P16.03.A Epithelioid gliobastoma requires rapid treatment and BRAF inhibitors should be made readily available for their treatment

Background

Epithelioid glioblastoma is a rare subtype of Glioblastoma. We examine two cases who presented acutely with symptoms of headache, neck stiffness and an eye squint. The purpose of this case review is to look at their management, the spread of the disease and propose the availability of BRAF inhibiting agents be made readily available for this subtype.

Material and Methods

The clinical records including pathology and surgical reports, multi-disciplinary team meeting documents, oncology plans and inpatient notes have all been reviewed alongside the literature on epithelioid GBM and BRAF V600e mutations and inhibitors.

Results

Patients were females aged 25 and 32 presenting with acute onset headache and neck stiffness to emergency Department. The 25 year old had developed a right eye squint within seven days of the other symptoms, her tumour was right frontal with midline shift. The 32 year old had symptoms for 10 days prior to presentation, the tumour was right temporal. They both underwent craniotomies. The frontal tumour was totally resected, while the temporal lobe tumour was haemorrhagic in nature and minimally de-bulked. Pre-operative stealth imaging showed that there had been an increase in the size of the temporal lesion in the fourteen days since presentation. Histology proved these to be epithelioid GBM’s with BRAF V600e mutations, IDH wild-type and TERT promoter mutant. Full pathology reports with molecular markers were available within ten days. The frontal lobe patient began chemo-radiation sixteen days from her surgical date. On day two she was admitted with severe headache and nausea. She became agitated, confused, and transferred back to the neurosurgery unit for management of hydrocephalus. She was diagnosed with PRES and simultaneously treated for this and hydrocephalus. Clinically she suffered storming, passing away exactly eight weeks from presentation. Seven days after surgery the temporal lobe tumour patient suffered a seizure and admitted for symptom management and expedite oncology treatment. She passed away six days later suffering continual neurological deterioration and the tumour progression with leptomeningeal spread. This was exactly four weeks from initial presentation.

Conclusion

The prognosis for epithelioid Glioblastoma is limited to weeks to short months. Extent of resection in these case studies demonstrates benefit in delaying progression though it is clear that time is of the essence from presentation, to surgery, to adjuvant treatment. Neither of these tumours were methylated meaning the standard treatment for glioblastoma is likely to lack efficacy. BRAF inhibitors should be made readily available for this rare sub-type to commence treatment expediently. Both patients suffered distressing neurological symptoms in their final days which require expert management and are best managed in a neurosurgical centre.

P17.08.B Single institutional retrospective review of re-irradiation in High Grade Gliomas in a tertiary UK centre

Background

Recurrent high grade gliomas (HGG) pose a treatment challenge as no definite guidelines exist. Re-excision could be appropriate in some cases while systemic therapy options are only a handful. We thus need to resort to the option of re-irradiation at some point but there could be a wide variety of techniques, volumes & doses to choose from due to lack of robust evidence. The UK wide BRIOCHe study for Glioblastoma Multiforme (GBM) will help in providing some standardisation. With this retrospective study, we aim to review our institutional practice with re-irradiation & our patient outcomes.

Material and Methods

Electronic health records over a period of 3 years from 1 Jun 2019 to 30 May 2021 were searched for patients with HGG that underwent a course of re-irradiation. Various patient factors, tumour & treatment factors at baseline and at recurrence and survival data were collected.

