Bench-to-bedside imaging in brain metastases: a road to precision oncology

Radiology has seen tremendous evolution in the last few decades. At the same time, oncology has made great strides in diagnosing and treating cancer. Distant metastases of neoplasms are being encountered more often in light of longer patient survival due to better therapeutic strategies and diagnostic methods. Brain metastasis (BM) is a dismal manifestation of systemic cancer. In the present scenario, magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET) are playing a big role in providing molecular information about cancer. Lately, molecular imaging has emerged as a stirring arena of dynamic imaging techniques that have enabled clinicians and scientists to noninvasively visualize and understand biological processes at the cellular and molecular levels. This knowledge has impacted etiopathogenesis, detection, personalized treatment, drug development, and our understanding of carcinogenesis. This article offers insight into the molecular biology underlying brain metastasis, its pathogenesis, imaging protocols, and algorithms. It also discusses disease-specific molecular imaging features, focusing on common tumors that spread to the brain, such as lung, breast, colorectal cancer, melanoma, and renal cell carcinoma. Additionally, it covers various targeted treatment options, criteria for assessing treatment response, and the role of artificial intelligence in diagnosing, managing, and predicting prognosis for patients with brain metastases.

Post-treatment imaging of gliomas: challenging the existing dogmas

Gliomas are the commonest malignant central nervous system tumours in adults and imaging is the cornerstone of diagnosis, treatment, and post-treatment follow-up of these patients. With the ever-evolving treatment strategies post-treatment imaging and interpretation in glioma remains challenging, more so with the advent of anti-angiogenic drugs and immunotherapy, which can significantly alter the appearance in this setting, thus making interpretation of routine imaging findings such as contrast enhancement, oedema, and mass effect difficult to interpret. This review details the various methods of management of glioma including the upcoming novel therapies and their impact on imaging findings, with a comprehensive description of the imaging findings in conventional and advanced imaging techniques. A systematic appraisal for the existing and emerging techniques of imaging in these settings and their clinical application including various response assessment guidelines and artificial intelligence based response assessment will also be discussed.

Stereotactic Radiosurgery (SRS) for Large Brain Metastases: Dosimetric and Clinical Predictors of Local Progression and Radionecrosis

PURPOSE/OBJECTIVE(S)

Stereotactic radiosurgery (SRS) provides high rates of local control for small brain metastases with low rates of radionecrosis (RN). Larger targets are associated with increased risk of both local progression (LP) and RN. In this analysis, we hypothesized that dosimetric and clinical parameters predict for risk of LP and RN in SRS targets larger than two centimeters.

MATERIALS/METHODS

We retrospectively reviewed patients with one or more targets with either an intact versus post-operative cavity larger than 2.0 cm treated with LINAC-based SRS between 2017 and 2022 at one institution. We assessed for association between patient, treatment, and disease variables with LP and RN. Variables assessed included tumor resection status, PDL1 positivity, target volume, maximum and minimum target dose, EQD2 and BED (a/b = 2 for necrosis and a/b = 10 for tumor control), as well as receipt of steroids, bevacizumab, or systemic therapy before or after SRS. Radionecrosis was determined by characteristic radiographic changes. Analyses were performed for the entire cohort and within subsets including by resection status and dose fractionation.

RESULTS

A total of 178 lesions in 143 patients were included. Targets with volume diameters measuring at least 2 cm were used. Median follow-up was 2.3 years. Overall survival at 1 and 2 years was 56% and 32%, respectively. Most lesions (n = 119) were resected and treated with SRS post-operatively. The most common dose and fractionation schemes used were 30 Gy in 5 fractions (n = 89) and 27 Gy in 3 fractions (n = 63). For the entire cohort, the cumulative incidence of LP 1 and 2 years was 26% and 34%, respectively. The cumulative incidence of radiographic radionecrosis at 1 and 2 years was 12% and 17%, respectively. There was no difference in LP or RN between 27 Gy in 3 fractions versus 30 Gy in 5 fractions (p>0.5 for both). Median planning target volume (PTV) size was 18.5 cc for the 27 Gy in 3 fraction group compared to 21.9 cc in the 30 Gy in 5 fraction group. Minimum or maximum dose within the target was not associated with increased risk of LP or RN. Among patients receiving 27 Gy in 3 fractions, patients treated with resection followed by SRS had lower risk of LP compared to those treated with SRS alone (HR: 0.15, 95% CI: 0.03-0.64, p = 0.011). Among patients receiving 30 Gy in 5 fractions, patients who received corticosteroids prior to SRS had a lower risk of RN (HR: 0.14, 95% CI: 0.03-0.66, p = 0.013). For the entire cohort as well as within all subgroups, PD-L1≥1% was associated with increased risk of RN (p<0.001 for all).

CONCLUSION

Selecting the optimal SRS dose fractionation and planning parameters to minimize both LP and RN remains a challenge for large targets. In this analysis, 27 Gy in 3 fractions appeared to provide equivalent LP and RN compared to 30 Gy in 5 fractions, and may be more convenient for patients. Patients with PD-L1≥1% with large brain targets treated with SRS may be at increased risk of RN; corticosteroid prophylaxis may be considered in this population.

Memantine for Pediatric Patients Receiving Cranial Irradiation: A Pilot Study

PURPOSE/OBJECTIVE(S)

While memantine has become standard in certain adults receiving brain RT to decrease the cognitive impacts of RT, it is unknown whether pediatric patients can take and tolerate memantine or experience benefit. In this prospective single-arm feasibility study, we hypothesized pediatric patients receiving brain RT would tolerate memantine with good treatment adherence.

MATERIALS/METHODS

Patients aged 4-18 years with a primary CNS malignancy (excluding WHO Grade IV astrocytoma and glioblastoma) receiving intracranial RT were eligible. A 6-month course of memantine was given during and after RT. Dosing began once daily at 5 mg with up-titration in 5 mg increments over 4 weeks to a weight-based maximum (0.4 mg/kg to the closest 5 mg), not to exceed 10 mg BID. To reduce patient and clinical research associate (CRA) burden, medication adherence was tracked via the Medisafe Pill and Reminder application which study staff helped install on the patient or parent's smart phone. A paper pill diary was provided for those unable to use the app. The primary endpoint was to achieve 80% adherence rate to memantine in 80% of patients measured 1-month post-RT.

