A Multicenter Study of Clinical to Planning Target Volume Margins for Adjuvant Partial Breast Irradiation Delivered on the 1.5T MR-Linear Accelerator

PURPOSE/OBJECTIVE(S)

Adjuvant partial breast irradiation (APBI) for early-stage breast cancer patients delivered on a conventional Linac commonly uses a clinical to planning target volume (CTV-PTV) margin of 10 mm. Published data suggest this margin could be reduced using an MR-guided workflow. This study quantifies the CTV to PTV margin for APBI delivered on the 1.5T MR-Linac (MRL) using an Adapt to Position (ATP) workflow.

MATERIALS/METHODS

All target contouring was done as per the IMPORT LOW trial and MRL Consortium guidelines. The CTV is the tumor bed defined by surgical clips including postsurgical changes. A single center cohort of ten patients was used to assess delineation error on ProKnow DS v1.28.0 by measuring CTV contour displacements on the CT planning scans (pCT) delineated by five breast radiation oncologists. All other error components were measured on treatment planning software on another single center cohort of ten patients. Target deformation error was measured as surgical clip displacements between the pCT and daily pre-treatment (pre-Tx) MRI scans. Intrafraction motion was determined by the CTV displacement between pre- and post-treatment MRIs (post-Tx) in available paired images from five patients. Matching error was estimated as the interobserver variation of three MRL radiographers registering the pCT with daily pre-Tx MRI. Technical delivery accuracy was estimated using the results from routine quality assurance measurements. Beam penumbral width (p) was estimated from the clinical treatment plans. The systematic (Σ) and random errors (σ) for each component were calculated in the left/right (X), superior/inferior (Y) and anterior/posterior (Z) directions. The contribution of these errors to the PTV margin, M was calculated using van Herk's formula with α and β being 2.50 and 1.64 respectively.

RESULTS

For APBI using an MRL ATP workflow, a CTV-PTV margin of 5.7 to 7.6 mm is required to achieve a 90% confidence of CTV coverage by the 95% isodose. Individual error components are in. Table 1 delineation error remains the largest component of error.

CONCLUSION

A minimum CTV-PTV margin of 6-8 mm is required for APBI using an MRL ATP workflow. Although smaller than margins used in conventional Linacs, the clinical benefits (in terms of fibrosis risk) of treating APBI patients on an MRL are likely to be modest. Further margin reductions may be possible using an "Adapt to Shape" workflow with daily online recontouring.

Adaptive radiotherapy for breast cancer

Research in the field of local and locoregional breast cancer radiotherapy aims to maintain excellent oncological outcomes while reducing treatment-related toxicity. Adaptive radiotherapy (ART) considers variations in target and organs at risk (OARs) anatomy occurring during the treatment course and integrates these in re-optimized treatment plans. Exploiting ART routinely in clinic may result in smaller target volumes and better OAR sparing, which may lead to reduction of acute as well as late toxicities. In this review MR-guided and CT-guided ART for breast cancer patients according to different clinical scenarios (neoadjuvant and adjuvant partial breast irradiation, whole breast, chest wall and regional nodal irradiation) are reviewed and their advantages as well as challenging aspects discussed.

Induction of Labour: Reviewing the past to improve the future

BACKGROUND

Women undergoing induction of labor should be empowered with accurate information.

OBJECTIVE

This study aimed to examine the characteristics of and indications for induction of labor and delivery outcomes to help inform practice and counseling.

STUDY DESIGN

We conducted a retrospective cohort study of all singleton pregnancies undergoing induction of labor over a 3-month period in a tertiary-level hospital in the Republic of Ireland. Data were obtained from paper and electronic registries. Descriptive and inferential statistics were performed on data collected.

RESULTS

There were 1084 women delivered, with an induction rate of 46.0% (n=499). Primiparous women were more likely to be induced compared with multiparous women (51.4%; n=254/494 vs 41.5%; n=245/590; P<.001), and were more likely to be induced for postmaturity (30.7%; n=78/254 vs 23.6%; 58/245; P≤.001). More than half (50.3%; 251/399) were induced before 40 weeks’ gestation, irrespective of parity. Multiparous women and those induced for maternal medical indications had a shorter overall time to delivery interval (21.7 hours [standard deviation, 13.0] vs 13.8 hours [standard deviation, 11.2]; P<.001 and 18.3 hours [standard deviation, 12.7] vs 14.7 hours [standard deviation, 12.4]; P<.01).

