Awareness and obscurity: demystifying genomic profiling in real-world practice for the members of the Turkish Society of Medical Oncology (TSMO)

OBJECTIVE

Molecular testing in oncology practice is increasingly being used to offer more relevant therapies to cancer patients. Our study aims to determine the real-world impact of routine incorporation of molecular testing among the Turkish Oncology community across all types of cancer and identify gaps for the first time.

SUBJECTS AND METHODS

This research was conducted in Turkey among medical oncologists from different backgrounds. The survey attendance was entirely voluntary. A questionnaire with twelve items (multiple choice +/- closed-ended) was utilized in this study to assess the effect of molecular tests in real clinical situations.

RESULTS

102 oncologists with various levels of experience participated in this study. Most of the respondents (97%) reported successful implementation of molecular testing. About 10% of the participating oncologists said they preferred genetic tests at the early stages of cancer, compared to the majority who preferred genetic tests at the terminal stage. Molecular tests are often performed in separate locations and 47% of the oncologists were using a targeted panel specific to the type of malignancy.

CONCLUSIONS

Several informational difficulties must be resolved in order to have early personalized therapy as the standard treatment. We need accessible, comprehensive, and regularly updated databases to compare genetic profiling and its therapeutic implications. We also need to continue educating patients and physicians.

OP0269 BIOMARKERS TO PREDICT RISK OF VENOUS THROMBOEMBOLISM IN PATIENTS WITH RHEUMATOID ARTHRITIS RECEIVING TOFACITINIB OR TUMOUR NECROSIS FACTOR INHIBITORS

Background

In the ORAL Surveillance study of patients (pts) aged ≥50 yrs with moderate to severe rheumatoid arthritis (RA) and ≥1 additional cardiovascular risk factor (NCT02092467), the incidence of pulmonary embolism was higher with tofacitinib than with tumour necrosis factor inhibitors (TNFi).1

Objectives

To explore whether biomarkers explained the associations of tofacitinib vs TNFi with venous thromboembolism (VTE) in ORAL Surveillance.

Methods

ORAL Surveillance was a prospective, open-label, event-driven, noninferiority, post-authorisation safety study. Pts were randomised 1:1:1 to receive tofacitinib 5 or 10 mg twice daily or a TNFi (adalimumab 40 mg every 2 weeks or etanercept 50 mg once weekly). For this exploratory post hoc analysis, 294 soluble, proteomic, genetic and antibody biomarkers were assessed (of which 79 have a known role in inflammation, coagulation, vascular biology and/or Janus kinase signalling). Biomarkers were quantified in serum collected at baseline (BL) and Month (M)12 in VTE cases and 4:1 matched controls. D-dimer was analysed with a larger control group (all eligible pts without VTE) and final adjudicated data from BL, M12 and study end.

Results

Of the 4362 randomised and treated pts, D-dimer was quantified in 3732 pts (54 with VTE; 3678 without) and the remaining biomarkers were analysed in 285 pts (57 VTE cases; 228 matched controls). BL characteristics were generally similar in those with or without VTE and between treatment groups. At BL, D-dimer levels were ≥2×upper limit of normal for ~50% of controls and 67% of VTE cases. Mean D-dimer levels decreased from BL to M12 in controls across treatment groups (Figure 1). Key findings from the biomarker analyses are shown in the Table 1. No biomarker showed a clear mechanistic association with the increased risk of VTE for tofacitinib vs TNFi, or demonstrated adequate performance for prognostic use in pts with RA.

Table 1.

Summary of results from biomarker analyses

BiomarkerKey resultsTier 1C-reactive protein•No association with VTE in any treatment arm at BL or M12D-dimer Thrombopoietin•Higher M12 levels were prospectively associated with greater risk of subsequent VTE with tofacitinib 10 mg BID ◦ For D-dimer, the same effect was observed with tofacitinib 5 mg BID •Treatment specificity of effects could not be establishedTier 2Factor VIII Thrombin–antithrombin complex Tissue factor pathway inhibitor Plasminogen activator inhibitor-1 Protein C Antithrombin Apolipoprotein C-III Leptin•No clinically meaningful differences across treatment armsTiers 3 & 4Exploratory proteomic assays (276 markers from multiplex panels)•Two biomarkers with no known relationship to VTE (angiogenin and TNFSF13B) showed significant associations with pulmonary embolism in the tofacitinib 10 mg BID arm ◦ Treatment specificity of effects could not be established for either analyteGenetic biomarkersFactor V Leiden R506Q, prothrombin G20210A and JAK2 V617F mutations•Factor V Leiden and prothrombin risk alleles, individually or combined, were associated with increased incidence of VTE but did not explain excess events with tofacitinib •No VTE cases or matched controls had the JAK2 mutationAntibody biomarkersACA IgG and IgM, anti-β2GP1 IgG and IgM•No statistical differences were observed between treatment arms or between VTE cases and matched controls

ACA, anticardiolipin antibody; β2GP1, beta-2-glycoprotein 1; IgG, immunoglobulin G; IgM, immunoglobulin M; JAK2, Janus kinase 2; TNFSF13B, tumour necrosis factor ligand superfamily member 13B

Conclusion

This post hoc exploratory analysis did not identify biomarkers at BL or M12 that explain the increased VTE risk for tofacitinib vs TNFi. Notably, ORAL Surveillance was neither designed nor powered to compare the risk of VTE across treatments or to identify biomarkers with a mechanistic relationship to VTE. Individual VTE risk should be considered when making decisions about initiation or maintenance of tofacitinib treatment.

References

[1]Ytterberg et al. N Engl J Med 2022; 386: 316-326.

Acknowledgements

Study sponsored by Pfizer Inc. Medical writing support was provided by Julia King, CMC Connect, and funded by Pfizer Inc.

