Lessons learned from Jordan's response to the Syria refugee crisis

The number of refugees across the world has jumped from 15.7 million to 34.6 million in the past 10 years, and their forced displacement situation remain for an average period of 20 years. To ensure sustainable benefits, health system strengthening through development cooperation should be a priority in parallel to humanitarian aid early on in refugee crises.

Outcomes of Bridging and Salvage Radiotherapy in Relapsed or Refractory Mantle Cell Lymphoma Patients Undergoing CD19-Targeted CAR T-Cell Therapy

PURPOSE/OBJECTIVE(S)

We sought to describe our early experience of using bridging and salvage radiation therapy (RT) in patients with relapsed/refractory mantle cell lymphoma (MCL) undergoing CD19-targeted chimeric antigen receptor (CAR) T-cell therapy.

MATERIALS/METHODS

A retrospective study was conducted for consecutive MCL patients who were treated with commercially available CD19-targeted CAR T-cell therapy between 2020 and 2022 at a single institution. Patients who received RT pre-and post-CAR T-cell therapy were identified and analyzed using descriptive and statistical analysis. Overall survival (OS) from the date of CAR T infusion was estimated with the Kaplan-Meier method. The duration of local control (LC) was defined as the time between the start date of RT and the date of in-field progression/relapse. Response to RT was analyzed based on the total number of irradiated sites.

RESULTS

A total of 21 patients with MCL who received CD19-targeted CAR T-cell therapy were identified (17 brexu cel, 3 tisa-cel, and 1 liso-cel) with a median follow-up of 15.3 months (24 days-36.2 months). The median age was 65 years at time of apheresis (43-83 years). The median OS for the entire cohort following CAR T-cell therapy was 17 months (95% CI: 14.2 months-not reached). Of the 21 patients, 1 patient received bridging RT prior to CAR T infusion, 1 patient received RT pre-and post-CAR T, and 5 patients received salvage RT post-CAR T with a total of 23 irradiated sites. Sites of RT include: extremities (10), central nervous system (3), pelvis/groin (3), head and neck (3), chest (2), abdomen (1), and multiple sites (1). The median dose/fractionation were 16.5 Gy (range, 3.6-45 Gy) and 5.5 fractions (range, 2-16 fractions)- radiation data was incomplete only for 1 patient who received RT at an outside institution. The in-field responses of the 21 evaluable sites were as follows: complete response (CR) (n = 18, 86%) and partial response (PR) (n = 3, 14%), translating into an LC rate of 100%; the remaining 2 sites were not evaluable since the patient died shortly after receiving RT due to progressive lymphoma. Notably, there was no correlation between RT dose and LC; 9 sites received low-dose RT (3.6-6 Gy) with responses as follows: CR (n = 6, 67%) and PR (n = 3, 33%). Only 1 patient experienced grade 3-4 RT-related toxicities. At the time of the last follow-up, 4 patients remained alive, and 3 patients succumbed to progressive lymphoma.

CONCLUSION

As no studies exclusively focusing on CAR T-cell therapy and bridging or salvage RT have been published among relapsed/refractory MCL patients, our early experience underlines that using RT as a bridging and salvage approach is associated with excellent in-field control and limited toxicity in the peri-CAR T setting. Low-dose RT for MCL appears to be very effective in this highly refractory population and warrants further investigation.

Omission of Chest Wall/Scar Boost and Skin Bolus Does Not Increase Risk of Local Recurrence for Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

For breast cancer patients receiving postmastectomy radiation (PMRT), little is known about the value of Chest Wall Boost (CWB) and Skin Bolus (SB) across different biological subtypes and patients with high-risk features.

MATERIALS/METHODS

We reviewed 2,917 charts of breast cancer patients treated with mastectomy between 2000-2020 at our institution. Only patients treated with PMRT were included. Patients with and without reconstruction were included. Reconstruction types included autologous or single-stage-direct-implant or two stages expanders/implant. PMRT was delivered with 3D conformal technique using photons and conventional fractionation (50-50.4 Gy in 25-28 fractions). CWB using enface electrons and 3-5 mm SB applied every other day were delivered at the discretion of the physician. Primary objectives were locoregional failure (LF) rates between CWB and No CWB groups; SB and No SB groups. Different subgroup analyses exploring the benefits of CWB and SB in different biological subtypes, patients with lymphovascular invasion (LVI+), positive margins (PM) and nipple sparing mastectomy (NSM) were conducted. Secondary objectives were toxicity of CWB and SB on different reconstruction outcomes and PMRT side effects. Logistic and cox regressions were used.