Results

Total of 8 patients received re-irradiation with all except one having a performance status of 1 at the time of treatment. Seven patients had GBM, one had transformation from baseline G2 glioma and the eighth patient had anaplastic oligodendroglioma (ODG). MGMT was methylated in 62.5% patients while IDH mutation was present only in the transformed glioma. Majority patients had radiotherapy dose of 60Gy/30 fractions with concurrent temozolomide (TMZ) at baseline to a median CTV volume of 186cc. A median of 6 cycles of TMZ were given in the adjuvant setting. Median time to recurrence from completion of adjuvant treatment was 6.7 months (range: 0.9 - 171.6 months). Most recurrences were in the same or an adjacent lobe whereas 1 patient had a multi-focal recurrence. Half the patients at recurrence underwent a re-resection. All patients had salvage chemotherapy at the time of recurrence with a median of 2 regimens and a median of 6 cycles prior to re-irradiation. All patients received a re-irradiation dose of 35Gy in 10 fractions to a median CTV volume of 149cc. The median interval from previous radiotherapy was 18.9 months (range: 11.6 - 190.5 months). The median time to progression from re-RT was 5.4 months (CI: 3.4 - 7.4) and median survival from re-RT was 7 months (CI: 6.2 - 7.8). The median overall survival since diagnosis was 35.1 months (CI: 22.2 - 48.1), one patient was lost to follow up.

Conclusion

Re-irradiation is a safe & feasible treatment option in carefully selected cases of high grade glioma.

P11.06.A benefits of carbohydrate loading drinks pre-operatively for patients with a presumed high-grade glioma planned for an awake craniotomy

Background

As part of enhanced recovery after surgery in neuro oncology, carbohydrate loading drinks were reviewed to see if there were any benefits in administering this pre operatively, in particularly for patients for awake craniotomy electively. This method is currently used in colorectal and spinal teams within the trust. Carbohydrate loading drinks are clear, and can be consumed up to 2 hours before induction of anaesthesia. Currently reviewed for patients for awake craniotomy with the vision to implement for all patients planned for craniotomy, both asleep and awake. The concept of this drink, is that it helps with post-operative nausea and vomiting , insulin resistance, helps with energy boost which is helpful during awake craniotomies and potentially during their engagement with therapists post operatively and wound healing (Hausel J et al, 2005). This could essentially lead to safer discharge, reduced risk of wound infection and reduced length of stay.

Material and Methods

In a single centre, data for patients who have undergone awake craniotomies this year were abstracted. Patients planned for an awake surgery were prescribed carb-loading drinks. Due to the start date of this study, there were already a number of patients who have had their awake craniotomies without having carb-loading drinks prescribed. The data for both cohorts enabled comparison on engagement during and after awake craniotomies with therapists and length of stay.

Results

The current data collected has found that the average length of stay in the group who were not prescribed carbohydrate loading drinks pre operatively, had an average length of stay 7.2 days in total, 50% had experienced nausea and vomiting post operatively, which led therapists unable to perform assessments. 66% of patients in this group were found to have some form of difficulties engaging with the therapists during the awake phase of their craniotomies. Compared with patients who were prescribed the carbohydrate loading drink, the average length of stay was 4.6 days, with no post operative nausea and vomiting, no difficulties engaging with therapists post operatively.

Conclusion

Though the current data is of a small volume, carbohydrate loading pre-operatively can help patients for elective awake craniotomies and reduce length of stay in hospital, optimising their recovery in a fast yet safe manner to ensure they are in the best performance status prior to commencing oncology treatment. With further analysis into the use of carb-loading drinks pre-operatively, this can be used widely within neuro-oncology surgeries.

Hausel J, Nygren J, Thorell A et al Randomized clinical trial of the effects of oral preoperative carbohydrates on postoperative nausea and vomiting after laparoscopic cholecystectomy. Br J Surg 2005; : 415-421. [PubMed] [Google Scholar]

P11.30.A Stereotactic Radiosurgery (SRS) for brain metastases in breast cancer: An evaluation of outcomes at a UK tertiary centre

Background

Brain metastases (BM) occur in approximately 10-30% of patients with breast cancer (BC). Patients with advanced breast cancer are living longer, and the incidence of BM are increasing. Stereotactic Radiosurgery (SRS) has emerged as a strategy to treat BM. We evaluated the outcomes and potential prognostic factors of patients with BM treated with SRS.

Material and Methods

Retrospective review of patients treated with linac-based SRS for BM from BC in a single tertiary centre between August 2017-September 2021. Overall survival (OS), intracranial progression-free survival (IPFS), and prognostic factors were evaluated using Kaplan-Meier analysis, log-rank test, and Cox proportional-hazards model.

