Evaluation of radiotherapeutic and immune-modulatory response to whole brain radiotherapy or stereotactic radiosurgery in patients with brain metastases from malignant melanoma treated with or without ipilimumab (ELEKTRA)

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Background: Immune checkpoint blockers have dramatically improved the survival of patients (pts) suffering from advanced metastasized melanoma. In pts with melanoma brain metastases (MBM) a combination with radiotherapy (RT) is routinely used. Methods: We prospectively included 106 pts with MBM in a non-randomized observational trial with 7 treatment cohorts. Patients in cohort 1-4 were treated with ipilimumab (+/- nivolumab) and either stereotactic (up to 3 MBM) or whole brain RT (≥ 4 MBM) before or after the start of immunotherapy. Cohort 5 and 6 included pts who received RT with an ipilimumab-free systemic treatment and cohort 7 pts were treated with ipilimumab (+/- nivolumab) and no RT. Primary endpoints were immunological response in the peripheral blood (FACS of T cell subsets, ELISpots against melanoma antigens) and radiological response, secondary endpoints were progression free and overall survival. Results: Included pts were in median 61 years old, 72% were male. At trial inclusion, 31% of pts had an elevated LDH. 39% of ipilimumab treated pts received combination therapy with nivolumab. Clinically, ipilimumab treated pts in the early RT groups had better responses of both intra- and extracranial disease (p = 0.04 for both). Multivariate analyses showed a better PFS for pts with early RT (p = 0.02) and normal LDH (p = 0.049). Type of radiation (p = 0.6) and immune therapy (p = 0.8) had no significant influence in this small cohort of pts. Immune monitoring revealed that ipilimumab leads to an increase in activated CD4+ and CD8+ T cells in the peripheral blood which was maintained in responding pts and higher in pts receiving early RT. Treg were not depleted in general but activated by ipilimumab. However, responders displayed a temporary decrease of Treg and activated Treg under treatment. An increase in the detection of melanoma antigens could be observed after 2 cycles of ipilimumab which was higher in pts with combined radioimmunotherapy compared to ipilimumab only. Conclusions: Preliminary data from this small observational trial might lead to a preference of a treatment sequence with radiotherapy first, followed by checkpoint inhibition in pts with MBM.

Helical tomotherapy in patients with leptomeningeal metastases

Purpose

Leptomeningeal metastasis (LM) is an increasingly common complication of late-stage systemic cancer, for which there is no standard treatment. We analyzed outcome and toxicity in patients with LM undergoing craniospinal irradiation via helical tomotherapy (HT-CSI) at our institution.

Patients and methods

The charts of 15 patients diagnosed with LM and undergoing HT-CSI between 2006 and 2014 were retrospectively assessed. Main neoplasms included breast cancer, lung cancer, and lymphoma. All patients presented with cranial neuropathy due to LM. Follow-up was performed regularly. Survival analysis was performed by the Kaplan–Meier method, and prognostic factors were tested using the COX-regression model.

Results

Median survival by cancer type was 6 (breast cancer), 1 (lung cancer), and 2 months (lymphoma), respectively. Median overall survival and relapse-free survival were calculated to be between 2 and 3 months. Six- and 12-month survival was 30% (95% CI 0.08–0.5) and 20% (95% CI 0.05–0.4), respectively. Symptom palliation occurred in 53% of patients in general, but in 67% of breast cancer patients, in particular. Patients with lung cancer experienced no improvement. Most common acute treatment-related toxicity at different levels were hematological toxicity, multiple cranial neuropathy, fatigue, infections, nausea, and headache.

Conclusion

HT-CSI can help meet the challenge of treating patients with LM, especially because it can palliate symptoms and improve neurological functions. One-year survival remains as disappointing as before.

The effect of real-time electronic monitoring of patient-reported symptoms and clinical syndromes in outpatient workflow of medical oncologists: E-MOSAIC, a multicenter cluster-randomized phase III study (SAKK 95/06)

BACKGROUND

Patients with advanced, incurable cancer receiving anticancer treatment often experience multidimensional symptoms. We hypothesize that real-time monitoring of both symptoms and clinical syndromes will improve symptom management by oncologists and patient outcomes.