RESULTS

A total of 1,103 patients with an overall median follow-up of 7.8 years were available for analysis. Among the entire cohort, 55.4% received CWB, 76% received SB, 48% had LVI, 23% with PM, 41% with NSM, 67% with Luminal A, 15% with Luminal B, 7% with HER2 enriched and 11% with triple negative. The 10 years incidence of LF was 6.5% and 4.0% for CWB and NO CWB, respectively (HR 1.6, p = 0.1); and 5.6% and 5.1% for SB and NO SB respectively (HR 0.9, p = 0.8). Multivariable analysis of LF adjusted for LVI, ECE, grade, tumor size, number of malignant nodes, and biological subtype showed no association of CWB and SB with local control (HR:1.4, p = 0.2 and HR:0.9, p = 0.8), respectively. Subgroup analyses confirmed no association of CWB or SB with improved local control across different biological subtypes, (LVI+), PM and NSM patients. On multivariable level CWB significantly increased reconstruction complications (OR 2.3, p = 0.001, OR 1.7, p = 0.008) for infection/necrosis (I/N) and overall reconstruction failure (ORF), respectively; while SB did not (OR 1.1, p = 0.8, OR 1.0, p = 0.9) for I/N and ORF, respectively. 56 patients needed treatment break, 49 of them (87%) had SB. Both CWB and SB significantly increased the risk of higher grade radiation dermatitis (2-4) in the entire cohort OR 2.1 p = 0.01, and OR 2.3, p = 0.02 for CWB and SB, respectively.

CONCLUSION

CWB and SB did not improve local control across different biological subtypes, patients with LVI, Positive Margins and NSM. CWB significantly increased reconstruction complications and SB increased treatment breaks and radiation dermatitis. These findings do not support routine usage of CWB and SB.

Predictors of Locoregional Recurrence and Distant Failure after Neoadjuvant Chemotherapy Among Patients Treated with Mastectomy Versus Breast-Conserving Surgery

PURPOSE/OBJECTIVE(S)

To assess the patterns and predictors of locoregional recurrence (LRR) and distant failure (DF) after neoadjuvant chemotherapy among patients treated with mastectomy vs. breast-conserving surgery (BCS). Our secondary objective is to identify the predictors of failure among patients who achieved complete pathological response (pCR).

MATERIALS/METHODS

Between 2000 and 2021, 1111 patients who had unilateral breast cancer were identified retrospectively in a single-institution database of consecutive patients who were treated with mastectomy or BCS following neoadjuvant chemotherapy. Multivariable analysis was performed using Cox proportional hazards model to identify the independent predictors associated with LRR and DF. Subgroup analysis was performed to identify the predictive factors associated with LRR and DF among patients (n = 273) who achieved pCR.

RESULTS

The median follow-up for the entire cohort was 5.9 years (range, 1.2 months - 21.8 years). For LRR, the 10-year cumulative incidence was 12.9% and 5.8% in BCS and mastectomy cohorts, respectively (HR 1.7, p = 0.03). For DF, the 10-year cumulative incidence was 19.9% and 29.4% in BCS and mastectomy cohorts, respectively (HR 0.65, p = 0.005). In mastectomy patients, the following factors were associated with LRR: lymphovascular invasion (LVI) (HR 3.8, p< 0.001) and luminal A or B subtype (HR 0.32, p = 0.002), while in BCS patients, LVI (HR 2.3, p = 0.039), extracapsular extension (ECE) (HR 4.5, p< 0.001), and luminal A or B subtype (HR 0.24, p< 0.001) were associated with LRR. Regarding risk factors for DF: LVI (HR 1.97, p< 0.001), number of malignant lymph nodes (HR 1.06, p< 0.001), achieving pCR (HR 0.26, p = 0.001), and triple-negative disease (HR 1.8, p = 0.005) were identified in mastectomy patients, while LVI (HR 2.64, p = 0.002), number of malignant lymph nodes (HR 1.13, p< 0.001), ECE (HR 2.07, p = 0.03), and triple-negative disease (HR 2.9, p = 0.001) were associated with DF for BCS patients. Subgroup analysis for those who achieved pCR showed that cN0 stage (HR 0.16, p = 0.08) and undergoing mastectomy (HR 0.4, p = 0.07) were associated with a lower risk of recurrence, whether LRR or DF, in those patients.

