Classification of Patients with Painful Tumors to Predict the Response to Palliative Radiotherapy

PURPOSE/OBJECTIVE(S)

Palliative radiotherapy is an effective and commonly used treatment for pain relief in metastatic cancer patients. This study aimed to classify the patients to predict their response to palliative radiotherapy.

MATERIALS/METHODS

This study used the data from our single-center, prospective observational study (UMIN000044984), which included all patients undergoing palliative radiotherapy for the painful tumor, except for postoperative setting or brain metastases. The eligibility criteria were as follows: (1) numerical rating scale (NRS) was two or more before treatment, and (2) underwent palliative radiotherapy between August 2021 and September 2022. Questionnaires for pain site, NRS, and presence/dose of opioids were obtained before, on the last day of treatment, two weeks later, one month later, three months later, and every three months after that. Patients with severe performance status (PS) were contacted by telephone. Pain response was defined to reduce NRS 2 or more at the treated site without an analgesic increase. The primary outcome was the response rate within three months of the treatment. We used multivariable logistic regression to find the independent prognostic factors for the response based on the following covariates: age, sex, PS, body mass index, NRS, history of radiotherapy, treated site, radiographic features (lytic/sclerotic/mixed), metastatic complication, presence/dose of opioids, bone-modifying agents, radiation dose, type of primary tumor, radiosensitivity, number of metastases, and days from diagnosis to treatment. A classification model was created using significant factors, and response rates were calculated for each class. Statistical significance was defined as P<0.05.

RESULTS

Among 488 targets of 300 patients registered, 366 targets of 261 patients met the criteria. The median age was 65 years, 44% were female, and PS (0/1/2/3/4) was 6/63/18/9/4%. The major type of tumor was gastrointestinal (32%), lung (19%), and breast (12%). Bone metastases were 75% at treated sites. Opioids were used by 72%, BMA was 27%, and chemotherapy was 50%. Re-irradiation rate was 22%. With a median follow-up of 5.8 months, 113 patients were alive, 129 had died, and 20 were lost follow-up. The average NRS was reduced from 6.1 to 3.1 from pretreatment to 3 months later per evaluable 232 targets, resulting in a pain relief rate of 60%. Opioids use (P<0.001) and re-irradiation (P<0.001) were significant factors of poor response in multivariate analysis. In our classification model, 89 targets were classified as class 1 (no opioids & no irradiation history), 211 were class 2 (other than class 1 and 3), and 66 were class 3 (opioids & re-irradiation), were 75/61/36% (P<0.001) of response rate. The 6-month cumulative pain progression rate was 12/22/32% (P<0.001), respectively.

CONCLUSION

Palliative radiotherapy is highly effective for patients with painful tumors especially for those without previous irradiation history or use of opioids.

Multicenter Retrospective Study of Stereotactic Body Radiotherapy for Patients with Previously Untreated Initial Small Hepatocellular Carcinoma

PURPOSE/OBJECTIVE(S)

The effectiveness of stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) has been shown in many studies and its therapeutic effect is similar to radiofrequency ablation (RFA). However, many of these studies were done in combination with transcatheter chemoembolization (TACE), for recurrent HCC, or on a small scale. To better understand the specific outcomes of SBRT for HCC, we conducted a multicenter retrospective analysis of SBRT for previously untreated initial HCC at Japanese Society of Clinical Oncology (JCOG) member hospitals.

MATERIALS/METHODS

Patientswho underwent SBRT for HCC at JCOG member hospitals between July 2013 and December 2017 and met the following eligibility criteria were included: (1) initial HCC; (2) ≤ 3 nodules, ≤ 5 cm in diameter; (3) a Child-Pugh (CP) score of A or B; and (4) unsuitability for or refusal of standard treatment, such as surgery, transplantation, RFA and TACE. We evaluated the overall survival (OS), recurrence-free survival (RFS) which was defined as the first instance of intra-hepatic recurrence after SBRT, disease-specific survival (DSS) using Kaplan-Meier analysis. Using Grey's test, patients who died of other diseases were analyzed as competing risks to estimate the cumulative incidence of local recurrence (CLR). Adverse events directly related to SBRT also analyzed using Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0).

