To assess the impact of the rapid assessment program on access to care, disease activity, and patient satisfaction.

Method

Once informed consent was obtained, patients were enrolled into the RAPID IBD program. This program consisted of four close monitoring time points at baseline, 1, 2, and 3 months, as well as two follow up time points at 6 and 12 months. At each timepoint patients completed questionnaires that evaluated disease activity, using the Modified Harvey Bradshaw Index (mHBI) for Crohn’s disease (CD), partial Mayo (pMayo) score and Simple Clinical Colitis Activity Index (SCCAI) for ulcerative colitis patients. At baseline, 3, 6, and 12 months, patients were also assessed on mental health, using the Patient Health Questionnaire (PHQ-9) and General Anxiety Disorder (GAD-7), and satisfaction of care, using the CACHE questionnaire.

Result(s)

Between January 2020 – August 2021, 216 patients were referred to the RAPID IBD program. The mean time from referral to clinical assessment was 8.1 days. Of those referred, 143 (71 CD, 62 UC, 6 IBDU, and 4 Query IBD) patients consented to and completed the 12-month RAPID IBD study. 34.9% of patients who had active disease at baseline achieved remission by 3 months (Table 1). At baseline 44.8% and 28.4% of patients experienced moderate to severe depression and anxiety, respectively. The greatest improvement in mental health was seen at 2 months where the proportion of patients experiencing moderate to severe depression and anxiety decreased to 27.5% and 18.3%, respectively (Table 2). Patient satisfaction, specific to clinical care, improved from a baseline score of 69.1% to 74.1% at 3 months (Table 3).

Image

Conclusion(s)

Implementation of a dedicated RAPID IBD clinic program reveals shorter wait times to be seen in clinic. By three months of enrollment, patients demonstrate improvements in clinical response, mental health, and satisfaction of care.

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Other

Please indicate your source of funding;

AMO Innovation Funding

Disclosure of Interest

None Declared

A219 BIOLOGIC USE DURING PREGNANCY IN WOMEN WITH INFLAMMATORY BOWEL DISEASE AND ASSOCIATED NEONATAL OUTCOMES: A RETROSPECTIVE CHART REVIEW

Background

Biologics are the mainstay of therapy for patients with advanced inflammatory bowel disease (IBD). Most biologics readily undergo placental transfer during the second trimester and remain detectable in infant serum for up to 12 months. Therefore, most clinical guidelines currently recommend avoiding live vaccines in the first 6 to 12 months for exposed infants. In Canada, the rotavirus vaccine is the only live vaccine administered before 6 months. Emerging evidence is suggesting that the vaccine may safely be given to infants with normal immune function, even if serum biologic level is detectable. Specialist assessment of infant immune function may help guide decision-making about rotavirus vaccine administration, but there remains a large gap in our knowledge of the impact of biologic exposure on the immune function of infants, necessitating further study.

Purpose

In this single-centre retrospective chart review, we aim to study the clinical outcomes, immune function, and rotavirus vaccine recommendations for infants exposed to biologics in utero during their first year of life.

Method

The study included mothers seen at the Pregnancy IBD Clinic at Mount Sinai Hospital in Toronto, ON, who were offered a referral to the Special Immunization Clinic (SIC) at The Hospital for Sick Children due to biologic exposure in utero. Data was collected on the recommendations made by paediatric specialists at SIC, based on complete blood count, lymphocyte phenotyping, and T-cell receptor excision analysis. Data was obtained on adverse neonatal outcomes in the first year of life, including prematurity, congenital malformations, and infections based on post-partum surveys completed by mothers and follow-up letters from SIC.

Result(s)

43 patients were referred to and seen by paediatric specialists at SIC between 2 to 12 months of age. 18 infants (42%) were exposed to Adalimumab in utero, 16 (37%) to Infliximab, 5 (12%) to Vedolizumab, and 4 (9%) to Ustekinumab. The rotavirus vaccine was recommended to 34 infants (81%) and not recommended to 3 (7%) for reasons including gastrointestinal illness, neutropenia, and low lymphocyte counts. Recommendation is pending for 6 infants (14%). Two infants (5%) had premature births. Four infants (9%) were admitted to the NICU for reasons including respiratory distress, and prematurity (9%). One infant (2%) had a congenital malformation, specifically bilateral sensorineural hearing loss. Six infants (14%) had upper respiratory tract infections, none of which required hospital admission or antibiotics.

Conclusion(s)

This study is currently in progress. Further data is required to assess whether biologic exposure in utero has a significant impact on neonatal immune function, especially beyond the first year of life, and whether there is a significant difference in vaccine recommendations and response based on the type of biologic received.

Disclosure of Interest

None Declared

A Novel Approach to Determining Tumor Progression Using a Three-Site Pilot Clinical Trial of Spectroscopic MRI-Guided Radiation Dose Escalation in Glioblastoma

Glioblastoma (GBM) is a fatal disease, with poor prognosis exacerbated by difficulty in assessing tumor extent with imaging. Spectroscopic MRI (sMRI) is a non-contrast imaging technique measuring endogenous metabolite levels of the brain that can serve as biomarkers for tumor extension. We completed a three-site study to assess survival benefits of GBM patients when treated with escalated radiation dose guided by metabolic abnormalities in sMRI. Escalated radiation led to complex post-treatment imaging, requiring unique approaches to discern tumor progression from radiation-related treatment effect through our quantitative imaging platform. The purpose of this study is to determine true tumor recurrence timepoints for patients in our dose-escalation multisite study using novel methodology and to report on median progression-free survival (PFS). Follow-up imaging for all 30 trial patients were collected, lesion volumes segmented and graphed, and imaging uploaded to our platform for visual interpretation. Eighteen months post-enrollment, the median PFS was 16.6 months with a median time to follow-up of 20.3 months. With this new treatment paradigm, incidence rate of tumor recurrence one year from treatment is 30% compared to 60-70% failure under standard care. Based on the delayed tumor progression and improved survival, a randomized phase II trial is under development (EAF211).