CONCLUSION

Our study demonstrates that LVI, biological subtype, ECE, tumor response, and the number of malignant lymph nodes after neoadjuvant chemotherapy are significant independent predictors of LRR and/or DF. These findings highlight the therapeutic significance of incorporating further therapy to optimize outcomes in these patients. In addition, patients with clinical node-negative at initial presentation and those undergoing mastectomy are associated with a low risk of subsequent failure after achieving pCR. This hypothesis-generating data highlights the role of revisiting the surgical approach for patients achieving pCR after neoadjuvant chemotherapy.

Increased Complication Rates with Proton Therapy in Breast Cancer Patients with Immediate, Implant-Based Reconstruction: Single-Institution Comparative Effectiveness Analysis

PURPOSE/OBJECTIVE(S)

To compare the impact of protons vs. photons on breast reconstruction complications, for patients (pts) receiving postmastectomy radiation (PMRT) with either single-stage direct-to-implant (DTI) or two-staged expander/implant (TE/I).

MATERIALS/METHODS

We reviewed the charts of 578 pts who underwent immediate reconstruction followed by radiation at our institution between 2010 and 2020. Pts with implant-based reconstruction using either TE/I or DTI and PMRT delivery in the presence of the prosthesis were included. Pts enrolled in active ongoing clinical trials were excluded from the analysis. The photon group received 3D conformal or IMRT/VMAT treatment with a median dose of 50-50.4 Gy in 25 to 28 fractions. For proton pts, treatment was delivered mainly with pencil beam scanning technique (PBS); few pts received passively scattered proton spread-out Bragg peak (SOBP). The complications were defined as infection/skin necrosis (I/N) requiring operative debridement, capsular contracture (CC) necessitating capsulotomy, and overall implant failure (ORF) as the removal of the permanent implant irrespective of replacement outcomes (i.e., with and without salvage reconstruction). We fit inverse-probability weighted cumulative incidence curves to adjust for confounding and non-random loss to follow-up. Various sensitivity analyses were conducted.

RESULTS

Four hundred ninety-five pts were available for the final analysis with an overall median follow-up of 55 months. 66 (13%) received protons, of which14 were treated with SOBP protons. 137 (28%) and 256 (56%) received photons with and without chest wall boost (CWB), respectively. The 5-year inverse probability-weighted risk of CC post-PMRT was 31% for protons vs. 10% for photons (RR:3.09, 95% CI: 1.77, 5.40). The 5 years ORF risk was 35.6% in protons compared to 22.7% in photons pts (RR: 1.57; 95% CI 1.0, 2.48). Hazard ratios from the adjusted Cox models were 3.79 (p<0.001) for CC and 2.05 (p<0.01) for ORF. No difference in I/N was noted between protons and photons pts. Sensitivity analysis showed that protons significantly increased CC risk vs photons both with CWB (HR:3.56, P<0.001) and without CWB (HR:3.9, p<0.001). Similar outcomes were observed with ORF, where protons increased the rate of ORF compared to photons, irrespective of CWB (HR 1.8, p = 0.038 with CWB; HR 2.4, p = 0.004 without CWB). No differences between PBS and SOBP proton techniques were noted.

CONCLUSION

Compared to photons, proton therapy increases the risk of capsular contracture requiring surgical intervention and hence overall reconstruction failure. This data should inform discussions about the risks and benefits of protons in patients with reconstruction, while awaiting mature data from ongoing clinical trials (RADCOMP) utilizing protons for breast cancer.

Is it the Type of Axillary Surgery or the Number of Removed Lymph Nodes That Increases the Risk of Breast Cancer Related Lymphedema (BCRL)? Results from a Prospective Screening Trial

PURPOSE/OBJECTIVE(S)

Axillary surgery has been identified as the main risk factor for BCRL regardless the delivery of regional nodal radiation (RLNR). Yet it remains unknown if it is the type of axillary surgery or the number of removed lymph nodes (LN) that increases BCRL risks.

