ACR-ARS Practice Parameter for Radiation Oncology

BACKGROUND

This practice parameter was revised collaboratively by the American College of Radiology (ACR), and the American Radium Society. This practice parameter provides updated reference literature regarding radiation oncology practice and its key personnel.

METHODS

This practice parameter was developed according to the process described under the heading The Process for Developing ACR Practice Parameters and Technical Standards on the ACR website ( https://www.acr.org/Clinical-Resources/Practice-Parameters-and-Technical-Standards ) by the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with the American Radium Society.

RESULTS

This practice parameter provides a comprehensive update to the reference literature regarding radiation oncology practice in general. The overall roles of the radiation oncologist, the Qualified Medical Physicist, and other specialized personnel involved in the delivery of external-beam radiation therapy are discussed. The use of radiation therapy requires detailed attention to equipment, patient and personnel safety, equipment maintenance and quality assurance, and continuing staff education. Because the practice of radiation oncology occurs in a variety of clinical environments, the judgment of a qualified radiation oncologist should be used to apply these practice parameters to individual practices. Radiation oncologists should follow the guiding principle of limiting radiation exposure to patients and personnel while accomplishing therapeutic goals.

CONCLUSION

This practice parameter can be used as an effective tool to guide radiation oncology practice by successfully incorporating the close interaction and coordination among radiation oncologists, medical physicists, dosimetrists, nurses, and radiation therapists.

The Radiosurgery Society Case-Based Discussion of the Management of Head and Neck or Skull Base Paragangliomas with Stereotactic Radiosurgery and Radiotherapy

Stereotactic radiosurgery (SRS) and fractionated stereotactic radiotherapy (FSRT) have been used for the treatment of head and neck or skull base paraganglioma for a considerable time, demonstrating promising local control rates and a favorable safety profile compared with surgical approaches. Nevertheless, the choice of treatment must be carefully tailored to each patient's preferences, tumor location, and size, as well as anticipated treatment-related morbidity. This case-based review serves as a practical and concise guide for the use of SRS and FSRT in the management of head and neck or skull base paragangliomas, providing information on the diagnosis, treatment, follow-up considerations, and potential pitfalls.

An overview of the therapeutic strategies for neoplastic meningitis due to breast cancer: when and why?

INTRODUCTION

Neoplastic meningitis (NM), also known as leptomeningeal carcinomatosis, is characterized by the infiltration of tumor cells into the meninges, and poses a significant therapeutic challenge owing to its aggressive nature and limited treatment options. Breast cancer is a common cause of NM among solid tumors, further highlighting the urgent need to explore effective therapeutic strategies. This review aims to provide insights into the evolving landscape of NM therapy in breast cancer by collating existing research, evaluating current treatments, and identifying potential emerging therapeutic options.

AREAS COVERED

This review explores the clinical features, therapeutic strategies, recent advances, and challenges of managing NM in patients with breast cancer. Its management includes multimodal strategies, including systemic and intrathecal chemotherapy, radiation therapy, and supportive care. This review also emphasizes targeted drug options and optimal drug concentrations, and discusses emerging therapies. Additionally, it highlights the variability in treatment outcomes and the potential of combination regimens to effectively manage NM in breast cancer.

EXPERT OPINION

Challenges in treating NM include debates over clinical trial end points and the management of adverse effects. Drug resistance and low response rates are significant hurdles, particularly inHER2-negative breast cancer. The development of more precise and cost-effective medications with improved selectivity is crucial. Additionally, global efforts are needed for infrastructure development and cancer control considering the diverse nature of the disease.

A prospective study of immune responses in patients with lung metastases treated with stereotactic body radiotherapy with or without concurrent systemic treatment

We prospectively evaluated the effects of stereotactic body radiotherapy (SBRT) on circulating immune cells. Patients with oligo-metastatic and oligo-progressive pulmonary lesions were treated with SBRT with (cSBRT) or without (SBRT group) concurrent systemic treatment (chemotherapy or immune checkpoint blockade) using different fractionation regimes. Immunoprofiling of peripheral blood cells was performed at baseline, during, at the end of SBRT, and at the first and second follow-ups. The study accrued 100 patients (80 with evaluable samples). The proportion of proliferating CD8+ T-cells significantly increased after treatment. This increase remained significant at follow-up in the SBRT group, but not in the cSBRT group and was not detected with doses of >10Gy per fraction indicating that lower doses are necessary to increase proliferating T-cells' frequency. We detected no favorable impact of concurrent systemic treatment on systemic immune responses. The optimal timing of systemic treatment may be post-SBRT to leverage the immune-modulating effects of SBRT.

Abstract 3320: Liquid biopsy to detect biomarkers in early-stage surgically-resected pancreatic cancer

Pancreatic ductal adenocarcinoma (PDAC) is a deadly disease with a five-year survival rate of around 7% due to its late diagnosis, rapid metastasis, and chemotherapy resistance. For a small proportion (10-20%) of early-stage patients however, surgical resection of the pancreatic tumor offers the best chance for survival (5-year rate of 20%). Given the clinical challenges and the need for personalized care strategies to maximize patient survival, we propose the utility of the minimally invasive liquid biopsy to identify circulating biomarkers in patient blood to guide prognosis and monitor treatment. This study used the non-enriching third generation High-Definition Single Cell Assay (HDSCA3.0) workflow to investigate the clinical significance of a heterogeneous circulating rare cell population in both the peripheral and portal vein blood of early-stage PDAC patients (n = 20) at four different time points—pre-, during, and post- surgical resection, as well as at one-week follow-up. Compared to normal donor samples (n = 50), PDAC patients had a significantly greater incidence of circulating tumor cells (CTCs: cytokeratin-positive (CK+) and CD35/45-negative). There was no significant difference in rare cell incidence between peripheral and portal vein samples. However, specific phenotypes of rare cells were observed at different frequencies based on time of sample collection. Patient samples collected pre-surgery had a significantly higher incidence of CTCs than samples collected during surgery, while post-surgery samples had a significantly higher incidence of total CK+ rare cells and mesenchymal CTCs (Vimentin-positive, CK+) than during-surgery samples. While post-surgical samples also had a higher total CK+ rare cell and CTC incidence than pre-surgical samples, the difference was not statistically significant. Additionally, patients who received neoadjuvant therapy with surgical resection had lower average incidence of rare cells. Overall, the data presented here reveal that 1) liquid biopsy analytes are detected at a higher incidence in localized PDAC than normal donors; 2) the time point of sample collection in relation to surgery leads to a statistically significant different in frequency of detectable analytes; and 3) anatomical location of blood draw is not associated with difference in rare cell incidence. This study demonstrates the liquid biopsy’s utility in early-stage PDAC detection at the time of surgical resection.

