Adjuvant Radiotherapy in Stage II Endometrial Cancer: Selective De-intensification of Adjuvant Treatment

AIMS

Risk stratification, including nodal assessment, allows for selective de-intensification of adjuvant radiotherapy in stage II endometrial cancer. Patterns of treatment and clinical outcomes, including the use of reduced volume 'mini-pelvis' radiotherapy fields, were evaluated in a population-based study.

MATERIALS AND METHODS

All patients diagnosed with pathological stage II endometrial cancer between 2000 and 2014, and received adjuvant radiotherapy in a regional healthcare jurisdiction were reviewed. Registry data were supplemented by a comprehensive review of patient demographics, disease characteristics and treatment details. The Charlson Comorbidity Score was calculated. Survival and recurrence data were analysed.

RESULTS

In total, 264 patients met the inclusion criteria. Most patients had endometrioid histology (83%); 41% of patients had International Federation of Gynecologists and Obstetricians grade 1 disease. Half (49%) had surgical nodal evaluation; 11% received chemotherapy. Most patients (59%) were treated with full pelvic radiotherapy fields ± brachytherapy. Seventeen per cent of patients received mini-pelvis radiotherapy ± brachytherapy, whereas 24% received brachytherapy alone. Five-year recurrence-free survival was 87% for the entire cohort, with no significant difference by adjuvant radiotherapy approach. Only one patient receiving mini-pelvis radiotherapy ± brachytherapy recurred in the pelvis but outside of the mini-pelvis field. Recorded late toxicity rates were highest for full pelvis radiotherapy + brachytherapy.

CONCLUSION

Risk stratification in a real-world setting allowed for selective de-intensification of adjuvant radiation with equivalent outcomes for stage II endometrial cancer. Mini-pelvis radiotherapy combined with brachytherapy is effective in highly selected patients, with the potential to decrease toxicity without compromising local control. Brachytherapy should be considered in low-risk stage II patients.

Does Loosening the Inclusion Criteria of the CROSS Trial Impact Outcomes in the Curative-Intent Trimodality Treatment of Oesophageal and Gastroesophageal Cancer Patients?

AIM

To determine the efficacy of preoperative chemoradiotherapy as per the CROSS protocol for oesophageal/gastroesophageal junction cancer (OEGEJC), when expanded to patients outside of the inclusion/exclusion criteria defined in the original clinical trial.

MATERIALS AND METHODS

Data were collected retrospectively on 229 OEGEJC patients referred for curative-intent preoperative chemoradiotherapy. Outcomes including pathological complete response (pCR), overall survival (OS), cancer-specific survival and recurrence-free survival (RFS) of patients who met CROSS inclusion criteria (MIC) versus those who failed to meet criteria (FMIC) were determined.

RESULTS

In total, 42.8% of patients MIC, whereas 57.2% FMIC; 16.6% of patients did not complete definitive surgery. The MIC cohort had higher rates of pCR, when compared with the FMIC cohort (33.3% versus 20.6%, P = 0.039). The MIC cohort had a better RFS, cancer-specific survival and OS compared with the FMIC cohort (P = 0.006, P = 0.004 and P = 0.009, respectively). Age >75 years and pretreatment weight loss >10% were not associated with a poorer RFS (P = 0.541 and 0.458, respectively). Compared with stage I-III patients, stage IVa was associated with a poorer RFS (hazard ratio (HR) = 2.158; 95% confidence interval (CI) = 1.339-3.480, P = 0.001). Tumours >8 cm in length or >5 cm in width had a trend towards worse RFS (HR = 2.060; 95% CI = 0.993-4.274, P = 0.052).

CONCLUSION

Our study showed that the robust requirements of the CROSS trial may limit treatment for patients with potentially curable OEGEJC and can be adapted to include patients with a good performance status who are older than 75 years or have >10% pretreatment weight loss. However, the inclusion of patients with celiac nodal metastases or tumours >8 cm in length or >5 cm in width may be associated with poor outcomes.