MATERIALS/METHODS

Between 2008 and 2021, 3,350 patients (pts) who received surgery for breast cancer were enrolled in a lymphedema screening trial. Patients with bilateral breast cancer or without axillary surgery were excluded. Perometry was used to assess limb volume preoperatively in all patients. BCRL was defined as a ≥10% relative arm-volume increase arising >3 months postoperatively. The cohort was divided by axillary surgery type: axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB). Radiation was delivered using 3D conformal technique and RLNR was defined as the usage of anterior supraclavicular field. No hypofractionation was used and doses ranged between 50 and 50.4 Gy in 25-28 fractions. Multivariable Cox proportional hazard models compared the cumulative incidence of BCRL and local failure between different patient groups.

RESULTS

After applying inclusion criteria, 2,623 pts were available with overall median follow-up s of 6.1 years. Of the entire cohort, 709 (27%) had ALND with a median of 16 LN removed, while 1,914 (73%) received SLNB only with a median of 2 LN removed. The median number of malignant LN and patients receiving RLNR was higher in ALND group compared to SLNB only group. Frequency distribution analysis showed that the main overlap between ALND and SLNB only groups happen in the range of 3-11 LN removed. Therefore, the primary analysis focused only on pts with 3-11 LN across both groups (n = 690: ALND n = 140, SLNB n = 550). The multivariable model adjusted for BMI, RLNR, age and breast surgery showed that in this group with 3-11 LN removed in both cohorts, ALND remained significantly associated with BCRL (HR: 4.2, p<0.0001). Separate analyses for the entire SLNB only group and ALND groups were conducted to evaluate if the BCRL risk increases per each removed LN within the same axillary surgery group. The multivariable analysis for SLNB only pts(N = 1,914) showed that for each LN removed the risk of BCRL did not increase significantly (HR:1.06, p = 0.3), similarly for ALND group (N = 709) for each LN removed (HR:1.02, p = 0.08). For pts with pathologic N2-N3 disease and clinical node negative without neoadjuvant chemotherapy receiving ALND, the number of LN removed did not significantly improve neither Local control (HR:1.02, p = 0.8) nor distant disease survival (HR:1.01, p = 0.6).

CONCLUSION

ALND procedure per se is the main risk factor for BCRL not the number of LNs removed. For high-risk pts with >N2 disease, aggressive ALND did not improve tumor outcome. De-escalation with targeted axillary sampling followed by RLNR should be evaluated. Future lymphedema research should account for type of axillary surgery instead of number of LNs removed as a factor. (NCT01521741).

Comparison between Pre-Pectoral and Post-Pectoral Implant Reconstruction and Different Radiation Modalities on Breast Reconstruction Complications

PURPOSE/OBJECTIVE(S)

Single Stage direct to implant (DTI) is a rising reconstruction approach. It has been speculated that prepectoral implant placement reduces reconstruction complications as well as using newer postmastectomy radiation (PMRT) modalities as protons. Largest series in this topic included 350 DTI patients with less than 30 patients receiving PMRT.

MATERIALS/METHODS

We reviewed the charts of 2,187 patients (pts) who underwent mastectomy and reconstruction at our institution between 2000 and 2020. Pts only receiving DTI with and without PMRT were included. PMRT was delivered either with 3D conformal photon +/- chest wall electron boost (CWB) or proton therapy mainly with pencil beam scanning. All pts received conventional fractionation (50-50.4 Gy in 25-28 fractions). Patients on active protons clinical trials were excluded. Primary endpoints were reconstruction complications defined as infection/necrosis (I/N) requiring debridement; capsular contracture (CC) requiring capsulotomy and overall reconstruction failure (ORF: removal of permanent implant for any complication with and without salvage reconstruction). Subgroup analysis for pts receiving PMRT was done to explore impact of proton and photons on complications. Logistic and cox regression were used.

RESULTS

Eight hundred nine pts received DTI, with an overall median follow-up of 6.2 years. Among the entire cohort, 78/809 (9.7%) had prepectoral implants while the rest had subpectoral implants with and without alloderm support. Of the entire cohort 391/809 (48.5%) received PMRT, among those 43/391 (11%) received protons. The 5 years cumulative incidence of CC was 8.5% and 6.6% among prepectoral vs subpectoral implants (HR = 1.2, p = 0.7). The 5 years cumulative incidence of ORF was 32.2% and 28.2% among prepectoral vs subpectoral implants (HR 1.1, p = 0.6). For pts receiving PMRT, the 5 years cumulative incidence of CC were 26.0% and 8.6% among protons vs photons (HR 3.7, p < 0.0005). The 5 years cumulative incidence of ORF were 38.2% and 30.1% among protons vs photons (HR 1.4, p = 0.2). Multivariable logistic regression analysis accounting for BMI, smoking history, diabetes, and PMRT showed no significant difference between prepectoral implants versus subpectoral coverage for CC (OR = 0.7, p = 0.5), and for ORF (OR = 0.9, p = 0.8). Subgroup multivariable analysis for those receiving PMRT only showed protons compared to photons significantly increased the risk of CC (OR = 5.3, p < 0.0001) and ORF (OR = 2.1, p = 0.03). No significant difference in I/N was noted between photons and protons or between prepectoral and subpectoral pts.