Citation Format: Emmeline Y. Lin, George Courcoubetis, Divya Suresh, Jeremy Mason, Stephen J. Pandol, Simon Lo, Nicholas Nissen, Srinivas Gaddam, Peter Kuhn, Stephanie N. Shishido. Liquid biopsy to detect biomarkers in early-stage surgically-resected pancreatic cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3320.

Multitasking dynamic contrast enhanced magnetic resonance imaging can accurately differentiate chronic pancreatitis from pancreatic ductal adenocarcinoma

Background and aims

Accurate differentiation of chronic pancreatitis (CP) and pancreatic ductal adenocarcinoma (PDAC) is an area of unmet clinical need. In this study, a novel Multitasking dynamic contrast enhanced (DCE) magnetic resonance imaging (MRI) technique was used to quantitatively evaluate the microcirculation properties of pancreas in CP and PDAC and differentiate between them.

Methods

The Multitasking DCE technique was able to acquire one 3D image per second during the passage of MRI contrast agent, allowing the quantitative estimation of microcirculation properties of tissue, including blood flow F_p, plasma volume fraction v_p, transfer constant K^trans, and extravascular extracellular volume fraction v_e. Receiver operating characteristic (ROC) analysis was performed to differentiate the CP pancreas, PDAC pancreas, normal control pancreas, PDAC tumor, PDAC upstream, and PDAC downstream. ROCs from quantitative analysis and conventional analysis were compared.

Results

Fourteen PDAC patients, 8 CP patients and 20 healthy subjects were prospectively recruited. The combination of F_p, v_p, K^trans, and v_e can differentiate CP versus PDAC pancreas with good AUC (AUC [95% CI] = 0.821 [0.654 - 0.988]), CP versus normal pancreas with excellent AUC (1.000 [1.000 - 1.000]), PDAC pancreas versus normal pancreas with excellent AUC (1.000 [1.000 - 1.000]), CP versus PDAC tumor with excellent AUC (1.000 [1.000 - 1.000]), CP versus PDAC downstream with excellent AUC (0.917 [0.795 - 1.000]), and CP versus PDAC upstream with fair AUC (0.722 [0.465 - 0.980]). This quantitative analysis outperformed conventional analysis in differentiation of each pair.

Conclusion

Multitasking DCE MRI is a promising clinical tool that is capable of unbiased quantitative differentiation between CP from PDAC.

Hypofractionated or Conventionally Fractionated Adjuvant Radiotherapy After Regional Lymph Node Dissection for High-Risk Stage III Melanoma

AIMS

Adjuvant radiotherapy can be beneficial after regional lymph node dissection for high-risk stage III melanoma, as it has been shown to reduce the risk of recurrence in the node field. However, the optimal fractionation schedule is unknown and both hypofractionated and conventionally fractionated adjuvant radiotherapy are used. The present study examined the oncological outcomes of these two approaches in patients treated in an era before effective systemic immunotherapy became available.

MATERIALS AND METHODS

This retrospective cohort study involved 335 patients with stage III melanoma who received adjuvant radiotherapy after therapeutic regional lymph node dissection for metastatic melanoma between 1990 and 2011. Information on tumour characteristics, radiotherapy doses and fractionation schedules and patient outcomes was retrieved from the institution's database and patients' medical records.

RESULTS

Hypofractionated radiotherapy (median dose 33 Gy in six fractions over 3 weeks) was given to 95 patients (28%) and conventionally fractionated radiotherapy (median dose 48 Gy in 20 fractions over 4 weeks) to 240 patients (72%). Five-year lymph node field control rates were 86.0% (95% confidence interval 78.4-94.4%) for the hypofractionated group and 85.5% (95% confidence interval 80.5-90.7%) for the conventional fractionation group (P = 0.87). There were no significant differences in recurrence-free survival (RFS) (41.7%, 95% confidence interval 32.5-53.5 versus 31.9%, 95% confidence interval 26.1-38.9; P = 0.18) or overall survival (41.2%, 95% confidence interval 32.1-52.8 versus 45.0%, 95% confidence interval 38.7-52.4; P = 0.77). On multivariate analysis, extranodal spread was associated with decreased RFS (P = 0.04) and the number of resected lymph nodes containing metastatic melanoma was associated with decreased RFS (P = 0.0006) and overall survival (P = 0.01).

CONCLUSION

Lymph node field control rates, RFS and overall survival were similar after hypofractionated and conventionally fractionated adjuvant radiotherapy. The presence of extranodal spread and an increasing number of positive lymph nodes were predictive of an unfavourable outcome.

Reperfusion strategy and late clinical outcomes of patients with ST-elevation myocardial infarction (STEMI) in the absence of standard modifiable risk factors (SMuRFs)

Introduction

There is growing evidence that patients presenting with STEMI in the absence of standard modifiable cardiovascular risk factors (SMuRFs; smoking, hypertension, hypercholesterolemia, diabetes) have poorer outcomes compared to those with atleast one SMuRF. It has been hypothesised that this may be in part due to decreased administration of pharmacotherapies in the post-infarct period due to perceived low risk. Long term outcomes of patients without SMuRFs based on reperfusion strategy received during the index admission have not been investigated.

Purpose

We sought to analyse late clinical outcomes of STEMI patients with and without SMuRFs based on reperfusion strategy received during the index admission.

