Novel Postoperative Hypofractionated Accelerated Radiation Dose-Painting Approach for Soft Tissue Sarcoma

Purpose

Hypofractionated radiation therapy (RT) offers benefits in the treatment of soft tissue sarcomas (STS), including exploitation of the lower α/β, patient convenience, and cost. This study evaluates the acute toxicity of a hypofractionated accelerated RT dose-painting (HARD) approach for postoperative treatment of STS.

Methods and Materials

This is a retrospective review of 53 consecutive patients with STS who underwent resection followed by postoperative RT. Standard postoperative RT dosing for R0/R1/gross disease with sequential boost (50 Gy + 14/16/20 Gy in 32-35 fractions) were replaced with dose-painting, which adapts dose based on risk of disease burden, to 50.4 and 63, 64.4, 70 Gy in 28 fractions, respectively. The first 10 patients were replanned with a sequential boost RT approach and dosimetric indices were compared. Time-to-event outcomes, including local control, regional control, distant control, and overall survival, were estimated with Kaplan-Meier analysis.

Results

Median follow-up was 25.2 months. Most patients had high-grade (59%) STS of the extremity (63%) who underwent resection with either R1 (40%) or close (36%) margins. Four patients experienced grade 3 acute dermatitis which resolved by the 3-month follow-up visit. The 2-year local control, regional control, distant control, and overall survival were 100%, 92%, 68%, and 86%, respectively. Compared with the sequential boost plan, HARD had a significantly lower field size (total V50 Gy; P = .002), bone V50 (P = .031), and maximum skin dose (P = .008). Overall treatment time was decreased by 4 to 7 fractions, which translated to a decrease in estimated average treatment cost of $3056 (range, $2651-$4335; P < .001).

Conclusions

In addition to benefits in cost, convenience, and improved biologic effect in STS, HARD regimen offers a safe treatment approach with dosimetric advantages compared with conventional sequential boost, which may translate to improved long-term toxicity.

Multi-institutional experience of MR-guided stereotactic body radiation therapy for adrenal gland metastases

Purpose

While dose escalation is associated with improved local control (LC) for adrenal gland metastases (AGMs), the proximity of gastrointestinal (GI) organs-at-risk (OARs) limits the dose that can be safely prescribed via CT-based stereotactic body radiation therapy (SBRT). The advantages of magnetic resonance-guided SBRT (MRgSBRT), including tumor tracking and online plan adaptation, facilitate safe dose escalation.

Methods

This is a multi-institutional review of 57 consecutive patients who received MRgSBRT on a 0.35-T MR linac to 61 AGMs from 2019 to 2021. The Kaplan-Meier method was used to estimate overall survival (OS), progression-free survival (PFS), and LC, and the Cox proportional hazards model was utilized for univariate analysis (UVA).

Results

Median follow up from MRgSBRT was 16.4 months (range [R]: 1.1-39 months). Median age was 67 years (R: 28-84 years). Primary histologies included non-small cell lung cancer (N = 38), renal cell carcinoma (N = 6), and melanoma (N = 5), amongst others. The median maximum diameter was 2.7 cm (R: 0.6-7.6 cm), and most AGMs were left-sided (N = 32). The median dose was 50 Gy (R: 30-60 Gy) in 5-10 fractions with a median BED10 of 100 Gy (R: 48-132 Gy). 45 cases (74 %) required adaptation for at least 1 fraction (median: 4 fractions, R: 0-10). Left-sided AGMs required adaptation in at least 1 fraction more frequently than right-sided AGMs (88 % vs 59 %, p = 0.018). There were 3 cases of reirradiation, including 60 Gy in 10 fractions (N = 1) and 40 Gy in 5 fractions (N = 2). One-year LC, PFS, and OS were 92 %, 52 %, and 78 %, respectively. On UVA, melanoma histology predicted for inferior 1-year LC (80 % vs 93 %, p = 0.012). There were no instances of grade 3+ toxicity.

Conclusions

We demonstrate that MRgSBRT achieves favorable early LC and no grade 3 + toxicity despite prescribing a median BED10 of 100 Gy to targets near GI OARs.

Non-cyanobacterial diazotrophs: global diversity, distribution, ecophysiology, and activity in marine waters

Biological dinitrogen (N2) fixation supplies nitrogen to the oceans, supporting primary productivity, and is carried out by some bacteria and archaea referred to as diazotrophs. Cyanobacteria are conventionally considered to be the major contributors to marine N2 fixation, but non-cyanobacterial diazotrophs (NCDs) have been shown to be distributed throughout ocean ecosystems. However, the biogeochemical significance of marine NCDs has not been demonstrated. This review synthesizes multiple datasets, drawing from cultivation-independent molecular techniques and data from extensive oceanic expeditions, to provide a comprehensive view into the diversity, biogeography, ecophysiology, and activity of marine NCDs. A NCD nifH gene catalog was compiled containing sequences from both PCR-based and PCR-free methods, identifying taxa for future studies. NCD abundances from a novel database of NCD nifH-based abundances were colocalized with environmental data, unveiling distinct distributions and environmental drivers of individual taxa. Mechanisms that NCDs may use to fuel and regulate N2 fixation in response to oxygen and fixed nitrogen availability are discussed, based on a metabolic analysis of recently available Tara Oceans expedition data. The integration of multiple datasets provides a new perspective that enhances understanding of the biology, ecology, and biogeography of marine NCDs and provides tools and directions for future research.

NIMG-01. PREDICTING POST-STEREOTACTIC RADIOTHERAPY MAGNETIC RESONANCE IMAGE OUTCOMES OF BREAST CANCER METASTASES TO THE BRAIN

BACKGROUND

Stereotactic radiosurgery (SRS) is a cornerstone in the management of Breast Cancer Metastases to the Brain (BCMB). While control rates are high following SRS, radiation necrosis is a rare but potentially devastating long-term toxicity. There is a clinical need for automated/semi-automated methods to assess tumor response and optimize the RT plans for local control with minimal long-term toxicity. Multiparametric MRI (mpMRI), particularly Apparent Diffusion Coefficient of water (ADC) maps, contain information that is mechanistically relatable to voxel-level tumor response to RT. We report a deep learning-based approach to predict post-SRS ADC maps, FLAIR, T2-weighted (T2W), T1-weighted unenhanced (T1W) and contrast-enhanced (T1WCE) images, from pre-SRS T1W, T1WCE, T2W and FLAIR images, ADC maps, and the delivered RT dose map. These “forward models” will enable the radiation oncologist to simulate radiologic outcomes and iteratively optimize RT plans for local control with minimal toxicity.

