Key challenges and developments in wildlife ecological risk assessment: Problem formulation

Problem formulation (PF) is a critical initial step in planning risk assessments for chemical exposures to wildlife, used either explicitly or implicitly in various jurisdictions to include registration of new pesticides, evaluation of new and existing chemicals released to the environment, and characterization of impact when chemical releases have occurred. Despite improvements in our understanding of the environment, ecology, and biological sciences, few risk assessments have used this information to enhance their value and predictive capabilities. In addition to advances in organism-level mechanisms and methods, there have been substantive developments that focus on population- and systems-level processes. Although most of the advances have been recognized as being state-of-the-science for two decades or more, there is scant evidence that they have been incorporated into wildlife risk assessment or risk assessment in general. In this article, we identify opportunities to consider elevating the relevance of wildlife risk assessments by focusing on elements of the PF stage of risk assessment, especially in the construction of conceptual models and selection of assessment endpoints that target population- and system-level endpoints. Doing so will remain consistent with four established steps of existing guidance: (1) establish clear protection goals early in the process; (2) consider how data collection using new methods will affect decisions, given all possibilities, and develop a decision plan a priori; (3) engage all relevant stakeholders in creating a robust, holistic conceptual model that incorporates plausible stressors that could affect the targets defined in the protection goals; and (4) embrace the need for iteration throughout the PF steps (recognizing that multiple passes may be required before agreeing on a feasible plan for the rest of the risk assessment). Integr Environ Assess Manag 2024;20:658-673. © 2022 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC). This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.

Palliative Management of Inoperable Malignant Bowel Obstruction: Prospective, Open Label, Phase 2 Study at an NCI Comprehensive Cancer Center

CONTEXT

Malignant bowel obstruction (MBO) is a common complication of intra-abdominal cancer, frequently seen in advanced gastrointestinal and gynecologic cancer. Management of MBO can be challenging, particularly if the patient is not a surgical candidate. No consensus exists on how best to manage these patients medically. Retrospective studies suggest that the combination of dexamethasone, octreotide and metoclopramide may lead to relief of obstruction and improvement in symptoms associated with the obstruction.

OBJECTIVES

This study seeks to prospectively evaluate the combination of drug "triple therapy" dexamethasone 4 mg BID, metoclopramide 10 mg Q6 and octreotide 300 mcg TID to assess tolerability, safety, and effect on symptoms and deobstruction.

METHODS

Adults admitted at Roswell Park Comprehensive Cancer Center with malignant bowel obstruction were eligible. Eligible patients who constented to the study were started on the triple therapy with close monitoring of symptoms and for adverse effects.

RESULTS

A total of 15 patients enrolled in the study. Two patients experienced bradycardia as adverse effect and there was no incidence of bowel perforation. All patients who completed the study had complete resolution of their nausea, and improvement in other symptoms including pain, constipation, tolerance of oral intake and resumption of bowel movements. Only two of the 15 patients were alive to complete the six-month post study follow up.

CONCLUSION

"Triple therapy" with dexamethasone, metoclopramide, and octreotide for management of nonsurgical MBO in this small sample size appears safe and well tolerated however a diagnosis of inoperable MBO remains associated with poor prognosis and death within months.

Navigating the global IV contrast shortage: The experience of a comprehensive cancer center

PURPOSE/OBJECTIVE(S)

In March 2022, a COVID-19 associated lockdown at an intravenous (IV) contrast production facility resulted in global shortages. We report our experience as a comprehensive cancer center navigating the IV contrast shortage.

METHODS

A triage prioritization system was developed to serve as a guideline for ordering clinicians to reduce contrast use. The triage team reviewed all requests and made final determination based on patient history, treatment plan, prior imaging, possible alternative modalities, and competing requests.

RESULTS

Our institution performed a median of 194 CT studies per day. Contrast utilization as a percentage of all CTs ordered was approximately 80% prior to the shortage, nadired at 9% during peak shortage, and has since returned to pre-shortage levels. Over the study period, 132 requests were reviewed. Fifty studies (38%) were approved by the team for contrast administration, 56 (42%) were recommended to be performed without contrast, 15 (11%) for a change in modality, and 11 (8%) were felt suitable for delay. There was overall general concordance between the recommendations of the triage team and studies conducted without significant distributional differences (χ2 = 4.004, two-tailed p = 0.2610).

CONCLUSION

The concept of resilience involves the development of system-based practices that allow for sustained operations during periods of sudden change, or loss of critical supplies. The effort to optimally allocate limited supply of contrast was an extensive effort across the organization including from senior leadership, IT, radiology, nursing, physicians, and APPs. Concepts from heuristics and behavioral science can aid the conservation of a scarce resource. Decisions made by the team appeared to be sound without any known patient harm associated with a lack of contrast.