CONCLUSION

Information on induction of labor can aid in the guidance and education of women undergoing the process, educate clinicians for appropriate counseling, and facilitate shared decision-making.

Exploring the views of undocumented migrant women on access to maternity services in the UK

Background

Migrant women face inequalities in access to health-care services and are known to experience poorer maternal and child outcomes than women born in the UK. The development of more restrictive health policies in the UK and Europe, including being denied or charged for healthcare at maternity services, may be exacerbating these outcomes, particularly among undocumented migrant women without permission to reside. We investigated undocumented migrant women's experiences of accessing maternity services in the UK and their impact on health outcomes.

Methods

We did semi-structured in-depth qualitative interviews with a purposive sample of migrant women (born outside the UK) who were aged 18 and over, and had experiences of pregnancy in the UK whilst undocumented. Participants were recruited through the Doctors of the World UK clinic. Interviews were transcribed and analysed using thematic analysis.

Results

We did interviews with 20 undocumented women (age range 31-40 years; mainly from Africa and Asia). Among participants, of whom 13 were pregnant at the time of interview, 10 (50%) first accessed antenatal care late (after the national target of 13 weeks). Women described an ongoing cycle of precariousness, defined by their legal status, social isolation, and poor economic status. Women reported receiving bills of up to £11,500 for maternity services (range £3,072 to £11.500). The impact of their experiences meant that they were deterred from seeking timely health care and were reluctant to present to health services, with women reporting fear and loss of trust in the health system.

Conclusions

These women's narratives illustrated the potential deterrent and detrimental impact of increasingly restrictive health policies on women's access to care and their health. UK and European health policies must be equitable, non-discriminatory, and better align with our commitments to promote universal health coverage among all individual residing in the region.

Key messages

Increasingly restrictive health policies may have a deterrent and detrimental impact on migrant women’s access to health care. Undocumented migrant women in the UK reported fear and loss of trust in the health system.

Smoking-a Major Cause of Polycythaemia

The importance of smoking in the aetiology of polycythaemia has been assessed in a group of patients referred to a general haematology clinic. All patients with true and relative polycythaemia (excluding those with polycythaemia rubra vera) were studied. Of the 21 such patients evaluated, 14 were smokers and had raised carboxyhaemoglobin levels and had no other demonstrable cause for their polycythaemia. The commonest physiological abnormality in these patients was a raised red cell mass combined with a low plasma volume. Six of the 14 patients were able to reduce their smoking with subsequent improvement in their haematocrits. These results suggest that smoking is a major cause of polycythaemia in an unselected series of referrals to a general haematology clinic. The early identification of these patients may be useful in planning therapy.

Abstract P3-08-06: Prognostic value of OncoMasTR: A novel multigene signature based on master transcriptional regulators

Background

Multigene prognostic signatures (MGPS) enable identification of candidate patients for treatment de-escalation in early stage breast cancer (BC). Here we present OncoMasTR, a MGPS for classifying the risk of distant metastasis (DM) in ER-positive, HER2-negative BC patients with up to 3 involved lymph nodes (LNs). OncoMasTR was discovered via a novel transcriptional network analysis methodology that identified genes that regulate previously identified prognostic biomarkers. These upstream genes, termed master transcriptional regulators (MTRs), were shown to provide improved prognostic performance compared with downstream genes. OncoMasTR has been mechanistically verified by RT-qPCR, immunohistochemistry and chromatin immunoprecipitation. OncoMasTR has been further trained to include clinicopathological information (CPI) to maximise its prognostic performance.

