Stereotactic ultrahypofractionated MR-guided radiotherapy for localized prostate cancer - Acute toxicity and patient-reported outcomes in the prospective, multicenter SMILE phase II trial

Background

Due to superior image quality and daily adaptive planning, MR-guided stereotactic body radiation therapy (MRgSBRT) has the potential to further widen the therapeutic window in radiotherapy of localized prostate cancer. This study reports on acute toxicity rates and patient-reported outcomes after MR-guided adaptive ultrahypofractionated radiotherapy for localized prostate cancer within the prospective, multicenter phase II SMILE trial.

Materials and methods

A total of 69 patients with localized prostate cancer underwent MRgSBRT with daily online plan adaptation. Inclusion criteria comprised a tumor stage ≤ T3a, serum PSA value ≤ 20 ng/ml, ISUP Grade group ≤ 4. A dose of 37.5 Gy was prescribed to the PTV in five fractions on alternating days with an optional simultaneous boost of 40 Gy to the dominant intraprostatic lesion defined by multiparametric MRI. Acute genitourinary (GU-) and gastrointestinal (GI-) toxicity, as defined by CTCAE v. 5.0 and RTOG as well as patient-reported outcomes according to EORTC QLQ-C30 and -PR25 scores were analyzed at completion of radiotherapy, 6 and 12 weeks after radiotherapy and compared to baseline symptoms.

Results

There were no toxicity-related treatment discontinuations. At the 12-week follow-up visit, no grade 3 + toxicities were reported according to CTCAE. Up until the 12-week visit, in total 16 patients (23 %) experienced a grade 2 GU or GI toxicity. Toxicity rates peaked at the end of radiation therapy and subsided within the 12-week follow-up period. At the 12-week follow-up visit, no residual grade 2 GU toxicities were reported and 1 patient (1 %) had residual grade 2 enteritic symptoms. With exception to a significant improvement in the emotional functioning score following MRgSBRT, no clinically meaningful changes in the global health status nor in relevant subscores were reported.

Conclusion

Daily online-adaptive MRgSBRT for localized prostate cancer resulted in an excellent overall toxicity profile without any major negative impact on quality of life.

Systemic GDF11 replenishment ignites myocardial injury through diminishing anti-apoptotic activity of cardiac progenitor cells

Background

Tissue damage due to acute myocardial infarction is caused by both the ischemic insult and subsequent reperfusion injury (I/R). Restoration of coronary blood flow accelerates cardiomyocyte death, a phenomenon referred to as reperfusion injury, the extent of which is partly modulated by cardiac progenitor cells (CPC). Development of novel therapies to reduce infarct size, the main determinant of outcome, represent a huge unmet medical need (1). Systemic levels of growth differentiation factor 11 (GDF11), a TGF-β superfamily member that shares 90% homology with myostatin, decline with age, and GDF11 replenishment by heterochronic parabiosis or systemic recombinant GDF11 (rGDF11) delivery was postulated to have rejuvenating effects (2).

Purpose

We aimed to probe the effects of systemic GDF11 replenishment on I/R injury and deepen insights into the molecular mechanisms involved.

Methods

We designed a vehicle-controlled study in which young (3–4 months) and old (22–24 months) C57Bl/6 mice were randomly assigned to either daily systemic rGDF11 or control treatment over 30 days before myocardial I/R injury was induced. Dissected hearts were subjected to in-depth profiling followed by IPA-guided -omics to identify key regulatory mechanisms. Finally, in vitro experiments on human CPCs and HL-1 cardiomyocytes were performed.