RESULTS

Eighteen patients (14 male and 4 female, median age 11.5 years (range: 4-18)) were enrolled from 2020-2022. The study closed early after enrolling 18 of 20 planned patients to avoid competing with the phase III randomized Children's Oncology Group (COG) study AACL2031. One patient withdrew for cognition-altering substance-use, leaving 17 patients with data available for analysis. Histologies included germ cell tumor (n = 6), craniopharyngioma (n = 3), choroid plexus papilloma (n = 2), ependymoma (n = 2), glial/astrocytoma (n = 2), medulloblastoma (n = 1), and meningioma (n = 1). Thirteen had surgery, and 9 received chemotherapy. Eight received craniospinal irradiation (CSI). Median RT dose was 54 Gy (range 36-59.4) in 30 fractions (range: 20-33). At data freeze, all 17 had passed the 1-month post-RT time point. One patient discontinued memantine after a single dose due to nausea. Pill-reports were available for 14 of the remaining 16; two patients did not complete digital pill logs. For those with complete logs, all adherence rates were above 80%, with a median of 99.32% pill completion rate (range: 92.67-100). Seven (50%) took 100% of prescribed doses. Irrespective of adherence for the 2 unavailable for evaluation, the primary endpoint was still achieved. Grade 1 toxicities included headache (n = 6, 35%) and constipation (n = 1, 6%); there were no grade 2+ toxicities. At last follow-up, 15/16 have completed the full 6-month memantine course. Secondary endpoints including neurocognitive evaluations have not yet been met and will be the subject of future reports.

CONCLUSION

Memantine is a feasible and well-tolerated addition to multi-modality treatment for pediatric brain tumors. Secondary endpoints of this study and results of the ongoing COG study are awaited to define the value of memantine in this population.

Clinical Outcomes for Chest Wall Ewing Sarcoma: A Multi-Center Single Institution Experience

PURPOSE/OBJECTIVE(S)

We report tumor and treatment characteristics, oncologic outcomes, and treatment-associated toxicities in a cohort of chest wall Ewing sarcoma (cwES) patients treated at a single tertiary care institution.

MATERIALS/METHODS

After IRB approval, patients with cwES treated from 1997-2022 were retrospectively reviewed. Patient, tumor, treatment, outcomes, and toxicity data were abstracted. Local control (LC), progression-free survival (PFS), and overall survival (OS) were defined from end of treatment and assessed using the Kaplan-Meier method. Log-rank test and unadjusted Cox models were performed to determine factors associated with outcomes.

RESULTS

The cohort includes 45 patients. Median age at diagnosis was 19.8 years (range: 3.5 - 57.8 years). Five patients (11.1%) presented with pleural effusion and eight patients with lung metastases (17.8%). Two (4.4%) patients had metastatic disease outside the thorax. Median tumor volume (TV) was 138.6 mL (range: 3.0-6762.0 mL). All patients received VDC/IE chemotherapy. LC modality was surgery (S) in 21 patients (47%), radiation therapy (RT) in 5 (11%), and S+RT in 19 (42%). Median TV was larger in S+RT patients (319.4 mL, range: 5.3-6761.9 mL) compared to RT (152.3 mL, range: 20.4-366.9 mL) or S (70.4 mL, range: 3.1-1037.8 mL) (p = 0.03). R0 and R1 resections were performed in 36 (90%) and 4 (10%) patients, respectively. Proton beam therapy was used in 15 (63%) patients. Median dose was 50.40 Gy (range: 34.2 - 60 Gy) in 28 fractions to the primary tumor or post operative bed. Median dose for hemithorax (1 patient, 2.2%) and whole lung irradiation (7 patients, 15.6%) was 15.0 Gy (range: 15.0-15.0 Gy) in 10 fractions. Median follow-up was 2.38 years (range: 0 - 21.90 years). Five-year LC, PFS, and OS for all patients was 77.9% (95% CI, 65.3 - 92.9%), 54.2% (95% CI, 39.9 - 73.5%), and 63.5% (95% CI, 49.3 - 81.8%), respectively. In patients with localized disease, 5-year LC, PFS, and OS were 82.4% (95% CI, 67.9-99.8%), 66.4% (95% CI, 49.7-88.8%), and 71.3% (95% CI, 54.2-93.9%), respectively. Two-year LC by modality was 100% for RT (95% CI, 100-100%), 84.2% (95% CI, 69.3- 100%) for S and 73.3% (95% CI, 54 - 99.5%) for S+RT (p = 0.51). On univariate analysis, TV ≥ 200 mL was associated with a significantly worse 5-year OS (49.5%, TV ≥ 200 mL vs. 80.8%, TV < 200 mL; HR 4.44, p = 0.032) and PFS (35.2%, TV ≥ 200 mL vs. 76%, TV < 200 mL; HR 3.55, p = 0.025). TV ≥ 200 mL trended towards worse 5-year LC: 69.2% for TV ≥ 200 mL versus 81.5% for TV <200 mL [HR 2.26(95% CI 0.49 - 10.47), p = 0.287]. Overall, low rates of grade ≥2 toxicity were observed: 4 (8.9%) fatigue, 4 (8.9%) radiation dermatitis, 1 (2.2%) chyle leak, 3 (6.6%) scoliosis, 4 (8.9%) infection, 1 (2.2%) pneumonia, and 1 (2.2%) chest wall deformity.

CONCLUSION

RT is a safe, effective local therapy for small to moderate cwES tumors. Patients with TV ≥ 200 mL had significantly worse survival outcomes and an inferior LC rate. This suggests large cwES tumors may benefit from an aggressive multi-modality approach.

