Optimizing lung cancer radiation therapy: A systematic review of multifactorial risk assessment for radiation-induced lung toxicity

BACKGROUND

Radiation therapy (RT) is essential in treating advanced lung cancer, but may lead to radiation pneumonitis (RP). This systematic review investigates the use of pulmonary function tests (PFT) and other parameters to predict and mitigate RP, thereby improving RT planning.

METHODS

A systematic review sifted through PubMed and on BioMed Central, targeting articles from September 2005 to December 2022 containing the keywords: Lung Cancer, Radiotherapy, and pulmonary function test.

RESULTS

From 1153 articles, 80 were included. RP was assessed using CTCAEv.4 in 30 % of these. Six studies evaluated post-RT quality of life in lung cancer patients, reporting no decline. Patients with RP and chronic obstructive pulmonary disease (COPD) generally exhibited poorer overall survival. Notably, forced expiratory volume in one second (FEV1) and diffusing capacity of the lung for carbon monoxide (DLCO) declined 24 months post-RT, while forced vital capacity (FVC) stayed stable. In the majority of studies, age over 60, tumors located in the lower part of the lung, and low FEV1 before RT were associated with a higher risk of RP. Dosimetric factors (V5, V20, MLD) and metabolic imaging emerged as significant predictors of RP risk. A clinical checklist blending patient and tumor characteristics, PFT results, and dosimetric criteria was proposed for assessing RP risk before RT.

CONCLUSION

The review reveals the multifactorial nature of RP development following RT in lung cancer. This approach should guide individualized management and calls for a prospective study to validate these findings and enhance RP prevention strategies.

[18F]FDG PET/CT for predicting triple-negative breast cancer outcomes after neoadjuvant chemotherapy with or without pembrolizumab

PURPOSE

To determine if pretreatment [18F]FDG PET/CT could contribute to predicting complete pathological complete response (pCR) in patients with early-stage triple-negative breast cancer (TNBC) undergoing neoadjuvant chemotherapy with or without pembrolizumab.

METHODS

In this retrospective bicentric study, we included TNBC patients who underwent [18F]FDG PET/CT before neoadjuvant chemotherapy (NAC) or chemo-immunotherapy (NACI) between March 2017 and August 2022. Clinical, biological, and pathological data were collected. Tumor SUVmax and total metabolic tumor volume (TMTV) were measured from the PET images. Cut-off values were determined using ROC curves and a multivariable model was developed using logistic regression to predict pCR.

RESULTS

N = 191 patients were included. pCR rates were 53 and 70% in patients treated with NAC (N = 91) and NACI (N = 100), respectively (p < 0.01). In univariable analysis, high Ki67, high tumor SUVmax (> 12.3), and low TMTV (≤ 3.0 cm3) were predictors of pCR in the NAC cohort while tumor staging classification (< T3), BRCA1/2 germline mutation, high tumor SUVmax (> 17.2), and low TMTV (≤ 7.3 cm3) correlated with pCR in the NACI cohort. In multivariable analysis, only high tumor SUVmax (NAC: OR 8.8, p < 0.01; NACI: OR 3.7, p = 0.02) and low TMTV (NAC: OR 6.6, p < 0.01; NACI: OR 3.5, p = 0.03) were independent factors for pCR in both cohorts, albeit at different thresholds.

CONCLUSION

High tumor metabolism (SUVmax) and low tumor burden (TMTV) could predict pCR after NAC regardless of the addition of pembrolizumab. Further studies are warranted to validate such findings and determine how these biomarkers could be used to guide neoadjuvant therapy in TNBC patients.

The mutational landscape of skull base and spinal chordomas and the identification of potential prognostic and theranostic biomarkers

OBJECTIVE

Chordomas are rare bone neoplasms characterized by a high recurrence rate and no benefit from any approved medical treatment to date. However, the investigation of molecular alterations in chordomas could be essential to prognosticate, guide clinical decision-making, and identify theranostic biomarkers. The aim of this study was to provide a detailed genomic landscape of a homogeneous series of 64 chordoma samples, revealing driver events, theranostic markers, and outcome-related genomic features.

METHODS

The authors conducted whole-exome sequencing (WES), targeted next-generation sequencing, and RNA sequencing of 64 skull base and spinal chordoma samples collected between December 2006 and September 2020. Clinical, histological, and radiological data were retrospectively analyzed and correlated to genetic findings.

RESULTS

The authors identified homozygous deletions of CDKN2A/2B, PIK3CA mutations, and alterations affecting genes of SWI/SNF chromatin remodeling complexes (PBRM1 and ARID1A) as potential theranostic biomarkers. Using matched germline WES, they observed a higher frequency of a common genetic variant (rs2305089; p.(Gly177Asp)) in TBXT (97.8%, p < 0.001) compared to its distribution in the general population. PIK3CA mutation was identified as an independent biomarker of short progression-free survival (HR 10.68, p = 0.0008). Loss of CDKN2A/2B was more frequently observed in spinal tumors and recurrent tumors.

CONCLUSIONS

In the current study, the authors identified driver events such as PBRM1 and PIK3CA mutations, TBXT alterations, or homozygous deletions of CDKN2A/2B, which could, for some, be considered potential theranostic markers and could allow for identifying novel therapeutic approaches. With the aim of a future biomolecular prognostication classification, alterations affecting PIK3CA and CDKN2A/2B could be considered as poor prognostic biomarkers.

Predictors of toxicity after curative reirradiation with intensity modulated radiotherapy or proton therapy for recurrent head and neck carcinoma: new dose constraints for pharyngeal constrictors muscles and oral cavity

BACKGROUND

Our study aims to identify predictive factors of moderate to severe (grade ≥ 2) late toxicity after reirradiation (reRT) of recurrent head and neck carcinoma (HNC) and explore the correlations between dose organs at risk (OAR) and grade ≥ 2 toxicity.

MATERIAL AND METHODS

Between 09/2007 and 09/2019, 55 patients were re-irradiated with IMRT or proton therapy with curative intent for advanced HNC. Our study included all patients for whom data from the first and second irradiations were available. Co-variables, including interval to reRT, size of re-irradiated PTV, and dose to OAR, were analyzed as potential predictors for developing moderate to severe long-term toxicity with death as a competing risk. Receiver-operator characteristics (ROC) analysis assessed the association between dose/volume parameters and the risk of toxicity.

RESULTS

Twenty-three patients participated in our study. After a median follow-up of 41 months, 65% of the patients experienced grade ≥ 2 late toxicity. The average dose to pharyngeal constrictor muscles (PCM) at the time of reRT showed an association with the risk of grade ≥ 2 dysphagia: AUC = 0.78 (95% CI: 0.53-1), optimal cut-off value = 36.7 Gy (sensitivity 62%/specificity 100%). The average dose to the oral cavity at the time of reRT showed an association with the risk of grade ≥ 2 dysgeusia: AUC = 0.96 (0.89-1), optimal cut-off value = 20.5 Gy (sensitivity 100%/specificity 88%).