Changing patterns of referral into a family history clinic and detection of ovarian cancer: a retrospective 10-year review

This study examines whether a change in the criteria for genetic testing for ovarian cancer risk changed the nature of referrals into our Familial Cancer service. This is a retrospective review of 273 women who underwent risk reducing surgery (RRS). The primary outcome was to establish whether there was an increase in women having RRS with a confirmed genetic mutation. Secondary outcomes included the incidence of occult cancer and of subsequent primary peritoneal cancer. The results showed an increase in women being offered RRS based on genetic diagnosis; 91% versus 32% before the criteria change. Four occult malignancies (1.5%) and two peritoneal cancers (0.7%) were noted.We have demonstrated a change in the nature of referrals to the familial cancer service from perceived risk to genetic diagnosis. We can now counsel women more accurately. With a defined risk we are enabling them to make an informed decision regarding risk reduction.

Final Report on Clinical Outcomes and Tumor Recurrence Patterns of a Pilot Study Assessing Efficacy of Belinostat (PXD-101) with Chemoradiation for Newly Diagnosed Glioblastoma

Glioblastoma (GBM) is highly aggressive and has a poor prognosis. Belinostat is a histone deacetylase inhibitor with blood–brain barrier permeability, anti-GBM activity, and the potential to enhance chemoradiation. The purpose of this clinical trial was to assess the efficacy of combining belinostat with standard-of-care therapy. Thirteen patients were enrolled in each of control and belinostat cohorts. The belinostat cohort was given a belinostat regimen (500–750 mg/m2 1×/day × 5 days) every three weeks (weeks 0, 3, and 6 of RT). All patients received temozolomide and radiation therapy (RT). RT margins of 5–10 mm were added to generate clinical tumor volumes and 3 mm added to create planning target volumes. Median overall survival (OS) was 15.8 months for the control cohort and 18.5 months for the belinostat cohort (p = 0.53). The recurrence volumes (rGTVs) for the control cohort occurred in areas that received higher radiation doses than that in the belinostat cohort. For those belinostat patients who experienced out-of-field recurrence, tumors were detectable by spectroscopic MRI before RT. Recurrence analysis suggests better in-field control with belinostat. This study highlights the potential of belinostat as a synergistic therapeutic agent for GBM. It may be particularly beneficial to combine this radio-sensitizing effect with spectroscopic MRI-guided RT.

A175 DISEASE ACTIVITY IN FIRST TRIMESTER IS ASSOCIATED WITH REDUCED GROWTH IN INFANTS BORN TO WOMEN WITH INFLAMMATORY BOWEL DISEASE

Background

Ulcerative colitis (UC) and Crohn’s disease (CD) are chronic inflammatory bowel diseases (IBD) that affect a significant portion of women in childbearing years. It is known that disease activity in early pregnancy negatively impacts obstetrical and perinatal outcomes, but the impact on infant growth is largely unknown.

Aims

The objective of this study was to compare the growth of infants born to women with active IBD during pregnancy versus those born to women with IBD in remission during pregnancy.

Methods

We conducted a prospective cohort study in a Canadian tertiary centre comprised of 98 pregnant women with IBD (63 with UC and 35 with CD) and 13 healthy pregnant women. We collected maternal demographic at trimester 1 and assessed disease activity at each trimester using clinical disease scores and fecal calprotectin. We then collected perinatal outcomes at delivery and followed the infants’ growth and feeding habits up to 12 months of age.

Results

A total of 103 mother-infant pairs were included in the study, of which 88 infants were born to women with IBD, and 15 born to women with active disease at trimester 1. Active disease at trimester 1 was associated with more adverse obstetrical outcomes, reduced 1-minute and 5-minute APGAR scores and more frequent NICU admissions. Infants born to women with active trimester 1 disease had reduced weight-for-age and length-for-age Z scores up to 6 months of age, in the absence of difference in feeding patterns. In addition, women with active disease at trimester 1 had increased expression of IL-8 and IFN-γ compared to those with trimester 1 remission.

Conclusions

Active IBD during first trimester is correlated with decreased infant weight and height up to 6 months of age, suggesting that strict disease control during first trimester, or even preconception, is essential for optimizing infant growth and perinatal outcomes.

Funding Agencies

None

A178 BIOLOGIC THERAPY DURING PREGNANCY AS PER GUIDELINE RECOMMENDATIONS REDUCES ADVERSE PREGNANCY RELATED OUTCOMES

Background

Inflammatory bowel disease (IBD) disease activity during pregnancy is associated with adverse neonatal and pregnancy-related outcomes. Biologics are used to suppress disease activity but crosses the placenta in the third trimester. Conflicting studies and guidelines on the timing of biologic dosing in pregnancy persist as we try to balance the risk of disease flare and possible adverse drug effects. The American Gastroenterology Association (AGA) recommends timing the final dose according to the half-life and dosing regimen of each biologic agent.

Aims

To compare neonatal and pregnancy-related outcomes in early versus late dosing of biologics.

Methods

This was a single-center retrospective cohort study conducted at Mount Sinai Hospital from 2016–2021. We included patients with an established diagnosis of IBD before pregnancy who were at least 18 years of age at the time of conception. All patients must have been treated with an IBD-specific biologic agent and had a documented final dose during the pregnancy. The early group received their last biologic dose earlier than the AGA recommendations and the late group received it within the recommended interval. A patient was considered to have a flare based on the overall clinical impression of their gastroenterologist informed by reported symptoms, investigations (fecal calprotectin, endoscopy), and response to treatment. Neonatal and pregnancy-related outcomes were compared amongst the two groups using the student’s t-test (for continuous variables) and Fischer’s exact test (for categorical variables) using SPSS Version 27.

Results

Of 322 patients who had a completed pregnancy at Mount Sinai Hospital, 107 were included in this study. 67 (62.6%) were in the early and 40 (37.4%) were in the late groups. Baseline characteristics including age, comorbidities, IBD phenotype and disease activity were similar between the two groups. The late group had significantly later gestational ages (37.4 vs 38.7 weeks, p=0.006), higher 5-minute Apgar scores (8.7 vs. 9.0, p=0.042), fewer NICU admissions (25.4% vs 5.0%, p=0.036), and fewer IBD flares (28.3% vs 11.1%, p=0.039) in the 6-month post-partum period. There were no significant differences in the rates of premature birth, caesarian sections, infections, and congenital abnormalities. Results are displayed in figure 1.

Conclusions

Our study suggests that late dosing of biologics according to the AGA guidelines was associated with favourable outcomes. However, this is an unadjusted analysis based on retrospective data and findings should be confirmed in a prospective manner to account for confounders.