Spot Scanning Proton Therapy for Pregnant Patients with Brain and Head and Neck Tumors

PURPOSE/OBJECTIVE(S)

When radiotherapy is medically necessary, x-ray based treatments (XRT) have traditionally been used to treat pregnant patients. Treatment planning and delivery techniques may be modified to minimize dose to the fetus but results in less optimal plans due to avoiding posterior beams or arcs. Monte Carlo calculations and published case studies suggest spot scanning proton therapy (PRT) reduces the equivalent dose to the fetus by a factor of 10 compared to XRT and does not require modified treatment planning techniques. However, due to concern for dose uncertainties and neutron scatter with PRT, few centers have adopted PRT over XRT for pregnant patients. The purpose of this work is to perform a retrospective study on the pregnant patients previously treated at our institution with XRT to measure the equivalent dose that would be delivered to the fetus with spot scanning PRT compared to XRT.

MATERIALS/METHODS

PRT plans were made for seven pregnant patients, 4 brain tumors and 3 head and neck tumors, who had received XRT. Due to the finite range of protons, the fetal exposure is dominated by neutrons and not the primary beam. Thus, no beam arrangement modifications were required to minimize fetal dose for PRT plans. Fetal dose measurements were performed with the patient plans using a Rando phantom and Wendi-2 (Thermo Scientific) meter placed at the phantom's abdomen. The Wendi-2 measures ambient dose equivalent, which accounts for the biological effect of the neutron energies. Measurements were made at various distances from isocenter to the center of the detector. The total dose equivalent from PRT at several out of field distances was compared to that from XRT. Patient specific measurements were used to determine the total fetal dose from each modality, accounting for the changing position of the fetus each week of the mother's treatment. The imaging dose for standard of practice imaging, including verification CT scans and daily alignment imaging, was also evaluated using a similar setup with a Fluke 451 dose meter.

RESULTS

The average measured fetal equivalent dose for the brain plans was 0.4 mSv for PRT and 7 mSv for XRT. For the head and neck plans, it was 6 mSv for PRT and 90 mSv for XRT. The dose from PRT was consistently at least a factor of 10 less than the XRT plans. In addition, the PRT plans were preferred by the physicians when considering tumor coverage and other normal tissue sparing. Daily imaging added between 0.05 and 1.5 mSv to the total dose in the PRT treatments.

CONCLUSION

This retrospective study showed that when treating brain or head and neck tumors in pregnant patients, the equivalent dose a fetus would receive with PRT is approximately a factor of 10 less than XRT without making any compromises in treatment planning. These results support changing the standard of practice to utilizing spot scanning PRT as the preferred method for treating pregnant patients with brain or head and neck tumors when available instead of XRT. We have brought this process to clinic at our center.

Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration)

Context

The COVID-19 pandemic and subsequent lockdowns adversely affected global healthcare services to varying extents. To accommodate its added burden, emergency services were affected along-with elective surgeries.

Aims

To quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the pandemic, across various hospitals in India.

Settings and Design

Multi-centric retrospective study.

Methods and Material

A research consortium led by World Health Organization (WHO) Collaboration Center (WHOCC) for Research in Surgical Care Delivery in Low-and Middle-Income countries, India, conducted this study with 5 centers. All surgeries performed during April 2020 (Wave I), November 2020 (Recovery I), and April 2021 (Wave II) were compared with those performed in April 2019 (pre-pandemic period).

Statistical Analysis Used

Microsoft Excel 2019 and SPSS Version 20.

Results

The total number of surgeries reduced by 77% during Wave I, which improved to a 52% reduction in Recovery I compared to the pre-pandemic period. However, surgeries were reduced again during Wave II to 68%, but the reduction was less compared to Wave I. Emergency and essential surgeries were affected along with the elective ones but to a lesser extent.

Conclusions

The present study has quantified the effects of the pandemic on surgical-care delivery across a timeline and documented a reduction in overall surgical volumes during the peaks of the pandemic (Wave I and II) with minimal improvement as the surge of COVID-19 cases declined (Recovery II). The surgical volumes improved during the second wave compared to the first one which may be attributable to better preparedness. Cesarean sections were affected the least.

Imaging Analytics using Artificial Intelligence in Oncology: A Comprehensive Review

The present era has seen a surge in artificial intelligence-related research in oncology, mainly using deep learning, because of powerful computer hardware, improved algorithms and the availability of large amounts of data from open-source domains and the use of transfer learning. Here we discuss the multifaceted role of deep learning in cancer care, ranging from risk stratification, the screening and diagnosis of cancer, to the prediction of genomic mutations, treatment response and survival outcome prediction, through the use of convolutional neural networks. Another role of artificial intelligence is in the generation of automated radiology reports, which is a boon in high-volume centres to minimise report turnaround time. Although a validated and deployable deep-learning model for clinical use is still in its infancy, there is ongoing research to overcome the barriers for its universal implementation and we also delve into this aspect. We also briefly describe the role of radiomics in oncoimaging. Artificial intelligence can provide answers pertaining to cancer management at baseline imaging, saving cost and time. Imaging biobanks, which are repositories of anonymised images, are also briefly described. We also discuss the commercialisation and ethical issues pertaining to artificial intelligence. The latest generation generalist artificial intelligence model is also briefly described at the end of the article. We believe this article will not only enrich knowledge, but also promote research acumen in the minds of readers to take oncoimaging to another level using artificial intelligence and also work towards clinical translation of such research.

Empirical Antitubercular Treatment for Lymphadenopathy: Are We Missing Lymphoma?

OBJECTIVE

To evaluate the proportion of patients who received empirical treatment with antitubercular therapy (ATT) prior to the diagnosis of Hodgkin lymphoma (HL) in the first multicentric, prospective study on HL from India, and to assess its impact on extent of disease at diagnosis and outcomes.

METHODS

Children < 18 y with biopsy proven HL were enrolled in InPOG-HL-15-01. Along with other clinical and epidemiological data, history of prior treatment with ATT was documented. All patients received treatment as per a risk-stratified, response-adapted strategy.

RESULTS

Out of 396, 115 (29%) children had received ATT prior to establishing a definitive diagnosis of HL. This cohort presented with advanced-stage disease (p = 0.001) and B symptoms (p = 0.001) in a higher proportion of cases. Consequently, those children were more likely to receive 6 rather than 4 cycles of chemotherapy (p = 0.001). They were more likely to have infradiaphragmatic involvement (p = 0.001). Overall survival and event-free survival were not different.

CONCLUSION

Empirical treatment with ATT in children presenting with lymphadenopathy continues to be practiced widely in India. The delay in diagnosis may contribute to children presenting with advanced-stage disease warranting more intensive treatment for successful outcomes.