Methods

All patients who underwent PCI between 2003 and 2014 were identified from a PCI centre STEMI database. Late clinical outcomes of patients with and without SMuRFs were analysed overall and based on reperfusion strategy [primary PCI (pPCI) vs pharmaco-invasive PCI (PI-PCI)]. Propensity matching was used to account for differences in baseline characteristics between the groups.

Results

Amongst 2,091 STEMI patients, 531 (25%) had no SMuRFs (51% pPCI, 49% PI-PCI) and 1560 (75%) had ≥1 SMuRF (52% pPCI, 48% PI-PCI). Unadjusted late mortality in SMuRF-less patients was 13.4% (18.8% pPCI, 7.7% PI-PCI) and for those with ≥1 SMuRF was 9.7% (11.0% pPCI, 8.4% PI-PCI). After propensity-matching clinical and angiographic characteristics, 5 year mortality rates were significantly higher for patients without SMuRFs compared to those with SMuRFs [HR 1.36, CI: 1.03–1.81, p=0.031]. This difference was attenuated for patients who underwent pPCI [HR 1.72, CI: 1.22–2.43, p=0.002]. Interestingly, this discrepancy was not observed amongst individuals who underwent pharmaco-invasive PCI [HR 1.13, CI: 0.53–1.48, p=0.638], as SMuRF-less patients had similar mortality rates to their counterparts. Long term rates of reinfarction, stent thrombosis and target vessel revascularisation were similar between the groups. Additionally, there was no significant difference in rates of stroke and major bleeding amongst all 4 subgroups.

Conclusion

Patients presenting with STEMI in the absence of SMuRFs have increased overall late mortality compared to those with at least one SMuRF. However, this difference was not observed in patients who underwent a pharmaco-invasive strategy, whereby patients without SMuRFs had similar outcomes to those with SMuRFs after adjusting for confounders. Our findings suggest the use of a pharmaco-invasive strategy in appropriate SMuRF-less patients presenting with STEMI.

Funding Acknowledgement

Type of funding sources: None.

Phase I trial of Bermekimab with nanoliposomal irinotecan and 5-fluorouracil/folinic acid in advanced pancreatic ductal adenocarcinoma

In this phase I dose-escalation trial, we assess the maximum tolerated dose (MTD) of Bermekimab in combination with Nanoliposomal Irinotecan (Nal-Iri) and 5-Fluorouracil/Folinic Acid (5-FU/FA). Secondarily, we investigate effects on weight, lean body mass, quality-of-life, the gut microbiome composition, inflammatory biomarkers, progression-free survival, and overall survival. This was a single-arm, open-label adaptive Bayesian dose-escalation study of Bermekimab combined with Nal-Iri and 5FU/FA in patients with advanced or locally advanced PDAC who failed gemcitabine-based chemotherapy. 22 patients enrolled between 2017 and 2019. 3 of 21 patients experienced dose-limiting toxicities attributable to the chemotherapy backbone. 58% (10/17) of patients exhibited weight stability. Physical performance status was preserved among all subjects. Patients reported improvements in quality-of-life metrics via QLQ-PAN26 questioner (-3.6, p = 0.18) and functional well-being (1.78, p = 0.02). Subjects exhibited a decrease in inflammatory cytokines, notably, vascular endothelial growth factor (-0.86, p = 0.017) with Bermekimab. Bermekimab treatment was associated with an increased abundance of gut health-promoting bacterial genera Akkermansia, with 3.82 Log2-fold change from baseline. In sum, Bermekimab is safe to be used in conjunction with Nal-Iri and 5-FU/FA chemotherapy. This benign toxicological profile warrants further Phase I/II investigation of Bermekimab in combinatorial strategies, and the impact of anti-IL-1α antibodies on the gut microbiome.Clinical trials registration: NCT03207724 05/07/2017.

Management of pouch neoplasia: consensus guidelines from the International Ileal Pouch Consortium

Surveillance pouchoscopy is recommended for patients with restorative proctocolectomy with ileal pouch-anal anastomosis in ulcerative colitis or familial adenomatous polyposis, with the surveillance interval depending on the risk of neoplasia. Neoplasia in patients with ileal pouches mainly have a glandular source and less often are of squamous cell origin. Various grades of neoplasia can occur in the prepouch ileum, pouch body, rectal cuff, anal transition zone, anus, or perianal skin. The main treatment modalities are endoscopic polypectomy, endoscopic ablation, endoscopic mucosal resection, endoscopic submucosal dissection, surgical local excision, surgical circumferential resection and re-anastomosis, and pouch excision. The choice of the treatment modality is determined by the grade, location, size, and features of neoplastic lesions, along with patients' risk of neoplasia and comorbidities, and local endoscopic and surgical expertise.

Trial in progress: A randomized phase II study of pembrolizumab with or without defactinib, a focal adhesion kinase inhibitor, following chemotherapy as a neoadjuvant and adjuvant treatment for resectable pancreatic ductal adenocarcinoma (PDAC)