CONCLUSION

Our analysis depicted an association between the dose to OAR and the risk of developing moderate to severe dysphagia and dysgeusia and proposed new dose constraints for PCM (36.7 Gy) and oral cavity (20.5 Gy).

Clinical Utility of Pre-Therapeutic [18F]FDG PET/CT Imaging for Predicting Outcomes in Breast Cancer

BACKGROUND

[18F]FDG PET/CT is used for staging and could also provide information associated with clinical outcomes. The objective of this study was to determine the clinical utility of biomarkers measured using [18F]FDG PET/CT to predict the absence of pathological complete response (no-pCR) and recurrence.

METHODS

In this retrospective study, we included patients with non-special-type breast carcinoma who underwent [18F]FDG PET/CT before neoadjuvant chemotherapy between 2011 and 2019. Clinicopathological data were collected. Tumor SUVmax and total metabolic tumor volume (TMTV) were measured from PET images. The association between biomarkers and no-pCR was studied using logistic regression. The cut-off value was determined using the area under the ROC Curve. To predict 3-year recurrence-free survival (RFS), we used a multivariable Cox model, and the cut-off value was determined using time-dependent ROC and predictiveness curves.

RESULTS

Two hundred and eighty-six patients were included in the analysis. One hundred and twelve patients had a pCR (39.2%). The pCR rate was significantly higher in patients with a high nuclear grade (p < 0.01), HER2+ and TNBC subtypes (p < 0.01), high Ki67 (p < 0.01), and low TMTV (p < 0.01). A high TMTV value (>9.0 cm3) was significantly associated with no-pCR in the whole cohort (OR = 2.4, 95% CI: 1.3-4.2, p < 0.01). After a median follow-up of 4.5 years, 65 patients experienced recurrence and 39 patients died. High TMTV (>13.5 cm3) was associated with shorter RFS (HR = 4.0, 95% CI: 1.9-8.4, p < 0.01).

CONCLUSION

High TMTV in pre-therapeutic imaging is associated with no-pCR and recurrence. It can help in identifying high-risk patients and be considered as an intensified or alternative adjuvant therapy for closely monitoring patients.

Curative high-dose reirradiation for patients with recurrent head and neck adenoid cystic carcinomas: outcomes and analysis of patterns of failure

BACKGROUND

To investigate the outcomes of patients who underwent curative reirradiation (reRT), with intensity-modulated radiation therapy (IMRT) or proton therapy (PT) for unresectable recurrent or second primary head and neck adenoid cystic carcinoma (HNACC).

METHODS

Ten patients, mostly KPS 90%, were reirradiated (3/10 with IMRT and 7/10 with PT) at a median maximum dose to the CTV of 64.2 Gy from July 2011 to November 2021. Locations at the time of reRT were mainly the sinus (4/10) and the salivary glands (including the parotid and submandibular gland, 3/10). CTCAEv5 was used to assess acute and late toxicities. Follow-up was the time between the end of reRT and the date of last news.

RESULTS

The median time between the two irradiations was 53.5 months (IQR: 18-84). After a median follow-up of 26 months (range, 12.5-51.8 months), six patients had developed a locoregional recurrence (LR), of which four occurred within the previously irradiated volume. Two and three-year locoregional failure-free survival (LFFS) and overall survival (OS) were 55.6% [95%CI: 31-99.7%], and 41% [18.5-94%] and 66.7% [42-100%] and 44.4% [21.4-92.3%], respectively. LFFS and OS were significantly better in the subgroup of sinus tumors (p = .013) and the subgroup of patients re-irradiated more than two years after the first course of irradiation (p = .01). Seven patients had impairments before the start of reRT, including hearing impairment (3/10) and facial nerve impairment (3/10). The most severe late toxicities were brain necrosis (2/10), osteoradionecrosis (1/10) and vision decreased (1/10).

CONCLUSION

Curative reRT for HNACC is possible for selected cases, but the LR rate in the irradiated field and the risk of severe toxicity remain high. Improved selection criteria and more carefully defined target volumes may improve outcome in these patients. A further study including larger cohort of patients would be useful to confirm these results.

PET/CT and SPECT/CT Imaging of HER2-Positive Breast Cancer

HER2 (Human Epidermal Growth Factor Receptor 2)-positive breast cancer is characterized by amplification of the HER2 gene and is associated with more aggressive tumor growth, increased risk of metastasis, and poorer prognosis when compared to other subtypes of breast cancer. HER2 expression is therefore a critical tumor feature that can be used to diagnose and treat breast cancer. Moving forward, advances in HER2 in vivo imaging, involving the use of techniques such as positron emission tomography (PET) and single-photon emission computed tomography (SPECT), may allow for a greater role for HER2 status in guiding the management of breast cancer patients. This will apply both to patients who are HER2-positive and those who have limited-to-minimal immunohistochemical HER2 expression (HER2-low), with imaging ultimately helping clinicians determine the size and location of tumors. Additionally, PET and SPECT could help evaluate effectiveness of HER2-targeted therapies, such as trastuzumab or pertuzumab for HER2-positive cancers, and specially modified antibody drug conjugates (ADC), such as trastuzumab-deruxtecan, for HER2-low variants. This review will explore the current and future role of HER2 imaging in personalizing the care of patients diagnosed with breast cancer.

Nivolumab plus chemoradiotherapy in locally-advanced cervical cancer: the NICOL phase 1 trial

Concurrent chemoradiotherapy (CRT) with blockade of the PD-1 pathway may enhance immune-mediated tumor control through increased phagocytosis, cell death, and antigen presentation. The NiCOL phase 1 trial (NCT03298893) is designed to determine the safety/tolerance profile and the recommended phase-II dose of nivolumab with and following concurrent CRT in 16 women with locally advanced cervical cancer. Secondary endpoints include objective response rate (ORR), progression free survival (PFS), disease free survival, and immune correlates of response. Three patients experience grade 3 dose-limiting toxicities. The pre-specified endpoints are met, and overall response rate is 93.8% [95%CI: 69.8-99.8%] with a 2-year PFS of 75% [95% CI: 56.5-99.5%]. Compared to patients with progressive disease (PD), progression-free (PF) subjects show a brisker stromal immune infiltrate, higher proximity of tumor-infiltrating CD3+ T cells to PD-L1+ tumor cells and of FOXP3+ T cells to proliferating CD11c+ myeloid cells. PF show higher baseline levels of PD-1 and ICOS-L on tumor-infiltrating EMRA CD4+ T cells and tumor-associated macrophages, respectively; PD instead, display enhanced PD-L1 expression on TAMs, higher peripheral frequencies of proliferating Tregs at baseline and higher PD-1 levels at week 6 post-treatment initiation on CD4 and CD8 T cell subsets. Concomitant nivolumab plus definitive CRT is safe and associated with encouraging PFS rates. Further validation in the subset of locally advanced cervical cancer displaying pre-existing, adaptive immune activation is warranted.

