An isotoxic planning comparison study for stage II-III non-small cell lung cancer: is intensity-modulated radiotherapy the answer?

AIMS

Recent clinical series suggest that treating patients with isotoxic twice-daily radiotherapy may be beneficial. This dosimetric planning study compared the use of intensity-modulated radiotherapy (IMRT) and three-dimensional conformal radiotherapy (3DRT) to deliver isotoxic treatment for non-small cell lung cancer (NSCLC) patients.

MATERIALS AND METHODS

Twenty patients with stage II/III NSCLC were selected. A dose-escalated plan was produced retrospectively for each using three different methods: (i) three to five beams 3DRT; (ii) seven beams inverse-planned conformal radiotherapy; (iii) seven beams IMRT. The starting point for dose escalation was 55.8 Gy in 1.8 Gy per fraction twice-daily. The number of fractions was then increased until one or more organ at risk tolerance dose was exceeded or a maximum dose of 79.2 Gy was reached.

RESULTS

The median escalated doses were 70.2, 66.6 and 64.8 Gy for IMRT, 3DRT and inverse-planned conformal radiotherapy, respectively. IMRT allowed a significant dose increase in comparison with the other two methods (P < 0.05), whereas no significant difference was found between 3DRT and inverse-planned conformal radiotherapy. IMRT was more successful at escalating dose in patients where the brachial plexus and spinal canal were close to the planning target volume. IMRT did not allow the escalation of dose beyond 70.2 Gy (82.8 Gy BED10, 69 Gy EQD2) due to the proximity of disease to the great vessels and the proximal bronchial tree.

CONCLUSIONS

IMRT allows increased dose escalation compared with conformal radiotherapy. However, there is limited opportunity to escalate the prescription dose beyond 70.2 Gy twice-daily in disease close to the central mediastinal structures.

Early reduction in tumour [18F]fluorothymidine (FLT) uptake in patients with non-small cell lung cancer (NSCLC) treated with radiotherapy alone

PURPOSE

Changes in tumour 3'-deoxy-3'-[(18)F]fluorothymidine (FLT) uptake during concurrent chemo-radiotherapy in patients with non-small cell lung cancer (NSCLC) have been reported, at variable time points, in two pilot positron emission tomography (PET) studies. The aim of this study was to assess whether FLT changes occur early in response to radiotherapy (RT) without concurrent chemotherapy and whether such changes exceed test-retest variability.

METHODS

Sixteen patients with NSCLC, scheduled to have radical RT, underwent FLT PET once/twice at baseline to assess reproducibility and/or after 5-11 RT fractions to evaluate response. Primary and nodal malignant lesions were manually delineated on CT and volume, mean and maximum standardized uptake values (SUV(mean) and SUV(max)) estimated. Analysis included descriptive statistics and parameter fitting to a mixed-effects model accounting for patients having different numbers of evaluable lesions.

RESULTS

In all, 35 FLT PET scans from 7 patients with a total of 18 lesions and 12 patients with a total of 30 lesions were evaluated for reproducibility and response, respectively. SUV(mean) reproducibility in primary tumours (SD 8.9%) was better than SUV(max) reproducibility (SD 12.6%). In nodes, SUV(mean) and SUV(max) reproducibilities (SD 18.0 and 17.2%) were comparable but worse than for primary tumours. After 5-11 RT fractions, primary tumour SUV(mean) decreased significantly by 25% (p = 0.0001) in the absence of significant volumetric change, whereas metastatic nodes decreased in volume by 31% (p = 0.020) with a larger SUV(mean) decrease of 40% (p < 0.0001). Similar changes were found for SUV(max).

CONCLUSION

Across this group of NSCLC patients, RT induced an early, significant decrease in lesion FLT uptake exceeding test-retest variability. This effect is variable between patients, appears distinct between primary and metastatic nodal lesions, and in primary tumours is lower than previously reported for concurrent chemo-RT at a similar time point. These results confirm the potential for FLT PET to report early on radiation response and to enhance the clinical development of novel drug-radiation combinations by providing an interpretable, early pharmacodynamic end point.