Disclosure of Interests

Zoltán Szekanecz Speakers bureau: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Paid instructor for: AbbVie, Eli Lilly, Gedeon Richter, Novartis, Pfizer Inc and Roche, Consultant of: AbbVie, Eli Lilly, Novartis, Pfizer Inc, Roche and Sanofi, Grant/research support from: Pfizer Inc, Christina Charles-Schoeman Consultant of: AbbVie, Gilead Sciences, Pfizer Inc and Sanofi-Regeneron, Grant/research support from: AbbVie, Bristol-Myers Squibb and Pfizer Inc, Ivana Vranic Shareholder of: Pfizer Inc, Employee of: Pfizer Ltd, Burak Sahin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Sara A Paciga Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Zhenyu Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Craig Hyde Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, David Martin Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Jeffrey I Weitz Speakers bureau: Anthos, Bayer AG, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Ionis, Janssen, Novartis, Pfizer Inc, PhaseBio, Portola and Servier Pharmaceuticals, Grant/research support from: Bayer AG and Boehringer Ingelheim

AB1323 THE MYSTERY OF FAMILIAL MEDITERRANEAN FEVER: IS THERE ANY FACTOR TRIGGERING THE ATTACKS?

Background

Familial Mediterranean Fever (FMF) is an autoinflammatory disease characterized by recurrent episodes of fever and serositis. Although it is known that the attack frequency differs among patients carrying different mutant genotypes [1], whether physical and environmental factors play a role in triggering attacks or whether they have an influence on timing of attacks remains to be elucidated.

Objectives

We aimed to identify different conditions causing flare-ups in FMF course and to investigate if there is a significant difference between patients carrying distinct mutations, regarding the distribution of the factors mentioned.

Methods

Two hundred patients were randomly selected among individuals who were routinely followed-up with FMF diagnosis in our centre. Individuals carrying only a variant of unknown significance or polymorphism such as R202Q, according to Infevers database, were excluded in order to gather a cohort consisting of patients with definite FMF. An inquiry was made based upon triggering factors determined by the patients themselves. The patients were classified into subgroups by their sex and mutation genotype. Since M694V variant is responsible for pronounced FMF course [2], we sorted the patients according to their status for M694V mutant allele. Group A included patients carrying M694V homozygously. Group B included patients carrying at least one M694V mutant allele whereas Group C consisted of patients who were non-M694V carriers. Chi-square test was performed to assess distribution of the trigger factors in terms of establishing its significance.

Results

Detailed distribution of trigger factors is shown in Table 1. 144 out of 200 patients described a culprit condition. Patients usually stated more than one factor, however some patients reported only one. The most-reported trigger factors by the cohort are summarized as following: 76 emotional stress (38%), 60 menstruation (30%), 40 cold exposure (20%), 34 fatigue (17%), 13 seasonal changes (6.5%). The distribution of trigger factors between Group A, B, and C were non-significant (p=0.88).

Table 1.

The distribution of triggering factors in subgroups.

GroupTotal(%)Reported trigger factor (%)Mens- truation(%)Emotionalstress(%)Cold exposure(%)Fatigue(%)Seasonalchanges(%)Others(%)Female12397 (78.8)60 (48.8)47 (38.2)24 (19.5)19 (15.4)7 (5.7)6 (4.9)Male7747 (61)-29 (37.7)16 (20.8)15 (19.5)6 (7.8)7 (9.1)Group A6144 (72.1)14 (23)24 (39.3)13 (21.3)12 (19.7)4 (6.6)6 (9.8)Group B165120 (72.7)49 (29.7)66 (40)34 (20.6)29 (17.6)13 (7.9)11 (6.6)Group C3524 (68.6)11 (31.4)10 (28.6)6 (17.1)5 (14.3)01 (2.8)

Group A: M694V homozygous patients, Group B: patients with at least one M694V allele, Group C: non-M694V carriers

Conclusion

We concluded that trigger factors did not vary between distinct mutant genotypes. Although emotional stress is the most reported trigger factor by the participants, one should bear in mind that emotional stress influences most chronic diseases negatively. We also observed that menstruation overtly triggers an FMF attack. Additionally, cold exposure should be considered as a notable trigger factor. It is still unclear what triggers an FMF attack in 28% of the patients, remains a mystery.

References

[1]Grossman C, Kassel Y, Livneh A, Ben-Zvi I. Familial Mediterranean fever (FMF) phenotype in patients homozygous to the MEFV M694V mutation. Eur J Med Genet. 2019 Jun;62(6):103532. doi: 10.1016/j.ejmg.2018.08.013.

[2]Egeli BH, Ugurlu S. Familial Mediterranean Fever: Clinical State Of The Art. QJM. 2020 Oct 20:hcaa291. doi: 10.1093/qjmed/hcaa291.

Disclosure of Interests

None declared

POS0869 CYTOKINES IN SYSTEMIC SCLEROSIS RELATED INTERSTITIAL LUNG DISEASE AND IDIOPATHIC PULMONARY FIBROSIS

Background

Immune pathways have been implicated in both systemic sclerosis (SSc)-related interstitial lung disease (ILD) and idiopathic pulmonary fibrosis (IPF). Determination of blood cytokine differences in these two disorders need to be elucidated to better understand potential biological processes and common pathogenic pathways.

Objectives

This study compared 87 circulating cytokine levels amongst healthy controls and both SSc-ILD and IPF. There was also exploration of the association between cytokine levels and disease progression based on the annualized rate of decline of forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO).

Methods

Levels of 87 plasma cytokines were measured using commercial panels for consecutive SSc-ILD, IPF, and healthy individuals recruited at a Canadian tertiary-care center. Pulmonary function tests were performed as clinically indicated every 3-12 months. Cytokine levels are compared using the Wilcoxon rank sum test for two samples pairwise. The association between differentially expressed cytokines with both percent predicted annualized FVC and DLCO change was assessed within each disease group using multiple linear models adjusted for age, sex, baseline FVC, and immunosuppressive or anti-fibrotic treatment at sampling. Correction for multiplicity of testing was by Holm’s method.

Results

There were 19 healthy controls, 40 SSc-ILD, and 17 IPF participants with clinical features shown in Table 1. Eotaxin-1 and interleukin 6 (IL-6) were significantly elevated in both SSc-ILD and IPF compared to healthy controls (Figure 1). SSc-ILD had significantly lower soluble epidermal growth factor receptor (sEGFR) and higher levels of both soluble tumor necrosis factor receptor type II (sTNFRII) and soluble vascular endothelial growth factor receptor-1 (sVEGFR1) compared to healthy controls. IPF cases were distinguished from healthy controls by significantly higher monocyte chemoattractant protein-1 (MCP-1) and monokine induced by gamma interferon (MIG, also known as CXCL9) levels. No significant association was found for any of the cytokines with ILD progression based on annualized rates of either FVC or DLCO change.