68 Ga-DOTATOC PET/CT Imaging of a Muscular Solitary Fibrous Tumor

ABSTRACT

A 73-year-old woman was referred for 68 Ga-DOTATOC PET/CT staging of a grade 2 pancreatic neuroendocrine tumor, which showed the primary pancreatic tumor, liver metastases, one left pleural metastasis, and high uptake in a mass of the right triceps brachii muscle. Two years before, she underwent 18 F-FDG PET/CT and 111 In-pentetreotide scan, respectively, with low and high uptake of each radiotracer in the triceps mass. Histopathological analysis revealed a solitary fibrous tumor. Immunohistochemistry showed no staining for SSTR-2 and SSTR-5, suggesting tumor overexpression of another somatostatin receptor. This case highlighted a potential pitfall on 68 Ga-DOTATOC PET/CT.

Total Metabolic Tumor Volume on 18F-FDG PET/CT Is a Useful Prognostic Biomarker for Patients with Extensive Small-Cell Lung Cancer Undergoing First-Line Chemo-Immunotherapy

Background: We aimed to evaluate the prognostic value of imaging biomarkers on 18F-FDG PET/CT in extensive-stage small-cell lung cancer (ES-SCLC) patients undergoing first-line chemo-immunotherapy. Methods: In this multicenter and retrospective study, we considered two cohorts, depending on the type of first-line therapy: chemo-immunotherapy (CIT) versus chemotherapy alone (CT). All patients underwent baseline 18-FDG PET/CT before therapy between June 2016 and September 2021. We evaluated clinical, biological, and PET parameters, and used cutoffs from previously published studies or predictiveness curves to assess the association with progression-free survival (PFS) or overall survival (OS) with Cox prediction models. Results: Sixty-eight patients were included (CIT: CT) (36: 32 patients). The median PFS was 5.9:6.5 months, while the median OS was 12.1:9.8 months. dNLR (the derived neutrophils/(leucocytes-neutrophils) ratio) was an independent predictor of short PFS and OS in the two cohorts (p < 0.05). High total metabolic tumor volume (TMTV^high if > 241 cm³) correlated with outcomes, but only in the CIT cohort (PFS for TMTV^high in multivariable analysis: HR 2.5; 95%CI 1.1-5.9). Conclusion: Baseline 18F-FDG PET/CT using TMTV could help to predict worse outcomes for ES-SCLC patients undergoing first-line CIT. This suggests that baseline TMTV may be used to identify patients that are unlikely to benefit from CIT.

[18F]-FDG PET and MRI radiomic signatures to predict the risk and the location of tumor recurrence after re-irradiation in head and neck cancer

PURPOSE

To evaluate whether radiomics from [18F]-FDG PET and/or MRI before re-irradiation (reRT) of recurrent head and neck cancer (HNC) could predict the occurrence and the location "in-field" or "outside" of a second locoregional recurrence (LR).

METHODS

Among the 55 patients re-irradiated at curative intend for HNC from 2012 to 2019, 48 had an MRI and/or PET before the start of the reRT. Thirty-nine radiomic features (RF) were extracted from the re-irradiated GTV (rGTV) using LIFEx software. Student t tests and Spearman correlation coefficient were used to select the RF that best separate patients who recurred from those who did not, and "in-field" from "outside" recurrences. Principal component analysis involving these features only was used to create a prediction model. Leave-one-out cross-validation was performed to evaluate the models.

RESULTS

After a median follow-up of 17 months, 40/55 patients had developed a second LR, including 18 "in-field" and 22 "outside" recurrences. From pre-reRT MRI, a model based on three RF (GLSZM_SZHGLE, GLSZM_LGLZE, and skewness) predicted whether patients would recur with a balanced accuracy (BA) of 83.5%. Another model from pre-reRT MRI based on three other RF (GLSZM_ LZHGE, NGLDM_Busyness, and GLZLM_SZE) predicted whether patients would recur "in-field" or "outside" with a BA of 78.5%. From pre-reRT PET, a model based on four RF (Kurtosis, SUVbwmin, GLCM_Correlation, and GLCM_Contrast) predicted the LR location with a BA of 84.5%.

CONCLUSION

RF characterizing tumor heterogeneity extracted from pre-reRT PET and MRI predicted whether patients would recur, and whether they would recur "in-field" or "outside".

Voxel-wise supervised analysis of tumors with multimodal engineered features to highlight interpretable biological patterns

Background

Translation of predictive and prognostic image‐based learning models to clinical applications is challenging due in part to their lack of interpretability. Some deep‐learning‐based methods provide information about the regions driving the model output. Yet, due to the high‐level abstraction of deep features, these methods do not completely solve the interpretation challenge. In addition, low sample size cohorts can lead to instabilities and suboptimal convergence for models involving a large number of parameters such as convolutional neural networks.

Purpose

Here, we propose a method for designing radiomic models that combines the interpretability of handcrafted radiomics with a sub‐regional analysis.

Materials and methods

Our approach relies on voxel‐wise engineered radiomic features with average global aggregation and logistic regression. The method is illustrated using a small dataset of 51 soft tissue sarcoma (STS) patients where the task is to predict the risk of lung metastasis occurrence during the follow‐up period.

Results

Using positron emission tomography/computed tomography and two magnetic resonance imaging sequences separately to build two radiomic models, we show that our approach produces quantitative maps that highlight the signal that contributes to the decision within the tumor region of interest. In our STS example, the analysis of these maps identified two biological patterns that are consistent with STS grading systems and knowledge: necrosis development and glucose metabolism of the tumor.

Conclusions

We demonstrate how that method makes it possible to spatially and quantitatively interpret radiomic models amenable to sub‐regions identification and biological interpretation for patient stratification.

Absolute lymphocyte count after COVID-19 vaccination is associated with vaccine-induced hypermetabolic lymph nodes on 18F-FDG PET/CT: a focus in breast cancer care

We aimed to predict the presence of vaccine-induced hypermetabolic lymph nodes (v-HLNs) on ¹⁸F-FDG PET/CT after coronavirus disease 2019 (COVID-19) vaccination and determine their association with lymphocyte counts. Methods: In this retrospective single-center study, we included consecutive patients who underwent ¹⁸F-FDG PET/CT imaging after messenger RNA– or viral vector–based COVID-19 vaccination between early March and late April 2021. Demographics, clinical parameters, and absolute lymphocyte count (ALC) were collected, and their association with the presence of v-HLNs in the draining territory was studied by logistic regression. Results: In total, 260 patients were eligible, including 209 (80%) women and 145 (56%) with breast cancer. The median age was 50 y (range, 23–96 y). The messenger RNA vaccine had been given to 233 (90%). Ninety (35%) patients had v-HLNs, with a median SUV_max of 3.7 (range, 2.0–26.3), and 74 (44%) displayed lymphopenia, with a median ALC of 1.4 × 10⁹/L (range, 0.3–18.3 × 10⁹/L). An age of no more than 50 y (odds ratio [OR], 2.2; 95% CI, 1.0–4.5), the absence of lymphopenia (OR, 2.2; 95% CI, 1.1–4.3), and less than a 30-d interval from the last vaccine injection to the ¹⁸F-FDG PET/CT (OR, 2.6; 95% CI, 1.3–5.6) were independent factors for v-HLNs on multivariate analysis. In breast cancer patients, the absence of lymphopenia was the only independent factor significantly associated with v-HLNs (OR, 2.9; 95% CI, 1.2–7.4). Conclusion: Patients with a normal ALC after COVID-19 vaccination were more likely to have v-HLNs on ¹⁸F-FDG PET/CT, both of which might be associated with a stronger immune response to vaccination.