Simultaneous cone beam CT scanning during prostate radiotherapy to produce clinically useful images

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Background: Cone beam CT (CBCT) images can be acquired during delivery of rotational radiotherapy. We assessed the quality of simultaneous CBCTs captured during prostate radiotherapy and studied the effects of arc delivery time on image quality. Methods: Fifty patients with localised prostate cancer were treated with radical rotational radiotherapy. Treatment was delivered using a single eight or 10 MV arc on an Elekta Synergy linear accelerator. Standard (stCBCT) and simultaneous CBCTs (siCBCT) were captured on fractions 1, 6, 11, and 16. The siCBCT image was reconstructed and optimised using in-house software. The image quality was assessed by four observers using a validated scoring tool. The scoring clinician was blinded to whether the scan was stCBCT or siCBCT. Results: Seventy-four siCBCT scans were performed with a mean arc delivery time of 120 seconds during which 688 CBCT frames were acquired. Following a software upgrade the subsequent 122 siCBCTs were obtained with a mean arc delivery time of 83 seconds during which 502 CBCT frames were acquired. There was moderate agreement between the four observers regarding the quality of the CBCTs (Fleiss’ kappa statistic 0.51). StCBCTs were of good quality and the four observers agreed that 98 to 100% of these scans were of sufficient quality to be used to make a clinical decision. The four observers assessed that 35 to 79% of siCBCTs were of sufficient quality to be used to make clinical decisions. Before the software upgrade 65 to 93% of siCBCTs were judged to be of sufficient quality to make a clinical decision ("slow" simultaneous CBCT). Following the software upgrade this proportion fell to 16 to 69% ("fast" simultaneous CBCT). Conclusions: SiCBCT can produce images which are clinically useful. Image quality is affected by bowel gas, patient habitus and scatter from the MV beam. Reducing arc delivery time and the number of CBCT frames acquired by approximately one-third reduces the quality of siCBCTs. Further development and refinement of siCBCT scanning is warranted. Future reductions in arc delivery times may have to be limited if the use of siCBCT scanning becomes standard practice.

Necrosis predicts benefit from hypoxia-modifying therapy in patients with high risk bladder cancer enrolled in a phase III randomised trial

BACKGROUND AND PURPOSE

Addition of carbogen and nicotinamide (hypoxia-modifying agents) to radiotherapy improves the survival of patients with high risk bladder cancer. The study investigated whether histopathological tumour features and putative hypoxia markers predicted benefit from hypoxia modification.

MATERIALS AND METHODS

Samples were available from 231 patients with high grade and invasive bladder carcinoma from the BCON phase III trial of radiotherapy (RT) alone or with carbogen and nicotinamide (RT+CON). Histopathological tumour features examined were: necrosis, growth pattern, growing margin, and tumour/stroma ratio. Hypoxia markers carbonic anhydrase-IX and glucose transporter-1 were examined using tissue microarrays.

RESULTS

Necrosis was the only independent prognostic indicator (P=0.04). Necrosis also predicted benefit from hypoxia modification. Five-year overall survival was 48% (RT) versus 39% (RT+CON) (P=0.32) in patients without necrosis and 34% (RT) versus 56% (RT+CON) (P=0.004) in patients with necrosis. There was a significant treatment by necrosis strata interaction (P=0.001 adjusted). Necrosis was an independent predictor of benefit from RT+CON versus RT (hazard ratio [HR]: 0.43, 95% CI 0.25-0.73, P=0.002). This trend was not observed when there was no necrosis (HR: 1.64, 95% CI 0.95-2.85, P=0.08).

CONCLUSIONS

Necrosis predicts benefit from hypoxia modification in patients with high risk bladder cancer and should be used to select patients; it is simple to identify and easy to incorporate into routine histopathological examination.

Obstetric complications and psychological well-being: experiences of Bangladeshi women during pregnancy and childbirth

Women in developing countries experience postnatal depression at rates that are comparable with or higher than those in developed countries. However, their personal experiences during pregnancy and childbirth have received little attention in relation to postnatal depression. In particular, the contribution of obstetric complications to their emotional well-being during the postpartum period is still not clearly understood. This study aimed to (a) describe the pregnancy and childbirth experiences among women in Bangladesh during normal childbirth or obstetric complications and (b) examine the relationship between these experiences and their psychological well-being during the postpartum period. Two groups of women--one group with obstetric complications (n=173) and the other with no obstetric complications (n=373)--were selected from a sample of women enrolled in a community-based study in Matlab, Bangladesh. The experiences during pregnancy and childbirth were assessed in terms of a five-point rating scale from 'severely uncomfortable=1' to 'not uncomfortable at all=5'. The psychological status of the women was assessed using a validated local version of the Edinburgh Postnatal Depression Scale (EPDS) at six weeks postpartum. Categorical data were analyzed using the chi-square test and continuous data by analysis of variance. Women with obstetric complications reported significantly more negative experiences during their recent childbirth [95% confidence interval (CI) 1.36-1.61, p<0.001] compared to those with normal childbirth. There was a significant main effect on emotional well-being due to experiences of pregnancy [F (4,536)=4.96, p=0.001] and experiences of childbirth [F (4,536)=3.29, p=0.01]. The EPDS mean scores for women reporting severe uncomfortable pregnancy and childbirth experiences were significantly higher than those reporting no such problems. After controlling for the background characteristics, postpartum depression was significantly associated with women reporting a negative childbirth experience. Childbirth experiences of women can provide important information on possible cases of postnatal depression.