Table 1.

Baseline patient characteristics stratified by disease groups

Healthy control(n = 19)SSc-ILD(n = 40)IPF(n = 17)Age, year51 ± 1956 ± 1273 ± 7Male, count (%)6 (32)12 (30)12 (71)Disease duration, yearNA6.41 (7.81)1.76 (2.14)Ever smoker, count (%)2 (11)19 (48)14 (82)•4 (82)oker0.4 [0, 1]11 [4, 29]19 [11, 35]Treatment presence, count (%)NA16 (40)7 (41)Baseline FVC %NA80 ± 2285 ± 21Baseline DLCO %NA51 ± 1749 ± 11Annualized FVC % changeNA-1.7 ± 8.2-6.2 ± 13.6Annualized DLCO % changeNA-0.5 ± 6.2-7.8 ± 18.6

The number (%), mean ± standard deviation, and median [interquartile range] are shown. Disease duration is defined as time of ILD first seen on HRCT in IPF and time from first non-Raynaud’s phenomenon in SSc-ILD. Treatment includes presence of ILD therapies: nintedanib, pirfenidone, mycophenolate mofetil, azathioprine, rituximab. FVC = forced vital capacity, DLCO = diffusing capacity for carbon monoxide

Figure 1.

Notched box plots of cytokine differences between disease groups. All cytokine levels are shown on a log scale. Overlap of notches indicates lack of a statistically significant difference in medians in a pairwise comparison. P-values are for SSc-ILD or IPF compared to healthy controls using Wilcoxon rank sum two-sample test corrected for multiple testing using Holms method.

Conclusion

Differences in seven circulating cytokines between healthy controls with both SSc-ILD and IPF show evidence of systemic cytokine activation. All seven cytokines have a role in immune cell extravasation and pro-fibrotic signaling, which provides further evidence of immune pathways involved in pulmonary fibrosis. Further studies will be pursued of longitudinal change of these biomarkers for halting or slowing disease progression and improving response to treatment.

Disclosure of Interests

Boyang Zheng: None declared, Kevin Keen Grant/research support from: Merck Canada Inc, Marvin Fritzler Shareholder of: Abbott Laboratories; Roche Holdings; Abcellera; Moderna, Speakers bureau: For diagnostic company: Werfen, Consultant of: For diagnostic company: Werfen; Aesku, Employee of: Medical Director of Mitogen Diagnostics, Christopher Ryerson Speakers bureau: Boehringer Ingelheim, Hoffmann-La Roche, Consultant of: Boehringer Ingelheim, Hoffmann-La Roche, Veracyte, Astra Zeneca, Grant/research support from: Boehringer Ingelheim, Hoffmann-La Roche, Pearce Wilcox Speakers bureau: Vertex, Valeo, Boehringer, Beth Whalen: None declared, Basak Sahin: None declared, Haiyan Hou Employee of: Mitogen Diagnostics, Penny Latham Employee of: Eve technologies, Mei Feng Zhang Employee of: Mitogen diagnostics, Iris Yao: None declared, James Dunne: None declared

Nasal secretory protein changes following intravenous choline administration in calves with experimentally induced endotoxaemia

Nasal secretory fluid proteomes (NSPs) can provide valuable information about the physiopathology and prognosis of respiratory tract diseases. This study aimed to determine changes in NSP by using proteomics in calves treated with lipopolysaccharide (LPS) or LPS + choline. Healthy calves (n = 10) were treated with LPS (2 μg/kg/iv). Five minutes after LPS injection, the calves received a second iv injection with saline (n = 5, LPS + saline group) or saline containing 1 mg/kg choline (n = 5, LPS + choline group). Nasal secretions were collected before (baseline), at 1 h and 24 h after the treatments and analysed using label-free liquid chromatography-tandem mass spectrometry (LCMS/MS). Differentially expressed proteins (>1.2-fold-change) were identified at the different time points in each group. A total of 52 proteins were up- and 46 were downregulated at 1 h and 24 h in the LPS + saline group. The upregulated proteins that showed the highest changes after LPS administration were small ubiquitin-related modifier-3 (SUMO3) and glutathione peroxidase-1 (GPX1), whereas the most downregulated protein was E3 ubiquitin-protein ligase (TRIM17). Treatment with choline reduced the number of upregulated (32 proteins) and downregulated proteins (33 proteins) in the NSPs induced by LPS. It can be concluded that the proteome composition of nasal fluid in calves changes after LPS, reflecting different pathways, such as the activation of the immunological response, oxidative stress, ubiquitin pathway, and SUMOylation. Choline treatment alters the NSP response to LPS.

Prognostic factors in medically inoperable early stage lung cancer patients treated with stereotactic ablative radiation therapy (SABR): Turkish Radiation Oncology Society Multicentric Study

OBJECTIVE

We identified factors influencing outcomes in patients with medically inoperable early stage lung cancer (MIESLC) treated with stereotactic ablative radiation therapy (SABR) at 14 centers in Turkey.

MATERIALS AND METHODS

We retrospectively analyzed 431 patients with stage I-II MIESLC treated with SABR from 2009 through 2017. Age; sex; performance score; imaging technique; tumor histology and size; disease stage radiation dose, fraction and biologically effective dose with an α/β ratio of 10 (BED₁₀ ); tumor location and treatment center were evaluated for associations with overall survival (OS), local control (LC) and toxicity.