METHODS

We trained a variant of the pix2pix Generative Adversarial Network (GAN) on MRI and RT dose map data from 18 BCMB patients treated with stereotactic radiation with confirmed controlled and locally recurrent metastases. Patients were treated with stereotactic radiation dose of 1-40 Gy between 2013-2019.

RESULTS

On test data from 6 BCMB patients, the trained forward model predicted post-SRS ADC values within the Gross Tumor Volume (GTV) that were broadly in agreement with ground truth post-SRS ADC maps. In agreement with expectations, the forward model also predicts increasing post-RT ADC within the GTV with increasing simulated RT doses in the range of 1-71 Gy. We have also explored an inverse model to predict the RT dose map required to produce “prescribed” post-SRS ADC values within the GTV.

CONCLUSIONS

We envision that the forward models will assist the radiation oncologist in initial RT dose plan optimization, while the inverse model may be useful for daily RT plan optimization.

Combined nivolumab and ipilimumab with or without stereotactic body radiation therapy for advanced Merkel cell carcinoma: a randomised, open label, phase 2 trial

BACKGROUND

Merkel cell carcinoma is among the most aggressive and lethal of primary skin cancers, with a high rate of distant metastasis. Anti-programmed death receptor 1 (anti-PD-1) and programmed death ligand 1 (PD-L1) monotherapy is currently standard of care for unresectable, recurrent, or metastatic Merkel cell carcinoma. We assessed treatment with combined nivolumab plus ipilimumab, with or without stereotactic body radiotherapy (SBRT) in patients with advanced Merkel cell carcinoma as a first-line therapy or following previous treatment with anti-PD-1 and PD-L1 monotherapy.

METHODS

In this randomised, open label, phase 2 trial, we randomly assigned adults from two cancer sites in the USA (one in Florida and one in Ohio) to group A (combined nivolumab and ipilimumab) or group B (combined nivolumab and ipilimumab plus SBRT) in a 1:1 ratio. Eligible patients were aged at least 18 years with histologically proven advanced stage (unresectable, recurrent, or stage IV) Merkel cell carcinoma, a minimum of two tumour lesions measureable by CT, MRI or clinical exam, and tumour tissue available for exploratory biomarker analysis. Patients were stratified by previous immune-checkpoint inhibitor (ICI) status to receive nivolumab 240 mg intravenously every 2 weeks plus ipilimumab 1 mg/kg intravenously every 6 weeks (group A) or the same schedule of combined nivolumab and ipilimumab with the addition of SBRT to at least one tumour site (24 Gy in three fractions at week 2; group B). Patients had to have at least two measurable sites of disease so one non-irradiated site could be followed for response. The primary endpoint was objective response rate (ORR) in all randomly assigned patients who received at least one dose of combined nivolumab and ipilimumab. ORR was defined as the proportion of patients with a complete response or partial response per immune-related Response Evaluation Criteria in Solid Tumours. Response was assessed every 12 weeks. Safety was assessed in all patients. This trial is registered with ClinicalTrials.gov, NCT03071406.

FINDINGS

50 patients (25 in both group A and group B) were enrolled between March 14, 2017, and Dec 21, 2021, including 24 ICI-naive patients (13 [52%] of 25 group A patients and 11 [44%] of 25 group B patients]) and 26 patients with previous ICI (12 [48%] of 25 group A patients and 14 [56%] of 25 group B patients]). One patient in group B did not receive SBRT due to concerns about excess toxicity. Median follow-up was 14·6 months (IQR 9·1-26·5). Two patients in group B were excluded from the analysis of the primary endpoint because the target lesions were irradiated and so the patients were deemed non-evaluable. Of the ICI-naive patients, 22 (100%) of 22 (95% CI 82-100) had an objective response, including nine (41% [95% CI 21-63]) with complete response. Of the patients who had previously had ICI exposure, eight (31%) of 26 patients (95% CI 15-52) had an objective response and four (15% [5-36]) had a complete response. No significant differences in ORR were observed between groups A (18 [72%] of 25 patients) and B (12 [52%] of 23 patients; p=0·26). Grade 3 or 4 treatment-related adverse events were observed in 10 (40%) of 25 patients in group A and 8 (32%) of 25 patients in group B.

INTERPRETATION

First-line combined nivolumab and ipilimumab in patients with advanced Merkel cell carcinoma showed a high ORR with durable responses and an expected safety profile. Combined nivolumab and ipilimumab also showed clinical benefit in patients with previous anti-PD-1 and PD-L1 treatment. Addition of SBRT did not improve efficacy of combined nivolumab and ipilimumab. The combination of nivolumab and ipilimumab represents a new first-line and salvage therapeutic option for advanced Merkel cell carcinoma.

FUNDING

Bristol Myers Squibb Rare Population Malignancy Program.

907 Modulation of tumor immunogenicity by DNA methylation of immune synapse genes in cancers

Background

Cancer immunotherapy represents a major paradigm shift in cancer care. Despite such breakthrough, majority of cancer patients remains refractory to existing immunotherapeutic modalities highlighting the inherent capacity of tumors to escape immunosurveillance mechanisms. Frequently, cancer cells utilize the epigenetic machinery to silence tumor suppressors or activate oncogenes for survival and proliferation. Likewise, tumor cells might employ the epigenetic reprogramming of immune-related pathways to evade the immune system. Methylation is one of the major epigenetic mechanisms modulating gene transcription. Thus, we investigated the methylation profile of both co-stimulatory and immune checkpoint genes in cancer.