Results

76 patients were included in the analysis. Out of these, 56 had first-line local treatment with SRS, either as primary (n=34) or adjuvant to surgery (n=22). Median age was 58 years old (range 37-86), and 88% had PS 0/1. One-year survival rate was 56%.

Median OS and IPFS from SRS was 16 months (95% CI 8-24) and 7 months (95% CI 2-12), respectively. However, there were significant differences in OS (p<0.001) and IPFS (p=0.001) based on molecular subtypes. Patients with triple-negative breast cancer (TNBC) (n=14) had median OS of 7 months (95% CI 2-12), ER+/HER2- (n=22) median OS of 22 months, ER-/HER2+ (n=8) median OS of 4 months (95% CI 0-9), and ER+/HER2+ (n=11) median OS of 36 months. Similar trend was seen with IPFS.

Patients with progressive extracranial disease compared to stable disease had shorter median OS (4 months vs 23 months, HR 2.4, p=0.01) and median IPFS (4 months vs 13 months, HR 2, p=0.03). Age ≥65 years was associated with shorter median OS (4 vs 23 months, HR 2.3, p=0.02). Patients with ≥4 brain metastases had shorter IPFS (4 months vs 11 months, HR 2.4, p=0.012), but no significant difference in OS. Volume of metastases did not affect outcome in this series.

30% of patients progressed intracranially after first-line SRS. 94 % had out-of-field recurrences, and 6% in-field recurrences. 59% had further SRS, 12 % WBRT, 6% surgery, and 23% had no further local treatment.

26 patients had second-line local treatment with SRS after first-line SRS (n=9), WBRT (n=9), or surgery +/- WBRT (n=8). There were no significant differences in outcome based on the modality of first-line local treatment.

Conclusion

SRS is an effective treatment for BM from BC. There were significant differences in survival based on age, molecular subtypes, and extracranial disease status.

Assessing access to mri in patients with cardiac implantable electronic devices in australia

Funding Acknowledgements

Type of funding sources: None.

Background

"Legacy" cardiac implantable electronic devices (CIEDs) have historically been considered non-MRI-conditional. However, a number of recent studies indicate that if certain protocols are followed, patients with such devices may undergo MRI without significant adverse outcomes. Nowadays, industry standards dictate that "modern" CIEDs are MRI compatible. Despite these developments, some patients with CIEDs are denied MRI. Paucity of access to this vital service has been shown to increase expense, lead to more invasive imaging and later diagnosis, and poorer patient outcomes. 

This study aims to identify if Australian public hospitals provide MRI services for patients with modern and legacy CIEDs, the characteristics of the services, and the barriers to implementing such a service. 

Methods

This study surveyed all Australian Tertiary Referral Public Hospitals (n = 38), with a mixed qualitative and quantitative questionnaire. 

Results

35 of the 38 sites completed the survey. Figure 1A shows that the majority of hospitals (30/35, 85.7%) offer MRIs for modern MRI-conditional CIEDs. In contrast, Figure 1B shows that only a minority of hospitals (3/35, 8.6%) offer MRIs for legacy CIEDs. 

Protocols governing patient eligibility vary greatly among hospitals that scan modern devices. Locations either allow all CIEDs to be scanned, only non-dependent CIEDs, or only pacemaker CIEDs. 1.5 Tesla is the preferred strength to scan Modern CIEDs (59%), however a sizeable proportion scan at only 3.0 Tesla (10%) or both strengths (31%). A majority (80%) of staff in attendance of the scan were ACLS-trained (Advanced Cardiac Life Support), with no correlation to strength of MRI used. A range of different personnel attend the scan with varied patient monitoring strategies, and a majority (79%) offer thoracic as well as extra-thoracic scanning. 

The few hospitals that scan legacy devices only scan at 1.5 tesla, and follow individualised protocols. These sites offer more personnel in attendance for the scan than for modern CIED scans, with all staff ACLS-trained including a physician who can direct CIED programming of required. These sites have more involved patient monitoring, and all also offer thoracic and extra-thoracic MRI scanning. 