Navigating the Global IV Contrast Shortage: The Experience of a Comprehensive Cancer Center

PURPOSE/OBJECTIVE(S)

In March 2022, a COVID-19 associated lockdown at an intravenous (IV) contrast production facility resulted in global shortages. We report our experience as a comprehensive cancer center navigating the IV contrast shortage through the development of an IV contrast triage team.

MATERIALS/METHODS

A triage prioritization system was established to serve as a guideline for ordering clinicians to reduce contrast use (Table 1). The triage team reviewed all requests and made final determination based on patient history, treatment plan, prior imaging, possible alternative modalities, and competing requests.

RESULTS

Our institution performed a median of 194 CT studies per day. Contrast utilization as a percentage of all CTs ordered was approximately 80% prior to the shortage, nadired at 9% during peak shortage, and has since returned to pre-shortage levels. While most requests for contrast were changed to non-contrast by the ordering clinician, 132 requests were reviewed by the triage team. Fifty studies (38%) were approved by the team for contrast administration, 56 (42%) were recommended to be performed without contrast, 15 (11%) for a change in modality, and 11 (8%) were felt suitable for delay. There was overall general concordance between the recommendations of the triage team and studies conducted without significant distributional differences (χ2 = 4.004, two-tailed p = 0.2610). We did not note any instances of patient harm associated with the lack of contrast or from the utilization of an alternative imaging modality.

CONCLUSION

The concept of resilience involves the development of system-based practices that allow for sustained operations during periods of sudden change, or loss of critical supplies. The effort to optimally allocate limited supply of contrast was an extensive effort across the organization including from senior leadership, IT, radiology, nursing, physicians, and APPs. Defaulting to an automatic cancelation of contrast requests, followed by review from an interdisciplinary triage team was effective in safely reducing contrast utilization. Decisions made by the team appeared to be sound without any known patient harm.

High Risk, High Reward: Frailty in Colorectal Cancer Surgery is Associated with Worse Postoperative Outcomes but Equivalent Long-Term Oncologic Outcomes

BACKGROUND

Frailty is a physiologic state that affects perioperative outcomes. Studies evaluating the impact of frailty on long-term oncologic outcomes are limited. This study evaluated perioperative and long-term oncologic outcomes for elderly patients undergoing colorectal surgery.

METHODS

Patients older than 65 years at the time of colorectal resection between July 2011 and September 2020 at Roswell Park Comprehensive Cancer Center were identified. Variables from the National Surgical Quality Improvement Program (NSQIP), the tumor registry, and electronic medical records (EMRs) were used to identify frail patients using the revised Risk Analysis Index (RAI-A) score. A score of 38 or higher defined a patient as "frail." Perioperative outcomes were evaluated using logistic regression and chi-square, and oncologic outcomes were evaluated using Kaplan-Meier analysis.

RESULTS

The study analyzed 411 patients. The mean age at surgery was 75.1 years. The median RAI-A score was 37, and 29.9 % of the patients were frail. The frail patients had significantly higher rates of overall complications (30.1 % vs 14.6 %; p < 0.001). They also had significantly higher rates of postoperative hospitalization longer than 30 days, postoperative delirium, and discharge to rehabilitation. No mortality differences were observed. The 318 patients with colorectal adenocarcinoma undergoing curative-intent resection were evaluated for oncologic outcomes. No differences with frailty in terms of overall survival, disease-specific survival, or progression-free survival were observed except for frail patients with stage 0 or 1 adenocarcinoma, who had worse overall survival than non-frail patients but equivalent other outcomes.

CONCLUSIONS

For elderly patients undergoing colorectal surgery, frailty is associated with higher postoperative complications, discharge to rehabitation, and prolonged hospitalization rates. Frailty does not affect long-term oncologic outcomes, so frail elderly patients gain the same oncologic benefit with surgery as non-frail patients.

Germline ATM variants predispose to melanoma: a joint analysis across the GenoMEL and MelaNostrum consortia

PURPOSE

Ataxia-Telangiectasia Mutated (ATM) has been implicated in the risk of several cancers, but establishing a causal relationship is often challenging. Although ATM single-nucleotide polymorphisms have been linked to melanoma, few functional alleles have been identified. Therefore, ATM impact on melanoma predisposition is unclear.

METHODS

From 22 American, Australian, and European sites, we collected 2,104 familial, multiple primary (MPM), and sporadic melanoma cases who underwent ATM genotyping via panel, exome, or genome sequencing, and compared the allele frequency (AF) of selected ATM variants classified as loss-of-function (LOF) and variants of uncertain significance (VUS) between this cohort and the gnomAD non-Finnish European (NFE) data set.