Methods

Data from The Cancer Genome Atlas (TCGA) were used for methylation profiling and RNA-sequencing analysis. Twenty-six epithelial cancer cell lines with more than 3 mock and three 5-azacitidine–treated samples were selected for analysis from the GSE57342 dataset. t-distributed stochastic neighbor embedding (t-SNE) was calculated using 247 probes for the selected 20 genes across all TCGA samples. t-SNE analysis was performed on 8,186 solid tumors and 745 normal adjacent tissues for methylation levels for all probes. For principal component analysis, first and second principal components were used to represent the overall methylation status for 8,931 tumor and normal samples in the TCGA database. Survival analyses were retrieved from a prior publication.1

Results

We found that methylation profile of immune synapse genes is distinct in tumor versus normal adjacent tissue. Interestingly, our results demonstrate hypermethylation of co-stimulatory genes such as CD40 and hypo-methylation of immune checkpoint genes such as HHLA2 and PDL1 across multiple tumor types in comparison with the normal adjacent tissue. In addition, an inverse correlation between methylation and gene expression was manifest among tumor and normal adjacent tissue, confirming the epigenetic mechanism of gene suppression by gene methylation. Furthermore, we observed a reversal of hypermethylation of the co-stimulatory genes including CD40 by the demethylating agent 5-azacytidine in the data set of 26 epithelial cancer cell lines. Finally, we found that that hypomethylation of co-stimulatory genes within the immune synapse correlates with functional T cell recruitment to the tumor microenvironment and is followed by a favorable clinical outcome in melanoma patients.

Conclusions

Our finding unveils methylation of immune synapse genes as a crucial driver of the immune evasive phenotype of cancer cells. Notably, identification of actionable targets to restore tumor immunogenicity is an attractive strategy in combination with immune checkpoint blockade.

Acknowledgements

This work was supported by NIH grant K08 CA194273, the Immunology Innovation Fund, an NCI Cancer Center Support grant, (P30-CA076292), the Miriam and Sheldon G. Adelson Foundation, and the Moffitt Foundation.

Reference

Liu J, Lichtenberg T, Hoadley KA, Poisson LM, Lazar AJ, Cherniack AD, Kovatich AJ, Benz CC, Levine DA, Lee AV, Omberg L, Wolf DM, Shriver CD, Thorsson V, Cancer Genome Atlas Research N, Hu H. An integrated TCGA pan-cancer clinical data resource to drive high-quality survival outcome analytics. Cell 2018;173(2):400–16 e11.

Presentation and management of patients with brain metastases of primary melanoma, non-small cell lung cancer, and breast cancer origin

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Background: As systemic therapy improves; the prevalence of brain metastases is increasing. Screening brain MRIs are currently recommended for all stage ≥ II non-small cell lung cancer (NSCLC) and stage IIIB–IV melanoma patients, but only when neurologic symptoms arise in stage IV or recurrent breast cancer (BC) patients. This study assessed the presentation and institutional outcomes treating brain metastases (BM) of BC, NSCLC, and melanoma origin. Methods: Patients with BM treated between 2014 and 2019 with primary melanoma, NSCLC, and BC were identified. Characteristics of initial BM diagnoses were retrieved from clinical chart review. Kruskal-Wallis and Pearson’s chi-square tests were used to test differences between groups. Overall survival (OS) was calculated from dates of initial BM diagnosis using the Kaplan–Meier method. Results: A total of 959 patients were identified (BC 18%, NSCLC 51%, melanoma 31%). BC patients were younger at initial presentation (BC median age: 57, NSCLC 65, melanoma 62, p< 0.0001). At BM diagnosis, BC patients were more likely to have concurrent systemic metastasis (BC 77%, NSCLC 42%, melanoma 69%, p< 0.0001), at least 5 BM (BC 27%, NSCLC 14%, melanoma 13%, p= 0.0004), and leptomeningeal disease (BC 23%, NSCLC 6%, melanoma 6%, p< 0.0001). Patients with BC were significantly more likely to receive whole brain radiation therapy (WBRT) (BC 58%, NSCLC 37%, melanoma 22%, p< 0.0001) and less likely to receive stereotactic radiation (BC 26%, NSCLC 48%, melanoma 58%, p< 0.0001) following initial BM diagnosis. There were no significant differences in surgical resection between cancer types (BC 24%, NSCLC 24%, melanoma 29%, p =0.166). Median OS was shorter for BC (BC 9.9 months, NSCLC 10.3 months, melanoma 13.7 months, p= 0.0006) following BM diagnosis. Conclusions: Our institutional analysis found BC patients were more likely to be younger, present with more advanced brain disease, require WBRT, and have poorer OS than NSCLC and melanoma patients following initial brain metastasis diagnosis. This may be due in part to a lack of brain MRI screening recommendations in BC. Further investigation is needed to determine which BC patients are at sufficient risk to warrant brain MRI screening.

Abstract PS15-06: The distribution of radiosensitivity index differs by PAM50 subtype in primary breast tumors

Background: Prior studies identified radiosensitive and radioresistant breast tumor phenotypes and demonstrated that gene-expression signatures such as the radiosensitivity index (RSI) can be used to derive biologically rational radiation dose selection. In this study, we assessed the RSI of primary breast tumor samples and its association with PAM50 subtype.Materials/Methods: Primary breast tumor samples were identified from a multi-institutional tissue biorepository. Tumors were excluded if they were treated with neoadjuvant therapy or had distant metastatic disease at the time of sample collection. The RSI gene signature and PAM50 subtype were assessed through transcriptomic profiling performed on Affymetrix microarray chips. Distribution of RSI values across PAM50 subtypes was assessed with the Kruskal-Wallis test. Differences in proportions of radioresistant and radiosensitive tumors among PAM50 subtypes were assessed with the Chi-squared test, where radioresistant was defined as RSI&gt;0.3745 based on prior studies. Clinicopathologic characteristics were obtained through clinical chart review. Results: A total of 637 primary breast tumors with available genomic profiling and clinical information were included for analysis. HIstologies were predominantly invasive ductal carcinoma (81.5%) and invasive lobular (11.6%). Most tumors were T1-T2 (91.7%) while 35.9% had pathologically positive lymph nodes. The distribution of RSI significantly differed by PAM50 classification (Kruskal-Wallis p &lt; 0.001). Proportions of radioresistant vs radiosensitive tumors varied significantly according to PAM50 subtype and are included in the accompanying table (Chi-squared p &lt; 0.001). Median follow-up was 89 months.