The predominant barrier identified was an absence of National Guidelines, followed by a lack of formal training or logistical device support.

Conclusions

The majority (85.7%) of Australian Tertiary Referral Public Hospitals have a MRI service for patients with modern CIEDs, but only 8.6% offer this service to patients with legacy CIEDs. 

This highlights the need for a national effort to guide the provision of MRI services for patients with CIEDs, and address the identified barriers.

Phase I trial of temsirolimus (TEM) plus sorafenib (SOR) in advanced hepatocellular carcinoma (HCC)

296

Background: SOR prolongs survival in patients (pts) with HCC. In preclinical studies, mammalian target of rapamycin (mTOR) inhibitors (I) impair HCC growth and angiogenesis. Adding mTOR-I to SOR augments antitumor effect. Phase I studies of mTOR-I plus SOR have shown tolerability but did not include cirrhotic pts. We developed a phase I trial of mTOR-I TEM plus SOR to determine safety, maximum tolerated dose (MTD), and recommended phase II dose (RP2D) in pts with HCC. The study was approved and funded by the National Comprehensive Cancer Network (NCCN).

Methods: Eligibility: Advanced HCC diagnosed histologically or clinically. No prior systemic therapy (Tx). Prior resection/local Tx permitted if ≥1 measurable site. ECOG score ≤2, Child-Pugh ≤7, bilirubin ≤2 mg/dL, platelets ≥75,000/mcL. Design: 3+3 escalation to MTD with dose-limiting toxicity (DLT) window 28 days; 6 pts at MTD for pharmacokinetics (PK). Endpoints: 1°: MTD, RP2D. 2°: Safety, toxicity, PK.

Results: 9 pts enrolled to date: 7 at DL1, 2 at DL-1. Toxicity: DL1: 1 DLT of Gr3 thrombocytopenia. 1 pt removed for hypertensive urgency, adjudicated not Tx-related. 1 pt not evaluable due to abscess. 1 pt removed for Gr3 hypersensitivity to TEM in cycle 2. All remaining pts required reduction and/or delay for adverse events (AE). Tx-related AE at DL1 include: fatigue 57%, Gr3 11%; weight loss 22%, all Gr1; anorexia 57%, all Gr1/2; diarrhea 71%, all Gr1/2; rash/hand-foot syndrome 71%, Gr3 11%; thrombocytopenia 57%, Gr3 11%; hypophosphatemia 77%, Gr3 57%, refractory 11%. Study de-escalated to DL-1 due to non-DLT cumulative AE. DL-1: 2 pts enrolled have not had DLT nor dose reduction to date. Response: 4 of 7 pts in DL1 were evaluable. 3 of 4 had stable disease as best response.

Conclusions: Tx-limiting, class-related AE occurred at DL1 of this double-biologic regimen. MTD in pts with Child-Pugh Class A cirrhosis appears lower than in pts without liver disease. Tolerability and dose delivery must be achieved to determine efficacy. A phase II study with correlative endpoints is planned at RP2D. Updated accrual and results will be presented.

[Table: see text]

[Table: see text]

Childbirth Following Breast Cancer: An Evaluation of the 'Healthy Mothers' Excess Mortality Risk

Background: The favorable outcome of mothers giving birth after breast cancer compared to those who do not, has been attributed to a healthy mother effect. Mainly former breast cancer patients with excellent health status and outlook proceed to having children after their disease. This study evaluates the excess mortality risk among these 'healthy mothers' and factors modifying this risk.Methods: By linking the Singapore Birth Registry (319'437 individuals) and Swedish Multi-Generation Cohort (11 million women) with the respective national cancer registries we identified all 509 women who gave birth >12 months after a breast cancer diagnosis. We calculated excess absolute mortality risks and Standardized Mortality Ratios (SMRs). We used Poisson regression analysis to calculate relative risks of death by country, period of follow up and interval between cancer diagnosis and subsequent birth.Results: The overall 15-year cumulative mortality was 18.2% (95% CI: 13.3 – 20.7%) which is substantially higher than that of the background population (SMR 13.3, 95%CI: 10.4-16.9). Excess mortality risks remained constant over follow up time and were comparable between Sweden and Singapore. Mortality risks decreased significantly with increasing interval between diagnosis and subsequent birth.Conclusion: Despite being 'healthy mothers', women who give birth after a diagnosis of breast cancer have a substantially higher risk of death than the background population. This information may be useful in a woman's decision whether to have a(another) child after breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3173.