Abstract LB-450: Necrosis predicts benefit from hypoxia-modifying therapy in urothelial cell carcinoma of the bladder

To investigate the ability of tumor necrosis to predict benefit following radiotherapy with and without hypoxia-modifying treatment in high grade urothelial cell carcinoma of the urinary bladder. Background: There is no predictive marker of hypoxia-modifying therapy in cancer patients in routine clinical use. Methods: We identified 231 patients who participated in the BCON phase III randomised trial comparing radical radiotherapy (RT) with and without carbogen and nicotinamide (CON) in patients with urothelial cell carcinoma of the bladder who were suitable for this retrospective study. Tumor necrosis was scored on whole tissue sections as absent or present. Results: Tumor necrosis was identified in 121 of the 231 patients (52%). 5-year overall survival estimates were 41% for the RT arm and 48% for the CON arm (log rank p=0.14). When stratified using tumor necrosis, the 5-year overall survival estimates were 48% (RT) and 39% (CON) (log rank p =0.32) in patients with no evident tumor necrosis, and 34% (RT) and 56% (CON) (log rank p=0.004) in patients with tumor necrosis. Multivariate analyses showed that the presence of tumor necrosis was a significant predictor of benefit from CON with the risk of dying 57% lower compared to RT alone (HR 0.43, 95% CI 0.25-0.73, p=0.002). This trend was not observed when there is no evident tumour necrosis (HR 1.64, 95% CI 0.95-2.85, p=0.08). Test for heterogeneity in treatment effect by necrosis strata (p=0.007 unadjusted, p=0.001 adjusted). Conclusions: Tumor necrosis significantly predicts benefit from radiotherapy with hypoxia-modifying treatment. Independent validation in a prospective trial is warranted.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-450. doi:1538-7445.AM2012-LB-450

Deciding to Change: Enhancing Client Motivation to Change Behaviour

Cognitive behaviour therapy concentrates on strategies to assist clients in changing their thoughts and/or their behaviour. The aim of this paper is to discuss research findings from the addictions field indicating that an effective approach to therapy is to enhance motivation for change. Research into stages and processes of change, decision making, and motivational interviewing is reviewed. The paper concludes by suggesting ways in which this research can be used by therapists to increase the likelihood that clients will engage in change and maintain change over time.

A pilot study to explore circulating tumour cells in pancreatic cancer as a novel biomarker

Background:

Obtaining tissue for pancreatic carcinoma diagnosis and biomarker assessment to aid drug development is challenging. Circulating tumour cells (CTCs) may represent a potential biomarker to address these unmet needs. We compared prospectively the utility of two platforms for CTC enumeration and characterisation in pancreatic cancer patients in a pilot exploratory study.

Patients and methods:

Blood samples were obtained prospectively from 54 consenting patients and analysed by CellSearch and isolation by size of epithelial tumour cells (ISET). CellSearch exploits immunomagnetic capture of CTCs-expressing epithelial markers, whereas ISET is a marker independent, blood filtration device. Circulating tumour cell expression of epithelial and mesenchymal markers was assessed to explore any discrepancy in CTC number between the two platforms.

Results:

ISET detected CTCs in more patients than CellSearch (93% vs 40%) and in higher numbers (median CTCs/7.5 ml, 9 (range 0–240) vs 0 (range 0–144)). Heterogeneity observed for epithelial cell adhesion molecule, pan-cytokeratin (CK), E-Cadherin, Vimentin and CK 7 expression in CTCs may account for discrepancy in CTC number between platforms.

Conclusion:

ISET detects more CTCs than CellSearch and offers flexible CTC characterisation with potential to investigate CTC biology and develop biomarkers for pancreatic cancer patient management.