Conclusion: Breast tumor PAM50 subtypes demonstrate significant variation in radiosensitivity. Further studies are needed to determine if genomic subtyping can refine the ability to predict clinical radiation response and further optimize individual therapy.

PAM50TotalBasalHer2LumALumBNormalRSI PhenotypeRadioresistantn (%)50 (60.2%)32 (42.1%)146 (54.4%)82 (45.3%)24 (82.8%)334 (52.4%)Radiosensitive n (%)33 (39.8%)44 (57.9%)122 (45.6%)99 (54.7%)5 (17.2%)303 (47.5%)Total837626818129637

Citation Format: Matthew Fahey, Nicholas Russo, Casey Liveringhouse, Matthew Mills, Kamran Ahmed, Roberto Diaz. The distribution of radiosensitivity index differs by PAM50 subtype in primary breast tumors [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS15-06.

RADT-02. CLINICAL OUTCOMES OF BREAST BRAIN METASTASES BY SUBTYPE FOLLOWING LINAC BASED STEREOTACTIC RADIATION

BACKGROUND

Management of breast cancer brain metastases has become an increasing concern due to improved systemic control. Failure patterns in the brain may vary by breast cancer subtype.

OBJECTIVE

In this study, we sought to distinguish our institutional clinical outcomes following stereotactic radiation by breast cancer subtype.

METHODS

A total of 180 breast cancer patients treated over 279 stereotactic sessions to 646 brain metastases were identified from our LINAC based stereotactic radiation institutional registry. Patients were treated between August 2004 and May 2019. Outcomes including distant brain metastases control (DC) as well as overall survival (OS) following stereotactic radiation were assessed from review of the clinical chart and radiologic examinations.

RESULTS

The median age of patients was 55 (range: 28-86 years). Subtypes in order of decreasing frequency were hormone receptor (HR)+ (n=64; 36%), HR+/HER2+ (n=47; 26%), triple negative (TN) (n=43; 24%), and HR-/HER2+ (n=26; 14%). TN patients had the shortest interval from systemic metastases to brain metastases diagnosis; HR-/HER2 + 16 months, HR+ 13.3 months, HR+/HER2 + 11 months, and TN 1.4 months (p=0.02). Median follow-up from brain metastases diagnosis was 21.2 months (range: 0.9-135.4 months). Twenty-four month Kaplan-Meier (KM) DC rates varied by subtype and were 49% (HR+/HER2+), 38% (HR+), 33% (HR-/HER2+) and 21% (TN) (p=0.0004), respectively. Similar differences were noted in OS with 24 month KM rates of 58% (HR+/HER2+), 51% (HR-/HER2+), 27% (HR+), and 14% (TN), p&lt; 0.0001. A total of 26 patients (14%) were noted to undergo leptomeningeal disease (LMD) progression. No differences were noted by subtype and LMD progression (p=0.88).

CONCLUSIONS

In our institutional series of breast cancer brain metastases treated with stereotactic radiation, significant differences were noted in clinical outcomes by breast cancer subtype. HR+/HER2+ patients had the best DC and OS rates while outcomes were poorest for TN patients.

Methylation of immune synapse genes modulates tumor immunogenicity

Cancer immune evasion is achieved through multiple layers of immune tolerance mechanisms including immune editing, recruitment of tolerogenic immune cells, and secretion of immunosuppressive cytokines. Recent success with immune checkpoint inhibitors in cancer immunotherapy suggests a dysfunctional immune synapse as a pivotal tolerogenic mechanism. Tumor cells express immune synapse proteins to suppress the immune system, which is often modulated by epigenetic mechanisms. When the methylation status of key immune synapse genes was interrogated, we observed disproportionately hypermethylated costimulatory genes and hypomethylation of immune checkpoint genes, which were negatively associated with functional T cell recruitment to the tumor microenvironment. Therefore, the methylation status of immune synapse genes reflects tumor immunogenicity and correlates with survival.

The prevalence of luminal B subtype is higher in older postmenopausal women with ER+/HER2- breast cancer and is associated with inferior outcomes

OBJECTIVES

To establish whether clinicopathologic and genomic characteristics may explain the poor prognosis associated with advanced age in ER+/HER2- breast cancer.

MATERIALS AND METHODS

The cohort included 271 consecutive post-menopausal patients with ER+/HER2- invasive breast cancer ages 55 years and older. Patients were categorized as "younger" (ages 55- < 75) and "older" (ages ≥75). The Kaplan-Meier method was used to estimate locoregional recurrence (LRR), recurrence-free interval (RFi), and overall survival (OS). Gene expression of tumor samples was assessed with Affymetrix Rosetta/Merck Human RSTA microarray platform. Differential gene expression analysis of tumor samples was performed using R package Limma.

RESULTS

271 breast cancer patients were identified, including 186 younger and 85 older patients. Older patients had higher rates of Luminal B subtype (53% vs 34%) and lower rates of Luminal A subtype (42% vs 58%, p = 0.02). Older patients were less likely to receive chemotherapy (9% vs 40%, p < 0.001) and hormone therapy (71% vs 89%, p < 0.001). For cases of grade 1-2 disease, older patients had a higher proportion of the luminal B subtype (49% vs. 30%, p = 0.014). Age ≥ 75 predicted for inferior OS (HR = 3.06, p < 0.001). The luminal B subtype predicted for inferior OS (HR = 2.12, p = 0.014), RFi (HR 5.02, p < 0.001), and LRR (HR = 3.12, p = 0.045). There were no significant differences in individual gene expression between the two groups.

CONCLUSION

Women with ER+/HER2- breast cancer ≥75 years old had higher rates of the more aggressive luminal B subtype and inferior outcomes. Genomic testing of these patients should be strongly considered, and treatment should be intensified when appropriate.

Automated Conjecturing II: Chomp and Reasoned Game Play

We demonstrate the use of a program that generates conjectures about positions of the combinatorial game Chomp—explanations of why certain moves are bad. These could be used in the design of a Chomp-playing program that gives reasons for its moves. We prove one of these Chomp conjectures—demonstrating that our conjecturing program can produce genuine Chomp knowledge. The conjectures are generated by a general purpose conjecturing program that was previously and successfully used to generate mathematical conjectures. Our program is initialized with Chomp invariants and example game boards—the conjectures take the form of invariant-relation statements interpreted to be true for all board positions of a certain kind. The conjectures describe a theory of Chomp positions. The program uses limited, natural input and suggests how theories generated on-the-fly might be used in a variety of situations where decisions—based on reasons—are required.