RESULTS

Seventy-three patients with 79 lesions from 14 hospitals were analyzed. The median age was 77 years (range; 50-89 years), and the median tumor size was 23 mm (range; 6-50 mm). The median radiation dose was 40 Gy (range; 35-60 Gy) in five fractions (range; 4-8). The median follow-up period was 45 months (range; 0-103 months). There were three cases where follow-up was not possible due to unexpected events unrelated to SBRT, while the remaining 70 patients were successfully followed for at least six months. The 2 and 3year OS, RFS, DSS, and CLR rates were 84.3% (95% CI: 75.8-92.8%) and 69.9% (95% CI: 58.7-81%), 67.5% (95% CI: 56.0-79.0%) and 57.9% (95% CI: 45.2-70.5%), 95.1% (95% CI:89.7-100%)/87.6% (95% CI:78.8-96.3%), and 11.4% (95% CI: 5.3-20.0%) and 20.0% (95% CI: 11.2-30.5%), respectively. Four cases (5.5%) of adverse events of grade 3 or higher were reported: one case of grade 3 laboratory toxicities, one case of grade 3 liver failure, one case of grade 3 portal tumor thrombosis, and one case of grade 4 duodenal ulcer. No grade 5 toxicities were observed.

CONCLUSION

The results of our study demonstrate that SBRT for HCC is highly effective in achieving local control and is safe to administer. In addition, survival outcomes are favorable. SBRT is a promising treatment modality, especially for small HCCs for that is not suitable for standard treatment.

Care Staff's Daily Living Decision-Making Support Scale for Older Adults with Dementia in Japan: Development of Validity and Reliability

This study aimed to develop and validate a scale to assess the daily-living decision-making support of care staff for older adults with dementia (OwDs) in Japan. A questionnaire survey was conducted among 138 care staff at two geriatric healthcare facilities from February to March 2021. The Daily Living Decision-Making Support Scale for Older Adults with Dementia (DL-DM) was developed using item analysis, factor analysis, and covariance structure analysis. The factor analysis yielded 12 items and three factors: (1) support for the formation and expression of intentions in daily life based on the life background and values of OwDs; (2) attitudes and devising ways to communicate regarding the formation and expression of intentions in OwDs daily lives; and (3) devising ways to support OwDs in realizing their intentions in daily life. The internal consistency reliability analysis yielded a Cronbach's α of 0.87 for the total scale. The DL-DM correlated with the concurrent validity measures as expected. The DL-DM demonstrated validity and reliability as a potential scale to assess support for OwDs in daily life decision-making. The results also suggest an association between the DL-DM and person-centered care for OwDs.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

The long-term outcome of transvaginal anterior levatorplasty for intractable rectovaginal fistula

AIM

Several procedures have been described for rectovaginal fistula with a wide range of success, but there is little information on the long-term outcome. The aim of the present study was to investigate the long-term outcome after transvaginal anterior levatorplasty (ALP) for intractable rectovaginal fistula.

METHOD

Data of 16 consecutive patients undergoing transvaginal ALP with fistulectomy and closure of the rectum and vagina between 1998 and 2011 were prospectively recorded and retrospectively investigated to study the long-term outcome.

RESULTS

Birth injury (n = 7), low anterior resection for rectal cancer (n = 3), pouch surgery for ulcerative colitis (n = 2) and a procedure for prolapse and haemorrhoids (n = 2) were the main causes of the fistula. Nine patients had a covering stoma before surgery. All patients underwent ALP, with a covering stoma in two patients. Infection occurred in one patient and wound rupture after surgery in another patient. These patients underwent reoperation by ALP. All fistulae had healed at a median follow-up of 84 (8-193) months after initial surgery or stoma closure.

CONCLUSION

Transvaginal ALP is effective for the treatment of mid or low rectovaginal fistula. The results show that a graft is not necessary regardless of whether or not previous surgery has been performed.

[Molecular dissection of Mycobacterium tuberculosis-containing phagosomes]

Mycobacterium tuberculosis is an intracellular bacterium that can proliferate within phagocytosed macrophages. M. tuberculosis gains this ability by inhibiting phagolysosome biogenesis. On the other hand, autophagy induction can eliminate infected mycobacteria in macrophages. Numerous reports have demonstrated the mechanism of membrane trafficking in macrophages infected with mycobacteria to elucidate how M. tuberculosis proliferates within macrophages. In this review, we make a commentary on the molecular dissection of M. tuberculosis-containing phagosomes demonstrating which host factors constitute the replication niche for mycobacteria, and approach the real images of mycobacterial phagosomes.

Transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele

BACKGROUND

We evaluated functional and morphological outcomes of transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele.

METHODS

Ten women (median 68 years) underwent transvaginal anterior levatorplasty with posterior colporrhaphy for symptomatic rectocele. Symptoms and continence were monitored before and after surgery. Manovolumetric study and defecography were performed in 9 of 10 patients before and 3-6 months after surgery. Twenty-one females without anorectal diseases were used as controls in manovolumetric study. The patients were followed up after a median of 89 months (range, 3-103).