RESULTS

LOF variants were more represented in our study cohort than in gnomAD NFE, both in all (AF = 0.005 and 0.002, OR = 2.6, 95% CI = 1.56-4.11, p < 0.01), and familial + MPM cases (AF = 0.0054 and 0.002, OR = 2.97, p < 0.01). Similarly, VUS were enriched in all (AF = 0.046 and 0.033, OR = 1.41, 95% CI = 1.6-5.09, p < 0.01) and familial + MPM cases (AF = 0.053 and 0.033, OR = 1.63, p < 0.01). In a case-control comparison of two centers that provided 1,446 controls, LOF and VUS were enriched in familial + MPM cases (p = 0.027, p = 0.018).

CONCLUSION

This study, describing the largest multicenter melanoma cohort investigated for ATM germline variants, supports the role of ATM as a melanoma predisposition gene, with LOF variants suggesting a moderate-risk.

Community resilience in a rural food system: documenting pathways to nutrition solutions

OBJECTIVE

To describe and determine the barriers and facilitators to food-related health behaviors of residents in a rural Mississippi Delta community.

STUDY DESIGN

Descriptive study of qualitative interviews.

METHODS

A non-random sample of 34 low-income, food-insecure adults residing in a rural Mississippi Delta community were interviewed using fuzzy cognitive mapping, a mixed methods approach.

RESULTS

Participants strongly emphasized the time restraints they faced in both procuring and preparing foods, due to substantial travel time required to procure groceries. Participants also identified key facilitators to healthy eating behaviors, including seasonal produce stands, foraging, fishing, home provisioning, and access to the local food pantry. These barriers and facilitators are highly interconnected with other influential factors including poverty, lack of health care, unemployment, and faith-based support systems.

CONCLUSIONS

While the connection between low food access and poor eating habits is well researched, this novel mixed-method approach details two important elements missing from the literature: (1) other factors often overlooked that mitigate or exacerbate this relationship and (2) the dynamic nature of the relationships between these factors, poor eating habits, and health. Additionally, this research examines these relationships in an underrepresented rural minority population where resources needed to mitigate poor health are often much more limited. Findings from this study are critical to health and food policy in Mississippi and more generally, rural communities.

Abstract PD3-06: Neratinib + fulvestrant for HER2-mutant, HR-positive, metastatic breast cancer: Updated results from the phase 2 SUMMIT trial

Background: HER2 mutations define a rare subset of metastatic breast cancer (MBC) with a unique mechanism of oncogenic addiction to HER2 signaling. Neratinib, an irreversible pan-HER tyrosine kinase inhibitor, has demonstrated single-agent clinical activity in HER2-mutant MBC. In HER2-mutant, HR+ MBC, neratinib + fulvestrant (N+F) appears synergistic vs single-agent neratinib, possibly due to more complete inhibition of bi-directional signaling between HER2 and estrogen receptors. Here we describe interim efficacy results of the expanded HER2-mutant, HR+ MBC cohort treated with N+F from SUMMIT (NCT01953926).

Methods: HR+ MBC patients (pts) with HER2 mutations documented by local testing received oral neratinib 240mg qd and intramuscular fulvestrant (labeled dose). Intensive loperamide prophylaxis was mandatory during cycle 1. Efficacy endpoints include objective response rate at week 8 (ORR8); confirmed objective response rate (ORR); clinical benefit rate (CBR); duration of response (DOR); progression-free survival (PFS); response was assessed by RECIST 1.1 and/or PET Response Criteria. Genomic profiling from fresh/archival tumor tissues and/or plasma cfDNA was performed retrospectively by next-generation sequencing (MSK-IMPACT).

Results: As of 18 May 2018, 46 HER2-mutant HR+ MBC pts have been treated with N+F. Most pts were pretreated, with 91% having received prior anti-cancer medication for MBC (range 0–10). ORR was 33% and median DOR in the 15 pts with a confirmed response was 9.2 months (95% CI 3.9–18.5). Twenty-four pts had prior fulvestrant exposure, and 19 had received prior CDK4/6i-based therapy. Clinical activity was observed with ORRs of 17% and 26% in prior fulvestrant-treated and prior CDK4/6i-treated pts, respectively. ORRs by HER2 mutation were: V777L 63% (5/8 pts); S310F/Y 67% (4/6 pts); G778_P780dup 50% (3/6 pts). Diarrhea was the most common adverse event (grade 3, 24%; grade 4, 0%). Median cumulative duration of grade 3 diarrhea was 3 days. There were no treatment discontinuations due to diarrhea.