Evaluation of the BAX® System for Detection of Listeria monocytogenes in Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® system and the standard cultural methods for detection of Listeria monocytogenes in foods. Six food types (frankfurters, soft cheese, smoked salmon, raw, ground beef, fresh radishes, and frozen peas) were analyzed by each method. For each food type, 3 inoculation levels were tested: high (average of 2 CFU/g), low (average of 0.2 CFU/g) and uninoculated controls. A total of 25 laboratories representing government and industry participated. Of the 2335 samples analyzed, 1109 were positive by the BAX system and 1115 were positive by the standard method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, except radishes, the BAX system performed as well as or better than the standard reference methods based on the Chi square results.

2286. Evaluating the Impact of Ceftolozane/Tazobactam on Clinical Outcomes in Patients with Multi-Drug-resistant Pseudomonas aeruginosa Pneumonia

Background

Ceftolozane/tazobactam is a novel cephalosporin and β-lactamase inhibitor antibiotic that has shown to have potent activity against Pseudomonas aeruginosa including strains exhibiting multi-drug resistance (MDR). The purpose of this study was to evaluate ceftolozane/tazobactam efficacy in MDR P. aeruginosa pneumonia compared with historical standard of care.

Methods

This was a retrospective cohort study of patients hospitalized across AdventHealth Central Florida campuses with MDR P. aeruginosa pneumonia from January 1, 2017 through December 31, 2018. This study included patients ≥ 18 years of age with a diagnosis of pneumonia and a positive respiratory culture with MDR P. aeruginosa. The primary outcome of this study was the rate of clinical cure by day 14 of definitive therapy. Secondary outcomes included 30-day readmission rate, average hospital length of stay (LOS), cost of admission, average ICU LOS after initiation of definitive antibiotic, and total days of antibiotic exposure for pneumonia. Data were analyzed with statistical computer software utilizing independent samples t-test and chi square tests of independence as appropriate.

Results

A total of 115 patients were included in the final analysis, 62 patients treated with ceftolozane/tazobactam and 53 patients treated with historical standard of care. Rate of clinical cure was similar between patients treated with ceftolozane/tazobactam, 72.6% (n = 45), and those treated with historical standard of care, 67.9% (n = 36), {X² (1) = 0.297, p = 0.683}. Other outcomes assessed were also similar between groups except for average hospital length of stay (42.7 days vs. 30.3 days t(113) = 2.054, p = 0.042), and cost of admission ($78,550 vs. $47,681, t(113) = 2.458, p = 0.016), which were significantly greater in the ceftolozane/tazobactam treatment group.

Conclusion

In patients diagnosed with MDR P. aeruginosa pneumonia, clinical cure rates were not significantly different between those treated with ceftolozane/tazobactam compared with historical standard of care. Significantly greater hospital length of stay and cost of admission was associated with use of ceftolozane/tazobactam, although many patient factors may have influenced these results.

Disclosures

All authors: No reported disclosures.

Partial Splenic Artery Embolization in 35 Cancer Patients: Results of a Single Institution Retrospective Study

PURPOSE

To evaluate the safety and efficacy of partial splenic embolization (PSE) in cancer patients with different etiologies of splenomegaly/hypersplenism.

MATERIALS AND METHODS

The medical records of 35 cancer patients who underwent 39 PSE procedures were analyzed. The splenomegaly/hypersplenism was due to chemotherapy (n = 17), portal hypertension (n = 10), or hematologic malignancy (n = 8). After the first 11 PSEs, celiac plexus neurolysis, corticosteroids, and non-steroid anti-inflammatory drugs (NSAIDs) were included in the post-procedural management.

RESULTS

PSE led to 59 ± 16% (mean ± standard deviation) splenic infarcts. The infarct volume per 1 mL 300-500 μm tris-acryl gelatin microspheres was not significantly different between the chemotherapy-induced group (264 ± 89 cm³) and the portal hypertension group (285 ± 139 cm³) but was significantly higher in the hematology group (582 ± 345 cm³). Platelet count increased from 65.7 ± 19.7 k/μl to a peak platelet count of 221 ± 83 k/μl at 2 weeks after PSE. Patients with a follow-up period of more than 1 year had the most recent platelet count of 174 ± 113 k/μl. Platelet count increase was significantly higher in the chemotherapy-induced group than the portal hypertension group. Adding celiac plexus neurolysis, corticosteroids, and NSAIDs to the post-procedural management resulted in a decreased rate of major complications from 73% to 46% and a decrease in the rate of moderate or severe pain from 92% to 20%.

CONCLUSIONS

PSE improved platelet counts in cancer patients despite different etiologies of splenomegaly. The addition of celiac plexus neurolysis, corticosteroids, and NSAIDS to the post-PSE treatment protocol reduced complications. Data from this study could help to predict the amount of 300-500 μm tris-acryl gelatin microspheres required to achieve a planned infarct size.

Toward a Protocol for Transmasculine Voice: A Service Evaluation of the Voice and Communication Therapy Group Program, Including Long-Term Follow-Up for Trans Men at the London Gender Identity Clinic

Purpose: A service evaluation was undertaken with 10 participants identifying as trans men who received voice and communication group therapy and 12-month follow-up at the London Gender Identity Clinic between February 2017 and March 2018, to investigate levels of satisfaction, how helpful they found the program in facilitating vocal change and skill development, and whether they would recommend it to others. Methods: Participant evaluations of overall and ideal rating of masculinity of voice, and level of feeling comfortable with voice, evaluations of voice skills and changes in speaking and reading fundamental frequency were retrospectively reviewed and analyzed. Results: Six participants reported being very satisfied with the service; four were satisfied. Eight participants found the program very helpful in achieving voice and communication change; two found it helpful. Eight strongly agreed and two agreed with recommending the service. Participants' overall and comfort ratings of voice significantly increased (p<0.01), while there was no significant change in ideal ratings (p=0.063), and a significant decrease in the difference between overall and ideal ratings (p<0.01). Participants achieved a significant decrease in fundamental frequency for reading and speaking (p<0.01), a significant decrease in voice fatigue (p=0.039) and restriction in voice adaptability (p<0.01), a significant increase in confidence in public speaking (p<0.01), but no significant change in vocal projection (p=0.07). Conclusion: Ten trans men reported high levels of satisfaction with the voice group program and long-term follow-up, making significant positive shifts in voice skills and vocal self-perception. These findings apply locally but suggest appropriate interventions toward a transmasculine voice modification protocol.