Psychological and social consequences among mothers suffering from perinatal loss: perspective from a low income country

Background

In developed countries, perinatal death is known to cause major emotional and social effects on mothers. However, little is known about these effects in low income countries which bear the brunt of perinatal mortality burden. This paper reports the impact of perinatal death on psychological status and social consequences among mothers in a rural area of Bangladesh.

Methods

A total of 476 women including 122 women with perinatal deaths were assessed with the Edinburgh Postnatal Depression Scale (EPDS-B) at 6 weeks and 6 months postpartum, and followed up for negative social consequences at 6 months postpartum. Trained female interviewers carried out structured interviews at women's home.

Results

Overall 43% (95% CI: 33.7-51.8%) of women with a perinatal loss at 6 weeks postpartum were depressed compared to 17% (95% CI: 13.7-21.9%) with healthy babies (p = < 0.001). Depression status were significantly associated with women reporting negative life changes such as worse relationships with their husband (adjusted OR = 3.89, 95% CI: 1.37-11.04) and feeling guilty (adjusted OR = 2.61, 95% CI: 1.22-5.63) following the results of their last pregnancy outcome after 6 months of childbirth.

Conclusions

This study highlights the greatly increased vulnerability of women with perinatal death to experience negative psychological and social consequences. There is an urgent need to develop appropriate mental health care services for mothers with perinatal deaths in Bangladesh, including interventions to develop positive family support.

Diarrhoea in Bangladeshi infants and its association with postnatal depression

Online: 19 July 2010 DOI: http://dx.doi.org/10.3329/bmrcb.v36i1.1924 Bangladesh J Med Res Counc Bull 2010; 36: 32-34  

Political and legal institutions and their influence on drug policy: an Australian perspective

ISSUES

Under a federal system of government, political power is separated and distributed between different institutions of government. The distribution of power to enact policies that influence alcohol and other drug use can impact on the associated harm.

APPROACH

A description of the separation of powers under a federal system of government is followed by three case studies of alcohol and other drug policies which have been influenced by the use of power by different institutions of government.

KEY FINDINGS

Whether or not a policy is enacted depends upon who has the power to bring such a policy into being, who has the power to prevent its enactment and whether those with such power choose to use them.

CONCLUSION

The enactment of policy is a political act, needing to be understood by those wishing to see evidence-based policies brought into being. An understanding of the separation of powers under a federal system of government is one aspect of the political process that those who work in the alcohol and other drug field need to understand.

Second malignancy risk associated with treatment of Hodgkin's lymphoma: meta-analysis of the randomised trials

BACKGROUND

Despite several investigations, second malignancy risks (SMR) following radiotherapy alone (RT), chemotherapy alone (CT) and combined chemoradiotherapy (CRT) for Hodgkin's lymphoma (HL) remain controversial.

PATIENTS AND METHODS

We sought individual patient data from randomised trials comparing RT versus CRT, CT versus CRT, RT versus CT or involved-field (IF) versus extended-field (EF) RT for untreated HL. Overall SMR (including effects of salvage treatment) were compared using Peto's method.

RESULTS

Data for between 53% and 69% of patients were obtained for the four comparisons. (i) RT versus CRT (15 trials, 3343 patients): SMR were lower with CRT than with RT as initial treatment (odds ratio (OR) = 0.78, 95% confidence interval (CI) = 0.62-0.98 and P = 0.03). (ii) CT versus CRT (16 trials, 2861 patients): SMR were marginally higher with CRT than with CT as initial treatment (OR = 1.38, CI 1.00-1.89 and P = 0.05). (iii) IF-RT versus EF-RT (19 trials, 3221 patients): no significant difference in SMR (P = 0.28) although more breast cancers occurred with EF-RT (P = 0.04 and OR = 3.25).

CONCLUSIONS

Administration of CT in addition to RT as initial therapy for HL decreases overall SMR by reducing relapse and need for salvage therapy. Administration of RT additional to CT marginally increases overall SMR in advanced stages. Breast cancer risk (but not SMR in general) was substantially higher after EF-RT. Caution is needed in applying these findings to current therapies.

Comparison of ABVD and Alternating or Hybrid Multidrug Regimens for the Treatment of Advanced Hodgkin's Lymphoma: Results of the United Kingdom Lymphoma Group LY09 Trial (ISRCTN97144519)

Purpose

To perform an open-label, randomized, controlled trial comparing treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) with two multidrug regimens (MDRs) for advanced Hodgkin's lymphoma (HL).