RESULTS

Median follow-up time was 27 months (range 1-115); median SABR dose was 54 Gy (range 30-70) given in a median three fractions (range 1-10); median BED₁₀ was 151 Gy (range 48-180). Tumors were peripheral in 285 patients (66.1%), central in 69 (16%) and <1 cm from mediastinal structures in 77 (17.9%). Response was evaluated with PET/CT in most cases at a median 3 months after SABR. Response rates were: 48% complete, 36.7% partial, 7.9% stable and 7.4% progression. LC rates were 97.1% at 1 year, 92.6% at 2 years and 91.2% at 3 years; corresponding OS rates were 92.6%, 80.6% and 72.7%. On multivariate analysis, BED₁₀ > 100 Gy (P = .011), adenocarcinoma (P = .025) and complete response on first evaluation (P = .007) predicted favorable LC. BED₁₀ > 120 Gy (hazard ratio [HR] 1.9, 95% confidence interval [CI] 1.1-3.2, P = .019) and tumor size (<2 cm HR 1.9, 95% CI 1.3-3, P = .003) predicted favorable OS. No grade 4-5 acute side effects were observed; late effects were grade ≤3 pneumonitis (18 [4.2%]), chest wall pain (11 [2.5%]) and rib fracture (1 [0.2%]).

CONCLUSION

SABR produced encouraging results, with satisfactory LC and OS and minimal toxicity. BED₁₀ > 120 Gy was needed for better LC and OS for large, non-adenocarcinoma tumors.

Impact of Prolonged Neoadjuvant Treatment-surgery Interval on Histopathologic and Operative Outcomes in Patients Undergoing Total Mesorectal Excision for Locally Advanced Rectal Cancer

BACKGROUND

This study primarily aimed to assess the impact of prolonged neoadjuvant treatment-surgery interval (PNSI) on histopathologic and postoperative outcomes. Impacts of the mode of neoadjuvant treatment (NT) and surgery on the outcomes were also evaluated in the same patient population.

PATIENTS AND METHODS

Between February 2011 and December 2017, patients who underwent NT and total mesorectal excision for locally advanced rectal cancer were included. PNSI was defined as >4 and >8 weeks after short-course and long-course NT modalities, respectively.

RESULTS

A total of 44 (27%) patients received short-course NT (standard interval: n=28; PNSI: n=16) and 122 (73%) patients received long-course NT (standard interval: n=39; PNSI: n=83). Postoperative morbidity was similar between the standard interval and PNSI in patients undergoing short-course [n=3 (11%) vs. n=3 (19%), P=0.455] and long-course [n=6 (15%) vs. n=16 (19%), P=0.602] NT. PNSI was associated with increased complete pathologic response in patients receiving short-course NT [0 vs. n=5 (31%), P=0.002]. Compared with short-course NT, long-course NT was superior in terms of tumor response based on the Mandard [Mandard 1 to 2: n=6 (21%) vs. 6 (38%), P=0.012] and the College of American Pathologists (CAP) [CAP 0 to 1: n=13 (46%) vs. n=8 (50%), P=0.009] scores. Postoperative morbidity was similar after open, laparoscopic, and robotic total mesorectal excision [n=1 (14.2%) vs. n=21 (21%) vs. n=6 (12.5%), P=0.455] irrespective of the interval time to surgery and the type of NT.

CONCLUSIONS

PNSI can be considered in patients undergoing short-course NT due to its potential oncological benefits. The mode of surgery performed at tertiary centers has no impact on postoperative morbidity after both NT modalities.

Evaluation of response to stereotactic radiosurgery in patients with radioresistant brain metastases

PURPOSE

Renal cell carcinoma (RCC) and melanoma have been considered 'radioresistant' due to the fact that they do not respond to conventionally fractionated radiation therapy. Stereotactic radiosurgery (SRS) provides high-dose radiation to a defined target volume and a limited number of studies have suggested the potential effectiveness of SRS in radioresistant histologies. We sought to determine the effectiveness of SRS for the treatment of patients with radioresistant brain metastases.

MATERIALS AND METHODS

We performed a retrospective review of our institutional database to identify patients with RCC or melanoma brain metastases treated with SRS. Treatment response were determined in accordance with the Response Evaluation Criteria in Solid Tumors.

RESULTS

We identified 53 radioresistant brain metastases (28% RCC and 72% melanoma) treated in 18 patients. The mean target volume and coverage was 6.2 ± 9.5 mL and 95.5% ± 2.9%, respectively. The mean prescription dose was 20 ± 4.9 Gy. Forty lesions (75%) demonstrated a complete/partial response and 13 lesions (24%) with progressive/stable disease. Smaller target volume (p < 0.001), larger SRS dose (p < 0.001), and coverage (p = 0.008) were found to be positive predictors of complete response to SRS.

CONCLUSION

SRS is an effective management option with up to 75% response rate for radioresistant brain metastases. Tumor volume and radiation dose are predictors of response and can be used to guide the decision-making for patients with radioresistant brain metastases.

First 500 Fractions Delivered with a Magnetic Resonance-guided Radiotherapy System: Initial Experience

Objectives

Improved soft-tissue visualization, afforded by magnetic resonance imaging integrated into a radiation therapy linear accelerator-based radiation delivery system (MR-linac) promises improved image-guidance. The availability of MR-imaging can facilitate on-table adaptive radiation planning and enable real-time intra-fraction imaging with beam gating without additional exposure to radiation. However, the novel use of magnetic resonance-guided radiation therapy (MRgRT) in the field of radiation oncology also potentially poses challenges for routine clinical implementation. Herein the early experience of a single institution, implementing the first MRgRT system in the country is reported. We aim to describe the workflow and to characterize the clinical utility and feasibility of routine use of an MR-linac system.

Methods

The ViewRay MRIdian MR-linac system consists of a split-magnet 0.35 T MR-imaging scanner with a double focused multi-leaf collimator (MLC) equipped 6MV linear accelerator. Unique to the system are the control console integrated on-table adaptive radiation therapy (oART) planning capabilities as well as automated beam gating based on real-time intra-fraction MR imaging. From the first day of clinical implementation, oART was performed according to physicians’ discretion when medically indicated. All fractions were delivered under real-time imaging with soft tissue-based automated beam gating with individualized gating boundary settings. Patients actively assisted in breath-hold beam gating with the help of custom designed prismatic glasses allowing sight of a computer monitor mounted on the back wall just behind the MRI system bore. Patient demographics and treatment experience, indications for MRgRT including diagnosis and disease site, radiation dose prescribed and fractionation scheme, utilization of oART, respiratory gating settings, as well as duration of each treatment phase were analyzed.