TPS4192

Background: PDAC is an aggressive cancer. It remains refractory to checkpoint inhibition because of its significant desmoplastic and immunosuppressive tumor microenvironment (TME). Focal adhesion kinase (FAK), a non-receptor tyrosine kinase, is involved in tumor progression in many cancers and appears to be a targetable master regulator of the TME in PDAC. FAK inhibition combined with anti-PD1 antibody has been shown to modulate pancreatic stellate cells and decrease immunosuppressive myeloid and T-reg cells, leading to increased CD8 infiltration and improved survival in PDAC mouse models. A recent single arm phase I study of defactinib, a FAK inhibitor, combined with pembrolizumab, an anti-PD1 antibody, and chemotherapy was shown to be safe, and two confirmed partial responses were observed in patients with microsatellite-stable disease. Furthermore, increased CD8 T cell infiltration was observed in metastatic biopsies. Given the promising preclinical data and efficacy signals, as well as safety of the phase I clinical trial, our current study aims to assess the translational and clinical effects of sequentially combined defactinib and pembrolizumab following neoadjuvant and adjuvant chemotherapy in patients with high-risk resectable PDAC. Methods: This study is a multi-center, two-arm, randomized, open label, phase II clinical trial of neoadjuvant and adjuvant immunotherapy with defactinib and pembrolizumab, following neoadjuvant standard of care (SOC) gemcitabine and nab-paclitaxel in subjects with high-risk resectable PDAC. The primary objectives aim to assess changes in CD8 T cell intratumoral infiltration utilizing multiplex IHC and the pathologic complete response rate with defactinib and pembrolizumab or pembrolizumab alone, following neoadjuvant chemotherapy. Secondary objectives include assessment of disease-free survival, overall survival, and safety. Translational exploratory objectives include evaluating stromal and immune signatures among treatment groups via multiplex IHC and RNA/DNA sequencing. 36 subjects will be randomly assigned to receive 400 mg defactinib PO BID and 200 mg pembrolizumab IV every 3 weeks (Arm A) or 200 mg pembrolizumab IV alone every 3 weeks (Arm B). After enrollment, subjects will undergo 2 cycles (̃2 months) of standard neoadjuvant therapy of gemcitabine and nab-paclitaxel, followed by 2 cycles (6 weeks) of investigational treatment (Arm A or B) before surgical resection. Following surgery, subjects will receive SOC adjuvant chemotherapy followed by investigational treatment (Arm A or B) for 8 cycles (̃24 weeks). Key inclusion criteria include: resectable PDAC, CA 19-9>200, no prior systemic treatment for PDAC, and ECOG PS ≤1. As of February 2022, 14 patients have been enrolled. Clinical trial information: NCT03727880.

Impact of site-specific metastases on survival outcomes in pancreatic adenocarcinoma (PDAC) patients: A national analysis

e16270

Background: PDAC is the third most fatal cancer, where most patients present with metastases at diagnosis. Previous studies, including a retrospective analysis from our single-center experience, suggests survival rates are significantly higher for those with lung-only metastases (mets) when compared to liver metastasis or other sites of metastases (liver+other). The objective of this analysis is to explore this difference based on sites and metastasis and the impact of chemotherapy from a national cohort. Methods: We identified PDAC patients (>18years) from with metastases to either 1) lung-only; 2) liver+other sites in the National Cancer Database diagnosed between 2010 and 2015.We analyzed patient characteristics, demographics, type of chemotherapy, and survival outcomes. Kaplan Meir survival curves were generated, and Cox proportional hazard models adjusted for age and sex were fit to evaluate associations between met site and survival. Survival was calculated from time of diagnosis to death and compared across mets site, receipt of chemotherapy, and treatment and type (single versus multi-agent). Results: 15359 PDAC patients were included in the analysis [51.6% male 48.4% female, mean age 69 years] of which 4512 (29.4%) patients had lung only mets and 10847 (70.6%) had liver + other mets. Median survival was 5.72 and 2.37 months for lung only vs. liver+other mets, respectively (log rank p<0.001). From a subset population of 8440 patients who received chemotherapy, median survival of 9.4 and 4.9 months for lung only and liver+other mets was observed, respectively [Table]. Median OS for single agent chemotherapy was 4.4 months (n=2637), with patients with lung only mets having a median OS of 7.1 months and those with liver+other mets having a median OS of 3.6 months. Median OS for patients treated with multi-agent chemotherapy (n=5380) was 7.4 months, with lung only met patients having a median OS of 11.6 months and those with liver+other mets having a median OS of 6.1 months. Hazard ratios (HR) and 95% confidence intervals (CI) are displayed in the table. Conclusions: In a national cohort, patients with metastatic PDAC and lung-only metastasis had improved survival when compared with liver +other metastasis. Further contemporary research is needed to understand the underlying biology that dictates the survival difference between lung metastasis vs other sites of metastatic disease in pancreatic cancer.[Table: see text]

Risk-reduction strategies for late complications arising from brain metastases treated with radiotherapy: a narrative review

OBJECTIVE

This review will focus on the late neurological complications from cranial irradiation and relevant mitigation strategies.

BACKGROUND

Radiotherapy (RT) remains an important pillar in the management of brain metastases. Patients being treated in the modern era do experience longer survival, because of superior intra- and extracranial disease control. As a result, they can be more prone to developing and manifesting late complications post-brain radiotherapy.

METHODS

A search and narrative review of prospective clinical trials relating to neurological toxicity outcomes was conducted.

CONCLUSIONS

Neurological toxicities can be challenging to diagnose and manage and should be considered during consideration of radiotherapy in brain metastasis, hence more emphasis should be placed on prevention and upfront mitigation of these complications, with novel strategies showing promising results in prospective trials being adopted into clinical practice.

Pericardiocentesis over 3 years at a tertiary referral Australian hospital

Funding Acknowledgements

Type of funding sources: None.

Background

 Pericardiocentesis is a lifesaving intervention performed both percutaneously or surgically. We analysed 3 years of experience in a major tertiary hospital in Sydney Australia. 

Purpose

 To examine the indications, safety and delivery of a pericardiocentesis service at a major teaching hospital. 

Methods

 We retrospectively audited consecutive patients who underwent pericardiocentesis for  pericardial effusion[PE] at a major teaching hospital from February 2018 to December 2020. Eligible patients were identified from the electronic medical records with this coding diagnosis.