Imaging of Neck Nodes in Head and Neck Cancers - a Comprehensive Update

Cervical lymph node metastases from head and neck squamous cell cancers significantly reduce disease-free survival and worsen overall prognosis and, hence, deserve more aggressive management and follow-up. As per the eighth edition of the American Joint Committee on Cancer staging manual, extranodal extension, especially in human papillomavirus-negative cancers, has been incorporated in staging as it is important in deciding management and significantly impacts the outcome of head and neck squamous cell cancer. Lymph node imaging with various radiological modalities, including ultrasound, computed tomography and magnetic resonance imaging, has been widely used, not only to demonstrate nodal involvement but also for guided histopathological evaluation and therapeutic intervention. Computed tomography and magnetic resonance imaging, together with positron emission tomography, are used widely for the follow-up of treated patients. Finally, there is an emerging role for artificial intelligence in neck node imaging that has shown promising results, increasing the accuracy of detection of nodal involvement, especially normal-appearing nodes. The aim of this review is to provide a comprehensive overview of the diagnosis and management of involved neck nodes with a focus on sentinel node anatomy, pathogenesis, imaging correlates (including radiogenomics and artificial intelligence) and the role of image-guided interventions.

Anatomical categorization of isolated non-focal dystonia: novel and existing patterns using a data-driven approach

According to expert consensus, dystonia can be classified as focal, segmental, multifocal, and generalized, based on the affected body distribution. To provide an empirical and data-driven approach to categorizing these distributions, we used a data-driven clustering approach to compare frequency and co-occurrence rates of non-focal dystonia in pre-defined body regions using the Dystonia Coalition (DC) dataset. We analyzed 1,618 participants with isolated non-focal dystonia from the DC database. The analytic approach included construction of frequency tables, variable-wise analysis using hierarchical clustering and independent component analysis (ICA), and case-wise consensus hierarchical clustering to describe associations and clusters for dystonia affecting any combination of eighteen pre-defined body regions. Variable-wise hierarchical clustering demonstrated closest relationships between bilateral upper legs (distance = 0.40), upper and lower face (distance = 0.45), bilateral hands (distance = 0.53), and bilateral feet (distance = 0.53). ICA demonstrated clear grouping for the a) bilateral hands, b) neck, and c) upper and lower face. Case-wise consensus hierarchical clustering at k = 9 identified 3 major clusters. Major clusters consisted primarily of a) cervical dystonia with nearby regions, b) bilateral hand dystonia, and c) cranial dystonia. Our data-driven approach in a large dataset of isolated non-focal dystonia reinforces common segmental patterns in cranial and cervical regions. We observed unexpectedly strong associations between bilateral upper or lower limbs, which suggests that symmetric multifocal patterns may represent a previously underrecognized dystonia subtype.

Imaging of brain metastasis in non-small-cell lung cancer: indications, protocols, diagnosis, post-therapy imaging, and implications regarding management

Increased survival (due to the use of targeted therapies based on genomic profiling) has resulted in the increased incidence of brain metastasis during the course of disease, and thus, made it essential to have proper imaging guidelines in place for brain metastasis from non-small-cell lung cancer (NSCLC). Brain parenchymal metastases can have varied imaging appearances, and it is pertinent to be aware of the various molecular risk factors for brain metastasis from NSCLC along with their suggestive imaging appearances, so as to identify them early. Leptomeningeal metastasis requires additional imaging of the spine and an early cerebrospinal fluid (CSF) analysis. Differentiation of post-therapy change from recurrence on imaging has a bearing on the management, hence the need for its awareness. This article will provide in-depth literature review of the epidemiology, aetiopathogenesis, screening, detection, diagnosis, post-therapy imaging, and implications regarding the management of brain metastasis from NSCLC. In addition, we will also briefly highlight the role of artificial intelligence (AI) in brain metastasis screening.

Intra-arterial chemotherapy in refractory and advanced intraocular retinoblastoma

Purpose

To evaluate the efficacy of secondary and salvage intra-arterial chemotherapy (IAC) as a globe salvage treatment modality in advanced and refractory intraocular retinoblastoma.

Methods

A retrospective chart review of advanced intraocular retinoblastoma (groups D and E International Classification of Retinoblastoma [ICRB] classification) patients refractory to intravenous chemotherapy (IVC) and undergoing IAC as the secondary and salvage treatment modality between December 2018 and June 2021 was carried out. All patients underwent the IAC procedure by super-selective ophthalmic artery catheterization and with triple-drug chemotherapeutic agents of melphalan, topotecan, and carboplatin. Data were collected about tumor regression, eye salvage, metastasis, and survival outcome at follow-up.

Results

Out of 13 patients, 12 patients received secondary IAC after being primarily treated with IVC and focal therapies and one patient received rescue IAC after recurrence following primary IAC. Mean number of IAC cycles administered was 2. Overall, globe salvage rate was 53.84%, with a mean follow-up of 17.53 months (range 6-37 months), three patients had enucleation for residual tumor or tumor recurrence. One patient developed metastasis post enucleation and two patients who were lost to follow-up after enucleation advice for residual tumor developed orbital tumor extension and eventually died of metastasis.

Conclusion

Secondary triple-drug IAC following failure of IVC, along with other adjunct treatment modalities might a be a cost-effective option for eye salvage in advanced intraocular retinoblastoma patients who refuse enucleation, with a globe salvage rate of 53.84%. It can also be an effective approach to improve treatment compliance and can help in addressing the barrier of treatment refusal when enucleation is advised.

Response assessment by positron emission tomography-computed tomography as compared with contrast-enhanced computed tomography in childhood Hodgkin lymphoma can reduce the need for radiotherapy in low- and middle-income countries

INTRODUCTION

The InPOG-HL-15-01, a multicentric prospective study, used a risk-stratified and response-based approach with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) backbone to treat children and adolescents with newly diagnosed Hodgkin lymphoma (HL) and reduce the use of radiation therapy (RT). Children/adolescents with bulky disease or inadequate response at early response assessment (ERA) after two cycles of chemotherapy were assigned to receive RT. For ERA, positron emission tomography computed tomography (PET-CT) was recommended but not mandatory in view of limited access. This study aimed to compare the impact of using contrast-enhanced computed tomography (CECT) and PET-CT on treatment decisions and outcomes.