Results

Between September 2018 and May 2019, 72 patients with 84 tumor sites were treated with MRgRT in 500 total fractions. Median patient age was 66 years (range: 28-83 years). Among 84 tumor sites, the most frequently treated regions were upper abdominal and pelvic (n = 36, 43% and n = 29, 34%, respectively). The most common diagnosis was prostate cancer, with 14 patients treated. In 69 patients (93.2%) oART was used at least once during a treatment course. Twenty-nine targets (43.1%) with significant breathing-related motion were treated in breath-hold with patient visual feedback. Median prescribed dose was 36.25 Gy (range: 24-70 Gy) in median five fractions (range: 3-28 fractions). A gating boundary of 3 mm around a gating region of interest (gROI) was most commonly used (range: 3-5 mm) with 95% of the gROI (range: 93-97%) required to be within the gating boundary for the beam to automatically engage. Mean total treatment time was 47 min (range: 21-125 min) and mean beam-on time was 16.7 min (range: 6-62 min).

Conclusions

MRgRT afforded by an MR-linac system has been successfully implemented into routine clinical use at our institution as the first system of its kind in Turkey. While the overall number of patients treated and fractions delivered is still limited, we have demonstrated the feasibility of both on-table adaptive radiation therapy as well as automated real-time beam gating on a daily basis in acceptable time schedules.

On demand pancreatic stenting in chronic pancreatitis might provide good palliation of pain

BACKGROUND AND AIM

Chronic pancreatitis (CP)-related pain is a considerable problem in gastroenterology practice that frequently requires several endoscopic interventions. We aimed to investigate the efficacy of pancreatic duct stenting performed on demand, instead of at defined intervals, for the management of the CP-related pain.

METHODS

This study is a retrospective evaluation of thirteen years of data. Sixty-seven patients with CP who suffered from intractable pain were enrolled in the study. Pancreatic stenting was performed mainly with single stents according to the diameter of the pancreatic duct and width of the stricture or, less frequently, with multiple stents aiming to achieve stricture resolution. The subsequent endoscopic session was scheduled based on the patient's symptoms.

RESULTS

Overall, 65 of 67 patients underwent successful pancreatic cannulation (technical success rate 97%). Fifty-seven patients with a pancreatic stenting history were still undergoing follow-up. Of these patients, 26 patients still had pancreatic ductal stents; however, the stents were removed from 31 patients. Only 8 patients (25%) required further endoscopic or surgical intervention because of the re-emergence of pain after a median stent-free period of 17 months (3-127 months). One patient with a biliary stricture and one patient with a pancreatic mass underwent surgery. Pancreatic stents remained for a median length of 14 months (3-84 months). During the follow-up period, 55 of 65 patients became pain-free or had partial pain relief (clinical success rate 84%).

CONCLUSIONS

On demand replacement of pancreatic stent is feasible in patients with CP and it might provide a good palliation of CP-related pain.

Extraordinarily Elevated Ca19-9 in Benign Conditions: A Case Report and Review of the Literature

Carbohydrate antigen CA19-9 is commonly used in the diagnosis of pancreatic and biliary malignancies. However, increases in its level in benign conditions such as acute cholangitis or pancreatitis have also been reported. A 79-year-old woman presented with cholangitis and a pancreatic pseudocyst while showing elevation of CA19-9 up to 35,500 U/mL. The patient was adequately treated and at two months’ follow-up the CA19-9 level had returned to normal.

Non-small Cell Lung Cancer with Multiple Brain Metastases Treated with Radiosurgery and Erlotinib: A Case Report

Brain metastases are commonly seen complications in non-small cell lung cancer (NSCLC) patients. The incidence of brain metastases is increasing as a result of more effective systemic targeted therapies with prolonged survival. The prognosis is usually poor, and up to six months of median survivals were reported with different therapeutic options. Here, we present an NSCLC case with multiple brain metastases treated with radiosurgery and systemic erlotinib therapy with prolonged survival. The use of tyrosine kinase inhibitors (TKI) in conjunction with either stereotactic radiosurgery or whole brain radiotherapy is not well established in terms of efficiency and toxicity. This reported case had an excellent response with a tolerable toxicity profile from the combination of either therapies.

Efficacy of paclitaxel in the treatment of Kaposi sarcoma

OBJECTIVE

Kaposi sarcoma is an angioproliferative disease. Kaposi sarcoma is clinicopathologically classified into four subgroups based on epidemiological data. For its systemic treatment, in addition to some chemotherapeutics, taxanes have also been used during the recent years for their anti-angiogenic properties. In this study, we aimed to compare paclitaxel and non-paclitaxel chemotherapeutic regimens in terms of efficacy and side effects.

PATIENTS AND METHODS

In our center, demographical, clinical and histopathological characteristics of a total of 13 patients diagnosed with Kaposi sarcoma who received therapy were retrospectively recorded based on their medical files

RESULTS

Among these subjects, 7 have been treated with paclitaxel and 6 with non-paclitaxel therapies. Eleven patients were male. Twelve patients were found to have classical type of Kaposi Sarcoma. The recurrence was observed in 2 patients treated with paclitaxel and in 1 patient treated with non-paclitaxel therapy. No statistically significant difference was found between the therapeutic modality, the stage of the disease and the percentage of the recurrence. Neuropathy developed in 3 patients treated with paclitaxel, whereas there was no neuropathy in the other group. Although the recurrence-free survival was worse in the patients treated with paclitaxel, there was no statistically significant difference.

CONCLUSIONS

Cytotoxic chemotherapy is effective in treating patients with Kaposi Sarcoma, although it is palliative. Taxanes have demonstrated effectiveness against AIDS-associated Kaposi Sarcoma. The experience suggests that paclitaxel is an effective alternative in the treatment of classical form Kaposi's sarcoma. There was no difference in efficacy between paclitaxel and non-paclitaxel therapies whereas difference in occurrence of neuropathy which is one of the side effects, showed borderline statistical significance.