RESULTS

Main symptoms (defecatory disorders in 9 patients, vaginal mass in 6, perineal discomfort in 2) disappeared after surgery. Six patients performed digitation preoperatively and gave up digitation on defecation after surgery. Stool incontinence disappeared in 4 of 5 preoperatively incontinent patients (Cleveland clinic score, 5-12) and continence score improved from 5 to 2 in the remaining patient. Three patients with urinary cough incontinence preoperatively did not experience incontinence after surgery but cough incontinence occurred occasionally in an 81-year-old patient postoperatively. Rectocele demonstrated on defecography disappeared postoperatively in all 9 patients who underwent defecography. High threshold volume and maximum tolerable volume, which were observed preoperatively, decreased to control levels after surgery.

CONCLUSION

Transvaginal anterior levatorplasty with posterior colporrhaphy might be an option for symptomatic rectocele to improve anorectal and urinary dysfunctions with morphological disorders.

A theoretical and experimental study on meridional–facial isomerization of tris(quinolin-8-olate)aluminum (Alq3)

The rationale behind the stereospecific synthesis of a facial isomer of tris(quinolin-8-olate)aluminum (Alq₃) is studied by density functional theory (DFT) calculations, which predict the favourable influence of an H₃O⁺ ion on the distribution ratio between a meridional and a thermodynamically unstable facial isomer.

Autophagy adaptor protein p62/SQSTM1 and autophagy-related gene Atg5 mediate autophagosome formation in response to Mycobacterium tuberculosis infection in dendritic cells

Mycobacterium tuberculosis is an intracellular pathogen that can survive within phagocytic cells by inhibiting phagolysosome biogenesis. However, host cells can control the intracellular M. tuberculosis burden by the induction of autophagy. The mechanism of autophagosome formation to M. tuberculosis has been well studied in macrophages, but remains unclear in dendritic cells. We therefore characterized autophagosome formation in response to M. tuberculosis infection in dendritic cells. Autophagy marker protein LC3, autophagy adaptor protein p62/SQSTM1 (p62) and ubiquitin co-localized to M. tuberculosis in dendritic cells. Mycobacterial autophagosomes fused with lysosomes during infection, and major histcompatibility complex class II molecules (MHC II) also localized to mycobacterial autophagosomes. The proteins p62 and Atg5 function in the initiation and progression of autophagosome formation to M. tuberculosis, respectively; p62 mediates ubiquitination of M. tuberculosis and Atg5 is involved in the trafficking of degradative vesicles and MHC II to mycobacterial autophagosomes. These results imply that the autophagosome formation to M. tuberculosis in dendritic cells promotes the antigen presentation of mycobacterial peptides to CD4⁺ T lymphocytes via MHC II.

Rab39a interacts with phosphatidylinositol 3-kinase and negatively regulates autophagy induced by lipopolysaccharide stimulation in macrophages

Rab39a has pleiotropic functions in phagosome maturation, inflammatory activation and neuritogenesis. Here, we characterized Rab39a function in membrane trafficking of phagocytosis and autophagy induction in macrophages. Rab39a localized to the periphery of LAMP2-positive vesicles and showed the similar kinetics on the phagosome to that of LAMP1. The depletion of Rab39a did not influence the localization of LAMP2 to the phagosome, but it augments the autophagosome formation and LC3 processing by lipopolysaccharide (LPS) stimulation. The augmentation of autophagosome formation in Rab39a-knockdown macrophages was suppressed by Atg5 depletion or an inhibitor for phosphatidylinostol 3-kinase (PI3K). Immunoprecipitation analysis revealed that Rab39a interacts with PI3K and that the amino acid residues from 34(th) to 41(st) in Rab39a were indispensable for this interaction. These results suggest that Rab39a negatively regulates the LPS-induced autophagy in macrophages.

Antigen 85A and mycobacterial DNA-binding protein 1 are targets of immunoglobulin G in individuals with past tuberculosis

Development of accurate methods for predicting progression of tuberculosis (TB) from the latent state is recognized as vitally important in controlling TB, because a majority of cases develop from latent infections. Past TB that has never been treated has a higher risk of progressing than does latent Mycobacterium tuberculosis infection in patients who have previously received treatment. Antibody responses against 23 kinds of M. tuberculosis proteins in individuals with past TB who had not been medicated were evaluated. These individuals had significantly higher concentrations of antibodies against Antigen 85A and mycobacterial DNA-binding protein 1 (MDP1) than did those with active TB and uninfected controls. In addition, immunohistochemistry revealed colocalization of tubercle bacilli, antigen 85 and MDP1 inside tuberculous granuloma lesions in an asymptomatic subject, showing that M. tuberculosis in lesions expresses both antigen 85 and MDP1. Our study suggests the potential usefulness of measuring antibody responses to antigen 85A and MDP1 for assessing the risk of TB progression.