Results

89 patients identified with mean age 60.8 ± 18.9years and 58.4%(51/89) male. Follow-up to August 2021 showed 41.5% had died, with an index hospitalisation mortality of 19%(17/89). Malignancy was the most common aetiology 30.3%(27/89) and attributable cause of hospitalisation death in 29.4%. Alternate causes included pericarditis 14.6%, idiopathic 13.4%, percutaneous-coronary-intervention(PCI) 5.6%(6/89) and electrophysiology 4.5%(4/89) complications. Three patients had aortic dissection (3.3%) and two were fatal. Clinical tamponade was present in 66.2%(55/89), PE identification occurred via echocardiography(TTE) in 55% cases (49/89) and incidental CT-diagnosis in 20.2%. TTE findings: right atrial collapse 54%(47/87), right ventricular collapse 60.9%(53/87), fixed and dilated inferior vena cava 64.7%. Pericardiocentesis was performed by cardiology trainees in 90.5% cases, 64.5% with consultant supervision and during working hours in 57.3% of cases. Percutaneous drainage was successful in 96%(72/75) of cases and was performed in the coronary care unit (30.3%), catheterisation laboratory (23.5%), emergency department (19.1%) and ICU (11.2%). Subxiphoid approach in 70%(62/89) was the most common then trans-apical 15%(13/89), parasternal 3%(3/89) and surgical 16%(14/89). TTE confirmed drain position in 76%(54/71), fluoroscopy in 28.5%(6/21) and agitated saline in 38.9%(30/77). Haemo-serous fluid noted in 77%(67/87) with average initial fluid drainage 480 ± 326mls and mean drain removal time 54 ± 33hrs. 17%(15/89) required re-drainage with adenocarcinoma found in 33.3%(5/15). Background antiplatelet treatment in 30.6%(27/88) and of these 67%(18/27) were on dual antiplatelets. 33%(29/89) patients were anticoagulated and 31.3%(9/29) required reversal prior to drainage. Complications were rare, 4%(3/75) had right heart chamber perforation needing emergency surgery. Two were post complex PCI (one died during admission from multiorgan failure) and one with pericarditis . 

Conclusions

 Pericardiocentesis is a safe and effective procedure for tamponade treatment and largely guided by echocardiography in our experience. Complications are rare and prognosis depends on aetiology with malignancy the most common. Drainage is often successfully performed emergently where the patient is located. Tamponade resulting from procedural complications are rare in our cohort.

Intravascular lithotripsy during percutaneous coronary intervention for calcified coronary lesions: analysis of patient and procedural characteristics and clinical outcomes

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Coronary artery calcification is frequently encountered during percutaneous coronary intervention (PCI). It can reduce PCI success and increase intra-procedural and post-procedural complications, including stent embolization, under-expansion and mal-apposition. Intravascular lithotripsy (IVL) is a new tool developed to treat calcified coronary lesions.

Purpose

Retrospective analysis of all cases of intravascular lithotripsy performed within our local health district to examine patient and procedural characteristics and clinical outcomes.

Methods

All patients undergoing PCI with intravascular lithotripsy between September 2019-August 2021 within our local health district were analysed. Patient and procedural characteristics and clinical outcomes were recorded.

Results

67 patients (50 men) were included with mean age 71.4 ± 8.7years. Risk factors prevalence included smoking (34%), hypertension (82%), dyslipidaemia (69%) and diabetes (46%). Trans-radial artery access was used in 38 patients (57%). IVL was performed most commonly in the left anterior descending artery (52%),[Figure 1]. IVL was utilised in 9 chronic total occlusions and 12 bifurcation lesions. Intracoronary (IC) imaging was performed in 59 patients (88%), intravascular ultrasound in 41(61%) and optical coherence tomography in 18 (27%). 41 (69%) patients had imaging performed pre and post IVL and post PCI.  IC imaging identified 14 cases with 270º calcification arc and 45 cases with 360º arc. Nine cases (13.4%) required rotational atherectomy prior to IVL (most commonly 1.75mm burr). Mean reference vessel diameter was 3.2 ± 0.3mm. Mean lesion length was 36.3 ± 16.5mm. Mean pre-PCI stenosis was 85.5 ± 10.8%. Drug eluting stents were successfully deployed in 57 cases (85%), 10 had balloon angioplasty alone. Mean stent length was 39.2 ± 17.8mm. Mean post-PCI stenosis was 4.5 ± 13.3% (median 0%). Figure 2 shows a statistically significant increase in minimum lumen diameter and minimum lumen area post-IVL and minimal-stent-area (MSA) post-PCI. Mean stent expansion was 83%. Mean screening time 35.8 ± 17.8 minutes with mean contrast used 207.3 ± 78.7mL. No sustained arrhythmias or side-branch loss occurred. Vessel rupture was recorded in one patient necessitating urgent cardiac surgery (due to oversized balloon) and in 4 cases the IVL balloon could not cross the lesion.

Conclusion

Our experience shows that IVL is safe and effective and facilitates stent delivery and expansion. Intracoronary imaging is important to determine the need for calcium modification and evaluate its success prior to stent delivery and to confirm optimised stent expansion. Abstract Figure. Breakdown of PCI Artery  Abstract Figure. IC Dimensions Pre/Post IVL/Post PCI

P2Y12 pre-treatment for NSTE-ACS in a tertiary hospital centre: real world compliance experience with ESC 2020 guidelines

Funding Acknowledgements

Type of funding sources: None.

Background

The 2020 ESC guidelines for managing NSTE-ACS recommend against routine pre-treatment with a P2Y12 receptor inhibitor if coronary anatomy is not known and an early (&lt;24h) invasive management is planned. With delayed (&gt;24h) invasive management, pre-treatment may be considered in selected cases.

Purpose

Evaluate antiplatelet pre-treatment practices for NSTE-ACS in a tertiary cardiology centre in Australia.

Methods

Retrospective analysis of NSTE-ACS cases from January to August 2021 were obtained from the cardiac laboratory database. Patients on a P2Y12 inhibitor prior to presentation were excluded. Clinical, demographic, angiographic and medication data were obtained from the electronic database.

Results

85 cases were included. Mean age was 62 ± 11.5 and 81% were male. The prevalence of hypertension, hypercholesterolaemia, type 2 diabetes and active smoking was 54.8%, 51.2%, 38.1% and 34.5% respectively. Mean time to angiography was 1.7 ± 1.4 days and the median peak pre-procedural troponin T was 191.5 (80 to 852). Access was predominantly radial (84.5%) with the remainder femoral (15.5%).

Angiographic findings included, obstructive disease amenable to percutaneous coronary intervention (50.0%), obstructive disease for surgical revascularisation (22.6%), and non-obstructive disease (27.4%). The mean time from angiography to surgical revascularisation was 6.4 ± 4.4 days. Three patients (3.6%) had bleeding [managed conservatively], specifically upper limb haematoma, groin haematoma, and haemoptysis.