Integration of radium-223 dichloride (Xofigo) into clinical practice for the treatment of castration-resistant prostate cancer

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Background: Radium-223 dichloride (Xofigo) is an FDA-approved radionuclide used to treat symptomatic bone metastases in patients with castration-resistant prostate cancer (CRPC) with no known visceral metastases. Outside of clinical trial, the benefits of Radium-223 dichloride (Ra-223) in the treatment of CRPC have not yet been fully delineated in real life setting. Therefore, the purpose of this study was to evaluate the outcome of patients with CRPC who were treated with Ra-223, especially studying the variables associated with completion of 6 cycles of therapy. Methods: A total of 114 patients with CRPC and bone metastases referred for treatment with Ra-223 between March 2010 and February 2018 were identified for retrospective analysis. A chart review was conducted to analyze clinical characteristics, treatments, and outcomes including radiologic bone scans. Categorical variables were compared using Chi-square and independent student t test, and survival rates were generated using Kaplan-Meier analysis. Multivariate analysis (MVA) Cox proportional hazard ratios (HR) model was used in the assessment of OS and PFS. Results: Of the 114 patients referred for treatment, the overall median OS was 12.6 months. In MVA, improved OS was most strongly associated with completion of all six doses (p < 0.001). Median OS for the 56 patients who received full treatment was 24 months, while median OS for the 107 patients who did not complete treatment was 5.9 months. In univariate analysis, treatment completion was significantly associated with prior Sipuleucel-T (p = 0.002), concurrent Denosumab (p = 0.027), and baseline PSA < 30 ng/mL (p = 0.004). Conclusions: Completion of treatment with Ra-223 is a significant factor associated with improved OS. Therefore it is clinically important to delineate which patients are to the most appropriate candidates to complete treatment. Factors notable for treatment completion suggest patients might benefit from initiating Ra-223 treatment after receiving Sipuleucel-T and while their PSA remains low. Further consideration should be given to the sequence of Ra-223 in clinical practice, including use of concurrent Abiraterone and Enzalutamide.

Diabetic macular oedema and diode subthreshold micropulse laser (DIAMONDS): study protocol for a randomised controlled trial

BACKGROUND

In the UK, macular laser is the treatment of choice for people with diabetic macular oedema with central retinal subfield thickness (CST) < 400 μm, as per National Institute for Health and Care Excellence guidelines. It remains unclear whether subthreshold micropulse laser is superior and should replace standard threshold laser for the treatment of eligible patients.

METHODS

DIAMONDS is a pragmatic, multicentre, allocation-concealed, randomised, equivalence, double-masked clinical trial that aims to determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser compared with standard threshold laser, for the treatment of diabetic macular oedema with CST < 400 μm. The primary outcome is the mean change in best-corrected visual acuity in the study eye from baseline to month 24 post treatment. Secondary outcomes (at 24 months) include change in binocular best corrected visual acuity; CST; mean deviation of the Humphrey 10-2 visual field; change in percentage of people meeting driving standards; European Quality of Life-5 Dimensions, National Eye Institute Visual Functioning Questionnaire-25 and VisQoL scores; incremental cost per quality-adjusted life year gained; side effects; number of laser treatments and use of additional therapies. The primary statistical analysis will be per protocol rather than intention-to-treat analysis because the latter increases type I error in non-inferiority or equivalence trials. The difference between lasers for change in best-corrected visual acuity (using 95% CI) will be compared to the permitted maximum difference of five Early Treatment Diabetic Retinopathy Study (ETDRS) letters. Linear and logistic regression models will be used to compare outcomes between treatment groups. A Markov-model-based cost-utility analysis will extend beyond the trial period to estimate longer-term cost-effectiveness.

DISCUSSION

This trial will determine the clinical effectiveness and cost-effectiveness of subthreshold micropulse laser, when compared with standard threshold laser, for the treatment of diabetic macular oedema, the main cause of sight loss in people with diabetes mellitus.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials, ISRCTN17742985 . Registered on 19 May 2017 (retrospectively registered).

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Evaluation of a Home Visiting and Befriending Scheme for Young Mothers: Newpin

Befriending schemes to support families with young children are now widespread in the United Kingdom. One such scheme, Newpin, which aims to prevent child abuse is described. Evaluation compared those recruited to befriend as well as those befriended. Assessments at baseline and 6 months' follow-up comprised interviews with mothers, developmental assessments of the children and observation of mother–child interaction using video tapes. All assessments were conducted in the home and similar measures were applied to a control sample in an area where a Newpin scheme was planned. Newpin recruits, whether befrienders or befriended had high rates of adverse early experiences, but depression was more common amongst those referred for befriending. Approximately a third did not sustain involvement in the scheme, but those that did were more likely to have had training as volunteers and mental health problems of more than 2 years' duration.

Low-Frequency and Broadband Vibration Energy Harvesting Using Base-Mounted Piezoelectric Transducers

Piezoelectric vibration energy harvesters often consist of a cantilevered beam composed of a support layer and one or two piezoelectric layers with a tip mass. While this configuration is advantageous for maximizing electromechanical coupling, the mechanical properties of the piezoelectric material can place limitations on harvester size and resonant frequency. Here, we present numerical and experimental results from a new type of piezoelectric energy harvester in which the mechanical properties and the resonant frequency of the cantilever beam resonator are effectively decoupled from the piezoelectric component. Referred to as a base-mounted piezoelectric (BMP) harvester in this paper, this new design features a piezoelectric transducer mounted beneath the base of the cantilevered beam resonator. The flexibility in the material choice for the cantilever beam resonator means that the resonant frequency and the beam dimensions are essentially free parameters. A prototype made with a 1.6 mm mm mm polyurethane beam, a PZT-5H piezoelectric transducer, and an 8.36-g tip mass is shown to produce an average power of 8.75 and at 45 Hz across a 13.0- load under harmonic base excitations of constant peak acceleration at 0.25 and 1.0-g, respectively. We also show an increase in full-width half-maximum bandwidth approximately from 1.5 to 5.6 Hz using an array of four individual BMP harvesters of similar dimensions with peak power generation of at 37.6 Hz across a 1.934- load at 0.25-g peak base excitation. Finite elements-based numerical simulations are shown to be in reasonable agreement with experimental results, indicating that the harvester behaves like a damped mass-spring system as proposed in this paper. Fabricated using casting and laser machining techniques, this harvester shows potential as a low-cost option for powering small, low-power wireless sensor nodes and other low-power devices.