 Neratinib + fulvestrantOutcomeaAll patients (N=46)Prior fulvestrant (N=24)Prior CDK4/6i-based therapy (N=19)ORR8 – n (%)19 (41.3)8 (33.3)7 (36.8)95% CI27.0–56.815.6–55.316.3–61.6ORR – n (%)15 (32.6)4 (16.7)5 (26.3)95% CI19.5–48.04.7–37.49.1–51.2DOR for each responder, months 5.6b; 9.2; 9.6b; 18.55.6b; 5.7b; 9.3; 9.6b; 12.9bCBR – n (%)27 (58.7)11 (45.8)9 (47.4)95% CI43.2–73.025.6–67.224.4–71.1Median (95% CI) time to event,c monthsPFS3.9 (3.6–5.7)3.7 (3.5–12.8)3.9 (1.9–NA)DOR9.2 (3.9–18.5)NANAaFor pts with both RECIST- and PET-evaluable lesions, the best of either RECIST or PET response was used to determine response; the earliest progression by RECIST or PET was used for progression; bPt has not progressed; cKaplan-Meier analysis; NA, not applicable

Conclusions: N+F demonstrates encouraging clinical activity with durable responses in heavily pretreated pts with HER2-mutant, HR+ MBC. Of note, responses were observed in pts who had received prior fulvestrant or CDK4/6 inhibitors. No new safety signals were identified; the rate of diarrhea was similar to single-agent neratinib and not dose limiting. Updated data after additional follow-up and genomic data will be presented.

Citation Format: Smyth LM, Piha-Paul SA, Saura C, Loi S, Lu J, Shapiro GI, Juric D, Mayer IA, Arteaga C, de la Fuente M, Brufksy AM, Mau-Sørensen M, Arnedos M, Moreno V, Sohn J-H, Schwartzberg L, Gonzàlez-Farré X, Cervantes A, Mann G, Shahin S, Cutler, Jr. RE, Eli LD, Xu F, Bagulho T, Lalani AS, Bryce R, Solit DB, Hyman DM, Meric-Bernstam F, Baselga J. Neratinib + fulvestrant for HER2-mutant, HR-positive, metastatic breast cancer: Updated results from the phase 2 SUMMIT trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD3-06.

Prospective Validation of the NCI Breast Cancer Risk Assessment Tool and the Autodensity Mammographic Density Tool on 40,000 Australian Screening Program Participants

Background: In Australia and elsewhere, there is a growing interest in delivering more personalised, risk-based breast cancer screening protocols. This requires reliable, feasible and accurate estimates of risk. The US National Cancer Institute Breast Cancer Risk Assessment Tool (BCRAT) and the AutoDensity fully automated mammographic density measurement tool have each been shown to stratify women into groups according to their risk of breast cancer; the AutoDensity tool also provides information on the likely sensitivity and specificity of mammographic screening tests. The Australian 'lifepool' cohort of over 53,000 women recruited predominantly through BreastScreen Australia screening program offers an opportunity to validate these tools and examine how they can be combined to estimate various risks. Aim: To validate BCRAT and AutoDensity on a large Australian population, and examine how the tools can be combined to provide information on breast cancer risk and the accuracy of the screening test. Methods: We use lifepool cohort questionnaire data and linked screening records and mammograms, cancer registrations and death records to describe the association between BCRAT and AutoDensity scores assessed at the time of screening and future breast cancer diagnosis. We use hazards models to account for censoring and describe outcomes according to mode of detection (screen-detected, interval cancers or other). Our primary analysis is restricted to women in the historical screening target age range of 50-69 with no prevalent breast cancer diagnosis on entry to the lifepool cohort. Results: The primary analysis included approximately 40,000 women with a median follow-up period of 4.5 years (1.1-6.5 years). The BCRAT tool generated a median 5-year breast cancer risk score of 1.5% (range 0.6%-22.0%). Compared with women in the lowest quintile of this score, women in the highest quintile had a 2.3-fold risk (95% CI 1.7-3.0, P < 0.001) of incident invasive breast cancer. For the approximately 35,000 women with digital screening mammograms on enrolment, women in the highest quintile of AutoDensity values had a 1.5-fold risk (95% CI 1.1-2.0 P = 0.011) of incident invasive breast cancer and a 2.6-fold risk (95% CI 1.1-6.2, P = 0.034) of an interval cancer compared with women in the lowest quintile. With BRCAT and AutoDensity measurements weakly correlated (r2= 0.003, P = 0.05), we demonstrate various approaches to combining this information to stratify women according to breast cancer risk and risk of an interval cancer. Conclusion: The US National Cancer Institute Breast Cancer Risk Assessment Tool and the AutoDensity mammographic density tool can be used to stratify breast cancer screening participants into risk groups according to their future breast cancer risk and the risk of an interval cancer. This is likely to be of interest to screening program managers and policy-makers, and women considering screening participation.