CONCLUSION

For breast cancer patients receiving single stage direct to implant reconstruction with and without PMRT, prepectoral implant placement did not reduce the risk of complications. Proton therapy compared to photons significantly increased the risk of capsular contracture requiring capsulotomies and significantly increased overall reconstruction failures with implants removal.

Genotype and allelic frequencies of a newly identified mutation causing blindness in jordanian awassi sheep flocks

A total of 423 blood samples were collected (during 2009 and 2010) from all the ram holdings at three major Jordanian governmental Awassi breeding stations (Al-Khanasry, Al-Mushairfa and Al-Fjaje) and two private flocks. All blood samples were screened for the presence of mutations at the CNGA3 gene (responsible for day blindness in Awassi sheep) using RFLP-PCR. The day blindness mutation was detected in all studied flocks. The overall allele and genotype frequencies of all studied flocks of the day blindness mutation were 0.088 and 17.49%, respectively. The genotype and allele frequencies were higher in station flocks than the farmer flocks (0.121, 24.15 and 0.012, 2.32, respectively). Al-Mushairfa and Al-Khanasry stations have the highest genotype and allele frequencies for the day blindness mutation that were 27.77, 30.00% and 0.14, 0.171, respectively. The investigated farmer flocks have low percentages (0.03, 5.88% at Al-Shoubak and 0.005 and 1.05%, at Al-Karak, respectively for genotype and allele frequencies) compared with the breeding stations. Ram culling strategy was applied throughout the genotyping period in order to gradually eradicate this newly identified day blindness mutation from Jordanian Breeding station, since they annually distribute a high percentage of improved rams to farmer’s flocks.

Effect of sulfide concentration on the location of the metal precipitates in inversed fluidized bed reactors

The effect of the sulfide concentration on the location of the metal precipitates within sulfate-reducing inversed fluidized bed (IFB) reactors was evaluated. Two mesophilic IFB reactors were operated for over 100 days at the same operational conditions, but with different chemical oxygen demand (COD) to SO(4)(2-) ratio (5 and 1, respectively). After a start up phase, 10mg/L of Cu, Pb, Cd and Zn each were added to the influent. The sulfide concentration in one IFB reactor reached 648 mg/L, while it reached only 59 mg/L in the other one. In the high sulfide IFB reactor, the precipitated metals were mainly located in the bulk liquid (as fines), whereas in the low sulfide IFB reactor the metal preciptiates were mainly present in the biofilm. The latter can be explained by local supersaturation due to sulfide production in the biofilm. This paper demonstrates that the sulfide concentration needs to be controlled in sulfate reducing IFB reactors to steer the location of the metal precipitates for recovery.

The effect of the extract of the miswak (chewing sticks) used in Jordan and the Middle East on oral bacteria

Chewing sticks are commonly used in Jordan, Saudi Arabia and the United Arab Emirates in particular, and the Middle East, Asia, and Africa in general, in addition to many other areas for oral hygiene, religious and social purposes. Recently, the World Health Organisation (WHO) has recommended and encouraged the use of these sticks as an effective tool for oral hygiene. The antibacterial activity of one of these sticks has been tested against some oral aerobic and anaerobic bacteria. Three methods of antibacterial activity were carried out: streaked plate method, ditch plate method, and tube dilution test for minimum inhibitory concentration (MIC). It was found that the extract of these sticks had a drastic effect on the growth of Staphylococcus aureus with MIC values of 69 mg/100 cc, while a variable effect on other bacterial species was noted. It is concluded that using chewing sticks twice a day on a regular basis may reduce the incidence of gingivitis and possibly dental caries. Apart from their antibacterial activity which may help control the formation and activity of dental plaque, they can be used effectively as a natural toothbrush for teeth cleaning. Such sticks are effective, inexpensive, common, available, and contain many medical properties.