Results

Myocardial Gdf11 expression declined with age, whereas myostatin (Mstn) showed an opposing expression pattern (Fig. 1A), a trend similarly observed upon I/R (Fig. 1B). Surprisingly, after the 30-day study period (Fig. 1C), young and aged rGDF11-treated mice showed higher I/R-induced infarct size and serum cardiac troponin I levels than controls, despite comparable areas at risk (Fig. 1D). Importantly, while proxies of necroptosis/pyroptosis remained unchanged, rGDF11-treated animals showed reduced cardiomyocyte viability irrespective of their age (Fig. 2A). Targeted transcriptomics applied on cardiac tissues of both groups identified the CPC-marker Nkx2–5 to be differentially regulated (Fig. 2B-C), an expression pattern validated in an independent cohort at both mRNA and protein levels (Fig. 2D). In the adult myocardium, the expression of both Nkx2–5 and its cofactor Gata4 is mainly confined to CPCs; indeed, similar reductions in Nkx2–5 and Gata4 expression were observed in CPCs exposed to rGDF11 (Fig. 2E) which coincided with accelerated cardiomyocyte death if cultured in conditioned media obtained from CPCs treated with rGDF11 (Fig. 2F), pointing toward a paracrine signalling pathway.

Conclusions

Myocardial expression of GDF11 declines with age, and is blunted upon I/R injury, thereby opposing the expression pattern of myostatin. Surprisingly, however, systemic GDF11 replenishment by rGDF11 supplementation enhances rather than reduces myocardial infarct size through augmented apoptosis, a phenomenon mediated by diminished cardioprotective function of CPCs.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Foundation for Cardiovascular Research – Zurich Heart House

Stability and reproducibility of 6013 deep inspiration breath-holds in left-sided breast cancer

Purpose

Patients with left-sided breast cancer frequently receive deep inspiration breath-hold (DIBH) radiotherapy to reduce the risk of cardiac side effects. The aim of the present study was to analyze intra-breath-hold stability and inter-fraction breath-hold reproducibility in clinical practice.

Material and methods

Overall, we analyzed 103 patients receiving left-sided breast cancer radiotherapy using a surface-guided DIBH technique. During each treatment session the vertical motion of the patient was continuously measured by a surface guided radiation therapy (SGRT) system and automated gating control (beam on/off) was performed using an audio-visual patient feedback system. Dose delivery was automatically triggered when the tracking point was within a predefined gating window. Intra-breath-hold stability and inter-fraction reproducibility across all fractions of the entire treatment course were analyzed per patient.

Results

In the present series, 6013 breath-holds during beam-on time were analyzed. The mean amplitude of the gating window from the baseline breathing curve (maximum expiration during free breathing) was 15.8 mm (95%-confidence interval: [8.5–30.6] mm) and had a width of 3.5 mm (95%-CI: [2–4.3] mm). As a measure of intra-breath-hold stability, the median standard deviation of the breath-hold level during DIBH was 0.3 mm (95%-CI: [0.1–0.9] mm). Similarly, the median absolute intra-breath-hold linear amplitude deviation was 0.4 mm (95%-CI: [0.01–2.1] mm). Reproducibility testing showed good inter-fractional reliability, as the maximum difference in the breathing amplitudes in all patients and all fractions were 1.3 mm on average (95%-CI: [0.5–2.6] mm).

Conclusion

The clinical integration of an optical surface scanner enables a stable and reliable DIBH treatment delivery during SGRT for left-sided breast cancer in clinical routine.

Optical Surface Scanning for Patient Positioning in Radiation Therapy: A Prospective Analysis of 1902 Fractions

Purpose/Objective:

Reproducible patient positioning remains one of the major challenges in modern radiation therapy. Recently, optical surface scanners have been introduced into clinical practice in addition to well-established positioning systems, such as room laser and skin marks. The aim of this prospective study was to evaluate setup errors of the optical surface scanner Catalyst HD (C-RAD AB) in different anatomic regions.

Material/Methods:

Between October 2016 and June 2017 a total of 1902 treatment sessions in 110 patients were evaluated. The workflow of this study included conventional setup procedures using laser-based positioning with skin marks and an additional registration of the 3-dimensional (3D) deviations detected by the Catalyst system. The deviations of the surface-based method were then compared to the corrections of cone beam computed tomography alignment which was considered as gold standard. A practical Catalyst setup error was calculated between the translational deviations of the surface scanner and the laser positioning. Two one-sided t tests for equivalence were used for statistical analysis.