Prognostic value of inflammatory response biomarkers using peripheral blood and [18F]-FDG PET/CT in advanced NSCLC patients treated with first-line chemo- or immunotherapy

OBJECTIVES

We aimed to compare the prognostic value of inflammatory biomarkers extracted from pretreatment peripheral blood and [18F]-FDG PET for estimating outcomes in non-small cell lung cancer (NSCLC) patients treated with first-line immunotherapy (IT) or chemotherapy (CT).

MATERIALS AND METHODS

In this retrospective multicenter study, we evaluated 111 patients with advanced NSCLC who underwent baseline [18F]-FDG PET/CT before IT or CT between 2016 and 2019. Several blood inflammatory indices were evaluated: derived neutrophil-to-lymphocyte ratio (dNLR), platelet-to-lymphocyte ratio (PLR), C-reactive protein (CRP) and systemic immune-inflammation index (SII). FDG-PET inflammatory parameters were extracted from lymphoid tissues (BLR and SLR: bone marrow or spleen-to-Liver SUVmax ratios). Association with survival and relationships between parameters were evaluated using Cox prediction models and Spearman's correlation respectively.

RESULTS

Overall, 90 patients were included (IT:CT) (51:39pts). Median PFS was 8.6:6.6 months and median OS was not reached:21.2 months. In the IT cohort, high dNLR (>3), high SII (≥1,270) and high SLR (0.77) were independent statistically significant prognostic factors for one-year progression-free survival (1y-PFS) and two-year overall survival (2y-OS) on multivariable analysis. In the CT cohort, high BLR (≥0.80) and high dNLR (>3) were associated with shorter 1y-PFS (HR 2.2, 95% CI 1.0-4.9) and 2y-OS (HR 3.4, 95CI 1.1-10.3) respectively, on multivariable analysis. Finally, BLR significantly but moderately correlated with most blood-based inflammatory indices (CRP, PLR and SII) while SLR was only associated with CRP (p < 0.01 for all).

CONCLUSION

In advanced NSCLC patients undergoing first-line IT or CT, pretreatment blood and inflammatory factors evaluating the spleen or bone marrow on [18F]-FDG PET/CT provided prognostic information for 1y-PFS and 2y-OS. These biomarkers should be further evaluated for potential clinical application.

Don't overlook spleen glucose metabolism on [18F]-FDG PET/CT for cancer drug discovery and development

Fluorine-18-fluorodeoxyglucose ([18F]-FDG) positron emission tomography/computed tomography (PET/CT) is a useful tool that assesses glucose metabolism in tumor cells to help guide management of cancer patients. However, the clinical relevance of glucose metabolism in healthy tissues, including hematopoietic tissues such as the spleen, has been potentially overlooked. Recent studies suggested that spleen glucose metabolism could improve the management of different cancers. Overall, the current literature includes 1,157 patients, with a wide range of tumor types. The prognostic and/or predictive value of spleen metabolism have been demonstrated in a broad spectrum of therapies including surgery and systemic cancer therapies. Most of these studies showed that high spleen glucose metabolism at baseline is associated with a poor outcome while treatment-induce change in spleen glucose metabolism is a multi-faceted surrogate of cancer-related inflammation, which correlates with immunosuppressive tumor microenvironment as well as with immune activation. In this systematic review, we seek to unravel the prognostic/predictive significance of spleen glucose metabolism on [18F]-FDG PET/CT and discuss how it could potentially guide cancer patient management in the future.

Immune Response Visualized In Vivo by [18F]-FDG PET/CT after COVID-19 Vaccine

Worldwide deployment of COVID-19 vaccines is in progress. Recent immune activation following vaccination can sometimes be seen in fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography ([18F]-FDG PET/CT). As previously evidenced, FDG-avid axillary lymph node(s) are common in patients receiving vaccines against SARS-CoV-2, influenza virus, or human papillomavirus, and reflect a regional immune response. In addition, these findings may also be accompanied by an increased spleen glucose metabolism after the COVID-19 vaccine, which captures a systemic immune response. Hence, we provide here a clinical example demonstrating that immune response could be associated with increased glucose metabolism in lymphoid organs such as lymph nodes and the spleen, which are critical modulators of T cell immunity. We believe that it is of paramount importance that nuclear physicians should be able to recognize clinical and imaging features of such immune responses upon vaccination for COVID-19 and beyond.

Total metabolic tumor volume and spleen metabolism on baseline [18F]-FDG PET/CT as independent prognostic biomarkers of recurrence in resected breast cancer

PURPOSE

We evaluated whether biomarkers on baseline [¹⁸F]-FDG PET/CT are associated with recurrence after surgery in patients with invasive breast cancer of no special type (NST).

METHODS

In this retrospective single-center study, we included consecutive patients with non-metastatic breast cancer of NST who underwent [¹⁸F]-FDG PET/CT before treatment, including surgery, between 2011 and 2016. Clinicopathological data were collected. Tumor SUVmax, total metabolic tumor volume (TMTV), and spleen- and bone marrow-to-liver SUVmax ratios (SLR, BLR) were measured from the PET images. Cut-off values were determined using predictiveness curves to predict 5-year recurrence-free survival (5y-RFS). A multivariable prediction model was developed using Cox regression. The association with stromal tumor-infiltrating lymphocytes (TILs) levels (low if <50%) was studied by logistic regression.

RESULTS

Three hundred and three women were eligible, including 93 (31%) with triple-negative breast carcinoma. After a median follow-up of 6.2 years, 56 and 35 patients experienced recurrence and death, respectively. The 5y-RFS rate was 86%. In multivariable analyses, high TMTV (>20 cm3) and high SLR (>0.76) were associated with shorter 5y-RFS (HR 2.4, 95%CI 1.3-4.5, and HR 1.9, 95%CI 1.0-3.6). In logistic regression, high SLR was the only independent factor associated with low stromal TILs (OR 2.8, 95%CI 1.4-5.7).