Factors associated with recurrent stroke and recanalization in patients presenting with isolated symptomatic carotid occlusion

Background and purpose

Patients with symptomatic internal carotid artery (ICA) occlusion constitute a small proportion of stroke/transient ischaemic attack patients who are at increased risk of early stroke recurrence and poor outcome. The optimal medical treatment for patients with symptomatic ICA occlusion who are ineligible for thrombolysis or thrombectomy is unknown.

Methods

Consecutive patients presenting at a single center with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) were retrospectively reviewed. Those treated with intravenous thrombolysis or intra‐arterial thrombolysis/thrombectomy were excluded. Patients were divided into two groups based on whether they experienced recurrent in‐hospital stroke.

Results

The selected study population (n = 33) represented a small (20.4%) proportion of all newly symptomatic carotid occlusions, who nevertheless had an elevated risk of recurrent stroke during admission (24.2%). Of the variables examined (age, gender, admission National Institutes of Health Stroke Scale score, vascular risk factors, atrial fibrillation, prior stroke/transient ischaemic attack and anticoagulation within 48 h of presentation), only anticoagulation was significantly associated with a lower risk of in‐hospital recurrent stroke. Anticoagulated patients showed a decreased incidence of stroke recurrence within the first week (6.7% vs. 38.9%, P = 0.032) and fewer strokes or deaths at 1 month (13.3% vs. 47.1%, P = 0.040). Hemorrhagic transformation was not observed in any patient. On follow‐up imaging, ICA recanalization was significantly more frequent in anticoagulated patients (46.2% vs. 9.1%, P = 0.047).

Conclusion

Patients with newly diagnosed symptomatic ICA occlusion (not involving the circle of Willis) represent a small but high risk subgroup of patients with carotid occlusion. Early anticoagulation was associated with fewer recurrent strokes and increased ICA recanalization. Larger scale prospective studies may be justified.

New method for estimating the volume and volume fractions of the nasal structures in the goose (Anser anser domesticus) using computed tomography images

1. The conchae within the nasal cavity of poultry are important for water and energy conservation, but have not been experimentally evaluated. The aim of the present study was to determine the accuracy of volume and volume fraction estimates of the conchae, nasal septum and nasal cavity. 2. The nasal cavities of 7 adult goose heads were scanned using computed tomography (CT), with images sampled randomly at a 1/5 sampling fraction. Physical sections were obtained from the same samples, using an electric saw that had an adjustable section range, and provided 14 to 15 sections with a thickness of 2.5 mm. The section surface areas of the nasal cavity, nasal septum and conchae were estimated using the Cavalieri principle. Results obtained using the CT and physical section images were compared. Volumes and volume fractions obtained from the physical sections were accepted as the gold standard and differences in the CT images were determined. 3. Multiplication of the data obtained on the CT images with the deviation percentage of the physical sections produced normalised values. No differences were observed between the gold standard data and the CT images. While it was possible to normalise the obtained data using the gold standard values, the raw data could also be used for comparative studies because the deviations from normal would be similar for all groups. 4. Our study showed that the nasal structures could be estimated in vivo using CT images.

Dosimetric and clinical predictors of acute esophagitis in lung cancer patients in Turkey treated with radiotherapy

BACKGROUND

The purpose of this study was to determine the clinical and dosimetric factors associated with acute esophagitis (AE) in lung cancer patients treated with conformal radiotherapy (RT) in Turkey.

MATERIALS AND METHODS

In this retrospective review 104 lung cancer patients were examined. Esophagitis grades were verified weekly during treatment, and at 1 week, and 1 and 2 months afterwards. The clinical parameters included patient age, gender, tumor pathology, number of chemotherapy treatments before RT, concurrent chemotherapy, radiation dose, tumor response to RT, tumor localization, interruption of RT, weight loss, tumor and nodal stage and tumor volume. The following dosimetric parameters were analyzed for correlation of AE: The maximum (Dmax) and mean (Dmean) doses delivered to the esophagus, the percentage of esophagus volume receiving ≥10 Gy (V10), ≥20 Gy (V20), ≥30 Gy (V30), ≥35 Gy (V35), ≥40 Gy (V40), ≥45 Gy (V45), ≥50 Gy (V50) and ≥60 Gy (V60).

RESULTS

Fifty-five patients (52.9%) developed AE. Maximum grades of AE were recorded: Grade 1 in 51 patients (49%), and Grade 2 in 4 patients (3.8%). Clinical factors had no statistically significant influence on the incidence of AE. In terms of dosimetric findings, correlation analyses demonstrated a significant association between AE and Dmax (>5117 cGy), Dmean (>1487 cGy) and V10-60 (percentage of volume receiving >10 to 60 Gy). The most significant relationship between RT and esophagitis were in Dmax (>5117 cGy) (p=0.002) and percentage of esophageal volume receiving >30 Gy (V30>31%) (p=0.008) in the logistic regression analysis.

CONCLUSIONS

The maximum dose esophagus greater than 5117 cGy and approximately one third (31%) of the esophageal volume receiving >30 Gy was the most statistically significant predictive factor associated with esophagitis due to RT.

PTEN, Akt, MAPK, p53 and p95 expression to predict trastuzumab resistance in HER2 positive breast cancer

PURPOSE

Mutations that activate the PIK3CA oncogene and inhibit the tumor suppressor gene PTEN action are commonly found in breast tumors. Akt is a key activator of cell survival. p53 is frequently found mutated in human tumors, and mutant p53 protein actively contributes to tumorigenesis. In selected cases of breast cancer, trastuzumab (TZMB) is incorporated in the primary treatment in the adjuvant and metastatic settings. Many studies have reported that selected patients are resistant to TZMB due to the presence of p95 HER2 fragments. To address this, we analysed PTEN, Akt, MAPK, p53 and p95 expression in breast cancer patients treated with TZMB.

METHODS

Out of 90 patients histologically diagnosed with breast cancer between 2004 and 2011, analysed were 25 patients with HER2 positive, and estrogen (ER) and progesterone receptors (PR) negative, metastatic or locally advanced disease. All 25 patients were treated with TZMB and resistance to TZMB was assessed. All patients were on anthracycline-and taxane-containing regimens. Tissue samples were obtained from paraffin blocks and evaluated immunohistochemically for PTEN, Akt, MAPK, p53, and p95 expression.