Results:

Data analysis revealed total deviations of 0.09 mm ± 2.03 mm for the lateral axis, 0.07 mm ± 3.21 mm for the longitudinal axis, and 0.44 mm ± 3.08 mm vertical axis for the Catalyst system, compared to −0.06 ± 3.54 mm lateral, 0.53 ± 3.47 mm longitudinal, and 0.19 ± 3.49 mm vertical for the laser positioning compared to cone beam computed tomography. The lowest positional deviations were found in the cranial region, and larger deviations occurred in the thoracic and abdominal sites. A statistical comparison using 2 one-sided t tests showed a general concordance of the 2 methods (P ≤ 0.036), excluding the vertical direction of the abdominal region (P = 0.198).

Conclusion:

The optical surface scanner Catalyst HD is a reliable and feasible patient positioning system without any additional radiation exposure. From the head to the thoracic and abdominal region, a decrease in accuracy was observed within a comparable range for Catalyst and laser-assisted positioning.

Real-time intra-fraction motion management in breast cancer radiotherapy: analysis of 2028 treatment sessions

BACKGROUND

Intra-fraction motion represents a crucial issue in the era of precise radiotherapy in several settings, including breast irradiation. To date, only few data exist on real-time measured intra-fraction motion in breast cancer patients. Continuous surface imaging using visible light offers the capability to monitor patient movements in three-dimensional space without any additional radiation exposure. The aim of the present study was to quantify the uncertainties of possible intra-fractional motion during breast radiotherapy.

MATERIAL AND METHODS

One hundred and four consecutive patients that underwent postoperative radiotherapy following breast conserving surgery or mastectomy were prospectively evaluated during 2028 treatment sessions. During each treatment session the patients' motion was continuously measured using the Catalyst™ optical surface scanner (C-RAD AB, Sweden) and compared to a reference scan acquired at the beginning of each session. The Catalyst system works through an optical surface imaging with light emitting diode (LED) light and reprojection captured by a charge coupled device (CCD) camera, which provide target position control during treatment delivery with a motion detection accuracy of 0.5 mm. For 3D surface reconstruction, the system uses a non-rigid body algorithm to calculate the distance between the surface and the isocentre and using the principle of optical triangulation. Three-dimensional deviations and relative position differences during the whole treatment fraction were calculated by the system and analyzed statistically.

RESULTS

Overall, the maximum magnitude of the deviation vector showed a mean change of 1.93 mm ± 1.14 mm (standard deviation [SD]) (95%-confidence interval: [0.48-4.65] mm) and a median change of 1.63 mm during dose application (beam-on time only). Along the lateral and longitudinal axis changes were quite similar (0.18 mm ± 1.06 mm vs. 0.17 mm ± 1.32 mm), on the vertical axis the mean change was 0.68 mm ± 1.53 mm. The mean treatment session time was 154 ± 53 (SD) seconds and the mean beam-on time only was 55 ± 16 s. According to Friedman's test differences in the distributions of the three possible directions (lateral, longitudinal and vertical) were significant (p < 0.01), in post-hoc analysis there were no similarities between any two of the three directions.

CONCLUSION

The optical surface imaging system is an accurate and easy tool for real-time motion management in breast cancer radiotherapy. Intra-fraction motion was reported within five millimeters in all directions. Thus, intra-fraction motion in our series of 2028 treatment sessions seems to be of minor clinical relevance in postoperative radiotherapy of breast cancer.