Patients and Methods

Eight hundred seven patients with advanced HL (stage III to IV, or earlier stage with systemic symptoms or bulky disease) were randomly assigned between ABVD and MDR specified before randomization as alternating chlorambucil, vinblastine, procarbazine, and prednisolone (ChlVPP) with prednisolone, doxorubicin, bleomycin, vincristine, and etoposide (PABIOE), or hybrid ChlVPP/etoposide, vincristine, and doxorubicin (EVA). Radiotherapy was planned for incomplete response or initial bulk disease.

Results

At 52 months median follow-up, 212 event-free survival (EFS) events (disease progression or any death) were reported. In the primary comparison, at 3 years EFS was 75% (95% CI, 71% to 79%) for ABVD and 75% (95% CI, 70% to 79%) for MDRs (hazard ratio [HR] = 1.05; 95% CI, 0.8 to 1.37; HR more than 1.0 favors ABVD). The 3-year overall survival (OS) rates were 90% (95% CI, 87% to 93%) in patients allocated ABVD and 88% (95% CI, 84% to 91%) in patients allocated MDRs (HR = 1.22; 95% CI, 0.84 to 1.77). Patients receiving MDRs experienced more grade 3/4 infection, mucositis, and neuropathy. One occurrence of myelodysplastic syndrome was reported, but no acute leukemia was reported. When the two MDRs are compared separately with ABVD, neither the alternating nor the hybrid regimen showed a statistically significant difference from ABVD for EFS or OS. Subgroup analysis suggested that MDRs may be associated with poorer outcomes in older patients (heterogeneity test of OS older or younger than 45 years, P = .020).

Conclusion

There was no evidence of significant difference in EFS or OS between ABVD and MDRs in the trial overall or if the two MDR versus ABVD comparisons are considered separately. ABVD remains the standard for treatment of advanced HL.

Impact of laparotomy and liver resection on the peritoneal concentrations of fibroblast growth factor 2, vascular endothelial growth factor and hepatocyte growth factor

PURPOSE

Some data have suggested that major surgery is associated with the post-operative growth of residual tumour masses but the mechanism of this is unknown. This study was designed to determine the relationship between intraperitoneal (IP) cytokine levels, and laparotomy in benign and malignant settings.

METHODS

Intraperitoneal fluid specimens were obtained at the start and at the end of laparotomy in patients with benign conditions (n=10) and in others undergoing resection of hepatic metastases from colorectal cancer (n=10). Using ELISA the concentration of the angiogenic cytokines, HGF, VEGF-A, VEGF-C, VEGF-D and FGF-2 was determined.

RESULTS

The data show that in 16 of 20 patients there was a significant increase (P=0.006) in the IP concentration of hepatocyte growth factor (HGF) but not in the other growth factors by the end of the operation. The mean increase in HGF concentration was 821.5 pg/ml (95% CI: 11.0-6,426.0). Neither the groups (malignant and non-malignant) nor the length of operation correlated with greater or lesser increases in HGF.

CONCLUSION

The observation that the increase in HGF occurred in both the cancer and non-cancer groups suggests that it is the surgery rather than the disease that is associated with the increased cytokine concentration. As HGF is a potent endothelial, epithelial and mesenchymal mitogen the data highlight HGF as a potential target for anti-cancer treatments in the peri-operative period. However, investigators should closely monitor wound healing as this may be compromised by this new class of drugs.

Analysis of aldehydes in beer using solid-phase microextraction with on-fiber derivatization and gas chromatography/mass spectrometry

A new, fast, sensitive, and solventless extraction technique was developed in order to analyze beer carbonyl compounds. The method was based on solid-phase microextraction with on-fiber derivatization. A derivatization agent, O-(2,3,4,5,6-pentafluorobenzyl)hydroxylamine (PFBOA), was absorbed onto a divinyl benzene/poly(dimethylsiloxane) 65-microm fiber and exposed to the headspace of a vial with a beer sample. Carbonyl compounds selectively reacted with PFBOA, and the oximes formed were desorbed into a gas chromatograph injection port and quantified by mass spectrometry. This method provided very high reproducibility and linearity. When it was used for the analysis of aged beers, nine aldehydes were detected: 2-methylpropanal, 2-methylbutanal, 3-methylbutanal, pentanal, hexanal, furfural, methional, phenylacetaldehyde, and (E)-2-nonenal.