The effect of army vest design on the occurrence of stress fractures and overuse injuries in female military recruits

INTRODUCTION

Stress fractures (SFs) occur when microdamage caused by repetitive mechanical load exceeds the biological load-bearing capacity of the bone. The study objective was to test whether a vest specifically designed and manufactured for female recruits, compared with the standard vest used on a regular basis by Border Police recruits, would reduce the incidence of SF in female Border Police recruits. Data based on reports of military personnel show that women are more likely to sustain SFs.

METHODS

A follow-up of 240 female Border Police infantry recruits, divided into two trial groups, was conducted from 2007 to 2009. Two different vests were evaluated-the standard special unit fighting vest, which was conventionally used by both men and women during basic training, and the new fighting vest, specially design for female body shape.

RESULTS

No significant difference was noted in the number of SFs between the two groups which may be attributed to increased weight of the new vest. There was a lower incidence of long bone SFs which may have been due to the superior vest design. The female Border Police Infantry recruits expressed great satisfaction with the new vest.

CONCLUSIONS

Increased effort should be invested to further reduce the weight of female combat gear, alongside efforts to improve fit and comfort.

Preexisting conditions in pediatric ALL patients: Spectrum, frequency and clinical impact

INTRODUCTION

The etiology of acute lymphoblastic leukemia remains undisclosed in the majority of cases. A number of rare syndromic conditions are known to predispose to different forms of childhood cancer including ALL. The present study characterized the spectrum and clinical impact of preexisting diseases in a cohort of ALL patients from Germany, Austria and Switzerland with a focus on genetic diseases predisposing to cancer development.

METHODS

Retrospective database and study chart review included all patients from Germany, Austria and Switzerland (n = 4939) enrolled into multicenter clinical trial AIEOP-BFM ALL 2000 between July 1999 and June 2009. Patients enrolled into study AIEOP-BFM ALL 2009 - which was initiated subsequent to AIEP-BFM ALL 2000 - who were reported with a cancer prone syndrome or chromosomal abnormality were additionally included in this study to increase conclusiveness of observations.

RESULTS

A total of 233 patients with at least one reported condition could be identified. The following conditions were reported in more than one patient: Gilbert's disease (n = 13), neurofibromatosis type I (n = 8), ataxia telangiectasia (n = 8), thalassemia (n = 7), Nijmegen Breakage syndrome (n = 6), cystic fibrosis (n = 4), glucose-6-phosphate dehydrogenase deficiency (n = 4), Noonan syndrome (n = 2), Klinefelter syndrome (n = 2), alpha-1-antitrypsin deficiency (n = 2), primary ciliary dyskinesia (n = 2). Especially those syndromes with a known cancer predisposition (NF type I, Ataxia telangiectasia, Nijmegen Breakage syndrome etc.) were associated with certain general and ALL-related characteristics, high therapy-related toxicity and reduced survival.

CONCLUSION

The spectrum of underlying diseases within ALL patients is dispersed. A small number of ALL patients are reported with cancer predisposition syndromes at initial diagnosis which are associated with high rates of therapy-related toxicity and a markedly reduced chance of survival. The true prevalence of these conditions within the ALL population remains unknown due to inapparent clinical presentation. A targeted clinical and/or genetic examination for certain diagnoses like NF type I, Ataxia telangiectasia or Nijmegen Breakage syndrome could identify patients who benefit from adjustment of antileukemic therapy or intensification of supportive care.

Large retroperitoneal hemangioma encompassing the renal vein

Retroperitoneal hemangioma (RH) is a rare and benign vascular malformation. RH may be detected incidentally or present with symptoms due to local invasion of adjacent structures. Management options include surgical resection, as well as serial observation with routine imaging. We describe a retroperitoneal hemangioma encompassing the renal vein that was discovered during diagnosis of acute appendicitis, and characterize diagnostic magnetic resonance imaging (MRI) findings seen with this condition.

Probing Atmospheric Electric Fields in Thunderstorms through Radio Emission from Cosmic-Ray-Induced Air Showers

We present measurements of radio emission from cosmic ray air showers that took place during thunderstorms. The intensity and polarization patterns of these air showers are radically different from those measured during fair-weather conditions. With the use of a simple two-layer model for the atmospheric electric field, these patterns can be well reproduced by state-of-the-art simulation codes. This in turn provides a novel way to study atmospheric electric fields.

Minimal residual disease-based treatment is adequate for relapse-prone childhood acute lymphoblastic leukemia with an intrachromosomal amplification of chromosome 21: the experience of the ALL-BFM 2000 trial

BACKGROUND

Recently, the UK CCLG and COG reported that an intrachromosomal amplification of chromosome 21 (iAMP21) in acute lymphoblastic leukemia (ALL) loses its adverse prognostic impact with intensified therapy.