Radiotherapy in the Multidisciplinary Management of Adenomyoepithelioma of the Breast with an Axillary Lymph Node Metastasis: A Case Report and Review of the Literature

We describe a case of aggressive adenomyoepithelioma (AME) of the breast with a lymph node metastasis. A 63-year-old female presented with a fluctuating breast mass and clinically palpable lymph nodes. The patient underwent excisional biopsy followed by mastectomy with lymph node dissection and adjuvant radiotherapy (RT). Clinical behavior of both benign and malignant AME is described with the review of the literature and treatment recommendations.

Design of Bioprosthetic Aortic Valves using biaxial test data

Bioprosthetic Aortic Valves (BAVs) do not have the serious limitations of mechanical aortic valves in terms of thrombosis. However, the lifetime of BAVs is too short, often requiring repeated surgeries. The lifetime of BAVs might be improved by using computer simulations of the structural behavior of the leaflets. The goal of this study was to develop a numerical model applicable to the optimization of durability of BAVs. The constitutive equations were derived using biaxial tensile tests. Using a Fung model, stress and strain data were computed from biaxial test data. SolidWorks was used to develop the geometry of the leaflets, and ABAQUS finite element software package was used for finite element calculations. Results showed the model is consistent with experimental observations. Reaction forces computed by the model corresponded with experimental measurements when the biaxial test was simulated. As well, the location of maximum stresses corresponded to the locations of frequent tearing of BAV leaflets. Results suggest that BAV design can be optimized with respect to durability.

The role of hematopoietic cell transplantation in adult ALL: clinical equipoise persists

Adults with acute lymphoblastic leukemia (ALL) in first complete remission (CR1) may be treated either with ongoing systemic chemotherapy or with allogeneic hematopoietic cell transplantation (alloHCT). Despite the presence of phase III trials to support clinical decision-making, we hypothesized that physicians who treat adult ALL would demonstrate wide practice variation. Canadian hematologists who treat ALL were surveyed electronically. Overall, 69 of 173 physicians responded (40%). There was high agreement with offering alloHCT for ALL with high-risk cytogenetics or induction failure after a single chemotherapy cycle. However, only a minority of respondents felt that age >35 years was an indication for alloHCT in CR1. Almost all respondents (96%) felt that a well-matched unrelated donor was an acceptable alternative to a sibling donor. There was uncertainty about the role of cord blood (53% agree) and the utility of reduced intensity conditioning HCT (41% agree). In contrast to the results of the MRC/ECOG study, respondents considered alloHCT to be particularly helpful in high-risk patients. Consensus was lacking on the use of cord blood, RIC alloHCT, and the application of MRD. Equipoise exists on the role of alloHCT in CR1 in ALL, suggesting that further trials in this area are required.

OPTN/SRTR 2011 Annual Data Report: lung

Lungs are allocated in part based on the Lung Allocation Score (LAS), which considers risk of death without transplant and posttransplant. Wait-list additions have been increasing steadily after an initial decline following LAS implementation. In 2011, the largest number of adult candidates were added to the waiting list in a single year since 1998; donation and transplant rates have been unable to keep pace with wait-list additions. Candidates aged 65 years or older have been added faster than candidates in other age groups. After an initial decline following LAS implementation, wait-list mortality increased to 15.7 per 100 wait-list years in 2011. Short- and long-term graft survival improved in 2011; 10-year graft failure fell to an all-time low. Since 1998, the number of new pediatric (aged 0-11 years) candidates added yearly to the waiting list has declined. In 2011, 19 pediatric lung transplants were performed, a transplant rate of 34.7 per 100 wait-list years. The percentage of patients hospitalized before transplant has not changed. Both graft and patient survival have continued to improve over the past decade. Posttransplant complications for pediatric lung transplant recipients, similar to complications for adult recipients, include hypertension, renal dysfunction, diabetes, bronchiolitis obliterans syndrome, and malignancy.