CONCLUSION

High total metabolic tumor volume and high spleen glucose metabolism on baseline [¹⁸F]-FDG PET/CT were associated with poor 5y-RFS after surgical resection in patients with breast cancer of NST. Spleen metabolism was inversely correlated with stromal TILs and might be a surrogate for an immunosuppressive tumor microenvironment.

Primary lymphedema French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins)

Primary lymphedema is a rare chronic pathology associated with constitutional abnormalities of the lymphatic system. The objective of this French National Diagnosis and Care Protocol (Protocole National de Diagnostic et de Soins; PNDS), based on a critical literature review and multidisciplinary expert consensus, is to provide health professionals with an explanation of the optimal management and care of patients with primary lymphedema. This PNDS, written by consultants at the French National Referral Center for Primary Lymphedema, was published in 2019 (https://has-sante.fr/upload/docs/application/pdf/2019-02/pnds_lymphoedeme_primaire_final_has.pdf). Primary lymphedema can be isolated or syndromic (whose manifestations are more complex with a group of symptoms) and mainly affects the lower limbs, or, much more rarely, upper limbs or external genitalia. Women are more frequently affected than men, preferentially young. The diagnosis is clinical, associating mild or non-pitting edema and skin thickening, as confirmed by the Stemmer’s sign (impossibility to pinch the skin on the dorsal side or the base of the second toe), which is pathognomonic of lymphedema. Limb lymphoscintigraphy is useful to confirm the diagnosis. Other causes of swelling or edema of the lower limbs must be ruled out, such as lipedema. The main acute lymphedema complication is cellulitis (erysipelas). Functional and psychological repercussions can be major, deteriorating the patient’s quality of life. Treatment aims to prevent those complications, reduce the volume with low-stretch bandages, then stabilize it over the long term by exercises and wearing a compression garment. Patient education (or parents of a child) is essential to improve observance.

Metabolic Response by 18F-FDG PET/CT in Metastatic Malignant Struma Ovarii Treated With Targeted Therapies

Malignant struma ovarii (MSO) is a rare malignant ovarian tumor, histologically identical to differentiated thyroid cancers. Given the rarity of this disease, there are no treatment guidelines, and the place of imaging for response assessment remains controversial. We report a metabolic response assessed by F-FDG PET/CT in a 71-year-old woman with radioiodine-refractory metastatic MSO treated by targeted therapies (first line with lenvatinib and second line with pazopanib). This case of exceptional response also highlights the usefulness of F-FDG PET/CT for therapeutic assessment of targeted drugs in such a rare clinical entity of malignant MSO.

FDG-PET biomarkers associated with long-term benefit from first-line immunotherapy in patients with advanced non-small cell lung cancer

OBJECTIVE

To determine FDG-PET biomarkers associated with long-term benefit (LTB) and survival in advanced non-small cell lung cancer (NSCLC) patients receiving first-line immunotherapy.

METHODS

In this multicenter study, we retrospectively analyzed advanced NSCLC patients with a PD-L1 tumor proportion score (TPS) ≥ 50%, who underwent FDG-PET/CT before first-line pembrolizumab, received from August 2017 to September 2019. Parameters extracted were SUVmax, SUVmean, TMTV (total metabolic tumor volume) and TLG (total lesion glycolysis). LTB was defined as objective (complete or partial) response or stable disease as best overall response, maintained for ≥ 12 months. A multivariate prediction model was developed using logistic regression for LTB and Cox models for progression-free survival (PFS) and overall survival (OS).

RESULTS

On the 63 eligible patients, with a median follow-up of 13.4 (range, 1.5-29.1) months, 17 (27%) had LTB. Median PFS and OS were 7.7 months (95%CI 5.0-10.5) and 12.1 months (95%CI 8.6-15.6). In multivariate analyses, high TMTV (> 84cm³) and high tumor SUVmean (> 10.1) remained independent factors for predicting LTB (OR 0.2; p = 0.03 and OR 3.7; p = 0.04) and PFS (HR 2.2; p = 0.02 and HR 0.5; p = 0.045). High TMTV was significantly associated with poor OS (HR 3.1; p = 0.03). No association was observed between tumor SUVmax or TLG and clinical outcomes.

CONCLUSIONS

In patients with advanced NSCLC and PD-L1 TPS ≥ 50%, baseline low TMTV and high tumor SUVmean correlate with survival and LTB from upfront pembrolizumab. Beyond the initial staging, FDG-PET/CT scan could provide relevant biomarkers associated with clinical outcomes that should be taken into account when considering first-line treatment options.

Clinical Implications of 18F-FDG PET/CT in Malignant Glomus Tumors of the Esophagus

The majority of glomus tumors are localized to cutaneous sites and are benign. However, extracutaneous malignant glomus tumors have been reported and are aggressive. Here, we report a case of a 45-year-old man who presented severe dysphagia, diagnosed with malignant glomus tumor of the esophagus. F-FDG PET/CT played a decisive role in several phases of the patient management offering previously unknown accuracy. It was first performed in the initial staging of local tumor extent before surgery. A year and a half after, F-FDG PET/CT helped to detect recurrence and, finally, was performed for response evaluation of several systemic therapies.

Early metabolic response of breast cancer to neoadjuvant endocrine therapy: comparison to morphological and pathological response

Background

Neoadjuvant endocrine therapy (NET) has shown efficacy in terms of clinical response and surgical outcome in postmenopausal patients with estrogen receptor-positive / HER2-negative breast cancer (ER+/HER2- BC) but monitoring of tumor response is challenging. The aim of the present study was to investigate the value of an early metabolic response compared to morphological and pathological responses in this population.

Methods

This was an ancillary study of CARMINA 02, a phase II clinical trial evaluating side-by-side the efficacy of 4 to 6 months of anastrozole or fulvestrant. Positron Emission Tomography/Computed Tomography using 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG-PET/CT) scans were performed at baseline (M0), early after 1 month of treatment (M1) and pre-operatively in 11 patients (74.2 yo ± 3.6). Patients were classified as early “metabolic responders” (mR) when the decrease of SUVmax was higher than 40%, and “metabolic non-responders” (mNR) otherwise. Early metabolic response was compared to morphological response (palpation, US and MRI), variation of Ki-67 index, pathological response according to the Sataloff classification and also to Preoperative Endocrine Prognostic Index (PEPI) score. It was also correlated with overall survival (OS) and recurrence-free survival (RFS).

Results

Tumor size measured on US and on MRI was smaller in mR than mNR, with the highest statistically significant difference at M1 (p = 0.01 and 7.1 × 10^− 5, respectively). No statistically significant difference in the variation of tumor size between M0 and M1 assessed on US or MRI was observed between mR and mNR. mR had a better clinical response: no progressive disease in mR vs 2 in mNR and 2 partial response in mR vs 1 partial response in mNR. One patient with a pre-operative complete metabolic response had the best pathological response. Pathological response did not show any statistically significant difference between mR and mNR. mR had better OS and RFS (Kaplan-Meier p = 0.08 and 0.06, respectively). All cancer-related events occurred in mNR: 3 patients died, 2 of them from progressive disease.