METHODOLOGY

396 patients were enrolled and 382 had an ERA at the assigned time point. Satisfactory response was defined as Deauville score 3 or less for patients undergoing PET-CT and complete response (CR)/very good partial response (VGPR) for patients undergoing CECT. Outcomes of interest incorporate 5 year event-free survival (EFS), EFS including abandonment (EFSa), and overall survival (OS).

RESULTS

At ERA, satisfactory response was documented in 277 out of 382 (72.5%) participants and this was significantly higher in PET-CT (151 out of 186, 81.2%) as compared with CECT-based assessments (126 out of 196, 64.3%) respectively (p value < .001). Amongst the 203 patients with nonbulky disease (wherein the indication for RT was entirely dependent on ERA), 96 out of 114 (84.2%) and 61 out of 89 (68.5%) patients achieved a satisfactory response according to the PET-CT and CECT (p value = .008) respectively and hence a lesser proportion of patients in the PET-CT arm received RT. Despite a lower usage of RT the 5 year OS of both groups, ERA based on CECT (91.8%) versus PET-CT (94.1%) was comparable (p value = .391) and so was the 5 year EFS (86.7 vs. 85.5%, p value = .724).

CONCLUSION

Use of PET-CT as the modality for ERA is more likely to indicate a satisfactory response as compared with CECT and thereby decreases the need for RT in response-based treatment algorithm for HL-afflicted children. The reduction in the application of RT did not impact the overall outcome and plausibly would lower the risk of delayed toxic effects.

Diagnosis, Treatment and Prevention of Nutritional Anemia in Children: Recommendations of the Joint Committee of Pediatric Hematology-Oncology Chapter and Pediatric and Adolescent Nutrition Society of the Indian Academy of Pediatrics

JUSTIFICATION

Anemia in children is a significant public health problem in our country. Comprehensive National Nutrition Survey 2016-18 provides evidence that more than 50% of childhood anemia is due to an underlying nutritional deficiency. The National Family Health Survey-5 has reported an increase in the prevalence of anemia in the under-five age group from 59% to 67.1% over the last 5 years. Clearly, the existing public health programs to decrease the prevalence of anemia have not shown the desired results. Hence, there is a need to develop nationally acceptable guidelines for the diagnosis, treatment and prevention of nutritional anemia.

OBJECTIVE

To review the available literature and collate evidence-based observations to formulate guidelines for diagnosis, treatment and prevention of nutritional anemia in children.

PROCESS

These guidelines have been developed by the experts from the Pediatric Hematology-Oncology Chapter and the Pediatric and Adolescent Nutrition (PAN) Society of the Indian Academy of Pediatrics (IAP). Key areas were identified as: epidemiology, nomenclature and definitions, etiology and diagnosis of iron deficiency anemia (IDA), treatment of IDA, etiology and diagnosis of vitamin B12 and/or folic acid deficiency, treatment of vitamin B12 and/or folic acid deficiency anemia and prevention of nutritional anemia. Each of these key areas were reviewed by at least 2 to 3 experts. Four virtual meetings were held in November, 2021 and all the key issues were deliberated upon. Based on review and inputs received during meetings, draft recommendations were prepared. After this, a writing group was constituted which prepared the draft guidelines. The draft was circulated and approved by all the expert group members.

RECOMMENDATIONS

We recommend use of World Health Organization (WHO) cut-off hemoglobin levels to define anemia in children and adolescents. Most cases suspected to have IDA can be started on treatment based on a compatible history, physical examination and hemogram report. Serum ferritin assay is recommended for the confirmation of the diagnosis of IDA. Most cases of IDA can be managed with oral iron therapy using 2-3 mg/kg elemental iron daily. The presence of macro-ovalocytes and hypersegmented neutrophils, along with an elevated mean corpuscular volume (MCV), should raise the suspicion of underlying vitamin B12 (cobalamin) or folic acid deficiency. Estimation of serum vitamin B12 and folate level are advisable in children with macrocytic anemia prior to starting treatment. When serum vitamin B12 and folate levels are unavailable, patients should be treated using both drugs. Vitamin B12 should preferably be started 10-14 days ahead of oral folic acid to avoid precipitating neurological symptoms. Children with macrocytic anemia in whom a quick response to treatment is required, such as those with pancytopenia, severe anemia, developmental delay and infantile tremor syndrome, should be managed using parenteral vitamin B12. Children with vitamin B12 deficiency having mild or moderate anemia may be managed using oral vitamin B12 preparations. After completing therapy for nutritional anemia, all infants and children should be advised to continue prophylactic iron-folic acid (IFA) supplementation as prescribed under Anemia Mukt Bharat guidelines. For prevention of anemia, in addition to age-appropriate IFA prophylaxis, routine screening of infants for anemia at 9 months during immunization visit is recommended.

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries

Background

Retinoblastoma is the most common intraocular cancer worldwide. There is some evidence to suggest that major differences exist in treatment outcomes for children with retinoblastoma from different regions, but these differences have not been assessed on a global scale. We aimed to report 3-year outcomes for children with retinoblastoma globally and to investigate factors associated with survival.

Methods

We did a prospective cluster-based analysis of treatment-naive patients with retinoblastoma who were diagnosed between Jan 1, 2017, and Dec 31, 2017, then treated and followed up for 3 years. Patients were recruited from 260 specialised treatment centres worldwide. Data were obtained from participating centres on primary and additional treatments, duration of follow-up, metastasis, eye globe salvage, and survival outcome. We analysed time to death and time to enucleation with Cox regression models.