The majority of patients (79.8%) received P2Y12 inhibitors (40.5% clopidogrel and 39.3% ticagrelor) prior to angiography. Of these, 49.3% had percutaneous angioplasty, 17.9% had surgical revascularisation and 32.8% had non-obstructive disease (managed with single antithrombotic agent). Of those who did not receive P2Y12 inhibitors [n = 17, 20.2%]. Of these, 53% had percutaneous angioplasty, 40% had surgical revascularisation, and 5% had non-obstructive disease.

Conclusions

Overall, pre-treatment with a P2Y12 inhibitor was still very common, risking delays to bypass surgery and increasing bleeding. Practice did not generally align with contemporary ESC 2020 guidelines. Understanding the reasons for guideline non-compliance would be important for optimising treatments. Education for emergency and cardiology staff as well as creation of local practice policies may help increase compliance with evidence-based guidelines.

Hyaluronan heterogeneity in pancreatic ductal adenocarcinoma: Primary tumors compared to sites of metastasis

BACKGROUND

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive cancers with poor survival. The dense desmoplastic stroma in PDAC contributes to treatment resistance. Among the components comprising the tumor stroma, hyaluronan (HA) has been demonstrated to play a critical role in tumor progression and survival. Previous preliminary studies have suggested differences in HA expression in primary and metastatic foci of PDAC. However, the effects of treatment and location of HA expression as a biomarker signature remain unknown; this study sought to compare HA expression in primary and metastatic sites of PDAC.

METHODS

Tissue from primary and metastatic PDACs were obtained from Cedars-Sinai Medical Center along with associated clinical data. Tissue slides were stained for H&E, HA, and CD44. Associations between HA levels and the evaluated variables were examined including progression free survival and overall survival.

RESULTS

HA score was significantly higher in primary PDACs compared to sites of metastases (p = 0.0148). Within the metastases, HA score was significantly higher in liver metastases compared to metastases at other sites (p = 0.0478). In the treatment-naive liver metastasis cohort, patients with HA high status had decreased progression free survival and overall survival compared to patients with HA low status (p = 0.0032 and p = 0.0478, respectively).

CONCLUSIONS

HA score is variable between primary PDAC, PDAC metastatic to the liver, and PDAC metastatic to other sites. Within liver metastases, patients with HA high status had decreased progression free survival and overall survival compared to patients with HA low status. HA levels can serve as a potential biomarker to guide pancreatic cancer treatments and trial design for agents targeting the stroma.

Focal Prostate Stereotactic Body Radiation Therapy With Correlative Pathological and Radiographic-Based Treatment Planning

Introduction

Advances in multiparametric MRI (mpMRI) combining anatomic and functional imaging can accurately identify foci of adenocarcinoma within the prostate, offering the possibility of partial gland therapy. We performed tandem prospective pilot trials to investigate the feasibility of focal prostate SBRT (f-SBRT) based on correlating diagnostic mpMRI and biopsies with confirmatory pathology in treatment planning.

Materials and Methods

Patients with pathologic focal Gleason 6–7 disease and a corresponding PIRADS 4–5 lesion on mpMRI underwent targeted and comprehensive biopsies using MRI/ultrasound fusion under electromagnetic sensor navigation. After rigorous analysis for imaging biopsy concordance, five of 18 patients were eligible to proceed to f-SBRT. Chi-squared test was used for differences from expected outcomes, and concordance was estimated with binomial distribution theory and Wilson’s method.

Results

Six patients had Gleason 6 and 12 had Gleason 3 + 4 disease (mean PSA: 5.8 ng/ml, range: 2.2–8.4). Absolute concordance was 43.8% (95% CI: 0.20, 0.64). Patterns of discordance included additional sites of ipsilateral disease, bilateral disease, and negative target. Five were upstaged to a new NCCN risk category necessitating treatment escalation. The five patients with concordant pathology completed three-fraction f-SBRT with sparing of the surrounding normal structures (including contralateral neurovascular bundle), with no reported grade 2+ toxicities and favorable PSA responses (mean: 41% decrease).

Conclusions

On our pilot trials of f-SBRT planning using rigorous imaging and pathology concordance, image-guided confirmatory biopsies frequently revealed additional disease, suggesting the need for caution in partial-gland therapy. For truly focal disease, f-SBRT provided excellent dosimetry, minimal toxicity, and encouraging biochemical response. Clinical Trial Registration: www.clinicaltrials.gov, NCT02681614; NCT02163317.

A multicentre study of naevus-associated melanoma vs. de novo melanoma, tumour thickness and body site differences

BACKGROUND

Whether melanoma in histological contiguity with a naevus [naevus-associated melanoma (NAM)] is distinctly different from melanoma arising de novo remains unclear.

OBJECTIVES

To determine whether the characteristics of de novo melanoma differ from NAM and are not due to naevus obliteration in thicker tumours.

METHODS

We conducted a multicentre retrospective study of de novo melanoma and NAM in seven referral centres in Europe, Australia and the USA between 2006 and 2015.

RESULTS

In a total of 9474 localized melanomas, de novo melanoma was associated with thicker tumours and body site differences compared with NAM. In the subset of T1 melanomas (n = 5307), similar body site differences were found in multivariate analysis by body site. When compared with NAM, de novo melanoma was more likely to affect older individuals (≥ 70 years) when located on the head/neck [odds ratio (OR) 4·65, 95% confidence interval (CI) 2·55-8·46], the trunk (OR 1·82, 95% CI 1·40-2·36) or the upper extremity (OR 1·69, 95% CI 1·14-2·50), was more likely to affect female patients when located on the lower extremities (OR 1·36, 95% CI 1·03-1·80), and was more likely to be of the nodular melanoma subtype (OR 2·23, 95% CI 1·14-4·35) when located on the trunk. De novo melanoma was less likely to have regression present compared with NAM.