PATIENT AND METHODS

We evaluated the prognosis of iAMP21 among patients from the ALL-BFM (Berlin-Frankfurt-Münster) 2000 trial with 46 of 2 637 (2%) patients iAMP21+.

RESULTS

8-year event-free-survival (EFS, 64 ± 8% vs. 81 ± 1%, p=0.0026) and cumulative incidence of relapse (CIR, 29 ± 8% vs. 14 ± 1%, p=0.008) of the iAMP21 cases were significantly worse compared with non-iAMP21 patients. Within the MRD low-risk group, iAMP21 cases (n=14) had an inferior 8-year EFS (76 ± 12% vs. 92 ± 1%, p=0.0081), but no increased CIR (10 ± 10% vs. 6 ± 1%, p=0.624). Within the MRD intermediate-risk group, iAMP21 cases (n=27) had a worse 8-year EFS (56 ± 11% vs. 78 ± 2%, p=0.0077) and CIR (44 ± 11% vs. 20 ± 2%, p=0.003) with 6/10 relapses occurring after 2 years.

CONCLUSIONS

Conclusively, we believe that there is no necessity for enrolling all iAMP21 patients into the high-risk arm of ongoing ALL-BFM trials because MRD low-risk patients have a moderate relapse risk under current therapy. Whether the increased relapse risk in MRD intermediate-risk patients can be avoided by late treatment intensification remains to be answered by the AIEOP-BFM ALL 2009 trial randomly using protracted pegylated L-asparaginase during delayed intensification and early maintenance.

Effective childhood cancer treatment: the impact of large scale clinical trials in Germany and Austria

In Germany and Austria, more than 90% of pediatric cancer patients are enrolled into nationwide disease-specific first-line clinical trials or interim registries. Essential components are a pediatric cancer registry and centralized reference laboratories, imaging review, and tumor board assistance. The five-year overall survival rate in countries where such infrastructures are established has improved from <20% before 1950 to >80% since 1995. Today, treatment intensity is tailored to the individual patient's risk to provide the highest chances of survival while minimizing deleterious late effects. Multicenter clinical trials are internationalized and serve as platforms for further improvements by novel drugs and biologicals.

Key treatment questions in childhood acute lymphoblastic leukemia: results in 5 consecutive trials performed by the ALL-BFM study group from 1981 to 2000

Between 1981 and 2000, 6 609 children (<18 years of age) were treated in 5 consecutive trials of the Berlin-Frankfurt-Münster (BFM) study group for childhood acute lymphoblastic leukemia (ALL). Patients were treated in up to 82 centers in Germany, Austria, and Switzerland. Probability of 10-year event-free survival (survival) improved from 65% (77%) in study ALL-BFM 81-78% (85%) in ALL-BFM 95. In parallel to relapse reduction, major efforts focused on reducing acute and late toxicity through advanced risk adaptation of treatment. The major findings derived from these ALL-BFM trials were as follows: 1) preventive cranial radiotherapy could be safely reduced to 12 Gy in T-ALL and high-risk ALL patients and eliminated in non-high-risk non-T-ALL patients, if it was replaced by high-dose and intrathecal methotrexate; 2) omission of delayed reintensification severely impaired outcome of low-risk patients; 3) 6 months less maintenance therapy caused an increase in systemic relapses; 4) slow response to an initial 7-day prednisone window was identified as adverse prognostic factor; 5) condensed induction therapy resulted in a significant improvement of outcome; 6) the daunorubicin dose in induction could be safely reduced in low-risk patients; 7) intensification of consolidation/reintensification treatment led to considerable improvement of outcome in high-risk patients.

CREBBP HAT domain mutations prevail in relapse cases of high hyperdiploid childhood acute lymphoblastic leukemia

Despite their apparently good prognosis ∼15% of high hyperdiploid (HD) childhood acute lymphoblastic leukemia (ALL) cases relapse. To search for responsible risk factors we determined copy number aberrations as well as copy neutral loss of heterozygosity (LOH) in 13 matched diagnosis and relapse samples and added the data of the only three available cases from the literature. Deletions and copy neutral LOH in 3 and 2 of the 16 cases directed us to the histone-modifying CREB-binding protein (CREBBP) gene, whose functional impairment is implicated in drug resistance. We therefore screened all samples for mutations in this gene and discovered 9 acquired sequence mutations in 7/16 cases, leading to an overall frequency of somatic CREBBP aberrations in HD ALL relapse cases of 63% that is considerably higher than that of the reported, mainly non-HD ALL (18.3%). Moreover, mutations in HD cases occur almost exclusively in the HAT domain (8/9; 89%). Hot spot mutations are present at diagnosis in 18.8% of relapsing HD ALL cases but in none of 40 respective cases remaining in long-term remission. Thus, the particular high incidence of CREBBP mutations in relapse-prone HD ALL cases could eventually be exploited for refined risk stratification and customized treatment in this genetic subgroup.