Findings

The cohort included 4064 children from 149 countries. The median age at diagnosis was 23·2 months (IQR 11·0–36·5). Extraocular tumour spread (cT4 of the cTNMH classification) at diagnosis was reported in five (0·8%) of 636 children from high-income countries, 55 (5·4%) of 1027 children from upper-middle-income countries, 342 (19·7%) of 1738 children from lower-middle-income countries, and 196 (42·9%) of 457 children from low-income countries. Enucleation surgery was available for all children and intravenous chemotherapy was available for 4014 (98·8%) of 4064 children. The 3-year survival rate was 99·5% (95% CI 98·8–100·0) for children from high-income countries, 91·2% (89·5–93·0) for children from upper-middle-income countries, 80·3% (78·3–82·3) for children from lower-middle-income countries, and 57·3% (52·1-63·0) for children from low-income countries. On analysis, independent factors for worse survival were residence in low-income countries compared to high-income countries (hazard ratio 16·67; 95% CI 4·76–50·00), cT4 advanced tumour compared to cT1 (8·98; 4·44–18·18), and older age at diagnosis in children up to 3 years (1·38 per year; 1·23–1·56). For children aged 3–7 years, the mortality risk decreased slightly (p=0·0104 for the change in slope).

Interpretation

This study, estimated to include approximately half of all new retinoblastoma cases worldwide in 2017, shows profound inequity in survival of children depending on the national income level of their country of residence. In high-income countries, death from retinoblastoma is rare, whereas in low-income countries estimated 3-year survival is just over 50%. Although essential treatments are available in nearly all countries, early diagnosis and treatment in low-income countries are key to improving survival outcomes.

Funding

Queen Elizabeth Diamond Jubilee Trust.

O108 Central adiposity influences serum calcium concentrations and increases risk of kidney stone disease

Introduction

Serum calcium (SCa) and adiposity are associated with kidney stone disease (KSD). We used conventional and genetic epidemiological approaches to further understanding of these relationships.

Methods

Waist-hip ratio (WHR), a marker of central adiposity, SCa and KSD data were analysed by adjusted linear regression using UK Biobank participants. Univariable, multivariable and mediation Mendelian randomisation (MR) were undertaken using 316 and 246 genetic instruments for WHR and SCa, respectively.

Results

Observational analyses of 3,466 KSD cases and 489,944 controls showed that participants of normal BMI (20–25kg/m2) but in the fifth quintile for WHR have greater risk of incident KSD compared to the first quintile (HR=1.39 (95%CI=1.18–1.63)). After adjustment for sex, age, serum vitamin D, and phosphate, higher WHR was positively associated with SCa (ß=0.04, 95%=CI 0.04–0.05, P&lt;0.001). Univariable MR demonstrated that relative risk of KSD increases with increasing WHR and SCa; 1 standard deviation (SD) increases relative risk by 46% (95%CI=1.27–1.67, P=5.9e-8) and 63% (95%CI=1.37–1.93, P=2.0E-8), respectively. A 1 SD increase in WHR increases SCa by 0.11mmol/L (95%CI=0.07–0.14, P=1.8e-8). Multivariable MR revealed that SCa and WHR independently increase KSD relative risk (OR=1.71, 95%CI=1.49–1.96, P&lt;0.001 and OR=1.41, 95%CI=1.17–1.69, P&lt;0.001 respectively). Mediation MR established that 14% of the effect of WHR on KSD risk is mediated via alterations in SCa.

Conclusion

Central adiposity is causally linked to KSD, partly by raising SCa. Mechanisms by which central adiposity increases KSD risk, independent of and via SCa, remain to be revealed and may identify novel therapeutic methods for KSD.

Take-home message

Central adiposity and serum calcium are independent, causal risk factors for kidney stone disease. One mechanism by which central obesity increases risk of kidney stone disease is by influencing serum calcium concentrations.

Diagnosis and Management of Acquired Aplastic Anemia: Consensus Statement of Indian Academy of Pediatrics

JUSTIFICATION

In India, there is a lack of uniformity of treatment strategies for aplastic anemia (AA), and many children are managed only with supportive care due to non-availability of hematopoietic stem cell transplantation (HSCT).

PROCESS

Eminent national faculty members were invited to participate in the process of forming a consensus statement in Hyderabad in July, 2016. Draft guidelines were circulated to all members, and comments received in a online meeting in October, 2020 were incorporated into the final draft. These were approved by all experts.

OBJECTIVE

To facilitate appropriate management of children with acquired aplastic anemia.

RECOMMENDATIONS

Key recommendations are: i) A bone marrow biopsy is must to make a diagnosis of AA; ii) Rule out inherited bone marrow failure syndromes (IBMFS), connective tissue disorders, viral infections, paroxysmal nocturnal hemoglobinuria (PNH), drug or heavy metal induced marrow suppression in all cases of AA; iii) Conservative approach to transfusions should be followed, with a target to keep hemoglobin >6 g/dL in children with no co-morbidities; iv) HLA-matched sibling donor HSCT is the preferred choice of treatment for newly diagnosed very severe/ severe AA; v) In absence of HLA-matched family donor, a matched unrelated donor (MUD) transplant or immunosuppressive therapy (IST) should be considered as alternate choice based on physician expertise; vi) Fludarabine, cyclophos-phamide and anti-thymocyte globulin (ATG) based conditioning with cyclosporine and methotrexate as graft versus host disease (GvHD) prophylaxis is the preferred regimen; vii) Horse ATG and cyclosporine are the recommended drugs for IST. One should wait for 3-6 months for the response assessment and consideration of next line therapy.

Use of rapid cardiac magnetic resonance imaging to guide chelation therapy in patients with transfusion-dependent thalassaemia in India: UMIMI study

Aims

To explore the impact of incorporating a faster cardiac magnetic resonance (CMR) imaging protocol in a low–middle-income country (LMIC) and using the result to guide chelation in transfusion-dependent patients.

Methods and results

A prospective UK–India collaborative cohort study was conducted in two cities in India. Two visits 13 months apart included clinical assessment and chelation therapy recommendations based on rapid CMR results. Participants were recruited by the local patient advocate charity, who organized the patient medical camps. The average scanning time was 11.3 ± 2.5 min at the baseline and 9.8 ± 2.4 min (P < 0.001) at follow-up. The baseline visit was attended by 103 patients (mean age 25 years) and 83% attended the second assessment. At baseline, 29% had a cardiac T₂* < 20 ms, which represents significant iron loading, and 12% had left ventricular ejection fraction <60%, the accepted lower limit in this population. Only 3% were free of liver iron (T₂* ≥ 17 ms). At 13 months, more patients were taking intensified dual chelation therapy (43% vs. 55%, P = 0.002). In those with cardiac siderosis (baseline T₂* < 20 ms), there was an improvement in T₂*—10.9 ± 5.9 to 13.5 ± 8.7 ms, P = 0.005—and fewer were classified as having clinically important cardiac iron loading (T₂* < 20 ms, 24% vs. 16%, P < 0.001). This is the first illustration in an LMIC that incorporating CMR results into patient management plans can improve cardiac iron loading.