RESULTS

TZMB resistance was detected in 5 (20%) patients. Akt expression was positive in 2 patients (8%) and MAPK, p95, and p53 expression was positive in 1 patient (4%); PTEN expression was negative in 3 patients (12%). No significant differences were found between TZMB resistance and PTEN, Akt, MAPK, p53, and p95 expression. Subgroup analysis was carried out in the neoadjuvant treatment group. Complete pathologic response was detected in 3 patients (21.4%). Statistically significant differences were not found between the complete response rate and PTEN, Akt, MAPK, and p95 expression. There was a statistically significant correlation between p53 expression and complete pathologic response (p=0.02).

CONCLUSION

No statistically significant correlation between TZMB resistance and the expression of these biomarkers was noted. In patients with HER2-positive breast cancer that were treated with 4 dose-dense sequential cycles of doxorubicin and cyclophosphamide, followed by TZMB and paclitaxel combination therapy in the neodjuvant setting, p53 expression could predict complete response to chemotherapy.

Nurse-assisted education and exercise decrease the prevalence and morbidity of lymphedema following breast cancer surgery

PURPOSE

To evaluate an educational and exercise program for the prevention and progression of post-mastectomy lymphedema of the arm and shoulder.

METHODS

Fifty-five patients who had undergone mastectomy and axillary lymph node dissection between June 2009 and January 2010 were included in this study. The patients were informed by a trainer nurse about the precautions they should take to prevent the development of lymphedema. The patients were also trained for the appropriate exercises and were given written educational material prepared by the investigators.

RESULTS

Among the participants, 96.4% underwent modified radical mastectomy (MRM) and 3.6% breast-conserving (BCS) surgery. The mean postoperative follow-up period was 9.87 ± 17.55 months. The degree of lymphedema was found lower, even within 6 months, in the patients that exercised as compared to the patients that did not (p<0.05).

CONCLUSIONS

The results indicate that the risk of development and progression of mastectomy-related lymphedema was reduced with education and exercise provided by trained nurses at an early stage.

Estimation of nasal cavity and conchae volumes by stereological method

BACKGROUND

Studies evaluating the mean volumes of nasal cavity and concha are very rare. Since there is little date on the mentioned topic, we aimed to carry out the presented study to obtain a volumetric index showing the relation between the nasal cavity and concha.

MATERIAL AND METHODS

The volumes of the nasal cavity and concha were measured in 30 males and 30 females (18-40 years old) on computed tomography images using stereological methods.

RESULTS

The mean volumes of nasal cavity, concha nasalis media, and concha nasalis inferior were 5.95 ± 0.10 cm(3), 0.56 ± 0.22 cm(3), and 1.45 ± 0.68 cm(3); 7.01 ± 0.18 cm(3), 0.67 ± 0.31 cm(3) and 1.59 ± 0.98 cm(3) in females and males, respectively. There were statistically significant differences in the volume of the nasal cavity and concha nasalis media (p 〈 0.05) between males and females, except for concha nasalis inferior (p 〉 0.05).

CONCLUSIONS

Our results could provide volumetric indexes for the nasal cavity and concha, which could help the physician to manage surgical procedures related to the nasal cavity and concha.

The estimation of the volume of sheep mandibular defects using cone-beam computed tomography images and a stereological method

OBJECTIVE

The Cavalieri principle of stereological methods is widely used to estimate the volume of structures. Recently in clinical practice, it has become common to use this approach for daily routine purposes. The Cavalieri principle provides quantitative and unbiased volume estimates which are independent of the observer. In the present study, the efficacy of using the Cavalieri principle to estimate the volume of sheep mandibular defects on cone beam CT (CBCT) scans was tested.

METHODS

24 differently sized defects were created on 4 sheep mandibles. Before the defects were created, the outer boundaries of the defects were determined using plaster casts. CBCT scans of the defects were taken. The scans were reconstructed in the coronal plane and sections of 0.2 mm thickness with 0.2 mm and 0.4 mm intervals were obtained. The volume of each defect was estimated using the Cavalieri principle. The models were created using light-body silicone for the estimation of the actual volume of each defect. They were immersed in water using a pycnometer and the actual volumes were obtained on the basis of the Archimedean principle. The actual and estimated volumes of the defects were compared using the Wilcoxon signed-rank test.

RESULTS

The results showed that the volumes from the Cavalieri estimates did not differ from the actual volumes of the defects (P > 0.05).

CONCLUSION

We concluded that the volume of mandibular defects can be accurately estimated using the Cavalieri principle on images from a CBCT scan.

Endoscopic treatment of biliary disorders in patients with Roux-en-Y hepaticojejunostomy via a permanent access loop

The management of biliary disorders in patients with Roux-en-Y hepaticojejunostomy anastomosis is challenging and remains controversial. Our aim is to share our experiences of endoscopic treatment via a permanent access loop in 5 patients. Endoscopic treatment via a permanent access loop is an invaluable procedure for the management of stenotic hepaticojejunostomy anastomosis, anastomotic leakage, and hepatolithiasis. It may even be life-saving for some patients.

Mucormycosis-associated fungal infections in patients with haematologic malignancies

Among patients with haematologic disorders, mucormycosis most commonly occurs in those with acute leukaemia or lymphoma who have developed neutropenia due to malignancy or to chemotherapy, and in transplanted patients receiving immunosuppressive treatment. Here, we aim to present a retrospective study conducted over a 5-year period (2001-2005). The study included 20 patients with haematologic malignancies with a proven mucormycosis admitted in Medical Oncology Divisions in Cukurova University Hospital. The most frequent sites of infection were paranasal sinuses (95%) and lung (5%). Antifungal treatment was empirically administered in 18 (90%) patients; 18 patients underwent radical surgical debridement (90%). The therapy was successful for only eight patients (40%). Eleven patients died within 1 months of the diagnosis of fungal infection: the cause of death was only by mucormycosis in four patients (36.6%), mucormucosis and systematic inflamatuar response syndrome (SIRS) in two patients (18.2%) and progression of haematologic disease in five patients (45.5%). At univariate analysis, the factors that correlated with a positive outcome from infection were the following: amphotericin B treatment, neutrophil recovery from postchemotherapy aplasia. At multivariate analysis, the factors that significantly correlated with recovery from infection were the liposomal amphotericin B treatment (p = 0.026), doses of L-AmB (p = 0.008) and the length of the treatment (p = 0.01), respectively. It seems to have increased in recent years. Although a reduction of mortality has been observed recently, the mortality rate still remains high. Extensive and aggressive diagnostic and therapeutic procedures are essential to improve the prognosis in these patients.