Mallards (Anas platyrhynchos) and wastewater ponds, Part II: Developmental, physiological, morphological and behavioural effects of ingestion of secondary clarified effluent water

Rather than migrating, mallard ducks may choose to overwinter in northern cities on open-water thermal refuges, such as municipal wastewater treatment ponds, which in Edmonton, Canada, stay ≥10°C during frigid winter months. Refuging mallards spend appreciable time daily on these ponds and hydrate using secondary clarified municipal wastewater (SCEW). We aimed to determine if SCEW ingestion affected mallard health. To this end, we gavaged newly hatched mallards (domesticated Pekin strain) over their first month with SCEW, as well as water representing negative and positive controls (municipal tap water, and the primary active ingredient from birth control pills, 17α-ethinyl estradiol (EE2), respectively). The gavage of SCEW did not affect mass of the body, liver, spleen or heart, but was associated with small increases in beak and wing chord length. In the positive control, EE2 gavage caused similar responses, but also increased tarsus and phallus length. The increases likely owed to the stimulatory effects of estrogenic substances on bone and phallus development. For the biotransformation enzyme CYP2H1, gene expression was numerically increased by both SCEW and EE2. In terms of behavior, SCEW and EE2 gavage reduced two infrequently detected behaviours, pecking and resting alone. Our results suggest that SCEW ingestion would be unlikely to cause any overt health effects in adults, but may evoke subtle, covert effects nevertheless.

Group and individual analyses of pre-, peri-, and post-movement related alpha and beta oscillations during a single continuous monitoring task

Band power linked to lower and upper alpha (i.e. 8-10Hz; 10-12Hz) and lower and upper beta (i.e. 12-20Hz; 20-30Hz) were examined during response related stages, including anticipation, response execution (RE), response inhibition (RI) and post response recovery (PRR). Group and individual data from 34 participants were considered. The participant's objective was to press a response key immediately following 4 non-repeating, single integer odd digits. These were presented amongst a continuous stream of digits and Xs. Electroencephalogram (EEG) signals were recorded from 32 electrodes (pooled to 12 regions). In the group analyses, participant EEG response was compared to baseline revealing that upper alpha desynchronised during anticipation, RE and RI; lower beta during anticipation and RE; and upper beta just RE. Upper alpha desynchronisation during rapid, unplanned RI is novel. Also, upper alpha and lower/upper beta synchronised during PRR. For upper alpha, we speculate this indexes brief cortical deactivation; for beta we propose this indexes response set maintenance. Lastly, lower alpha fluctuations correlated negatively with RT, indexing neural efficiency. Individual analyses involved calculation of the proportion of individuals displaying the typical RE and PRR trends; these were not reflected by all participants. The former was displayed individually by the largest proportion in upper alpha recorded left fronto-centrally; the latter was most reliably displayed individually in lower beta recorded mid centro-parietally. Therefore, group analyses identified typical alpha and beta synchronisation/desynchronisation trends, whilst individual analyses identified their degree of representation in single participants. Attention is drawn to the clinical relevance of this issue.

Hepatic radioembolization from transradial access: initial experience and comparison to transfemoral access

PURPOSE

Despite the growing evidence in the cardiology literature that transradial approach has substantial benefits over transfemoral access, this technique is rarely used during interventions in the systemic circulation. The aim of this study was to evaluate the feasibility of transradial approach for hepatic radioembolization and to compare it with transfemoral approach.

METHODS

Sixty-four hepatic radioembolizations performed in 50 patients were included in the study. Thirty-three procedures were performed via radial access in 27 patients, and 31 procedures were performed via femoral access in 23 patients.

RESULTS

There was 100% technical success in performing hepatic radioembolization in both groups. The majority (97%) of the patients who underwent transradial radioembolization reported preference for radial artery access. The fluoroscopy time was significantly longer (9.45±5.09 min vs. 5.72±3.67 min, P < 0.01) and the radiation dose was significantly higher (597.8±585.2 mGy vs. 302.8±208.3 mGy, P < 0.01) in the radial group compared with the femoral group. The direct cost savings using radial access versus femoral access is approximately $100/procedure. In addition, there was a one hour (50%) shorter postprocedural stay for patients who underwent the transradial procedure.

CONCLUSION

Transradial access is feasible for hepatic radioembolization. The transradial approach is cheaper and offers improved patient comfort. However, it is technically challenging, with longer fluoroscopy times and higher radiation doses. Transradial approach should be considered as a primary choice in patients with low platelet count and/or morbid obesity. Transradial access should be in the procedural repertoire of every interventional radiologist.

The Role of Sulfur Dioxide in Stratospheric Aerosol Formation Evaluated Using In-Situ Measurements in the Tropical Lower Stratosphere

Stratospheric aerosols (SAs) are a variable component of the Earth's albedo that may be intentionally enhanced in the future to offset greenhouse gases (geoengineering). The role of tropospheric-sourced sulfur dioxide (SO₂) in maintaining background SAs has been debated for decades without in-situ measurements of SO₂ at the tropical tropopause to inform this issue. Here we clarify the role of SO₂ in maintaining SAs by using new in-situ SO₂ measurements to evaluate climate models and satellite retrievals. We then use the observed tropical tropopause SO₂ mixing ratios to estimate the global flux of SO₂ across the tropical tropopause. These analyses show that the tropopause background SO₂ is about 5 times smaller than reported by the average satellite observations that have been used recently to test atmospheric models. This shifts the view of SO₂ as a dominant source of SAs to a near-negligible one, possibly revealing a significant gap in the SA budget.