Conclusion

For thalassaemia patients in an LMIC, a simplified CMR protocol linked to therapeutic recommendation via the patient camp model led to enhanced chelation therapy and a reduction in cardiac iron in 1 year.

Hodgkin Lymphoma in Children Under 5 Years: Do They Behave Differently?

The median age of presentation for Hodgkin lymphoma (HL) is lower in developing countries with a higher proportion under 5 years of age possibly attributable to the high prevalence of Epstein-Barr virus-driven disease. It is unclear whether the clinical presentation and outcomes of this cohort are different with concern regarding late effects being most pronounced in this age group. We report the outcome of children under 5 years of age enrolled in the InPOG-HL-15-01, the first multicentric collaborative study for newly diagnosed children and adolescents with HL from India. Thirty-five (9%) of the study population was younger than 5 years with a striking male preponderance of 34:1. They were less likely to have bulky disease, mediastinal or splenic involvement. The outcomes appear to be at least as favorable as in the older patient group. Efforts need to be made to evolve treatment strategies that spare this very young cohort from potential late effects.

Primary orbital yolk sac tumor presenting as fungating mass

Primary yolk sac tumor of the orbit is a rare entity. Orbital involvement is usually seen in young children and proptosis is the commonest presentation. Aggressive orbital involvement and presentation as a fungating mass is rarely seen. We report a case of primary orbital yolk sac tumor with an aggressive presentation that responded well to systemic chemotherapy.

Outcomes of COVID-19 in children with cancer – Report from the Indian Pediatric Oncology Group (InPOG) COVID-19 registry in India

Introduction

The clinical outcomes of COVID-19 infection in children with cancer have been variable worldwide. Therefore, we aimed to collect data from all regions in India through a national collaborative study and identify factors that cause mortality directly related to COVID-19 infection.

Methods

Data was collected prospectively on children across India on cancer therapy and diagnosed with COVID-19 infections from 47 centers from April 2020 to October 2021. Information was recorded on the demographics, the number of children that required intervention, and the outcome of the infection. In addition, we analyzed the impact of the delta variant in 2021.

Results

A total of 659 children were studied, of whom 64% were male and 36% were female. The data from the eastern region was sparse, and this was a collection bias. COVID-19 infection was predominantly seen in children less than five years. The delta variant had a higher impact in the southern region, and this was statistically significant. Of the 659 children, 30 children died (4.5%), however only 7 of the deaths were directly attributed to COVID-19 infection (1%).

Conclusion

The study reports the largest nationally representative cohort of children with cancer and COVID-19 to date in India. We identified demographic and clinical factors associated with increased all-cause mortality in patients with cancer. Complete characterization of the cohort has provided further insights into the effects of COVID-19 on cancer outcomes. The low mortality allows us to recommend that specific cancer treatments be continued without delays in therapy.

Ectopic Cushing's syndrome from an ACTH-producing pheochromocytoma with a non-functioning pituitary adenoma

Summary

An adrenocorticotropic hormone (ACTH)-producing pheochromocytoma (PCC)/paraganglioma is the cause of ectopic Cushing's syndrome (CS) in 5.2% of cases reported in the literature. We present a previously healthy 43-year-old woman admitted to our hospital with cushingoid features and hypertensive urgency (blood pressure = 200/120 mmHg). Her 24-h urinary free cortisol was >4270 nmol/day (reference range (RR) = 100-380 nmol/day) with a plasma ACTH of 91.5 pmol/L (RR: 2.0-11.5 pmol/L). Twenty-four-hour urinary metanephrines were increased by 30-fold. Whole-body CT demonstrated a 3.7-cm left adrenal mass with a normal-appearing right adrenal gland. Sellar MRI showed a 5-mm sellar lesion. MIBG scan revealed intense uptake only in the left adrenal mass. She was managed pre-operatively with ketoconazole and phenoxybenzamine and underwent an uneventful left laparoscopic adrenalectomy, which resulted in biochemical resolution of her hypercortisolemia and catecholamine excess. Histology demonstrated a PCC (Grading System for Adrenal Pheochromocytoma and Paraganglioma score 5) with positive ACTH staining by immunohistochemistry. A PCC gene panel showed no mutations and there has been no evidence of recurrence at 24 months. This case highlights the difficult nature of localizing the source of CS in the setting of a co-existing PCC and sellar mass.

Learning points

An adrenocorticotropic hormone (ACTH)-producing pheochromocytoma (PCC) is an important item to be considered in all patients presenting with ectopic Cushing's syndrome (CS). In exceptionally rare cases, patients with ectopic CS may present with multiple lesions, and a systematic approach considering all potential sources is crucial to avoid misdiagnosis. CS with a large adrenal mass but lacking contralateral adrenal atrophy should raise suspicion of an ACTH-dependent process. In patients with clinical suspicion of PCC, clinicians should be mindful of the use of steroids and beta-blockers without appropriate alpha blockade as they may precipitate an adrenergic crisis.

Risk based and response adapted radiation therapy for children and adolescents with newly diagnosed advanced stage Hodgkin lymphoma treated with ABVD chemotherapy: a report from the Indian pediatric oncology group study InPOG-HL-15-01

This multi-centric prospective study (InPOG-HL-15-01) assessed epidemiological, clinical and outcome data of advanced stage Hodgkin Lymphoma (IIB, III and IV) in children and adolescents (N = 262). Chemotherapy regimen was ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) and radiotherapy (RT) was restricted to patients with bulky disease at diagnosis or with suboptimal response at early response assessment (ERA). ERA revealed complete response in 175 (68.1%), partial response in 77 (29.9%), stable disease in 2 (0.8%), and progressive disease in 3 (1.2%) patients. RT was administered to 111 (97 bulky disease, 14 suboptimal response) patients. Five-year event free (EFS) and overall survival for the whole cohort was 81.1% and 90.8% respectively. On multivariate analysis, the only statistically significant predictor of EFS was use of RT (89% versus 74.2%; p-value <0.001). This study reinforces the benefit of consolidative RT in bulky disease and in those with suboptimal response at ERA on an ABVD backbone.