Symptomatic pulmonary embolism after outpatient arthroscopic procedures of the knee: the incidence and risk factors in 418,323 arthroscopies

Pulmonary embolism is a serious complication after arthroscopy of the knee, about which there is limited information. We have identified the incidence and risk factors for symptomatic pulmonary embolism after arthroscopic procedures on outpatients. The New York State Department of Health Statewide Planning and Research Cooperative System database was used to review arthroscopic procedures of the knee performed on outpatients between 1997 and 2006, and identify those admitted within 90 days of surgery with an associated diagnosis of pulmonary embolism. Potential risk factors included age, gender, complexity of surgery, operating time defined as the total time that the patient was actually in the operating room, history of cancer, comorbidities, and the type of anaesthesia. We identified 374,033 patients who underwent 418,323 outpatient arthroscopies of the knee. There were 117 events of pulmonary embolism (2.8 cases for every 10 000 arthroscopies). Logistic regression analysis showed that age and operating time had significant dose-response increases in risk (p < 0.001) for a subsequent admission with a pulmonary embolism. Female gender was associated with a 1.5-fold increase in risk (p = 0.03), and a history of cancer with a threefold increase (p = 0.05). These risk factors can be used when obtaining informed consent before surgery, to elevate the level of clinical suspicion of pulmonary embolism in patients at risk, and to establish a rationale for prospective studies to test the clinical benefit of thromboprophylaxis in high-risk patients.

Meeting report from the 7th International Melanoma Congress, Sydney, November, 2010

The 2010 7th International Melanoma Congress sponsored by the Society for Melanoma Research and held in Sydney, Australia, was held together with the International Melanoma and Skin Cancer Centers group and the International Melanoma Pathology Study Group. As a consequence, there were over 900 registrants that included a wide range of clinicians (surgeons, medical oncologists, dermatologists) specialising in the management of melanoma as well as scientists and students carrying out laboratory-based research in melanoma. There was a general consensus that this grouping of clinicians, pathologists and scientists was mutually advantageous and plans are afoot to continue this grouping in future meetings. The meeting was dominated by the advances being made in treatment of melanoma with selective BRAF inhibitors but interest in epithelial mesenchymal transition and phenotypic changes in melanoma was apparent in many of the talks. The authors have attempted to capture many of the new developments in melanoma research but apologize to those speakers and poster presenters who had equally important findings not captured in these summaries.

Beyond accuracy: creating a comprehensive evidence base for TB diagnostic tools

The need for a strong and comprehensive evidence base to support decision making with regard to the implementation of new and improved diagnostic tools and approaches has been highlighted by a number of stakeholders; these include members of the New Diagnostics Working Group (NDWG) and the Subgroup for Introducing New Approaches and Tools of the Stop TB Partnership. To compile such evidence in a systematic manner, we have developed an impact assessment framework (IAF) which links evidence on inputs to outcomes. The IAF comprises five interconnected layers: effectiveness analysis, equity analysis, health systems analysis, scale-up analysis and policy analysis. It can be used by new diagnostics developers and other interested research teams to collect as much policy-relevant data as possible prior to, during and after the demonstration phase of tool development. The evidence collated may be used by international and national policy makers to support adoption, implementation and scale-up decisions. The TREAT TB (Technology, Research, Education and Technical Assistance for TB) initiative uses the IAF in its operational research and field evaluations of new tools and approaches for TB diagnosis. It has also been incorporated into the NDWG's recent publication: 'Pathways to better diagnostics for tuberculosis: a blueprint for the development of TB diagnostics'. This article describes the IAF and the process of improving it and suggests next steps in overcoming the challenges in its implementation.

Recommendations for the development and application of wildlife toxicity reference values

Toxicity reference values (TRVs) are essential in models used in the prediction of the potential for adverse impacts of environmental contaminants to avian and mammalian wildlife; however, issues in their derivation and application continue to result in inconsistent hazard and risk assessments that present a challenge to site managers and regulatory agencies. Currently, the available science does not support several common practices in TRV derivation and application. Key issues include inappropriate use of hazard quotients and the inability to define the probability of adverse outcomes. Other common problems include the continued use of no-observed- and lowest-observed-adverse-effect levels (NOAELs and LOAELs), the use of allometric scaling for interspecific extrapolation of chronic TRVs, inappropriate extrapolation across classes when data are limited, and extrapolation of chronic TRVs from acute data without scientific basis. Recommendations for future TRV derivation focus on using all available qualified toxicity data to include measures of variation associated with those data. This can be achieved by deriving effective dose (EDx)-based TRVs where x refers to an acceptable (as defined in a problem formulation) reduction in endpoint performance relative to the negative control instead of relying on NOAELs and LOAELs. Recommendations for moving past the use of hazard quotients and dealing with the uncertainty in the TRVs are also provided.