CONCLUSIONS

Clinicopathological and body site differences between de novo melanoma and NAM support the divergent pathway model of development. These differences were also found in thin melanomas, suggesting that de novo melanomas are different from NAM and their differences are not due to the obliteration of naevus remnants in thicker tumours.

Lentigo maligna: defining margins and predictors of recurrence utilizing clinical, dermoscopic, confocal microscopy and histopathology features

BACKGROUND

Lentigo maligna (LM) is a subtype of melanoma in situ with poorly defined margins and a high recurrence rate. The biological behaviour of LM appears to differ widely between cases, from biologically indolent to biologically active variants, with some patients experiencing multiple recurrences. It is not known whether this is secondary to inadequate margins, field cancerization or the innate biology of the lesion itself.

OBJECTIVES

(a) Describe the margins of LM in detail by analysing LM in three zones, that is centre, edge and surround using reflectance confocal microscopy (RCM) and histopathology; (b) ascertain association of histological distance of LM and atypical melanocytic hyperplasia from the surgical margin with multi-recurrent (MR) disease and (c) identify features (clinical, dermoscopy, RCM and histopathology) associated with MR LM.

METHODS

(1) Descriptive observational study comparing the centre, edge and surround of LM on histopathology and RCM; (2) retrospective cohort study comparing parameters associated with MR and non-recurrent (NR) LM.

RESULTS

30 patients (median follow-up time 6.2 years) were included. On histopathology, confluent or near confluent lentiginous proliferation, melanocyte density >15 per 0.5 mm and adnexal spread were best for distinguishing surround from edge of LM. On RCM, predominant melanocytes, lentiginous proliferation and pleomorphism distinguished surround from centre/edge. MR patients had a median histological distance of LM from the surgical margin of 2mm (versus NR patients with an average distance of 4mm). MR patients had a greater proportion of more florid features, compared with NR on histopathology at both the centre and the edge but were similar in the surround.

CONCLUSION

These data may help pathologists and confocalists better define margins of LM. More florid features in MR patients, despite a similar background of sun-damaged skin, suggest the innate biology of the lesion rather than the field of cancerization may explain MR LM.

Outcomes following stereotactic radiosurgery or whole brain radiation therapy by molecular subtype of metastatic breast cancer

Background

This study quantified clinical outcomes by molecular subtype of metastatic breast cancer (BC) following whole brain radiation therapy (WBRT) or stereotactic radiosurgery (SRS). Doing so is important for patient counseling and to assess the potential benefit of combining targeted therapy and brain radiotherapy for certain molecular subtypes in ongoing trials.

Materials and methods

The National Cancer Database was queried for BC (invasive ductal carcinoma) cases receiving brain radiotherapy (divided into WBRT and SRS ). Statistics included multivariable logistic regression to determine factors associated with SRS delivery, Kaplan-Meier analysis to evaluate overall survival (OS), and Cox proportional hazards modeling.

Results

Of 1,112 patients, 186 (16.7%) received SRS and 926 (83.3%) underwent WBRT. Altogether, 410 (36.9%), 195 (17.5%), 162 (14.6%), and 345 (31.0%) were ER+/HER2−, ER+/HER2+, ER−/HER2+, and ER−/HER2−, respectively. In the respective molecular subtypes, the proportion of subjects who underwent SRS was 13.4%, 19.4%, 24.1%, and 15.7%. Respective OS for WBRT patients were 12.9, 22.8, 10.6, and 5.8 months; corresponding figures for the SRS cohort were 28.3, 40.7, 15.0, and 12.9 months (p < 0.05 for both). When comparing OS between treatment different histologic subtypes, patients with ER−/HER2+ and ER−/HER2− disease had worse OS than patients with ER+/HER2− disease, for both patients treated with SRS and for patients treated with WBRT.

Conclusions

Molecular subtype may be a useful prognostic marker to quantify survival following SRS/WBRT for metastatic BC. Patients with HER 2-enriched and triple-negative disease had the poorest survival following brain irradiation, lending credence to ongoing studies testing the addition of targeted therapies for these subtypes.

Microdiversity of Enterococcus faecalis isolates in cases of infective endocarditis: selection of non-synonymous mutations and large deletions is associated with phenotypic modifications

Context: Today, infective endocarditis (IE) caused by Enterococcus faecalis represents 10% of all IE and is marked by its difficult management and the frequency of relapses. Although the precise reasons for that remain to be elucidated, the evolution of the culprit strain under selective pressure through microdiversification could be, at least in part, involved. Material and methods: To further study the in situ genetic microdiversity and its possible phenotypic manifestations in E. faecalis IE, we sequenced and compared multiple isolates from the valves, blood culture and joint fluid of five patients who underwent valvular surgery. Growth rate and early biofilm production of selected isolates were also compared. Results: By sequencing a total of 58 E. faecalis genomes, we detected a considerable genomic microdiversity, not only among strains from different anatomical origins, but also between isolates from the same studied cardiac valves. Interestingly, deletions of thousands of bases including the well-known virulence factors ebpA/B/C, and srtC, as well as other large prophage sequences containing genes coding for proteins implicated in platelet binding (PlbA and PlbB) were evidenced. The study of mutations helped unveil common patterns in genes related to the cell cycle as well as central metabolism, suggesting an evolutionary convergence in these isolates. As expected, such modifications were associated with a significant impact on the in-vitro phenotypic heterogeneity, growth, and early biofilm production. Conclusion: Genome modifications associated with phenotypic variations may allow bacterial adaptation to both antibiotic and immune selective pressures, and thus promote relapses.

Histopathological features of complete pathological response predict recurrence-free survival following neoadjuvant targeted therapy for metastatic melanoma

BACKGROUND

Recent clinical trials demonstrated the safety and efficacy of neoadjuvant dabrafenib and trametinib (DT) among patients with surgically resectable clinical stage III BRAFV600E/K mutant melanoma. Although patients achieving a complete pathological response (pCR) exhibited superior recurrence-free survival (RFS) versus those who did not, 30% of pCR patients relapsed. We sought to identify whether histopathological features of the pathological response further delineated risk of relapse.