Methods

Two independent sample sets: 225 patients from Malmö University Hospital and 100 patients from Skåne University Hospital were used for training, cross-validation and refinement of OncoMasTR. RNA extracted from 225 archived tissues was analysed by RT-qPCR to measure the expression levels of the MTRs. Statistical models of all possible combinations of MTRs were trained and cross-validated (1,000 times x 2-fold) using the first set of 225 samples. Statistical models with the best cross-validated performance were further evaluated on RT-qPCR data from the second independent set of 100 samples. Robustness of the data was verified by assessing the reproducibility of OncoMasTR across 6 days, using 6 unique kit lots, conducted by 4 operators on 3 RT-qPCR instruments.

Results

In the first training set of 225 patients, OncoMasTR classified up to 72% of LN0 patients and 58% of LN0-3 patients as low risk, with ≤ 5.0% DM within each group. When incorporating CPI, its prognostic performance further improved to a c (concordance) index &gt; 0.8. Results showed that the OncoMasTR molecular score and CPI add statistically significant prognostic value to each other. In the independent verification set, all patients with DM were correctly classified as high risk (p&lt;0.01). In relation to reproducibility, the OncoMasTR test displayed robust performance; the molecular score coefficient of variation was 2.6% across days, kit lots, operators and instruments. Individual MTR assays demonstrated linearity over &gt;2000-fold RNA input range and PCR efficiencies ranged from 92% to 101%.

Conclusions

OncoMasTR development and verification results show analytical robustness and clinically accurate risk stratification. Furthermore, OncoMasTR's binary classification of risk avoids an ambiguous intermediate risk classification and has potential to provide clinicians with useful, actionable information to support treatment decisions. The OncoMasTR test is now ready for large-scale clinical validation.

Citation Format: Barron S, Jirström K, Jernström H, Ingvar C, Moran B, Wang C-JA, Loughman T, Fender B, Dynoodt P, Lopez-Ruiz C, Russell N, Gallagher WM. Prognostic value of OncoMasTR: A novel multigene signature based on master transcriptional regulators [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-08-06.

Maternity Ultrasound in the Republic of Ireland 2016; A Review

Antenatal ultrasound, comprising of a dating ultrasound in the late first trimester followed by a fetal anomaly scan, is a recognised and necessary component of good antenatal care. We conducted a telephone survey of all 19 obstetric units to ascertain the status of maternity ultrasound provision in Ireland. Fetal anomaly ultrasound is offered universally to all women in 7/19 (37%) units, selectively to some women in 7/19 (37%) units and not offered at all in the remaining 5/19 (26%) units. Overall ? 41,700 (64%) women receive a fetal anomaly ultrasound nationally. Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally. This study highlights the lack of development in Irish maternity ultrasound services over the last decade. Substantial investment by health care policy makers is urgently needed.

The BIG 2.04 MRC/EORTC SUPREMO Trial: pathology quality assurance of a large phase 3 randomised international clinical trial of postmastectomy radiotherapy in intermediate-risk breast cancer

Introduction

SUPREMO is a phase 3 randomised trial evaluating radiotherapy post-mastectomy for intermediate-risk breast cancer. 1688 patients were enrolled from 16 countries between 2006 and 2013. We report the results of central pathology review carried out for quality assurance.

Patients and methods

A single recut haematoxylin and eosin (H&E) tumour section was assessed by one of two reviewing pathologists, blinded to the originally reported pathology and patient data. Tumour type, grade and lymphovascular invasion were reviewed to assess if they met the inclusion criteria. Slides from potentially ineligible patients on central review were scanned and reviewed online together by the two pathologists and a consensus reached. A subset of 25 of these cases was double-reported independently by the pathologists prior to the online assessment.

Results

The major contributors to the trial were the UK (75%) and the Netherlands (10%). There is a striking difference in lymphovascular invasion (LVi) rates (41.6 vs. 15.1% (UK); p = <0.0001) and proportions of grade 3 carcinomas (54.0 vs. 42.0% (UK); p = <0.0001) on comparing local reporting with central review. There was no difference in the locally reported frequency of LVi rates in node-positive (N+) and node-negative (N−) subgroups (40.3 vs. 38.0%; p = 0.40) but a significant difference in the reviewed frequency (16.9 vs. 9.9%; p = 0.004). Of the N− cases, 104 (25.1%) would have been ineligible by initial central review by virtue of grade and/or lymphovascular invasion status. Following online consensus review, this fell to 70 cases (16.3% of N− cases, 4.1% of all cases).