Assessment of the Likelihood of Invasive Breast Cancer When Core Needle Biopsy Shows DCIS

Background: Ductal carcinoma in-situ (DCIS) on core needle biopsy (CNB) may be associated with a final diagnosis of invasive cancer (IC). As patients with IC need axillary assessment, those at risk of upstaging may be appropriate for sentinel node biopsy (SNB) at initial surgery, preventing the need for re-operation. We assessed this risk using pre-operative factors to develop a management algorithm.Materials and Methods: All patients whose CNB showed DCIS or DCIS with microinvasion (DCISm) from a single population-based breast screening program in Australia between 1994 and 2006 were studied. Medical records were reviewed for demographic, radiologic, clinical and pathologic data.Results: 11 of 15 DCISm cases (73.3%) and 65 of 375 DCIS cases (17.3%) were upstaged to IC. Microinvasion on CNB overwhelmingly predicted presence of frank invasive cancer. For cases of DCIS, multivariate analysis showed that (1) palpability (p=0.009), (2) large mammographic size ≥20mm (p=0.001) and (3) prolonged screening interval ≥3 years (p=0.008) were associated with upstaging. On univariate analysis, (4) non-calcific mammographic features (mass, architectural distortion or non-specific density) were significantly associated with upstaging (p=0.001). There was a trend towards upstaging in patients with high grade DCIS on CNB (p=0.07). Factors not associated with upstaging were microcalcifications (p=0.12), comedonecrosis (p=0.14), age (p=0.38) and CNB method (p=0.50). The rate of upstaging increases with the number of associated risk factors present in a patient: 8.3% in patients with no risk factors, 21.2% in those with one risk factor, 38.6% in those with two risk factors, and 52.9% in those with three risk factors. 13 patients (3.3%) had lymph node metastases.Conclusions: The risk of upstaging can be estimated using pre-operative features in patients with DCIS on CNB. We propose a management algorithm that includes SNB for DCIS patients: with microinvasion on core biopsy, with two or more predictive factors, and those with planned total mastectomy.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3111.

Phase II window study on rituximab in newly diagnosed pediatric mature B-cell non-Hodgkin lymphoma (NHL)

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Background: Pediatric mature B-cell NHL differ from aggressive B-NHL of adults in terms of biology and treatment outcome. In contrast to adults, rituximab (Rx) is not established in the treatment of pediatric B-NHL has not be determined yet. Even the activity of Rx in pediatric B-NHL is not determined. We conducted a phase II window study to examine the activity of Rx in newly diagnosed pediatric B-NHL. Methods: Eligibility: age < 19 y, CD20 + B-NHL, ≥ 1 measurable lesion/s, informed consent. Exclusion: Lansky performance scale 5, pre-treatment, impaired renal-, heart-, liver-function, hepatitis B, pre-existing disease, pregnancy. Treatment: Rx 375 mg/m2 IV at day 1; concomitant therapy: Rasburicase, steroids only for anaphylaxis, intrathecal (IT) triple drug at days 1, 3 for CNS+ pts only. Begin of chemotherapy at day 5. Response evaluation: product of 2 perpendicular diameters of 1 - 3 index lesions/% blasts in BM/PB within 24 h prior to Rx and at day 5: responder (RP): at least 1 lesion with at least objective effect (decrease of ≥25%) and no progress (increase of ≥25 %) at other sites. Study plan: Simon 2-stage phase II with α and β = 5%. Response rate (RR) for poor activity was set to 45%, for good activity 65%. 33 pts entered the first stage, final evaluation after 79 pts. Results: One hundred thirty-six pts were enrolled from 04/04–08/08. NTC °3/4 toxicities: general condition 16%, fatigue 13%, anaphylaxis (chill/fever/bronchospasm) 6 (1/2/4)%, infection 3%, S-GOT/GPT 10%, acute tumor lysis (ATL) 7%, capillary leakage (0), toxic death (0). Forty-nine pts were not evaluable for response: Withdrawal (anaphylaxis 8, ATL 2, suspected progression, not verified 4, other 2), IT therapy in CNS- pts (8), corticosteroids (3), technical inadequacy of response evaluation (21), no index lesion (1). Of the 87 evaluable pts 37 were RPs (42.5%, 95%-CI 32% - 54%). RR by histology: BL/B-ALL 29/68, DLBCL 6/14, juvenile follicular lymphoma 1/2, PMBCL 1/1, B-NHL nfs 0/2. Fifty pts were non-RPs. Conclusions: Although the RR was lower than requested Rx as single agent is active in pediatric B-NHL.

No significant financial relationships to disclose.