3D faces are recognized more accurately and faster than 2D faces, but with similar inversion effects

Recognition of faces typically occurs via holistic processing where individual features are combined to provide an overall facial representation. However, when faces are inverted, there is greater reliance on featural processing where faces are recognized based on their individual features. These findings are based on a substantial number of studies using 2-dimensional (2D) faces and it is unknown whether these results can be extended to 3-dimensional (3D) faces, which have more depth information that is absent in the typical 2D stimuli used in face recognition literature. The current study used the face inversion paradigm as a means to investigate how holistic and featural processing are differentially influenced by 2D and 3D faces. Twenty-five participants completed a delayed face-matching task consisting of upright and inverted faces that were presented as both 2D and 3D stereoscopic images. Recognition accuracy was significantly higher for 3D upright faces compared to 2D upright faces, providing support that the enriched visual information in 3D stereoscopic images facilitates holistic processing that is essential for the recognition of upright faces. Typical face inversion effects were also obtained, regardless of whether the faces were presented in 2D or 3D. Moreover, recognition performances for 2D inverted and 3D inverted faces did not differ. Taken together, these results demonstrated that 3D stereoscopic effects influence face recognition during holistic processing but not during featural processing. Our findings therefore provide a novel perspective that furthers our understanding of face recognition mechanisms, shedding light on how the integration of stereoscopic information in 3D faces influences face recognition processes.

Right frontal gamma and beta band enhancement while solving a spatial puzzle with insight

Solving a problem with an "a-ha" effect is known as insight. Unlike incremental problem solving, insight is sudden and unique, and the question about its distinct brain activity, intrigues many researchers. In this study, electroencephalogram signals were recorded from 12 right handed, human participants before (baseline) and while they solved a spatial puzzle known as the '10 coin puzzle' that could be solved incrementally or by insight. Participants responded as soon as they reached a solution and reported whether the process was incremental or by sudden insight. EEG activity was recorded from 19 scalp locations. We found significant differences between insight and incremental solvers in the Gamma and Beta 2 bands in frontal areas (F8) and in the alpha band in right temporal areas (T6). The right-frontal gamma indicates a process of restructuring which leads to an insight solution, in spatial problems, further suggesting a universal role of gamma in restructuring. These results further suggest that solving a spatial puzzle via insight requires exclusive brain areas and neurological-cognitive processes which may be important for meta-cognitive components of insight solutions, including attention and monitoring of the solution.

Abstract P1-10-04: A prospective study of patterns of chemotherapy, colony-stimulating factor use, and burden of colony-stimulating factor injections in patients with early-stage breast cancer

Background: Febrile neutropenia (FN) is a common side effect of myelosuppressive chemotherapy. Primary prophylaxis with colony-stimulating factors (CSFs) can reduce FN incidence and is recommended when a patient has a high risk of FN (&gt; 20%). In the prophylactic setting, CSFs should be administered at least 24 hours after chemotherapy completion. Patient burden associated with CSF administration is not well understood. Here we describe current patterns of chemotherapy use and burden of CSF injections for patients with early-stage breast cancer (ESBC) in US clinical practice.

Methods: This was a prospective cohort study of adult ESBC patients receiving their first chemotherapy course who had a high risk of FN based on high- or intermediate-risk chemotherapy regimen and individual FN risk factors. The burden associated with CSF injections was assessed via questionnaires among patients who received CSF, and a subset analysis of patient burden in the first cycle of chemotherapy is reported.

Results: 598 patients completed the "burden of CSF injections" questionnaire following the first cycle of chemotherapy. Most patients were &lt; 65 years old (76.8%), had a BMI &lt; 30 kg/m2 (54.9%), and had few comorbidities (see table for additional characteristics and comorbidities). The three most common chemotherapy regimens received were ddAC-T (34.4%), TC (23.4%), and TCH (15.6%). 98.3% of patients received prophylaxis with CSF in the first chemotherapy cycle: 94.6% of these received pegfilgrastim, and 5.4% received filgrastim. Among all patients who received CSF, mean (SD) one-way travel time for a single CSF injection was 31 (25) minutes; mean (SD) time in office to receive a CSF injection was 41 (68) minutes. Across the first chemotherapy cycle, mean (SD) time missed from work for CSF administration was 3.1 (9.3) hours, and mean (SD) time missed from non-work activities was 5.5 (14.4) hours. 66.3% of patients had someone else assist them with travel to the clinic to receive CSF, of which 98.8% were helped by an unpaid caregiver. When patients were questioned about the subjective burden of CSF injections, 25.4% reported some degree of bother, and 15.9% reported at least moderate inconvenience.