Conclusions

FDG-PET/CT imaging could become a “surrogate marker” to monitor tumor response, especially as NET is a valuable treatment option in postmenopausal women with ER+/HER2- BC.

A Postreconstruction Harmonization Method for Multicenter Radiomic Studies in PET

Several reports have shown that radiomic features are affected by acquisition and reconstruction parameters, thus hampering multicenter studies. We propose a method that, by removing the center effect while preserving patient-specific effects, standardizes features measured from PET images obtained using different imaging protocols. Methods: Pretreatment ¹⁸F-FDG PET images of patients with breast cancer were included. In one nuclear medicine department (department A), 63 patients were scanned on a time-of-flight PET/CT scanner, and 16 lesions were triple-negative (TN). In another nuclear medicine department (department B), 74 patients underwent PET/CT on a different brand of scanner and a different reconstruction protocol, and 15 lesions were TN. The images from department A were smoothed using a gaussian filter to mimic data from a third department (department A-S). The primary lesion was segmented to obtain a lesion volume of interest (VOI), and a spheric VOI was set in healthy liver tissue. Three SUVs and 6 textural features were computed in all VOIs. A harmonization method initially described for genomic data was used to estimate the department effect based on the observed feature values. Feature distributions in each department were compared before and after harmonization. Results: In healthy liver tissue, the distributions significantly differed for 4 of 9 features between departments A and B and for 6 of 9 between departments A and A-S (P < 0.05, Wilcoxon test). After harmonization, none of the 9 feature distributions significantly differed between 2 departments (P > 0.1). The same trend was observed in lesions, with a realignment of feature distributions between the departments after harmonization. Identification of TN lesions was largely enhanced after harmonization when the cutoffs were determined on data from one department and applied to data from the other department. Conclusion: The proposed harmonization method is efficient at removing the multicenter effect for textural features and SUVs. The method is easy to use, retains biologic variations not related to a center effect, and does not require any feature recalculation. Such harmonization allows for multicenter studies and for external validation of radiomic models or cutoffs and should facilitate the use of radiomic models in clinical practice.

Metastatic Renal Cell Carcinoma in a Renal Allograft: A Sustained Complete Remission After Stimulated Rejection

We report the case of a 40-year-old woman who recovered from a diffuse metastatic renal cell carcinoma that developed from a kidney allograft. She was successfully treated by the induction of tumor rejection. Immunosuppression was discontinued, and transplant nephrectomy was deliberately delayed based on the expectation that the tumor mass would trigger the alloimmune response, which was stimulated with pegylated interferon-α-2a. Three years later, the patient remained in complete remission. Despite this severe context, the present case shows that the poor prognosis of allograft metastatic renal cell carcinoma could be dramatically reversed by taking advantage of the donor tumor origin to actively induce a specific alloimmune rejection of the tumor.

Abstract P4-01-03: Predictive value of FDG-PET/CT after neoadjuvant endocrine treatment in breast cancer

Background: Neaodjuvant endocrine therapy (NET) has demonstrated efficacy in terms of clinical response and outcome in hormone-receptor positive (HR+) post-menopausal patients (pts) with breast cancer (BC) not eligible for primary breast conservative surgery (BCS). However, the monitoring of tumor response to NET is challenging and clinical response is the current gold standard. The aim of the present study was to investigate the contribution of the early metabolic response (eMR) at one month in FDG-PET/CT in a NET setting for post-menopausal pts with HR+, HER2- BC compared to morphological and pathological responses. We also aimed to evaluate the prognostic value of eMR.

Methods: This was a prospective and ancillary study of CARMINA 02, UCBG0609 (Cancer in press), a phase II clinical trial evaluating the efficacy of 4 to 6 months neoadjuvant anastrozole or fulvestrant. FDG-PET/CT exams were performed at baseline (M0), after 1 month of treatment (M1: eMR) and pre-Op (late metabolic response: lMR) in 11 pts (74.2 years ± 3.6) from 2007 to 2010. Pts were classified “metabolic responders” (mR) if SUVmax values decrease was ≥ 40% at M1 and “non-metabolic responders” (mNR) if otherwise; lMR was also assessed in mR and mNR groups defined at M1. We compared eMR to morphological response (clinical, breast US and MRI) at M1 and pre-op, to the pathological response according to Sataloff classification and to Ki67 score variation during treatment. Early metabolic response was also correlated with the PEPI (Preoperative Endocrine Prognostic Index) score and survival (overall survival, OS and relapse free survival, RFS).

Results: Main results are summarized in Table I. There was a significant difference between mR and mNR pts at M1 (eMR) and pre-op (lMR). One patient with a complete metabolic response at pre-op had the best pathological response (Sataloff TB). Also, mR pts had a better clinical response: 2 partial response (PR) in mR vs 1 in mNR group and 2 mNR patients were classified PD (progressive disease). There was a trend toward better survival for mR pts in OS and RFS (Kaplan-Meier p=0.18 and 0.06, respectively) and all the pejorative events occurred in the mNR group: 3 deaths and 3 metastatic progressions. Besides, no difference in eMR was observed regarding the histological subtype (ductal or lobular; p&gt;0.05) nor the treatment group (p&gt;0.05).

Table I: Metabolic, morphological and pathological response at M1, Pre-Op and on the surgical specimen.  MR : 5ptsmNR : 6ptsP valueM1SUVmax2.6±1.13.9±1.40.00017 Clinical size42.5mm±11.951.7mm±7.50.19 US size22.6mm±6.334.2mm±2.40.02 MRI size21.2mm±4.239.7mm±4.79.16 E-5 Ki 673.6%±1.98.2%±80.19Pre-OpSUVmax2±1.33.3±1.40.018 Clinical size31mm±12.448.3mm±10.80.035 US size18.5mm±7.331.3mm±9.50.07 MRI size17.9mm±7.134.8mm±7.70.003Surgical SpecimenSataloff (TA+TB vs TC+TD)20% vs 80%0 vs 100%1 PEPI score (I+II vs III)80% vs 20%33 vs 67%0.048 Ki 678.6%±9.812.3%±7.90.41

Conclusions: These preliminary results showed the value of the early metabolic response in FDG- PET/CT in a NET setting compared to the morphological or the pathological responses alone. Early metabolic responders patients had better OS, RFS and PEPI scores.

Citation Format: Boughdad S, Champion L, Becette V, Cherel P, Fourme E, Edeline V, Lemonnier J, Lerebours F, Alberini JL. Predictive value of FDG-PET/CT after neoadjuvant endocrine treatment in breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-01-03.