PATIENTS AND METHODS

In this prospective multicenter cluster-randomized phase-III trial, patients with incurable, symptomatic, solid tumors, who received new outpatient chemotherapy with palliative intention, were eligible. Immediately before the weekly oncologists' visit, patients completed the palm-based E-MOSAIC assessment (Edmonton-Symptom-Assessment-Scale, ≤3 additional symptoms, estimated nutritional intake, body weight change, Karnofsky Performance Status, medications for pain, fatigue, nutrition). A cumulative, longitudinal monitoring sheet (LoMoS) was printed immediately. Eligible experienced oncologists were defined as one cluster each and randomized to receive the immediate print-out LoMoS (intervention) or not (control). Primary analysis limited to patients having uninterrupted (>4/6 visits with same oncologist) patient-oncologist sequences was a mixed model for the difference in patients global quality of life (G-QoL; items 29/30 of EORTC-QlQ-c30) between baseline (BL) and week 6. Intention-to-treat (ITT) analysis included all eligible patients.

RESULTS

In 8 centers, 82 oncologists treated 264 patients (median 66 years; overall survival intervention 6.3, control 5.4 months) with various tumors. The between-arm difference in G-QoL of 102 uninterrupted patients (intervention: 55; control: 47) was 6.8 (P = 0.11) in favor of the intervention; in a sensitivity analysis (oncologists treating ≥2 patients; 50, 39), it was 9.0 (P = 0.07). ITT analysis revealed improvement in symptoms (difference last study visit-BL: intervention -5.4 versus control 2.1, P = 0.003) and favored the intervention for communication and coping. More patients with high symptom load received immediate symptom management (chart review, nurse-patient interview) by oncologists getting the LoMoS.

CONCLUSION

Monitoring of patient symptoms, clinical syndromes and their management clearly reduced patients' symptoms, but not QoL. Our results encourage the implementation of real-time monitoring in the routine workflow of oncologist with a computer solution.

CEP-stable, sub-6 fs, 300-kHz OPCPA system with more than 15 W of average power

We report on a CEP-stable OPCPA system reaching multi-GW peak powers at 300 kHz repetition rate. It delivers 15 W of average power, over 50 µJ of compressed pulse energy and a pulse duration below 6 fs. By implementing an additional pump-seed-synchronization, the output parameters are stabilized over hours with power fluctuations of less than 1.5%.

Circular grating waveguide structures for intracavity generation of azimuthal polarization in a thin-disk laser

We report on the generation of beams with azimuthal polarization using resonant grating waveguide structures (GWSs) inside an Yb:YAG thin-disk laser (TDL) oscillator. Two different GWS concepts were used to select the polarization of the emitted beam. The first uses the resonant reflection principle, and the second is based on the leaky-mode approach already reported in our previous work. Up to 93 W and 103 W of output power were extracted from a TDL with an optical efficiency, η(oo), of 36.2% and 40.1% using the first and the second approaches, respectively. In both cases, a pure azimuthal polarization and a beam quality factor, M2, of about 2.2 were measured. The design, fabrication, and different experimental results, as well as the laser performances for both GWSs, are discussed in the present Letter.

Single-layer resonant-waveguide grating for polarization and wavelength selection in Yb:YAG thin-disk lasers

A single-layer resonant-waveguide grating consisting of a sub-wavelength grating coupler etched into a waveguide is proposed in order to achieve high polarization and high spectral selectivity inside an Yb:YAG thin-disk laser resonator. The designed structure was fabricated with the help of a Lloyd's-mirror interference lithography setup followed by reactive ion beam etching down to the desired grating groove depth. The wavelength and polarization dependent reflectivity is measured and compared to the design results. The behaviour of the device at higher temperatures is also investigated in the present work. The device is introduced as the end mirror of an Yb:YAG thin-disk laser cavity. Output powers of up to 123 W with a spectral bandwidth of about 0.5 nm (FWHM) is demonstrated in a multimode configuration (M2~6). In fundamental-mode operation (TEM00 with M2~1.1) 70 W of power with a spectral bandwidth of about 20 pm have been obtained. Moreover, the degree of linear polarization was measured to be higher than 99% for both multimode and fundamental mode operation.

Laser direct writing of rotationally symmetric high-resolution structures

We present a laser direct writing system for the efficient fabrication of high-resolution axicon structures. The setup makes use of scanning beam interference lithography incorporated with a fringe locking scheme for tight fringe phase control and allows us to fabricate large area structures with a period down to 450 nm.