Funding Agencies

None

A177 INADEQUATE OR EXCESSIVE GESTATIONAL WEIGHT GAIN IN INFLAMMATORY BOWEL DISEASE AND IMPACT ON PREGNANCY AND NEONATAL OUTCOMES

Background

Patients with inflammatory bowel disease (IBD) are at a risk of adverse pregnancy outcomes. Prior studies have suggested that inadequate gestational weight gain is associated with preterm birth and intrauterine growth restriction.

Aims

We sought to characterize the proportion of people with IBD who gain inadequate or excessive weight during pregnancy and how this affects pregnancy and neonatal outcomes.

Methods

Pregnant patients with ulcerative colitis (UC), Crohn’s disease (CD), and inflammatory bowel disease unclassified (IBD-U) were identified retrospectively at Mount Sinai Hospital from 2016 to 2020. Total gestational weight gain (GWG) was calculated as the difference of the weight recorded at time of labor and pre-pregnancy weight. GWG was categorized as inadequate GWG, adequate GWG, and excessive GWG based on the pre-pregnancy body-mass index and standards set by the U.S. Institute of Medicine. Neonatal-related outcomes were also recorded for each patient and included preterm delivery, small for gestational age (SGA) and large for gestational age (LGA). Multiple logistic regression was used to assess the association between gestational weight gain and outcomes while controlling for maternal age, history of gestational diabetes, and preconception disease activity.

Results

225 pregnancies were included (106 UC, 115 CD, 4 IBD-U). Forty-eight patients (21.3%) had inadequate, 91 (40.4%) adequate, and 86 (38.2%) excessive GWG. People of East Asian, African, and Hispanic ethnicity were more likely to have inadequate GWG. People with inadequate GWG were more likely than those with excessive GWG to have lower preconception BMI (21.7 vs 25.5 kg/m2, P=0.001). IBD type was not associated with inadequate GWG or excessive GWG, though people with inadequate GWG were 2-fold less likely to be on anti-TNF therapy. People with excessive GWG were more likely than those with adequate GWG to have babies with higher birth weight (3,364g vs 3,132g, P=0.003). People with inadequate GWG were not at increased risk of SGA compared to those with adequate GWG (adjusted odds ratio (aOR), 1.01; 95% CI: 0.37 – 2.71, P=0.99). Those with excessive GWG were substantially less likely to have an infant with SGA (aOR, 0.23; 95% CI: 0.07 – 0.72, P=0.01). On multivariable logistic regression analysis, excessive GWG was not associated with increased odds of delivering infants with LGA (aOR, 1.46; 95% CI: 0.54 – 3.95, P=0.46). There was no association between non-adequate gestational weight gain and preterm delivery or Caesarean delivery.

Conclusions

Less than half of persons with IBD have adequate GWG during pregnancy. Inadequate GWG was not associated with poor neonatal outcomes, and excessive GWG appeared to protect against delivering infants born SGA.

Funding Agencies

None

A174 PERCEPTIONS OF CANNABIS USE IN WOMEN WITH INFLAMMATORY BOWEL DISEASE OF REPRODUCTIVE AGE: A CROSS-SECTIONAL STUDY

Background

Cannabis use in inflammatory bowel disease (IBD) may lead to improvement in pain and general health perception. However, its use during pregnancy may result in adverse outcomes such as preterm birth and altered fetal brain development. It remains unknown how women with IBD perceive Cannabis use during pregnancy and whether they discuss its use with their health-care providers.

Aims

To determine practices in, and perceptions of, cannabis use during pregnancy in women with IBD of reproductive age.

Methods

Women with IBD (age 18–45) were recruited at Mount Sinai Hospital and via social media platforms. Participants anonymously completed surveys on baseline demographics and IBD characteristics. They also completed a Cannabis questionnaire which asked about current use, perceived risks during pregnancy, and discussions with health-care providers. Categorical variables were reported as frequencies and compared using the chi-square test. Continuous variables were reported as medians and compared using the Mann-Whitney U test.

Results

Sixty-four women were included, 26 (40.6%) with ulcerative colitis, 37 (57.8%) with Crohn’s disease, and 1 (1.6%) with indeterminate colitis. Nineteen (29.7%) were preconception, 40 (62.5%) were pregnant, and 5 (7.8%) were post-partum. Eleven (18.0%) patients reported current Cannabis use, 4 (6.3%) during pregnancy. Cannabis users were more likely to have discussed its use with a health-care provider compared to non-users (45.5% vs. 5.7%, p&lt;0.001) and had longer IBD duration (12.00 vs. 9.00 years, p=0.05). Twenty-five (42.4%) were unsure of the risks of Cannabis use in pregnancy, of which only two had discussed this with a health-care provider. Reasons for fear of Cannabis use included risk of fetal oxygen restriction (n=13, 20.3%), impact on brain development (n=29, 46.0%), and risk of fetal respiratory issues (n=18, 28.6%). Only eight (12.5%) patients reported having a conversation about Cannabis use during pregnancy with their health-care provider; all of whom felt its consumption was unsafe during pregnancy.

Conclusions

Many women with IBD report being unsure of risks of Cannabis use during pregnancy. With the legalization of Cannabis in Canada, it is imperative patients and health-care providers discuss the risks and benefits of its use, particularly during vulnerable times such as pregnancy.

Funding Agencies

None

A76 MEDICATION ADHERENCE AND BELIEFS ABOUT MEDICATION AND THE CORRELATION WITH KNOWLEDGE ABOUT INFLAMMATORY BOWEL DISEASE (IBD) IN PREGNANCY

Background

Inflammatory bowel disease (IBD) is a group of chronic inflammatory conditions including ulcerative colitis (UC), Crohn’s disease (CD) or IBD-unclassified that affect women of childbearing age. women with IBD have poor knowledge of disease management during pregnancy, as demonstrated by studies using the validated Crohn’s and Colitis Pregnancy Knowledge (CCPKnow) tool. These patients who lack knowledge about IBD and reproduction tend to have misguided fears and make uninformed decisions such as voluntary childlessness (VC) or poor medication adherence.

