Progression-Free Survival in Patients with WHO-2 Meningioma Undergoing Active Surveillance Based on DOTATATE PET Evidence of Gross Total Resection: Prospective Observational Study

PURPOSE/OBJECTIVE(S)

MRI is the standard of care for meningioma radiotherapy planning, but lacks sensitivity for postoperative small volume disease and osseous or parenchymal invasion. NRG-BN003 (NCT03180268) randomizes patients with WHO-2 meningiomas and MRI-determined gross total resection (GTR) to observation or 60 Gy IMRT to the resection bed. More sensitive and specific imaging biomarkers than MRI may improve clinical outcomes in meningioma by limiting unnecessary irradiation of normal tissues and improving radiotherapy targeting. [68Ga]-DOTATATE, a PET radiotracer targeting somatostatin receptor 2 (SSTR2) is a highly sensitive and specific meningioma biomarker. Our dedicated DOTATATE brain PET/MRI and PET/CT protocol allows meningioma differentiation from post-treatment change, using SUV analysis and Patlak modeling. Our prospective IRB-approved observational trial (NCT04081701) has imaged >100 patients with meningioma. In the sub-analysis presented here, we prospectively evaluated PFS in patients with WHO-2 tumors and postoperative GTR as determined by [68Ga]-DOTATATE brain PET/MRI or PET/CT who were managed solely with active surveillance. We hypothesized that the PFS of patients with GTR by PET managed with active surveillance would be higher than reported PFS data for patients with MRI-determined GTR, using NRG-BN003's observation arm (randomized trial comparing observation to fractionated RT) as a reference standard.

MATERIALS/METHODS

From the cohort of >100 patients with SSTR2-positive brain neoplasms enrolled between 9/2019 and 10/2022 and imaged according to our previously published protocol, a sub-cohort of patients were selected with WHO-2 meningioma, postoperative findings of GTR, and postoperative active surveillance with periodic MRI every 3-6 months. Kaplan-Meier survival analysis was performed.

RESULTS

A total of 12 patients met inclusion criteria. Mean patient age was 64 years and 5 (42%) were female. Mean follow up period was 23.4 months (range: 7-38). 83% (10/12) patients underwent postoperative PET/MRI and 17% (2/12) underwent PET/CT. 2 patients (17%) progressed, at 22 and 34 months, respectively; the remainder remain progression-free. Both patients who had progression were successfully salvaged with focal fractionated radiosurgery. Kaplan-Meier analysis demonstrated PFS at almost 3 years to be 75%, which is substantially higher than the reported 3-year PFS of 60% in the literature. Overall survival was 100%.

CONCLUSION

[68Ga]-DOTATATE PET can improve the specificity of imaging-based assessment of the extent of resection of WHO-2 meningiomas, thereby improving clinical outcomes. In this cohort of patients with completely resected WHO-2 meningiomas (as assessed by postoperative gadolinium-enhanced MRI and DOTATATE PET) who are conservatively managed, recurrences have been rare and amenable to radiosurgical salvage.

Association of risky driving behavior with psychiatric disorders among Iranian drivers: A case-control study

PURPOSE

This study aimed to investigate the possible association between psychological disorders and risky driving behavior (RDB) in Iran.

METHODS

This case-control study conducted in Shiraz, Iran in 2021. The case group included drivers with psychological disorders and the control group included those without any disorders. The inclusion criteria for selecting patients were: active driving at the time of the study, being 18 - 65 years old, having a driving license, having a psychological disorder including depression, bipolar disorder, anxiety spectrum disorder, or psychotic disorder spectrum confirmed by a psychiatrist, and completing an informed consent form. The exclusion criterion was the existence of conditions that interfered with answering and understanding the questions. The inclusion criteria for selecting the healthy cases were: active driving at the time of the study, being 18 - 65 years old, having a driving license, lack of any past or present history of psychiatric problems, and completing an informed consent form. The data were gathered using a researcher-made checklist and Manchester driving behavior questionnaire. First, partition around medoids method was used to extract clusters of RDB. Then, backward logistic regression was applied to investigate the association between the independent variables and the clusters of RDB.

RESULTS

The sample comprised of 344 (153 with psychological disorder and 191 without confirmed psychological disorder) drivers. Backward elimination logistic regression on total data revealed that share of medical expenditure ≤ 10% of total household expenditure (OR = 3.27, 95% CI: 1.48 - 7.24), psychological disorder (OR = 3.08, 95% CI: 1.67 - 5.70), and substance abuse class (OR = 6.38, 95% CI: 3.55 - 11.48) were associated with high level of RDB.

CONCLUSION

Substance abuse, psychological illnesses, and share of medical costs from total household expenditure were found to be main predictors of RDB. Further investigations are necessary to explain the impact of different psychological illnesses on driving behavior.

Cost-Effectiveness Analysis of 68Ga-DOTATATE PET/MRI in Radiotherapy Planning in Patients with Intermediate-Risk Meningioma

BACKGROUND AND PURPOSE

While contrast-enhanced MR imaging is the criterion standard in meningioma diagnosis and treatment response assessment, gallium 68Ga-DOTATATE PET/MR imaging has increasingly demonstrated utility in meningioma diagnosis and management. Integrating 68Ga-DOTATATE PET/MR imaging in postsurgical radiation planning reduces the planning target volume and organ-at-risk dose. However, 68Ga-DOTATATE PET/MR imaging is not widely implemented in clinical practice due to higher perceived costs. Our study analyzes the cost-effectiveness of 68Ga-DOTATATE PET/MR imaging for postresection radiation therapy planning in patients with intermediate-risk meningioma.

MATERIALS AND METHODS

We developed a decision-analytical model based on both recommended guidelines on meningioma management and our institutional experience. Markov models were implemented to estimate quality-adjusted life-years (QALY). Cost-effectiveness analyses with willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were performed from a societal perspective. Sensitivity analyses were conducted to validate the results. Model input values were based on published literature.

RESULTS

The cost-effectiveness results demonstrated that 68Ga-DOTATATE PET/MR imaging yields higher QALY (5.47 versus 5.05) at a higher cost ($404,260 versus $395,535) compared with MR imaging alone. The incremental cost-effectiveness ratio analysis determined that 68Ga-DOTATATE PET/MR imaging is cost-effective at a willingness to pay of $50,000/QALY and $100,000/QALY. Furthermore, sensitivity analyses showed that 68Ga-DOTATATE PET/MR imaging is cost-effective at $50,000/QALY ($100,000/QALY) for specificity and sensitivity values above 76% (58%) and 53% (44%), respectively.

CONCLUSIONS

68Ga-DOTATATE PET/MR imaging as an adjunct imaging technique is cost-effective in postoperative treatment planning in patients with meningiomas. Most important, the model results show that the sensitivity and specificity cost-effective thresholds of 68Ga-DOTATATE PET/MR imaging could be attained in clinical practice.