Impact of Older Age on Presentation and Management of Breast Cancer in the Multi-Ethnic Population of Singapore

Background: Studies in Caucasian populations have shown that older breast cancer patients are less likely to be treated according to standard guidelines and that this under-treatment is strongly associated with impaired survival. In Asia, where population sizes and life expectancy rates are rising, the number of older women developing breast cancer is growing rapidly. This study aims to evaluate characteristics and treatment patterns of older breast cancer patients in the multi-ethnic population of Singapore, where breast cancer rates have tripled over the past three decades.Methods: This study includes all 2547 women, diagnosed with breast cancer between 1995 and 2006 at the National University Hospital in Singapore. Patients were classified into younger (< 65 years, n=2220) and older (>= 65 years, n=327). Differences in patient and tumor characteristics and treatment between older and younger age groups were explored using multivariate logistic regression models.Results: Even though older Singapore breast cancer patients had more favorable tumor characteristics than younger ones (better tumor differentiation, more often expressing estrogen and progesterone receptors), they presented significantly more often with stage III (adjusted Odds Ratio [ORadj] 1.57, 95%CI 1.0-2.4) and metastatic disease (ORadj 4.3, 95%CI 2.9-6.5). Elderly women were at increased risk not to receive breast surgery (ORadj 1.61, 95%CI 1.0-2.6) and axillary clearance (ORadj 1.74, 95%CI 1.2-2.6). In case of stage I disease, older women were significantly less likely than younger women to be treated with breast conserving surgery (ORadj 0.31, 95%CI 0.2-0.5).Conclusion: Similar to their Caucasian counterparts, older Asian breast cancer patients in Singapore are diagnosed at a later stage and receive less often standard treatment than younger women. Further studies are being undertaken to estimate the impact of these discrepancies on outcome.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 3078.

Transmitral Doppler: a new transthoracic contrast method for patent foramen ovale detection and quantification

OBJECTIVES

This study compared a new transthoracic echocardiographic (TTE) method for detection of right to left bubble passage, transmitral Doppler (TMD), against two-dimensional (2D) TTE contrast study and the gold standard, of transesophageal echocardiography (TEE), and assessed its utility in quantitative assessment of patent foramen ovales (PFO).

BACKGROUND

Current TTE methods are relatively insensitive in PFO detection and do not allow quantitative assessment of right to left shunt.

METHODS

In 44 patients (59 years, range 34 to 76 years) saline contrast and color Doppler studies were performed in three conditions--TTE TMD, TTE 2D and TEE. Bubble transit on the TMD was measured semiquantitatively by a visual bubble score and objectively by integrating the acoustic power within the mitral velocity envelope.

RESULTS

By TEE it was determined that 17 patients (39%) had PFOs; 16 had right to left contrast passage, and only 1 had left to right flow by color Doppler. Against TEE contrast study, the sensitivity of TMD and 2D contrast studies were 100% and 75%, respectively, with specificity of 96% and 100%. Greater than 10 bubbles on a single beat of the resting contrast TMD identified patients with a maximum resting TEE PFO opening diameter >2 mm with 78% sensitivity and 100% specificity. There was a strong correlation (r2 = 0.72, p<0.01) between the TMD acoustic power and PFO opening diameter.

CONCLUSIONS

Transmitral Doppler is a sensitive and specific method for TTE PFO detection that allows quantification of right to left bubble passage and may obviate the need for TEE in many patients after stroke.