Detection of gastric MALT lymphoma spreading to the small bowel by enteroscopy

Mucosa-associated lymphoid tissue (MALT) lymphoma is thought to be a multifocal disease with sometimes synchronous involvement of various mucosal structures. In this study we aimed to evaluate the potential involvement of the small bowel in patients suffering from gastric MALT lymphoma by analyzing the results of enteroscopy, a technique that allows easy and safe access to the small bowel with the potential for histological assessment of biopsy samples. We have retrospectively evaluated 347 enteroscopies and found nine patients with gastric MALT lymphoma who had undergone push enteroscopy with serial biopsies during staging. All patients tolerated enteroscopy without side effects, and no local complications occurred. In eight cases no evidence of duodenal or jejunal involvement was found macroscopically or by histological assessment of biopsies, while in one patient enteroscopy revealed jejunal MALT lymphoma infiltration with macroscopic accentuation of mucosal parts and consecutive histopathological verification more distal than 50 cm. This single-center retrospective analysis shows that enteroscopy can provide additional diagnostic information in patients with gastric MALT lymphoma, although the number of patients was small and only one out of nine patients showed hitherto undetected MALT lymphoma deposits. Further studies may quantify the additional diagnostic yield provided by this easy and safe endoscopic method.

High-power radially polarized Yb:YAG thin-disk laser with high efficiency

Radially polarized beams with an output power of 275 W, M2=2.3 and an efficiency of about 52.5% were generated from an Yb:YAG thin-disk laser. An intra-cavity circular resonant waveguide grating was used as a polarization selective mirror inside the laser cavity. We report on the design and the fabrication using a scanning beam interference lithography system and discuss the calculated and measured performances of the presented polarizing grating mirrors.

Treatment of pancreatic cancer with two novel histone deacetylase inhibitors NVP-LAQ824 and NVP-LBH589

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Background: Pancreatic cancer is the fifth to sixth leading cause of cancer death in Europe and up to 90% of patients will present with locally advanced or metastatic disease. Unfortunately, little progress has been obtained from chemotherapy regimens in the past decade. Treatment with histone deacetylase inhibitors, like NVP-LAQ824 and NVP-LBH589, either alone or in combination with conventional chemotherapy may be a novel alternative. Methods: Cell-growth inhibition by NVP-LAQ824 and NVP-LBH589 was studied in vitro in 8 human pancreatic cancer cell lines by MTT assay. In addition, the anti-tumoral effect of NVP-LBH589 was studied in a chimeric mouse model. Anti-tumoral drug mechanism was assessed by immunoblotting for p21WAF-1, acH4, p42/p44, Phospho-p42/p44, AKT, Phospho- AKT, cell cycle analysis, TUNEL assay, and immunohistochemistry for MIB-1. Results: In vitro treatment with both compounds significantly suppressed the growth of all cancer cell lines (mean IC50 (6d) 0.06 and 0.03 μM, respectively) and was associated with hyperacetylation of nucleosomal histones H4, increased expression of p21WAF-1, and cell cycle arrest at G2/M-checkpoint. After 21 d, NVP-LBH589 alone reduced tumor mass in vivo by 70% and in combination with gemcitabine by 81% in comparison to placebo for cell line L3.6 pl. Further analysis of the tumor specimens revealed slightly increased apoptosis (TUNEL) and no significant reduction of cell proliferation (MIB-1). Protein levels of p42/p44, and AKT remained stable, whereas levels of Phospho-p42/p44 and Phospho-AKT increased. Conclusions: Our findings suggest that NVP-LBH589 > NVP-LAQ824 are active against human pancreatic cancer in vitro. In addition, NVP-LBH589 demonstrated significant in vivo activity and potentiated the efficacy of gemcitabine, although the precise mechanism of drug action is not yet completely understood. Therefore, further preclinical and clinical evaluation of this new drug for the treatment of pancreatic cancer is recommended.

No significant financial relationships to disclose.

Diagnostic cholangiopancreatography

As in recent years, the articles on diagnostic endoscopic retrograde cholangiopancreatography (ERCP) published between July 2001 and June 2002 again reflect a defensive attitude and are mainly concerned with magnetic resonance cholangiopancreatography (MRCP) and the complications associated with the new imaging method. Diagnostic ERCP is declining in importance and has held its position mainly due to new advances in tissue sampling, pressure measurement, and the use of echo probes and miniature endoscopes. Problems of training in ERCP have still not yet been resolved, due to the contradictions inherent in low case loads, the desire to offer a wide spectrum of training, and issues of quality assurance.