METHODS

Surgical resection specimens from DT-treated patients in two phase 2 clinical trials were reviewed. Histopathological features, including relative amounts of viable tumour, necrosis, melanosis, and fibrosis (hyalinized or immature/proliferative) were assessed for associations with patient outcomes.

RESULTS

Fifty-nine patients underwent surgical resection following neoadjuvant DT. Patients achieving pCR (49%) had longer RFS compared with patients who did not (P = 0.005). Patients whose treated tumour showed any hyalinized fibrosis had longer RFS versus those without (P = 0.014), whereas necrosis (P = 0.012) and/or immature/proliferative fibrosis (P = 0.026) correlated with shorter RFS. Multivariable analyses showed absence of pCR or presence of immature fibrosis independently predicted shorter RFS. Among pCR patients, mature/hyalinized-type fibrosis correlated with improved RFS (P = 0.035).

CONCLUSIONS

The extent and composition of the pathological response following neoadjuvant DT in BRAFV600E/K mutant melanoma correlates with RFS, including pCR patients. These findings support the need for detailed histological analysis of specimens collected after neoadjuvant therapy.

Feasibility and safety study of 22-gauge endoscopic ultrasound (EUS) needles for portal vein sampling in a swine model

Background and study aims  Endoscopic ultrasound (EUS) has been used for portal vein sampling in patients with pancreaticobiliary cancers for enumerating circulating tumor cells but is not yet a standard procedure. Further evaluation is needed to refine the methodology. Therefore, we evaluated the feasibility and safety of 19-gauge (19G) versus a 22-gauge (22 G) EUS fine-needle aspiration needles for portal vein sampling in a swine model. Methods  Celiotomy was performed on two farm pigs. Portal vein sampling occurred transhepatically. We compared 19 G and 22 G needles coated interiorly with saline, heparin or ethylenediaminetetraacetic acid (EDTA). Small- (10 mL) and large- (25 mL) volume blood collections were evaluated. Two different collection methods were tested: direct-to-vial and suction syringe. A bleeding risk trial for saline-coated 19 G and 22 G needles was performed by puncturing the portal vein 20 times. Persistent bleeding after 3 minutes was considered significant. Results  All small-volume collection trials were successful except for 22 G saline-coated needles with direct-to-vial method. All large-volume collection trials were successful when using suction syringe; direct-to-vial method for both 19 G and 22 G needles were unsuccessful. Collection times were shorter for 19 G vs. 22 G needles for both small and large-volume collections ( P  < 0.05). Collection times for saline-coated 22 G needles were longer compared to heparin/EDTA-coated ( P  < 0.05). Bleeding occurred in 10 % punctures with 19 G needles compared to 0 % with 22 G needles. Conclusion  The results of this animal study demonstrate the feasibility and the safety of using 22 G needles for portal vein sampling and can form the basis for a pilot study in patients.

Association of metabolic syndrome with glioblastoma: a retrospective cohort study and review

Background

Metabolic syndrome is identified as a risk factor for the development of several systemic cancers, but its frequency among patients with glioblastoma and its association with clinical outcomes have yet to be determined. The aim of this study was to investigate metabolic syndrome as a risk factor for and affecting survival in glioblastoma patients.

Methods

A retrospective cohort study, consisting of patients with diagnoses at a single institution between 2007 and 2013, was conducted. Clinical records were reviewed, and clinical and laboratory data pertaining to 5 metabolic criteria were extrapolated. Overall survival was determined by time from initial surgical diagnosis to date of death or last follow-up.

Results

The frequency of metabolic syndrome among patients diagnosed with glioblastoma was slightly greater than the frequency of metabolic syndrome among the general population. Within a subset of patients (n = 91) receiving the full schedule of concurrent radiation and temozolomide and adjuvant temozolomide, median overall survival was significantly shorter for patients with metabolic syndrome compared with those without. In addition, the presence of all 5 elements of the metabolic syndrome resulted in significantly decreased median survival in these patients.

Conclusions

We identified the metabolic syndrome at a slightly higher frequency in patients with diagnosed glioblastoma compared with the general population. In addition, metabolic syndrome with each of its individual components is associated with an overall worse prognosis in patients receiving the standard schedule of radiation and temozolomide after adjustment for age.

Is sore throat an underreported and under-estimated quality indicator for endoscopic procedures? Results from a large prospective cohort

Background and study aims  Patients often develop sore throat after upper endoscopy procedures but there data are very limited on the magnitude of the problem. The aim of this study was to evaluate and identify independent risk factors of sore throat in patients undergoing endoscopy. Patients and methods  Data were collected prospectively on consecutive outpatient endoscopy procedures performed at Cedars-Sinai Medical Center from October 2018 to February 2019. Procedure nurses collected pre-procedure, intra-procedure, and immediate post-procedure surveys including evaluation of sore throat (pain scale from 1 - 10). Significant univariate variables ( P  < 0.05) were entered into a multivariate logistic regression model. Results  Data were collected on 715 patients. Four hundred seventy-two patients (mean age = 61 years, females = 53 %) were included in the analysis and 85 patients (18 %) experienced post-procedure sore throat. On univariate analysis, female gender, oral endoscopic ultrasound (EUS), oral double balloon enteroscopy (DBE), fellow involvement, throat suctioning, general anesthesia, oral airway, and prolonged procedure (> 30 minutes) were risk factors for sore throat (all P  < 0.05). On the multivariate analysis, independent risk-factors for post-procedure sore throat were oral DBE (odds ratio [OR] 5.2), oral airway (OR 4.8), general anesthesia (OR 2.7), fellow involvement (OR 2.5), oral EUS (OR 2.4), and female gender (OR 2.0). Conclusions  Contrary to popular belief, our study found that post-procedural sore throat is more common (18 %) than previously reported. Two types of endoscopic procedures, two anesthesia maneuvers, female gender, and fellow involvement were all independent risk factors. This is of particular concern for interventionalists who perform EUS and oral DBE as these patients are at higher risk for sore throat.