Aims

We aim to understand the correlation between improved knowledge about IBD and Medication Adherence Report Scale (MARS) and Beliefs about Medication Questionnaire (BMQ)

Methods

Adult women with IBD attending the pregnancy IBD clinic at the University of Alberta from 2014–2018 were enrolled. Each patient completed the Crohn’s and Colitis Pregnancy Knowledge (CCPKnow) questionnaire at baseline and after individualized education delivered at each clinic visit. BMQ and MARS Questionaries were completed using a 0–5 Likert scale at each visit. BMQ and MARS data were analysed using Wilcoxon signed ranks test by comparing pre-conception, intrapartum data (trimester) and post-partum scores. BMQ questions were classified under the BMQ Concerns category and BMQ necessity category for regression analysis.

Results

A total of 117 patients were enrolled in this study. 55 patients with CD (47.1%) and 62 patients with UC (52.9%). Statistically, a significant change was noted when comparing the median Trimester BMQ scores to pre-conception BMQ scores. (Z of -2.667, p=0.008) and Median post-partum BMQ scores to Median pre-conception BMQ scores. (Z of -2.547, p=.011). Trimester BMQ Concerns data had a strong negative correlation with CPPKnow scores (Correlation Co-efficient -.528, p<0.05). Median Trimester MARS data had a strong positive correlation with CPPKnow scores (Correlation Co-efficient 0.644, p<0.05).

Conclusions

Increased CPPKnow scores in patients were correlated with patients that were less concerned about IBD medication use and were noted to have higher medication adherence as reflected in the MARS scores post-intervention. A dedicated pregnancy clinic aimed at improving IBD and pregnancy knowledge in women would encourage greater adherence to IBD medication.

Funding Agencies

None

How can tobacco policy models quality be assessed: a systematic review

 

Policy simulation models (PSMs) have been used extensively, both to shape health policies before real-world implementation and to evaluate post-implementation impact. However, an accepted quality assessment framework for simulation models is lacking. This systematic review aimed to develop a novel quality assessment framework for tobacco control PSMs. We searched five databases to identify peer-reviewed tobacco control PSMs that projected tobacco-use and tobacco-related outcomes from smoking policy scenarios. We extracted information on modelling inputs, structure and outputs. Using our proposed quality assessment framework, we scored models on nine dimensions: representativeness of population, policy effectiveness evidence, simulated smoking histories, simulated smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity. We then compared the model score with the number of cited papers using each model. The results were narratively presented. After screening 5046 candidate papers; 145 papers were included and categorised into 25 PSMs. After scoring the models using our proposed framework, we observed that seven models were given seven and more points. The higher-scored models were generally those with a higher number of publications. While all included models had been subject to sensitivity analysis, other best practices were often lacking. Nine models did not explicitly consider smoking-related diseases. Smoking histories were commonly collapsed into crude smoking status categories rather than reflecting smoking intensity or quitting history. Furthermore, only four models estimated policy equity impact. Our systematic review revealed a variety of modelling techniques used in tobacco control. Our novel quality assessment framework offers a potential quality measure for tobacco control policy simulation models. It may guide health decision modellers and inform health policymaking.

Key messages

All nine framework dimensions were observed in two tobacco control PSM, suggesting the framework relevance and feasibility. However, few models achieved high scores in all dimensions. This novel quality assessment framework aims to support the development and sharing of good modelling practice and thus promote better health policy decision-making.

SYST-07. PILOT STUDY UTILIZING THE HDAC INHIBITOR BELINOSTAT WITH CHEMORADIATION FOR NEWLY-DIAGNOSED GLIOBLASTOMA

PURPOSE

Glioblastomas (GBMs) are highly aggressive brain tumors with poor prognosis. Belinostat is a histone deacetylase inhibitor with blood–brain barrier permeability, anti-GBM activity, and potential to enhance chemoradiation. This clinical trial sought to determine a tolerable dose of concurrent belinostat and assess the clinical efficacy of combining this drug with standard-of-care therapy.

METHODS

13 patients each were enrolled in control and belinostat cohorts. The belinostat cohort was given a belinostat regimen (500-750mg/m2 1x/day x 5 days) every 3 weeks (weeks 0, 3, and 6 of RT). All patients received standard temozolomide and radiation therapy (RT). Patient outcomes included progression-free survival, overall survival (OS), and analysis of recurrence pattern of the recurrent gross tumor volume (rGTV).

RESULTS

Belinostat at 750 mg/m2 produce dose-limiting toxicities (DLTs) in 2 of 3 patients while belinostat at 500 mg/m2 did not result in DLTs. Median OS was 18.5 months for the belinostat cohort and 15.8 months for the control cohort (p=0.53). The rGTVs in the control cohort occurred in areas that received higher radiation doses than that in the belinostat cohort. For those belinostat patients that experienced out-of-field recurrences, tumors were detectable by spectroscopic MRI (sMRI) before RT. In particular, one belinostat patient had an IDH-mutant GBM that had an extraordinary response to therapy with significant shrinkage of enhancing tumor much greater than expected.

CONCLUSION

Belinostat given concurrently at 500 mg/m2 is well-tolerated. While median OS was not significantly increased for the belinostat cohort, recurrence analysis suggests better in-field control with belinostat, suggesting a radio-sensitizing effect. This study suggests that belinostat can act as a synergistic therapeutic agent for GBMs that may be further enhanced by sMRI-guided RT and may be particularly effective against IDH mutant tumors. A trial is currently in development using belinostat with sMRI-guided RT for IDH-mutant high-grade gliomas.

The Longitudinal Imaging Tracker (BrICS-LIT):A Cloud Platform for Monitoring Treatment Response in Glioblastoma Patients

Glioblastoma is a common and aggressive form of brain cancer affecting up to 20,000 new patients in the US annually. Despite rigorous therapies, current median survival is only 15-20 months. Patients who complete initial treatment undergo follow-up imaging at routine intervals to assess for tumor recurrence. Imaging is a central part of brain tumor management, but MRI findings in patients with brain tumor can be challenging to interpret and are further confounded by interpretation variability. Disease-specific structured reporting attempts to reduce variability in imaging results by implementing well-defined imaging criteria and standardized language. The Brain Tumor Reporting and Data System (BT-RADS) is one such framework streamlined for clinical workflows and includes quantitative criteria for more objective evaluation of follow-up imaging. To facilitate accurate and objective monitoring of patients during the follow-up period, we developed a cloud platform, the Brain Imaging Collaborative Suite's Longitudinal Imaging Tracker (BrICS-LIT). BrICS-LIT uses semiautomated tumor segmentation algorithms of both T2-weighted FLAIR and contrast-enhanced T1-weighted MRI to assist clinicians in quantitative assessment of brain tumors. The LIT platform can ultimately guide clinical decision-making for patients with glioblastoma by providing quantitative metrics for BT-RADS scoring. Further, this platform has the potential to increase objectivity when measuring efficacy of novel therapies for patients with brain tumor during their follow-up. Therefore, LIT will be used to track patients in a dose-escalated clinical trial, where spectroscopic MRI has been used to guide radiation therapy (Clinicaltrials.gov NCT03137888), and compare patients to a control group that received standard of care.