18F-FDG PET/CT to Predict Response to Neoadjuvant Chemotherapy and Prognosis in Inflammatory Breast Cancer

The aim of this prospective study was to assess the predictive value of (18)F-FDG PET/CT imaging for pathologic response to neoadjuvant chemotherapy (NACT) and outcome in inflammatory breast cancer (IBC) patients.

METHODS

Twenty-three consecutive patients (51 y ± 12.7) with newly diagnosed IBC, assessed by PET/CT at baseline (PET1), after the third course of NACT (PET2), and before surgery (PET3), were included. The patients were divided into 2 groups according to pathologic response as assessed by the Sataloff classification: pathologic complete response for complete responders (stage TA and NA or NB) and non-pathologic complete response for noncomplete responders (not stage A for tumor or not stage NA or NB for lymph nodes). In addition to maximum standardized uptake value (SUVmax) measurements, a global breast metabolic tumor volume (MTV) was delineated using a semiautomatic segmentation method. Changes in SUVmax and MTV between PET1 and PET2 (ΔSUV1-2; ΔMTV1-2) and PET1 and PET3 (ΔSUV1-3; ΔMTV1-3) were measured.

RESULTS

Mean SUVmax on PET1, PET2, and PET3 did not statistically differ between the 2 pathologic response groups. On receiver-operating-characteristic analysis, a 72% cutoff for ΔSUV1-3 provided the best performance to predict residual disease, with sensitivity, specificity, and accuracy of 61%, 80%, and 65%, respectively. On univariate analysis, the 72% cutoff for ΔSUV1-3 was the best predictor of distant metastasis-free survival (P = 0.05). On multivariate analysis, the 72% cutoff for ΔSUV1-3 was an independent predictor of distant metastasis-free survival (P = 0.01).

CONCLUSION

Our results emphasize the good predictive value of change in SUVmax between baseline and before surgery to assess pathologic response and survival in IBC patients undergoing NACT.

¹⁸F-FDG PET/CT imaging versus dynamic contrast-enhanced CT for staging and prognosis of inflammatory breast cancer

PURPOSE

Inflammatory breast cancer (IBC) is the most aggressive type of breast cancer with a poor prognosis. Locoregional staging is based on dynamic contrast-enhanced (DCE) CT or MRI. The aim of this study was to compare the performances of FDG PET/CT and DCE CT in locoregional staging of IBC and to assess their respective prognostic values.

METHODS

The study group comprised 50 women (median age: 51 ± 11 years) followed in our institution for IBC who underwent FDG PET/CT and DCE CT scans (median interval 5 ± 9 days). CT enhancement parameters were net maximal enhancement, net early enhancement and perfusion.

RESULTS

The PET/CT scans showed intense FDG uptake in all primary tumours. Concordance rate between PET/CT and DCE CT for breast tumour localization was 92%. No significant correlation was found between SUVmax and CT enhancement parameters in primary tumours (p > 0.6). PET/CT and DCE CT results were poorly correlated for skin infiltration (kappa = 0.19). Ipsilateral foci of increased axillary FDG uptake were found in 47 patients (median SUV: 7.9 ± 5.4), whereas enlarged axillary lymph nodes were observed on DCE CT in 43 patients. Results for axillary node involvement were fairly well correlated (kappa = 0.55). Nineteen patients (38%) were found to be metastatic on PET/CT scan with a significant shorter progression-free survival than patients without distant lesions (p = 0.01). In the primary tumour, no statistically significant difference was observed between high and moderate tumour FDG uptake on survival, using an SUVmax cut-off of 5 (p = 0.7 and 0.9), or between high and low tumour enhancement on DCE CT (p > 0.8).

CONCLUSION

FDG PET/CT imaging provided additional information concerning locoregional involvement to that provided by DCE CT on and allowed detection of distant metastases in the same whole-body procedure. Tumour FDG uptake or CT enhancement parameters were not correlated and were not found to have any prognostic value.

An open-label randomized, multicenter, phase II study on neoadjuvant treatment with trastuzumab plus docetaxel versus trastuzumab plus docetaxel plus bevacizumab according to positron emission tomography (PET) value modification in patients with early stage HER2-positive breast cancer (AVATAXHER): Design description

TPS646

Background: For patients with early HER2+ breast cancer at diagnosis, addition of trastuzumab (T) to 6 cycles of preoperative docetaxel (D) can reach a pathological complete response (pCR) in ~50% of cases, and a high rate of conservative surgery. pCR can be predicted by changes of Fluorodeoxyglucose (FDG) tumor uptake evaluated by Positon Emission Tomography (PET) after one cycle of therapy. In order to increase this pCR rate, adding an antiangiogenic compound could be considered. Pre-clinical and phase I-II data support that the combination of bevacizumab (B) and T is synergistic and safe when patients are chemotherapy naïve. The neoadjuvant AVATAXHER trial (EUDRACT 2009-013410-26) investigates the potential increase of pCR rate by combining B with T and D for patients with HER2+ breast cancer who are not predicted for pCR by FDG PET. Methods: In this multicenter, open-label, phase II trial, 2 phases are planned after a selection period: phase I: all patients receive two cycles of therapy combining T (8 mg/kg at the first cycle, then 6 mg/kg) and D (100 mg/m2). FDG PET is also performed within 7 days before cycle 1 (baseline) and less than 3 days before cycle 2 in order to calculate changes of the tumor FDG uptake between baseline and after cycle 1 (ΔSUV). Phase 2: if ΔSUV≥70%, patients will continue to receive T and D for (cycles 3 to 6: D 100 mg/m2 + T 6 mg/kg); if ΔSUV<70%, patients are randomized 2:1 to arm A (cycles 3 to 6 D 100 mg/m2 + T 6 mg/kg + B 15 mg/kg) or arm B ( cycles 3 to 6: D 100 mg/m2 + T 6 mg/kg). The primary endpoint is pCR rate evaluated post-surgery 4 to 6 weeks after the last treatment of cycle 6. Enrolment began in May 2010 and 125 patients were to be recruited in 26 sites. According to the hypothesis that 60% of patients will have a ΔSUV<70%, it is presumed that 72 patients will be randomized. There are currently 107 patients included (as of 06 January 2012 ), 95 of them reached the phase 1; 52 of them (55%) showed a ΔSUV<70% and after randomization 34 were included in arm A and 18 in arm B.

P4-15-03: Patient-Provider Communication and Patient Informational Needs for Breast Reconstruction Post-Mastectomy: Results from a National Survey

For many women, the complexity of processing and learning about their breast cancer diagnosis is further complicated by decisions to be made about breast reconstruction post-mastectomy. Existing studies suggest that these women are provided with information about breast reconstruction options of differing depth, breadth, and quality, but little is known about how this information is received by the patient as well as the value of this information. Guided by Social Cognitive Theory, the Cancer Support Community (CSC) conducted a national survey in an effort to better understand patients’ information-seeking experiences, patient-provider communication, and knowledge about breast reconstruction. 840 U.S. women with breast cancer (762 eligible for breast reconstruction who were then eligible to answer survey questions pertaining to their experiences) participated in the survey online or by paper-and-pencil at CSC affiliate sites in 2010. In addition to demographics, information about their diagnosis, treatment, and experience with reconstruction, women rated their experience with receiving breast reconstruction information from their healthcare professionals as well as their experience searching for and receiving information about options and realistic expectations for breast reconstruction.