Conclusions: Among the high- and intermediate-risk regimens investigated here, dose-dense and taxane-based chemotherapy regimens were common. As many high-risk patients with ESBC receive primary prophylaxis with CSF, travel and time needed to receive CSF can contribute to patient and caregiver burden.

Patient CharacteristicsN = 598 Age, mean (SD) years55.1 (11.3) BMI, mean (SD) kg/m230.7 (7.5) HER2+23.2% Luminal Aa52.0% Triple negative21.6% Stage at diagnosis  124.6% 253.7% 321.2% Missing0.5%Comorbidities &gt; 10% Hypertension37.5% Hyperlipidemia24.7% Depression13.9% Diabetes mellitus13.4% Osteoarthritis12.7% Gastroesophageal reflux disease12.2% Hypothyroidism12.0% Anxiety11.9%aHormone receptor positive but HER2 negative.

Citation Format: Li X, Barron R, Tzivelekis S, Li Y, Chandler D, Xu H, Morrow PK, Klippel Z, Nagarajan A, Reiner M, Page JH. A prospective study of patterns of chemotherapy, colony-stimulating factor use, and burden of colony-stimulating factor injections in patients with early-stage breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-10-04.

Abstract P5-09-13: The effect of bone pain–specific education vs general chemotherapy side-effect education on reported bone pain in patients (pts) with breast cancer receiving chemotherapy and pegfilgrastim

Background: Mild-to-moderate bone pain is the most commonly reported adverse event (AE) associated with pegfilgrastim, but pt education has not been specifically studied in the management of pegfilgrastim-related bone pain. We investigated the effect of pt education on reported bone pain in pts with breast cancer receiving adjuvant or neoadjuvant chemotherapy and pegfilgrastim.

Methods: In this single-blind study, female pts ≥ 18 years of age with newly diagnosed stage I–III breast cancer, planning ≥ 4 cycles of neoadjuvant or adjuvant chemotherapy with pegfilgrastim support starting in cycle 1, were randomized 1:1 to view one of two 2-minute educational DVDs: a general educational DVD (GE-DVD) on chemotherapy side effects or a more specific DVD on bone pain following chemotherapy and pegfilgrastim (BP-DVD). Pts were excluded if they were not able to understand English, were scheduled to receive weekly chemotherapy, had ongoing chronic pain requiring treatment, had received chemotherapy for cancer within the last 5 years, or had previously received G-CSF. Pts were required to watch the DVD on 2 separate days during clinic visits up to and including the visit for pegfilgrastim administration in cycle 1. In each of the four cycles of the study period, pts completed a brief bone pain survey once per day for 5 days, beginning the day they received pegfilgrastim; severity of pain was rated on a scale of 0–10. Pts also recorded any medications taken to alleviate bone pain. Pts were asked about AEs at the beginning of each chemotherapy cycle and at the safety follow-up visit.