Interferon beta overexpression attenuates adipose tissue inflammation and high-fat diet-induced obesity and maintains glucose homeostasis

The worldwide prevalence of obesity is increasing, raising health concerns regarding obesity-related complications. Chronic inflammation has been characterized as a major contributor to the development of obesity and obesity-associated metabolic disorders. The purpose of the current study is to assess whether overexpression of interferon beta (IFNβ1), an immune-modulating cytokine, will attenuate high fat diet-induced adipose inflammation and protect animals against obesity development. Using hydrodynamic gene transfer to elevate and sustain blood concentration of IFNβ1 in mice fed a high fat diet, we showed that overexpression of Ifnβ1 gene markedly suppressed immune cell infiltration into adipose tissue, and attenuated production of pro-inflammatory cytokines. Systemically, IFNβ1 blocked adipose tissue expansion and body weight gain, independent of food intake. Possible browning of white adipose tissue might also contribute to blockade of weight gain. More importantly, IFNβ1 improved insulin sensitivity and glucose homeostasis. These results suggest that targeting inflammation represents a practical strategy to block the development of obesity and its related pathologies. In addition, IFNβ1-based therapies have promising potential for clinical applications for the prevention and treatment of various inflammation-driven pathologies.

EFFECT OF RESTRICTED HIP FLEXOR MUSCLE LENGTH ON HIP EXTENSOR MUSCLE ACTIVITY AND LOWER EXTREMITY BIOMECHANICS IN COLLEGE-AGED FEMALE SOCCER PLAYERS

BACKGROUND

Hip flexor tightness is theorized to alter antagonist muscle function through reciprocal inhibition and synergistic dominance mechanisms. Synergistic dominance may result in altered movement patterns and increased risk of lower extremity injury.

HYPOTHESIS/PURPOSE

To compare hip extensor muscle activation, internal hip and knee extension moments during double-leg squatting, and gluteus maximus strength in those with and without clinically restricted hip flexor muscle length.

DESIGN

Causal-comparative cross-sectional laboratory study.

METHOD

Using a modified Thomas Test, female soccer athletes were assigned to a restricted (>0 ° of sagittal plane hip motion above the horizontal; n=20, age=19.9 ± 1 years, ht=167.1 ± 6.4 cm, mass=64.7 ± 8.2kg) or normal (>15 ° of sagittal plane hip motion below horizontal; n=20, age=19.4 ± 1 years, ht=167.2 ± 5.5 cm, mass=61.2 ± 8.6 kg) hip flexor muscle length group. Surface electromyographic (sEMG) activity of the gluteus maximus and biceps femoris, and net internal hip and knee extension moments were measured between groups during a double-leg squat. Isometric gluteus maximus strength was assessed using handheld dynamometry.

RESULTS

Individuals with restricted hip flexor muscle length demonstrated less gluteus maximus activation (p=0.008) and a lower gluteus maximus : biceps femoris co-activation ratio (p=0.004). There were no significant differences (p>0.05) in hip or knee extension moments, isometric gluteus maximus strength, or biceps femoris activation between groups.

CONCLUSIONS

Female soccer athletes with hip flexor muscle tightness exhibit less gluteus maximus activation and lower gluteus maximus : biceps femoris co-activation while producing similar net hip and knee extension moments. Thus, individuals with hip flexor muscle tightness appear to utilize different neuromuscular strategies to control lower extremity motion.

LEVEL OF EVIDENCE

3.

Widespread Distribution and Expression of Gamma A (UMB), an Uncultured, Diazotrophic, γ-Proteobacterial nifH Phylotype

Marine dinitrogen (N2) fixation studies have focused nearly exclusively on cyanobacterial diazotrophs; however γ-proteobacteria are an abundant component of the marine community and have been largely overlooked until recently. Here we present a phylogenetic analysis of all nifH γ-proteobacterial sequences available in public databases and qPCR data of a γ-proteobacterial phylotype, Gamma A (UMB), obtained during several research cruises. Our analysis revealed a complex diversity of diazotrophic γ-proteobacteria. One phylotype in particular, Gamma A, was described in several traditional and quantitative PCR studies. Though several γ-proteobacterial nifH sequences have been described as laboratory contaminants, Gamma A is part of a large cluster of sequences isolated from marine environments and distantly related to the clade of contaminants. Using a TaqMan probe and primer set, Gamma A nifH DNA abundance and expression were analyzed in nearly 1000 samples collected during 15 cruises to the Atlantic and Pacific Oceans. The data showed that Gamma A is an active, cosmopolitan diazotroph found throughout oxygenated, oligotrophic waters reaching maximum abundances of 8 x 104 nifH DNA copies l-1 and 5 x 105 nifH transcript copies l-1. Gamma A nifH transcript abundances were on average 3 fold higher than nifH DNA abundances. The widespread distribution and activity of Gamma A indicate that it has potential to be a globally important N2 fixing organism.

Characterizing spatial uncertainty when integrating social data in conservation planning

Recent conservation planning studies have presented approaches for integrating spatially referenced social (SRS) data with a view to improving the feasibility of conservation action. We reviewed the growing conservation literature on SRS data, focusing on elicited or stated preferences derived through social survey methods such as choice experiments and public participation geographic information systems. Elicited SRS data includes the spatial distribution of willingness to sell, willingness to pay, willingness to act, and assessments of social and cultural values. We developed a typology for assessing elicited SRS data uncertainty which describes how social survey uncertainty propagates when projected spatially and the importance of accounting for spatial uncertainty such as scale effects and data quality. These uncertainties will propagate when elicited SRS data is integrated with biophysical data for conservation planning and may have important consequences for assessing the feasibility of conservation actions. To explore this issue further, we conducted a systematic review of the elicited SRS data literature. We found that social survey uncertainty was commonly tested for, but that these uncertainties were ignored when projected spatially. Based on these results we developed a framework which will help researchers and practitioners estimate social survey uncertainty and use these quantitative estimates to systematically address uncertainty within an analysis. This is important when using SRS data in conservation applications because decisions need to be made irrespective of data quality and well characterized uncertainty can be incorporated into decision theoretic approaches.