Lung and heart allocation in the United States

Lung and heart allocation in the United States has evolved over the past 20-30 years to better serve transplant candidates and improve organ utilization. The current lung allocation policy, based on the Lung Allocation Score, attempts to take into account risk of death on the waiting list and chance of survival posttransplant. This policy is flexible and can be adjusted to improve the predictive ability of the score. Similarly, in response to the changing clinical phenotype of heart transplant candidates, heart allocation policies have evolved to a multitiered algorithm that attempts to prioritize organs to the most infirm, a designation that fluctuates with trends in therapy. The Organ Procurement and Transplantation Network and its committees have been responsive, as demonstrated by recent modifications to pediatric heart allocation and mechanical circulatory support policies and by ongoing efforts to ensure that heart allocation policies are equitable and current. Here we examine the development of US lung and heart allocation policy, evaluate the application of the current policy on clinical practice and explore future directions for lung and heart allocation.

The role of allogeneic stem cell transplantation for adult acute lymphoblastic leukemia

Acute lymphoblastic leukemia remains a challenging disease in adults. With modern multi-drug induction chemotherapy regimens, complete remission can be achieved in most patients. However, without additional therapy at the time of the first remission, most patients will eventually relapse. Regardless of the treatment option chosen at the time of relapse, outcomes after relapse are poor, with only around 10% of all patients surviving after relapse. Thus, decision-making at the time of achieving the first complete remission is critical. Allogeneic stem cell transplantation is highly effective at preventing relapse, but with significant treatment related toxicity. Ongoing chemotherapy in the form of consolidation and maintenance may be less effective at preventing relapse, but with lower toxicities. Thus, the superiority of allogeneic stem cell transplantation must be balanced against the lower toxicity of consolidation chemotherapy. This decision is further complicated by rapid changes in the field of hematopoietic stem cell transplantation, such as the use of reduced intensity conditioning regimens and alternative stem cell sources such as cord blood transplants. The available evidence suggests that allogeneic transplantation is a viable treatment option for patients in first complete remission, with overall survival superior to traditional consolidation and maintenance chemotherapy. However, whether transplantation based post-remission therapy is superior to modern, pediatric-based non-transplant chemotherapy regimens remains unclear.

Long-term follow-up of patients undergoing auto-SCT for advanced germ cell tumour: a multicentre cohort study

Failure of cisplatin-based chemotherapy in advanced germ cell tumour (GCT) is associated with a poor outcome. High-dose chemotherapy and auto-SCT is one therapeutic option, although the long-term outcome after this procedure is unclear. We conducted a multicentre cohort study of consecutive patients undergoing a single auto-SCT for GCT between January 1986 and December 2004. Of 71 subjects, median follow-up is 10.1 years. OS at 5 years is 44.7% (95% confidence interval (CI) 32.9-56.5%) and EFS is 43.5% (95% CI 31.4-55.1%). There were seven (10%) treatment-related deaths within 100 days of auto-SCT. Three (4.2%) patients developed secondary malignancies. Of 33 relapses, 31 occurred within 2 years of auto-SCT. Two very late relapses were noted 13 and 11 years after auto-SCT. In multivariate analysis, favourable outcome was associated with IGCCC (International Germ Cell Consensus Classification) good prognosis disease at diagnosis, primary gonadal disease and response to salvage chemotherapy. We conclude that auto-SCT results in successful outcome for a relatively large subgroup of patients with high-risk GCT. Late relapses may occur, a finding not previously reported.

MEG response to median nerve stimulation correlates with recovery of sensory and motor function after stroke

OBJECTIVE

Hemiparesis due to damage by stroke in primary motor cortex (MI) or its underlying projections presents a problem for functional neuroimaging technologies that attempt to evaluate the neurophysiological basis for restoration of motor function. Traditional assessments of MI function require patients to move their fingers, hands, or limbs, which can be either impossible or markedly compromised after stroke. We recently demonstrated in normal subjects that magnetoencephalography (MEG), a non-invasive neuromagnetic functional imaging technique, detects neuronal response elicited by electrical median nerve stimulation in MI, as well as primary somatosensory cortex (SI). In the present study, we used the MEG response from median nerve stimulation to investigate the recovery of primary motor and somatosensory in acute ischemic stroke patients.