Evaluation of a virtual endoscopy simulator for training in gastrointestinal endoscopy

BACKGROUND AND STUDY AIMS

Skills in gastrointestinal endoscopy mainly depend on experience and practice. Training on endoscopy simulators may decrease the time needed to reach competency in endoscopy. The purpose of the study was to determine whether the GI-Mentor, a virtual reality endoscopy simulator, can distinguish between beginners and experts in endoscopy and to assess whether training improves the performance of beginners.

METHODS

A total of 13 beginners and 11 experts (more than 1,000 procedures) in gastrointestinal endoscopy were included. The baseline assessment consisted of virtual endoscopies and skill tests. The beginners were randomly allocated to receive training (n = 7) or no training (n = 6). The training group was allowed to practice using the simulator for 2 hours per day. After 3 weeks participants were re-evaluated with two new virtual endoscopy cases and one virtual skill test. Insertion time, correctly identified pathologies, adverse events and skill test performance were recorded.

RESULTS

The baseline assessment revealed significant differences favoring the experts for virtual endoscopies and skill tests. Significant differences in favor of experts were found for successful retroflection during esophagogastroduodenoscopy (EGD) (P < 0.005); adverse events during colonoscopy (P < 0.02); insertion time (P < 0.001); correctly identified pathologies in gastroscopy and colonoscopy (P < 0.02); and skill test performance (P < 0.01). The final evaluation showed significant differences between training and no-training groups, in favor of the training group, for the number of adverse events during virtual endoscopy (P < 0.04), for the insertion time during colonoscopy (P < 0.03); and for skill test performance (P < 0.01). The training group improved its abilities on the simulator significantly. Differences between experts and the training group were no longer seen.

CONCLUSION

This virtual endoscopy simulator is capable of identifying differences between beginners and experts in gastrointestinal endoscopy. A 3-week training improves the performance of beginners significantly. This quite fast improvement in endoscopic skills certainly cannot be seen in clinical practice; no conclusions can be made about the impact of virtual simulator training on real-life endoscopy, and this must be evaluated.

Forceps biopsy and brush cytology during endoscopic retrograde cholangiopancreatography for the diagnosis of biliary stenoses

BACKGROUND

For evaluating pancreaticobiliary stenoses during endoscopic retrograde cholangiopancreatography (ERCP) tissue sampling techniques may be important. Brush cytology and forceps biopsy during ERCP are two potential, but so far only incompletely evaluated, tools for the diagnosis of malignant biliary or pancreatic stenoses.

METHODS

Between 1992 and 1995 we acquired 133 cytologic and/or histologic samples from 119 patients who underwent ERCP because of biliary duct stenoses. Sixteen patients had to be excluded from the study due to insufficient follow-up information. After papillotomy, brush cytology was performed in 65 cases (63 patients), and forceps biopsy in 119 cases (106 patients under fluoroscopic guidance. Both methods were applied in combination 51 times (48 patients). The nature of the stenoses was confirmed by surgery, autopsy, or by the subsequent clinical course.

RESULTS

The sensitivity was 46.7% for brush cytology and 64.9% for forceps biopsy. The combined application of both methods resulted in superior sensitivity (70.4%). Specificity was 100% for all methods.

CONCLUSIONS

These numbers lead us to recommend a combined and more frequent application of brush cytology and forceps biopsy of bile duct stenoses to enhance the diagnostic yield whenever substantial influence on therapy can be expected.

Two cases of fractured esophageal nitinol stents

We report here on two cases of fractured nitinol stents in the esophagus. In case 1, the correctly inserted stent broke spontaneously shortly after insertion. In a second case, a nitinol stent broke after laser application due to tumor ingrowth with massive bleeding. In both cases, a second stent was implanted in order to reestablish food passage. The fracture of the stent in case 1 seemed to be caused by defective material, whilst in case 2 the stent broke because of thermal overstrain during laser application. The use of electrocoagulation or laser in the stent area should therefore be avoided; argon plasma coagulation may offer an effective alternative in treating tumor ingrowth. As there was a risk from piercing broken filaments with the second stent, covering a fracture using stents with tight walls or plastic tubes seems to be a more effective approach than the inserting an uncovered stent type.