Prevalence of growth hormone deficiency in patients with unexplained chronic fatigue after undergoing bone marrow transplantation in adulthood

PURPOSE

Many patients who undergo bone marrow transplantation (BMT) in adulthood experience unexplained chronic fatigue which can have a major impact on their health-related quality of life (QoL). Pre-BMT treatment regimens increase the risk of developing acquired growth hormone deficiency (GHD), which results in a clinical syndrome with decreased energy and has additionally been linked to metabolic syndrome.

METHODS

Using the gold-standard insulin hypoglycemic test (IHT), we evaluated the prevalence of GHD in 18 post-BMT adult patients with unexplained chronic fatigue, as well as the correlation between peak serum GH response and QoL scores, the metabolic syndrome, and insulin resistance. Peak serum GH cut-point less than 3.0 ug/L was used for the diagnosis of severe GHD. The Fatigue Severity Scale and Quality of Life in Adult GHD Assessment questionnaires were used to quantify fatigue symptoms.

RESULTS

The prevalence of severe GHD within this sample of 18 patients was 50%. A trend between lower peak serum GH response and higher fatigue and QoL-AGHDA scores was observed.

CONCLUSIONS

GHD may represent a remediable contributor to post-BMT chronic fatigue in adults, further studies are needed to evaluate the potential role of screening and GH replacement therapy in this vulnerable patient population.

IMPLICATIONS FOR CANCER SURVIVORS

GHD may be a treatable explanation for disabling post-BMT fatigue pending results of intervention studies.

Effects of probiotics on bone mineral density and bone turnover: A systematic review

Probiotic supplements have been shown to improve bone health in animal models, although it remains uncertain whether these beneficial effects extend to humans. We undertook a systematic review of the literature to determine the effects of probiotic interventions on skeletal outcomes in postmenopausal women. MEDLINE, EMBASE, CENTRAL, and the Cochrane Database of Systematic Reviews were searched from inception to October 2020 for controlled trials comparing the effects of probiotic-containing supplements with placebo on bone mineral density (BMD) or bone turnover markers. Risk of bias was assessed using the Cochrane Risk of Bias 2 Tool. Of 338 records identified, six randomized, placebo-controlled trials (n = 632) were eligible for inclusion. All studies assessed postmenopausal women for durations of 6-12 months; three were considered to be at high risk of bias. Four studies examined Lactobacillus-containing probiotics, one assessed a proprietary blend of lactic acid bacteria, and one evaluated Bacillus subtilis. Effects of probiotic interventions on BMD were inconsistent, with the majority of studies demonstrating no benefit at the spine or hip. Probiotic effects on bone turnover markers were similarly heterogeneous. High quality studies are needed to determine whether probiotic interventions have a role in maintaining bone health in humans.

Listening to community concerns in the COVID-19 infodemic: A WHO digital approach

Background

The Infodemic (too much information including false or misleading information in digital and physical environments) during the COVID-19 pandemic has led to confusion, risk-taking and behaviors that can amplify outbreaks, and reduce effectiveness of pandemic response efforts. To address this challenge, the WHO Information Network for Epidemics (EPI-WIN), in collaboration with research partners, developed a public health Infodemic intelligence analysis methodology for weekly analysis of digital media data to identify, categorize, and understand key concerns expressed in online conversations.

Methods

Thirty-five keyword-based searches (per language) using Meltwater Explore and Google Trends were created and grouped according to a set of pandemic public health taxonomy categories developed specifically for this analysis. The taxonomy has five thematic categories of conversation about COVID-19 and public health response: (1) the cause of the illness, (2) the illness, (3) the treatment, (4) the interventions and (5) Information.

Results

The two most recurring topics to attract increasing interest were Vaccines and Asymptomatic transmission followed by Immunity, Cause of the virus, Vulnerable communities and Reduction of movement, and Risk factors based on demographics and risk of misinformation.

Conclusions

The application of this taxonomy to online social listening week-on-week resulted in a better in-time understanding of the evolution and dynamics of high velocity conversations about COVID-19 globally during the pandemic and proposes a quantifiable approach to support planning of risk communication response.

Key messages

Describe widespread innovation in social listening methods for greater accountability to affected populations. Formulate insights into how digital media can be better utilized for more rapidly responding to the evolving needs of communities.

WHO public health research agenda for managing infodemics

Background

Following the World Health Organization's initial infodemic consultation in April 2020, a major infodemic conference was organised virtually in June-July 2020. Hundreds of experts participated to define science of infodemiology and build a public health research agenda that serves as a playbook for conducting relevant researches. Research Agenda provides guidance to invest in research and innovation so that we have better interventions and tools to understand, measure and respond to infodemics, and steer people towards timely, accessible, understandable information for good health choices.

Methods

The research agenda was developed during a virtual meeting, followed by research question prioritization exercise. It consisted of eight days spread out over four weeks. These were made up of: public preconference meeting; scientific conference, consisting of opening/closing plenary meetings either side of four separate “topic sprint” days; final public meeting to present the meeting outcomes.

After the meeting, a process took place to gather and rank research questions based on the research agenda created during the meeting.

Results

The following five streams and 65 research questions were developed. Measuring and monitoring the impact of infodemics during health emergencies Detecting and understanding the spread and impact of infodemics Responding and deploying interventions that protect against the infodemic and mitigate its harmful effects Evaluating infodemic interventions and strengthening resilience of individuals and communities to infodemics Promoting the development, adaptation and application of tools for managing infodemics.

Conclusions

Five streams with 65 research questions were developed and prioritized to structuralise infodemic management based on evidence. The conference yielded on the development of an infodemiology glossary, which can be used by the community of research.

Key messages

Discuss investments in research and innovation to enable a whole-of-society response to infodemics. Explain the practice of infodemic management as a discipline.