3D whole-brain metabolite imaging to improve characterization of low-to-intermediate grade gliomas

PURPOSE

MRI is the standard imaging modality used for diagnosis, treatment planning, and post-treatment management of gliomas. Contrast-enhanced T1-weighted (CE-T1w) MRI is used to plan biopsy and radiation for grade IV gliomas but is less effective for grade II and III gliomas (i.e., low-to-intermediate grade gliomas) which may have minimal or no enhancement. Magnetic resonance spectroscopic imaging (MRSI) is an advanced MRI technique that has been shown, to improve diagnostic yield of biopsy and target delineation for grade IV glioma. The purpose of this study is to determine if MRSI can improve characterization and tissue sampling of low-to-intermediate grade gliomas.

METHODS

Prospective grade II and grade III glioma patients were enrolled to undergo whole brain high-resolution MRSI prior to tissue sampling. Choline/N-acetyl-aspartate (Cho/NAA) maps were overlaid on anatomic imaging and imported into stereotactic biopsy software. Patients were treated with standard-of-care surgery and radiation. Volumes of spectroscopically abnormal tissue were generated and compared with anatomic imaging and areas of enhancing recurrence on follow-up imaging.

RESULTS

Ten patients had pathologic diagnosis of grade II (n = 4) or grade III (n = 6) with a median follow-up of 27.3 months. Five patients had recurrence, and regions of recurrence were found to overlap with metabolically abnormal regions on MRSI at the time of diagnosis.

CONCLUSION

MRSI in low-to-intermediate grade glioma patients is predictive of areas of subsequent recurrence. Larger studies are needed to determine if MRSI can be used to guide surgical and radiation treatment planning in these patients.

A multisite clinical trial of spectroscopic MRI-guided radiation dose escalation for newly-diagnosed glioblastomas

2018

Background: Glioblastoma (GBM) is the most common adult primary malignant brain tumor. These pts have poor outcomes [median overall survival (OS) ̃ 16 months] despite radiation therapy (RT) to 60 Gy and temozolomide (TMZ). Magnetic resonance spectroscopy (MRS) measures levels of specific metabolites in the brain including choline (Cho) and N-acetyl aspartate (NAA). Previously, we found that high Cho/NAA ratios can aid in localizing regions of brain at high risk for GBM recurrence that may not be appreciated on standard contrast-enhanced (CE) MRI. Based on this finding, we conducted a clinical trial to assess the feasibility and safety of using an advanced volumetric MRS technique termed spectroscopic MRI (sMRI) to guide RT dose escalation for newly-diagnosed GBMs. Methods: Our clinical trial (NCT03137888) funded by the NCI (RO1CA214557) enrolled pts at 3 institutions (Emory U, U Miami, Johns Hopkins U) from 5/2017 to 4/2019. This study was approved by the IRB at each respective institution. Eligibility criteria included newly-diagnosed GBM pts ≥ 18 years of age with a tumor site that could be adequately imaged by sMRI. Cho/NAA ratio was normalized to the contralateral normal appearing white matter (NAWM). For RT planning, standard gross tumor volumes (GTV1 & 2) were defined based on T2-FLAIR and T1 CE MRIs and 5 mm margins were added to generate clinical tumor volumes (CTV1 & 2). GTV3 ( = CTV3, sMRI-defined) was generated by the union of residual CE tumor and Cho/NAA ≥ 2x NAWM. To remain eligible, CTV3 was required to be ≤ 65 cc. Planning target volumes (PTVs) were generated by applying a 3 mm margin around CTVs. 50.1, 60 and 75 Gy in 30 fractions were prescribed to PTV1, PTV2 and PTV3, respectively. All pts received standard concurrent/adjuvant TMZ. Survival curves were generated by the Kaplan-Meier method. Toxicities were assessed according to CTCAE v4.0. Results: 30 pts met eligibility and were treated on study. Mean/median ages were 56.4/58.9 years. 9 pts (30%) were MGMT methylated; 2 pts (6.7%) harbored an IDH1 mutation. With median followup of 21.4 months in censored pts, median OS was 23.0 months. 11 of 30 pts were documented to have experienced grade 3 or greater toxicities that were at least possibly due to their treatment. Of the 7 pts who experienced these by 9 months post-RT, most were attributable to TMZ (thrombocytopenia x 4, thrombocytopenia/neutropenia x 1, transaminitis x 1) and only one case (headaches/fatigue x 1) could potentially be ascribed to RT. Increased risk of pseudoprogression or radiation necrosis, especially beyond 3 months post-RT, was noted but these were clinically manageable and did not result in toxicity ≥ grade 3. Conclusions: Dose-escalated RT to 75 Gy guided by sMRI appears feasible and safe for pts with newly-diagnosed GBMs. OS outcome is also quite promising and warrants additional testing. Based on these results, a phase II randomized trial is planned at ECOG-ACRIN (EAF211). Clinical trial information: NCT03137888.

A163 MAJORITY OF INFLAMMATORY BOWEL DISEASE PATIENTS WITH RECURRENT CLOSTRIDIOIDES INFECTION DO NOT REQUIRE FECAL MICROBIOTA TRANSPLANTATION

Background

Patients with inflammatory bowel disease (IBD) are at increased risk of developing Clostridioides difficile infection (CDI) and have worse outcomes including higher rates of colectomy and death, and experience higher rates of recurrent CDI (rCDI). However, it is still not clear whether rCDI is a cause of refractory IBD or a consequence of the inflammatory state in the colon.