Survey participants came from 46 states, were primarily Caucasian (85%), and the mean age at diagnosis was 48.9 years old. Most women reported that either a plastic surgeon (73.3%) or a breast surgeon (64.0%) had spoken to them about reconstruction, followed by oncologist (34.2%) and surgical oncologist (24.8%). Of women whose healthcare team had spoken with them about reconstruction, 57.1% reported that reconstruction was first discussed at diagnosis. Women reported that this information was somewhat (35.1%) or extremely (55.5%) useful, though they sought additional information elsewhere. Aside from their health care team, most women (60%) sought information about reconstruction from other women with breast cancer and half sought information from the Internet. Participants reported that they would have liked to have had more information prior to reconstruction about a variety of topics, including: how they would look after reconstruction (34.8% endorsing), how they would feel after reconstruction (35.5%), and information about their future breast health (25.9%). Open-ended responses suggest many patients experience gaps in information with regard to establishing realistic expectations about the procedures and outcomes, providing comprehensive information at various stages throughout the process, and across various treatment options.

Though many participants reported satisfaction with how information about reconstruction was provided to them and the quality and scope of this information, responses suggest that there is work to be done with regard to establishing realistic expectations about the procedures and outcomes, providing comprehensive information at various stages throughout the process, and across various treatment options.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-15-03.

PD06-10: Breast Cancer Patient Distress Associated with Difficulties Navigating the Costs Associated with Care: Results from a National Education Program

Compounding the stressors related with a diagnosis of breast cancer can be the associated direct and indirect costs of cancer care. To address this need, the Cancer Support Community (CSC) in 2009 developed an evidence-based, professionally-led national education workshop for cancer patients and caregivers entitled Frankly Speaking About Cancer: Coping with the Cost of Care. As part of this workshop, participants completed a survey describing their experiences coping with the cost of cancer care. To date, responses from 465 participants (representing 46 workshops) have been analyzed. Of those participants, 105 are women diagnosed with breast cancer. Though workshop participants were affected by a wide variety of cancer diagnoses, half of those with cancer attending the workshop (50%) were affected by breast cancer. No significant differences between breast cancer patients and individuals with other cancers were found. Analyses are based on responses from breast cancer patients only. Participants’ pre-workshop rating of their understanding about the financial aspects of their breast cancer care was low (m =2.8, s.d.=1.0) and was significantly less than their level of knowledge post-workshop (m =4.1, s.d.=0.7, p &lt;.05).

Most attendees (72.8%) reported experiencing some degree of emotional distress from trying to manage cancer care costs, and nearly one-third of attendees (30.1%) reported significant distress. Most (64.8%) reported that their healthcare team did not discuss financial aspects of care with them. Of attendees whose team did discuss it with them, typically it was a social worker, physician, or nurse. Of those who had this discussion, only 34% reported that this information was actually useful to them. Not surprisingly then, attendees reported they have looked elsewhere for information about managing the costs of care, such as patient support organizations (40.2%), the Internet (43.5%), and other patients (41.3%).

A positive to arise from the workshop is that most participants (69.9%) reported the intention to discuss financial aspects of their care with their healthcare team based on what they had learned from the workshop. Intention to have this discussion with their healthcare team was both positively correlated with having experienced emotional distress about the cost of their care (r=.29, p &lt;.05) as well as negatively correlated with their level of pre-workshop knowledge about financial issues in breast cancer care (r=-.28, p &lt;.05).Taken together, these data highlight significant obstacles that individuals face in receiving meaningful information relevant to managing the costs associated with cancer care.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD06-10.

Fumagillin for treatment of intestinal microsporidiosis in renal transplant recipients

We report 10 cases of intestinal microsporidiosis due to Enterocytozoon bieneusi in renal transplant (RT) recipients who were treated with fumagillin. All patients presented with afebrile subacute diarrhea (median of 2 weeks), associated with abdominal cramps (n = 5), and weight loss (n = 6), a mean of 68 months after RT. The diagnosis was made by the identification of microsporidial spores in stools with the use of appropriate staining and confirmed by a specific polymerase chain reaction assay for E. bieneusi in 7 patients. Median CD4 cell count was 292 cells/mm(3). All patients received a median of 14 days of oral fumagillin (20 mg tid), and four patients also discontinued or tapered their immunosuppressive regimen (mycophenolate mofetil in 3, and azathioprine in 2). Clinical symptoms resolved rapidly with the clearance of microsporidial spores from stools in all patients. A severe but reversible thrombocytopenia was observed in one patient during fumagillin therapy, and another patient presented with abdominal cramps. Trough levels of tacrolimus measured in seven patients dropped below 5 ng/mL in six of them after 7-14 days of fumagillin. Intestinal microsporidiosis can cause subacute diarrhea in RT recipients. Fumagillin is an effective treatment with an acceptable safety profile, but monitoring of tacrolimus levels is warranted.

Pharmacoeconomic assessment of specific immunotherapy versus current symptomatic treatment for allergic rhinitis and asthma in France

OBJECTIVES

The therapeutic benefit of specific immunotherapy (SIT) in allergic rhinitis and asthma has been endorsed by expert consensus. This study compared the cost/efficacy (C/E) of SIT with current symptomatic treatments (CST) for allergic rhinitis and asthma.

METHODS

A C/E analysis was performed using a decision tree model. The decision tree and medical and economic hypotheses were defined by a panel of experts. The perspective adopted was that of the French Social Security. The costs and efficacy of SIT and CST were compared for dust-mite and pollen allergies, in adults and children. Direct medical costs included diagnosis and follow-up, consultations, CST and SIT. End-point economic criteria were cost per stabilised patient and cost per asthma case avoided. A sensitivity analysis was performed for each model.

RESULTS

In adults, the incremental costs per asthma case avoided with injectable SIT were 393 Euro and 1327 Euro for dust-mite and pollen allergy, respectively, over a 6-year period. For sublingual SIT, the costs per asthma case avoided were 3158 Euro and 1708 Euro, respectively. In children, over a 7-year period, the incremental costs per asthma case avoided with injectable SIT were 583 Euro and 597 Euro for dust-mite and pollen allergy, respectively. For sublingual SIT the incremental costs were 3938 Euro and 824 Euro.

CONCLUSION

Compared to CST, SIT is a cost-effective treatment in pollen and dust-mite-induced allergic rhinitis and asthma. Sublingual SIT is an attractive option in pollen-induced rhinitis, particularly in children. SIT appears to be an economically relevant strategy compared to CST.