Epiphytic algae on mosses in the Altindere Valley National Park (Maçka-Trabzon/Turkey)

Species composition and abundance of epiphytic algae on mosses growing in the Altindere Valley National Park were investigated in March 2008. The epiphytic algae identified in these samples were 27 species in total, 15 of the Bacillariophyta, 7 of the Cyanophyta, 4 of the Chlorophyta and a single of the Euglenophyta species. The members of the Bacillariophyta were more frequently found among these epiphytic algae on mosses. Netrium digitus (Ehrenb.) Itzigs and Rothe var. curtum (Borge) Willi Krieg. was recorded for the first time in the desmids flora of Turkey. The epiphytic algal flora on mosses at the submerged habitat was the richest of the three habitats.

Comparison of four methods for the estimation of intracranial volume: a gold standard study

Investigators can infer how much reduction in volume has occurred since brain volume was at its peak, by combining measures of brain volume with measures of intracranial volume (ICV). Several methodologies have been proposed to asses the ICV. However, we have not seen a gold-standard study evaluating the results of the methodologies for the assessment of ICV. In the present study, the actual intracranial volume of 20 dry skulls was measured using the water-filling method, using this as a gold standard. Anthropometry, cephalometry, point-counting, and planimetry techniques were applied to the same skulls to estimate the ICV. Anthropometric and cephalometric measurements were carried out directly on skulls and roentgenograms, respectively. Consecutive computed tomography sections at a thickness of 10 mm were used to estimate the ICV of the skulls by means of the point-counting and planimetry methods. The mean (+/-SD) of the actual ICV measured by the water-filling method was 1,262.0 +/- 160.4 cm(3) (1,389.5 +/- 96.5 cm(3) for males and 1,134.5 +/- 94.3 cm(3) for females, respectively). Our results showed that the estimated values obtained by all four methods differed from the actual volumes of the skulls (P < 0.05). The data obtained by anthropometry resulted in overestimation. However, cephalometry, point-counting, and planimetry methods produced underestimation. After calibration, there were no significant differences between the actual volumes and the results of the four methods (P > 0.05). While the anthropometric method is easy and quick to apply, its result may deviate from the actual values. The optimized stereological techniques of point-counting and planimetry methods may provide unbiased ICV results since they take the third dimension of the structures into account.

Topoisomerase-II, c-erb B2, c-kit and bcl-2 expression in non-small cell lung cancer treated with docetaxel and gemcitabine based threapy

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Background: This study was conducted to determine the expression of the topoisomeras-II, c-erb B2, c-kit and bcl-2 in patients with non-small cell lung cancer (NSCLC). Material-methods: These factors expression were identified by immunohistochemical method in 62 NSCLC patients pathologically verified on before therapy. Results: 3 patients were in stage-II, 10 in stage-IIIA, 21 in stage-IIIB and 28 in stage-IV. 14 patients had refused therapy, 12 were undergone to surgery alone and 36 recieved multimodality therapy. 27 patients recieved docetaxel-cisplatin therapy and 7 had recieved gemcitabine-cisplatin therapy. Of those docetaxel treated patients 14 received radiation therapy and others undewent surgery in combination therapy. In 31 patients topoisomerase-II was +2 (50%), +1 in 3 patients, +3 in 27 patients and in 1 patient the expression was negative. c-erb B2 was negative in 1, +1 in 2, +2 in 14 and +3 in 45 patients. bcl-2 was negative in 9, +1 in 16, +2 in 22 and +3 in 15 patients. c-kit was negative in 9, +1 in 26, +2 in 15 and +3 in 12 patients. Statistical analysis was done by SPSS- 14 software program. The disease stage, received therapies and the expression of the these proteins was correlated, median survival time and possible prognostic factors were identified. There were statistically significant between stage and patient status (P=0.000), either with therapy or no therapy (p=0.003), bcl-2 (p=0.09) and c-kit (p=0.022), respectively. There were statisticaly significant between stage and bcl-2 (p=0.023), bcl-2 and c-kit (p=0.001), respectively. At the end of the follow-up time, 38 (61.3%) patients were alive. The median survival was 37.2 months. There were not any prognostic values for topoisomerase-II (p=0.7), c-erb B2 (p=0.6), bcl-2 p=0.15) and c-kit (p=0.118) expression. Conclussion: In conclussion, we suggested that the treatment modality of patients with NSCLC should be combination therapy. The patients received docetaxel based therapy had long median survival time. In addition there was no prognosticeffect of the expression of the topoisomeras-II, c- erb B2, c-kit and bcl-2 in patients with non-small cell lung cancer (NSCLC).

No significant financial relationships to disclose.

Early decision for precut sphincterotomy: is it a risky preference?

The aim of this prospective study was to evaluate the results and the complications at a tertiary referral center which frequently uses precutting techniques for biliary cannulation. Four hundred seventy patients with naive papilla for whom biliary intervention was planned were included in the study. If the selective cannulation was not achieved after a few trials, precutting sphincterotomy was performed. The results were evaluated for the frequency, success, and complication rates of precutting. Precutting was performed on 238 (50.6%; 117 male, 121 female; mean age, 58.5 +/- 16.2 years) of 470 patients. Total success rate of endoscopic retrograde cholangiopancreatography (ERCP) was 99.2% (236/238). The rate of complications in patients with versus without precutting was 7 (2.9%) versus 3 (1.3%) for pancreatitis, 2 (0.8%) versus 1 (0.4%) for perforation, and 7 (2.9%) versus 3 (1.3%) for bleeding. The differences between the rates were not significant. Early precutting can be preferable in prolonged cannulation trials of therapeutic ERCP.