Aims

We aimed to assess the outcomes of rCDI in patients with active IBD compared to inactive IBD in the era of fecal microbiota transplantation (FMT)

Methods

This is a retrospective cohort of adult IBD patients with rCDI at the IBD centre at the University of Alberta hospital between 2014–2017. rCDI was defined as a recurrent episode occurring within 60 days of the prior after successful treatment with antibiotics. We collected demographic and clinical characteristics, along with the rCDI-related and FMT outcomes in patients with active and inactive IBD. Active IBD was based on clinical assessment using a combination of disease severity scores (Harvey Bradshaw Index, partial Mayo scores), presence of active disease on colonoscopy, clinical symptoms and/or treatment escalation or change in the month leading up to rCDI diagnosis.

Results

Over the study period, 56 IBD patients (50% ulcerative colitis, 28/56) had a total of 85 rCDI episodes. Thirty-four percent (19/56) of patients had two or more rCDI episodes. Forty-one percent (35/85) of rCDI episodes were toxin positive while the remainder were only PCR positive. Thirty-nine percent (33/85) had active IBD at the time of CDI diagnosis. Patients with active IBD were more likely to have rCDI (1.7 rCDI episodes vs. 1.5, p=0.018). IBD treatment escalation was also more likely in the active IBD cases (79% vs. 44%, p = 0.002) with the use of steroids (27% vs 2%, p = 0.001) and addition of biologics (18% vs. 2%, p = 0.013). Active IBD cases were also more likely to be hospitalized (30% vs. 10%, p = 0.02) and were more likely to receive FMT (27% vs. 4%, p = 0.003). There was no difference in the time between rCDI episodes, antibiotic exposure or colectomy rates between the two groups.

Conclusions

Compared to IBD patients in remission, patients with active IBD are more likely to experience rCDI, IBD treatment escalation and FMT. It is interesting to note that only 27% of patients with recurrent CDI required FMT suggesting CDI may be a marker of active or refractory disease rather than a cause. Larger, prospective studies are needed to help clarify this association.

Funding Agencies

None

CTNI-13. UPDATES ON CLINICAL OUTCOMES AND TUMOR RECURRENCE PATTERNS OF A HUMAN PILOT STUDY ASSESSING EFFICACY OF BELINOSTAT (PXD-101) COMBINING WITH CHEMORADIATION IN TREATING GLIOBLASTOMA

INTRODUCTION

Glioblastoma (GBM) is highly aggressive with poor prognosis. Belinostat is a histone deacetylase inhibitor with blood–brain barrier permeability that has anti-GBM activity and may enhance effects of chemoradiation. Our institution conducted a clinical trial evaluating clinical efficacy of belinostat with standard-of-care therapy for GBMs.

METHODS

13 and 14 patients were enrolled into cohort 1 (c1, control) or cohort 2 (c2, belinostat) with 12 in each group with sufficient follow-up MRIs for recurrence analysis. All patients received concurrent, adjuvant temozolomide and focal radiation therapy (RT). For c2 patients, the belinostat regimen (500-750mg/m2 1x/day x 5 days) was given over three cycles every 3 weeks (weeks -1, 2, and 5 of RT). RT margins of 5–10 mm and 3 mm were added to generate clinical tumor volumes and planning target volumes (PTVs). PTV1 (based on FLAIR MRI) and PTV2 (based on CE-T1w MRI) received 51 and 60 Gy, respectively, over 30 fractions. Volume at initial recurrence (rGTV) was contoured.

RESULTS

Mean age was 58.3 years for c1 and 51.1 years for c2. Patient/tumor characteristics were similar between cohorts. Median OS were 16.6 and 18.5 months for c1 and c2 (p=0.538), respectively. Average minimum, maximum and mean radiation dose to rGTV was 54.1 Gy, 64.2 Gy and 62 Gy, for c1, and 47.5 Gy, 57.6 Gy and 53.5 Gy, for c2 (p=0.322, 0.088 and 0.071), respectively. The mean overlap between rGTV and PTV1/PTV2 for c1 & c2 were 99.2% & 96.9%/99.8% & 78.7% (p=0.489/0.133), respectively.

CONCLUSION

Median OS was slightly longer for c2 though not statistically significant. rGTV in c1 received higher radiation doses and had more overlap with PTV2 than in c2. Out-of-field recurrence appears more likely in c2 suggesting better infield control with belinostat. This study highlights the potential of belinostat as a synergistic therapeutic agent for GBM treatment.

A220 A COMPREHENSIVE SYSTEMATIC REVIEW AND META-ANALYSIS OF THE RISK OF ADVERSE NEONATAL OUTCOME IN INFLAMMATORY BOWEL DISEASE AND PREGNANCY

Background

Inflammatory bowel disease (IBD) often affects women in their child-bearing years. These women may be at an increased risk of adverse neonatal outcomes.

Aims

The aim of this study was to evaluate the risk of these outcomes in this population of patients, with an emphasis of determining risk factors for development of these conditions.

Methods

Medline, Embase, and Cochrane library were searched through to May 2019 for studies reporting adverse neonatal outcomes in IBD patients. Weighted odds ratios (OR) with 95% confidence intervals (CI) were calculated to assess the risk of these outcomes in patients with IBD compared to healthy controls, with risk factors such as disease activity and medication exposure also being assessed.

Results

Sixty studies were included (8194 pregnancies with inflammatory bowel disease and 3253 healthy pregnancies). Compared to healthy controls, patients with inflammatory bowel disease were more likely to deliver infants with low birth weight (LBW) (OR 2.78, 95% CI 1.16–6.66) and infants who were admitted to the neonatal intensive care unit (NICU) (OR 3.33, 95% CI 1.83–6.05). Patients with Crohn’s disease had an increased risk of infants born with congenital anomalies (OR 3.03, 95% CI, 1.43–6.42), whereas patients with ulcerative colitis had an increased risk of preterm delivery (OR 2.68, 95% CI, 1.12–6.43). Active disease increased the risk of preterm birth (OR 2.06, 95% CI 1.21–3.51), LBW (OR 2.96, 95% CI 1.54–5.70), and small for gestation age (OR 2.62, 95% CI 1.18–5.83) compared to disease in remission. Tumor necrosis factor antagonists was associated with increased risk of NICU admission (OR 2.42, 95% CI 1.31–4.45) and LBW (OR 1.54, 95% CI, 1.01–2.35).