Results: Of the 312 pts screened, 304 were enrolled, and of those, 300 received pegfilgrastim in cycle 1: 149 in the GE-DVD arm and 151 in the BP-DVD arm. Baseline demographics and characteristics were largely balanced between the arms, but fewer pts in the GE-DVD arm were Hispanic/Latino (3.4% vs 7.9%). Fewer pts in the GE-DVD arm were ER positive (59.1% vs 69.5%) and PR positive (46.3% vs 59.6%), while more were HER2 positive (30.2% vs 18.5%). Receipt of taxane-based chemotherapy regimens was balanced between the arms. Pt-reported maximum bone pain was similar in the GE-DVD arm vs the BP-DVD arm (cycle 1, 3.2 vs 3.5, P = .3479; across all cycles, 4.1 vs 4.6, P = .2196). Pt-reported mean bone pain was also similar between arms (cycle 1, 1.6 vs 1.8, P = .3188; across all cycles, 1.5 vs 1.6, P = .5846) as was area under the curve for pt-reported bone pain (cycle 1, 6.7 vs 7.6, P = .3346; across all cycles, 6.3 vs 6.6, P = .6255). All-grade bone pain and grade 3/4 bone pain from AE reporting were similar between the arms. Pt-reported bone pain and bone pain from AE reporting were highest in cycle 1; pain decreased thereafter and remained stable in cycles 2, 3, and 4. Bone pain medication usage was similar between the arms; usage was highest in cycle 1 and decreased with each subsequent cycle. Pain therefore appeared to be truly stable in cycles 2, 3, and 4, not just better medicated.

Conclusions: Our bone pain–specific educational program did not improve perceptions of bone pain reported by this pt population. Bone pain was highest in cycle 1, decreased in cycle 2, and then remained stable.

Citation Format: Maxwell CL, Guinigundo AS, Vanni L, Morrow PK, Reiner M, Shih A, Klippel Z, Blanchard E. The effect of bone pain–specific education vs general chemotherapy side-effect education on reported bone pain in patients (pts) with breast cancer receiving chemotherapy and pegfilgrastim. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-09-13.

WEB as part of a multimodality treatment in complex, large, and partially thrombosed intracranial aneurysms: a single-center observational study of technical success, safety, and recurrence

Introduction

Complex, large, wide-neck aneurysms, but particularly partially thrombosed intracranial aneurysms (PTIAs), have a greater tendency to recanalize after coil occlusion. The Woven Endovascular Bridge (WEB) combines shape memory wires braided to a relatively uniform, dense surface, which may limit its compaction and its incorporation into an existing aneurysm clot and may thus reduce PTIA recurrence.

Objective

To carry out a retrospective analysis of our experience with the WEB as part of a complex treatment in conjunction with other implants to assess the efficacy and safety of this technique.

Methods

Among 43 aneurysms treated with the WEB in our center, eight complex, large, wide-neck aneurysms were treated in conjunction with other implants (additional WEBs, coils, stents, flow diverters). Six of these eight aneurysms were PTIAs. All patients were followed up by DSA between 3½ and 38 months.

Results

All eight (100%) of the complex, large, wide-neck aneurysms were treated successfully and without periprocedural adverse events (0%). At follow-up, the two non-thrombosed aneurysms were completely occluded, but all six PTIAs recurred (75%) and were re-treated. There was no morbidity or mortality in these eight patients.

Conclusions

Treatment of large, complex aneurysms with the WEB in conjunction with other implants was technically successful and safe but did not prevent recurrence of partially thrombosed aneurysms in our center. PTIA re-treatment was possible and not limited by the previously placed WEB.

[Severe hypernatremia. Case report, pathophysiology and therapy]

The case of a female patient with a suprasellar optic glioma is reported, who was admitted to the intensive care unit due to decompensated diabetes insipidus with hypernatremia of 194 mmol/l. The sodium concentration was reduced slowly over 4 days and the patient recovered without sequelae. Based on this case the article deals with the pathophysiology and therapy of hypernatremia. An increase in extracellular osmolarity leads to augmented production of intracellular osmolytes in order to maintain the cell volume constant. Due to this counterregulation correction of the sodium concentration must be done with caution.

[Motivational interviewing integrated into cognitive behavioral therapy in obesity treatment]

Cognitive behavioural therapy is a well-known approach which has proved its efficacy in the treatment of eating disorders and obesity. Nevertheless, eating disordered and obese patients are often ambivalent towards treatment and as a consequence, they can't benefit fully from therapy or drop out easily. Nowadays, motivational issues are widely recognized as a critical point. Motivational Interviewing is now considered as valuable to enhance compliance to treatments.