METHODS

Twelve patients with unilateral ischemic strokes that affected sensorimotor functions of their hand were studied in the acute stage (4.4+/-1.2 days, mean+/-SD) and during a 1-month follow-up (38.6+/-5.6 days, except for one patient's follow-up done 6 month after stroke).

RESULTS

Among the multiple cortical sources localized after median nerve stimulation, one source localized to SI and another localized to the vicinity of MI. Changes in the source strengths of the first component post-stimulus of MI and SI correlated with the extent of recovery of sensorimotor functions as determined by neurological exams.

CONCLUSIONS

This study provides a novel way of indirectly assessing MI function using MEG during the acute stroke phase, when many patients often cannot perform motor tasks due to paralysis.

Associative priming by targets and distractors during rapid serial visual presentation: does word meaning survive the attentional blink?

In 5 experiments, 432 college students viewed lists of words containing 2 targets (Target 1 [T1] and Target 2 [T2]) presented by rapid serial visual presentation at 10 words per second. Identification of T1 caused a 500-ms impairment in the identification of T2 (the attentional blink [AB]). Improved recall of T2 was observed throughout the time course of the AB when T2 was a strong associate of either T1 or a priming distractor (PD). When participants ignored T1, the AB was eliminated, but the amount of priming was not affected. Priming of T2 by PD was temporary (100-200 ms after the onset of PD). Although target priming and distractor priming both survived the AB, the 2 forms of priming appeared to have different bases. In contrast to priming by PD, priming by T1 was larger, modulated by backward associative strength, and longer lasting. Priming and the AB are hypothesized to result from on-line attentional processes, but recall from RSVP lists is also influenced by off-line memory processes.

Associative priming by targets and distractors during rapid serial visual presentation: does word meaning survive the attentional blink?

In 5 experiments, 432 college students viewed lists of words containing 2 targets (Target 1 [T1] and Target 2 [T2]) presented by rapid serial visual presentation at 10 words per second. Identification of T1 caused a 500-ms impairment in the identification of T2 (the attentional blink [AB]). Improved recall of T2 was observed throughout the time course of the AB when T2 was a strong associate of either T1 or a priming distractor (PD). When participants ignored T1, the AB was eliminated, but the amount of priming was not affected. Priming of T2 by PD was temporary (100-200 ms after the onset of PD). Although target priming and distractor priming both survived the AB, the 2 forms of priming appeared to have different bases. In contrast to priming by PD, priming by T1 was larger, modulated by backward associative strength, and longer lasting. Priming and the AB are hypothesized to result from on-line attentional processes, but recall from RSVP lists is also influenced by off-line memory processes.

The influence of illusory contours on the detection of luminance increments and decrements

The experiment of Dresp and Bonnet [(1991) Vision Research, 31, 1813-1817] was replicated and extended to include measurements of both luminance increment and decrement detection across high luminance illusory contours. The results reveal that illusory contours can influence the detectability of both luminance decrements and increments and, in addition, that the magnitude and even the direction of the effect which illusory contours produce on visual thresholds may vary considerably across individual observers. Finally, in contrast to the monophasic pattern of threshold variation across low luminance illusory contours, the pattern across high luminance contours is oscillatory.

Optimal experiments in electrical impedance tomography

Electrical impedance tomography (EIT) is a noninvasive imaging technique which aims to image the impedance within a body from electrical measurements made on the surface. The reconstruction of impedance images is a ill-posed problem which is both extremely sensitive to noise and highly computationally intensive. The authors define an experimental measurement in EIT and calculate optimal experiments which maximize the distinguishability between the region to be imaged and a best-estimate conductivity distribution. These optimal experiments can be derived from measurements made on the boundary. The analysis clarifies the properties of different voltage measurement schemes. A reconstruction algorithm based on the use of optimal experiments is derived. It is shown to be many times faster than standard Newton-based reconstruction algorithms, and results from synthetic data indicate that the images that it produces are comparable.

A hybrid phantom for electrical impedance tomography

One of the design considerations for electrical impedance tomography phantoms is that they must be easy to model accurately. This paper describes a phantom with this property. Experimental results from its evaluation and testing are given.