Conclusions

Patients with inflammatory bowel disease are at an increased risk of developing adverse neonatal outcomes such as preterm birth, LBW, congenital anomalies, and NICU admissions. Patients with clinically active disease and those exposed to anti-TNF therapy may be at higher risk of developing these adverse outcomes. The findings of this study are important to communicate to patients and healthcare providers alike. Furthermore, this information may help to mitigate these risks through collaborative specialized care during pregnancy in order to reduce the overall morbidity and mortality for both mother and baby.

Funding Agencies

None

A237 SHARED DECISION MAKING: DESIGN OF A PREGNANCY IN IBD DECISION AID (PIDA)

Background

Given a significant proportion of women with inflammatory bowel disease (IBD) are of child-bearing age, the development of a pregnancy IBD decision aid would benefit patients and clinicians. Lack of IBD-specific reproductive knowledge has been associated with increased “voluntary childlessness” and may contribute to inappropriate medication changes during or after pregnancy. Decision aids support decision making in pregnancy in general, as well as in multiple other chronic diseases. However existing literature has not identified such a resource for women with IBD.

Aims

To develop a decision aid to improve decision making regarding preconception and pregnancy in IBD among women with IBD.

Methods

We followed the International Patient Decision Aids Standards (IPDAS). A steering committee of Canadian and Australian health care professionals with an interest in IBD management in pregnancy, in addition to patient representatives, was established. Themes chosen for discussion included inheritance, fertility, nutrition, medications, mode of delivery, breastfeeding, infant health. Initial patient and clinician focus groups were conducted and responses recorded with written/audio mediums. We developed an electronic PIDA draft that incorporates individualised information (type of IBD, pre-conception or pregnant, surgical history, medications) in personalized decision making. Further patient focus groups and interviews were conducted to obtain user opinion of the PIDA draft.

Results

In July 2017, patient and clinician focus groups were conducted at a Canadian site. Three patients (pre-conception) attended the focus group. Patient concerns - impact of disease and surgery on fertility and preterm delivery; impact of drug therapies on the fetus/ infant; impact of active disease on maternal and fetal/infant health. The clinician focus group included 3 IBD specialists, 2 IBD fellows, 2 IBD nurses, an obstetrician and a neonatal intensivist. Clinician concerns - absence of pre-conception counselling and lack of patient understanding about the impact of disease activity and IBD medication use in pregnancy. Additional patient feedback obtained through interviews (n=15) at two Canadian sites since March 2019 regarding the current electronic PIDA was positive, with comments about content, personalization, readability and unbiased presentation. Suggestions were made for inclusion of additional content such as impact of IBD on sexual function, laboratory changes during pregnancy, and timing of medications post-partum.

Conclusions

The pre and post PIDA design patient and clinician focus groups and interviews affirmed the role for PIDA. Main decisions considered necessary to address included ideal timing of conception pending disease activity, management of medications, and delivery methods. Ongoing user feedback will be obtained at Australian and Canadian sites during planned alpha testing.

Funding Agencies

WCHRI, Sinai Health System, UBC

A244 MATERNAL THIOPURINE AND ANTI-TUMOR NECROSIS FACTOR THERAPY DURING PREGNANCY IS ASSOCIATED WITH AN INCREASED RISK OF PLACENTAL-RELATED DISEASES

Background

Though previous studies have suggested that most therapies for inflammatory bowel disease (IBD) are safe during pregnancy, the effect of these medications on placental-related diseases remain unknown.

Aims

To determine the effect of gestational medication exposure on pregnancy-related outcomes in patients with IBD.

Methods

We retrospectively reviewed the University of Alberta and University of Toronto pregnancy databases to identify patients (age &gt; 18) who underwent routine assessment by a gastroenterologist at least once during pregnancy (first trimester (T1), second trimester (T2), and third trimester (T3). Pregnancy-related outcomes (maternal, obstetrical, and neonatal) were recorded from obstetrical records. Low-birth weight (LBW) was defined as an infant weight &lt; 2500g at birth. Pre-term delivery was defined as birth &lt; 37 weeks gestation. Medication exposure, such as 5-aminosalicylates (5-ASA), thiopurines, steroids, and anti-tumor necrosis factor (TNF) therapy was recorded for each trimester. Categorical variables were statistically compared using the Chi-square (x2) test through the SPSS software.

Results

A total of 84 patients were included. Compared to those not exposed to thiopurines, patients exposed to thiopurine therapy during T2 had an increased risk of pre-term birth (26.7% vs. 7.7%, p=0.046) and pre-eclampsia (13.3% vs. 0%, p=0.008) and a trend towards an increased risk of placental abruption (6.7% vs, 0%, p=0.061). Furthermore, compared to those not treated with corticosteroids, those prescribed corticosteroid therapy during any trimester had an increased risk of pre-term birth (T1 exposure: 50% vs. 10.2%, p=0.024; T2 exposure: 37.5% vs. 8.5%. p=0.018; T3 exposure: 42.9% vs. 8.8%, p=0.008) and infants born with LBW (T1 exposure: 50.0% vs. 7.8%, p=0.009; T2 exposure: 37.5% vs. 8.2%, p=0.015; T3 exposure: 57.1% vs. 8.6%, p=0.0005). Those exposed to corticosteroids in T3 only had an increased risk of PPROM (60.0% vs. 7.5%, p=0.0003) and chorioamnionitis (14.3% vs. 0%, p=0.002). Finally, anti-TNF therapy in T2 was associated with an increased risk of pre-eclampsia (9.1% vs. 0%, p=0.040. 5-ASA therapy was not associated with an increased risk of any adverse pregnancy-related outcome. No medication increased the risk of other maternal (i.e. gestational diabetes, emergency Cesarean-section delivery) and neonatal (intensive care unit admission, congenital anomalies) outcomes.

Conclusions

Placental related diseases, such as pre-eclampsia, appear to be increased with maternal exposure to thiopurine and anti-TNF therapy during pregnancy. Larger studies are required to confirm these associations.

Funding Agencies

None

A250 SYSTEMATIC REVIEW WITH META-ANALYSIS: ADVERSE PREGNANCY-RELATED OUTCOMES WITH INFLAMMATORY BOWEL DISEASE

Background

Inflammatory bowel disease (IBD) is a chronic inflammatory condition. While it is reported that IBD may result in adverse pregnancy-related outcomes, its effects on placental related diseases are relatively not known.

Aims

The aim of our work was to determine the risk of adverse pregnancy outcomes in patients with IBD.

Methods

Medline, Embase, and Cochrane library were searched for studies that reported adverse maternal and obstetrical outcomes in patients with IBD. Weighted odds ratios (OR) with 95% confidence intervals (CI) were calculated for the risk of these outcomes in patients with IBD compared to healthy controls.

Results

Fifty-three studies were included (7917 patients with IBD and 3253 healthy controls). Cesarean delivery was more common in patients with IBD compared to healthy controls (OR 1.79, 95% CI, 1.16–2.77). This remained significant for UC (OR 1.80, 95% CI, 1.21–2.90) but not CD (OR 1.48, 95% CI, 0.94–2.34). Similarly, gestational diabetes occurred more commonly in IBD (OR 2.96, 95% CI, 1.47–5.98). Furthermore, the incidences of placental diseases were low, 2.0% (95% CI, 0.9–3.1%) for pre-eclampsia, 3.3% (95% CI, 0–7.2%) for placental abruption, 0.5% (95% CI, 0.2–0.9%) for placenta previa, and 0.3% (95% CI, 0–0.5%) for chorioamnionitis. Finally, patients with IBD were more likely to experience preterm premature rupture of membranes (PPROM, OR 12.10, 95% CI, 2.15–67.98), but not an early pregnancy loss (OR 1.63, 95% CI 0.49–5.43). Anti-tumour necrosis factor therapy was not associated with chorioamnionitis (OR 1.12, 95% CI, 0.16–7.67), early pregnancy loss (OR 1.49, 95% CI, 0.83- 2.64), and placenta previa (OR 1.58, 95% CI, 0.30–8.47).

Conclusions

Patients with IBD are more likely to develop adverse pregnancy-related outcomes such as Gestational Diabetes and PPROM. Pregnancy in patients with IBD should be considered a high-risk period and as such, a multi-disciplinary team, including gastroenterologists, obstetricians and maternal-fetal medicine specialists, is necessary to recognize and effectively manage adverse obstetrical outcomes in order to reduce overall morbidity and mortality.

Funding Agencies

None

A162 THE UTILITY OF FECAL CALPROTECTIN IN PREDICTING SEVERITY OF CLOSTRIDIUM DIFFICILE INFECTION: A SYSTEMATIC REVIEW

Background

Clostridium difficile is an anaerobic, spore-forming, gram-positive bacillus, and a leading cause of infectious diarrhea in hospitalized patients. It is associated with high mortality and morbidity, and places an enormous burden on the healthcare system. Symptoms and severity of CDI vary widely, from illness that resolves with antibiotics, to toxic megacolon, colectomy, and death. The ability to risk-stratify patients to predict severe versus non-severe outcomes at baseline would be clinically useful. The role of fecal calprotectin in predicting severity of CDI has not been well established.

Aims

To perform a systematic review of the literature on the ability of fecal calprotectin to predict disease severity in patients with CDI.

Methods

PubMed, OVID (EMBASE/MedLine) and Cochrane Library databases were searched up until October 2, 2019. Publications of pediatric populations, Inflammatory Bowel diseases, and those only published as abstracts were excluded.

Results

130 non-duplicate citations were screened; after title/abstract screening, and full-text review, 7 articles were included for analysis. Articles were from 2014 onwards, and varied from 29 to 232 patients/samples analyzed; 832 patients in total were analyzed. Three studies were conducted in the USA, two in Europe, one in Israel and in South Korea. Four studies were prospective, and the remaining three were retrospective cohort studies. There was significant heterogeneity between studies with respect to population size, age (when reported), fecal calprotectin assay and cutoff used, method of diagnosis of CDI, and criteria for defining disease severity. There was wide variation in median fecal calprotectin levels between studies. Four studies demonstrated a statistically significant difference of fecal calprotectin according to disease severity, and three did not, of which two of these demonstrated an overall predictive trend with fecal calprotectin.

Conclusions

It is unclear whether fecal calprotectin is predictive of severity of CDI in adult patients without IBD. In the existing literature, there seems to be a statistically significant association or trend towards association in most studies, but due to heterogeneity of methods, assays, cutoffs and populations, the data within these studies cannot be pooled in meta-analysis. Further high-powered, well-designed studies are required to clarify this important clinical question.

Funding Agencies

None

Multicenter Study of the Real-World Use of Ceftaroline versus Vancomycin for Acute Bacterial Skin and Skin Structure Infections

The objective of this study was to determine if real-world ceftaroline treatment in adults hospitalized for acute bacterial skin and skin structure infections (ABSSSI) is associated with decreased infection-related length of stay (LOSinf) compared to that with vancomycin. This was a retrospective, multicenter, cohort study from 2012 to 2017. Cox proportional hazard regression, propensity score matching, and inverse probability of treatment weighting (IPTW) were used to determine the independent effect of treatment group on LOSinf The patients were adults hospitalized with ABSSSI and treated with ceftaroline or vancomycin for ≥72 h within 120 h of diagnosis at four academic medical centers and two community hospitals in Arizona, Florida, Michigan, and West Virginia. A total of 724 patients were included (325 ceftaroline treated and 399 vancomycin treated). In general, ceftaroline-treated patients had characteristics consistent with a higher risk of poor outcomes. The unadjusted median LOSinf values were 5 (interquartile range [IQR], 3 to 7) days and 6 (IQR, 4 to 8) days in the vancomycin and ceftaroline groups, respectively (hazard ratio [HR], 0.866; 95% confidence interval [CI], 0.747 to 1.002). The Cox proportional hazard model (adjusted HR [aHR], 0.891; 95% CI, 0.748 to 1.060), propensity score-matched (aHR, 0.955; 95% CI, 0.786 to 1.159), and IPTW (aHR, 0.918; 95% CI, 0.793 to 1.063) analyses demonstrated no significant difference in LOSinf between groups. Patients treated with ceftaroline were significantly more likely to meet criteria for discharge readiness at day 3 in unadjusted and adjusted analyses. Although discharge readiness at day 3 was higher in ceftaroline-treated patients, LOSinf values were similar between treatment groups. Clinical and nonclinical factors were associated with LOSinf.