Conclusions

These data have important implications for the design, powering and interpretation of outcomes from this and future clinical trials. If critical pathology criteria are determinants for trial entry, serious consideration should be given to up-front central pathology review.

Electronic supplementary material

The online version of this article (doi:10.1007/s10549-017-4145-4) contains supplementary material, which is available to authorized users.

Cytomegalovirus Infection and Rates of Antiviral Resistance Following Intestinal and Multivisceral Transplantation

BACKGROUND

Cytomegalovirus (CMV) disease is a common and clinically significant complication following intestinal or multivisceral transplantation. CMV disease is more common in cases of serologic mismatch between donor and recipient. Though in some cases it may be asymptomatic, in the immunosuppressed population it often manifests with evidence of systemic infection or end-organ disease.

METHODS

We conducted a retrospective review of all patients undergoing intestinal or multivisceral transplantation over 8 years at our institution.

RESULTS

Forty-eight transplantations were performed, with 40% of the patients (19/48) having ≥1 episode of CMV viremia, which rose to 90% in the "donor-positive, recipient-negative" (DPRN) serologic mismatch group. The median time to 1st episode following transplantation was 22.3 weeks (range, 1-78) and median duration of each episode was 4.9 weeks (range, 1.6-37.4). Six of the 19 viremic patients (31.6%) developed virologic resistance with 4 of these occurring in the DPRN group. Four of the 6 patients with drug-resistant CMV died with CMV viremia. All patients with drug resistance acquired ganciclovir resistance; these patients were more challenging to manage with second-line toxicity-limited treatments, including foscarnet, cidofovir, and leflunomide. CMV immunoglobulin has been used and we briefly discuss the use of CMV-specific adoptive T-lymphocyte transfer in the management of 1 case.

CONCLUSIONS

Post-transplantation CMV disease continues to be challenging to manage, and there is little consensus on optimal management strategies in this patient group, with a significant requirement for novel therapies; these may be pharmacologic or cell based. Extensive multidisciplinary discussion is important for most cases, but particularly for those patients who acquire virologic resistance.

Reduced intensity allogeneic stem cell transplantation for follicular lymphoma relapsing after an autologous transplant achieves durable long-term disease control: an analysis from the Lymphoma Working Party of the EBMT†

BACKGROUND

Patients with follicular lymphoma (FL) relapsing after an autologous transplant (autoSCT) may be treated with a variety of therapies, including a reduced intensity allogeneic transplant (RICalloSCT). We conducted a retrospective analysis of a large cohort of patients undergoing RICalloSCT for FL in this setting.

PATIENTS AND METHODS

A total of 183 patients, median age 45 years (range 21-69), had undergone an autoSCT at a median of 30 months before the RICalloSCT. Before the RICalloSCT, they had received a median of four lines (range 3-10) of therapy and 81% of patients had chemosensitive disease and 16% had chemoresistant disease. Grafts were donated from sibling (47%) or unrelated donors (53%).

RESULTS

With a median follow-up of 59 months, the non-relapse mortality (NRM) was 27% at 2 years. The median remission duration post-autoSCT and RICalloSCT was 14 and 43 months, respectively. The 5-year relapse/progression rate, progression-free survival and overall survival were 16%, 48% and 51%, respectively, and were associated with age and disease status at RICalloSCT.

CONCLUSION

These data suggest that an RICalloSCT is an effective salvage strategy in patients with FL recurring after a prior autoSCT and might overcome the poor prognostic impact of early relapse after autoSCT.

In patients older than 55 years with AML in first CR, should we search for a matched unrelated donor when an old sibling donor is available?

Allogeneic hematopoietic transplantation is increasingly used in patients aged 55 years or more with AML. The question of whether outcomes can be improved with an allele-level 8/8 HLA-matched unrelated donor (MUD) rather than an older HLA-matched sibling (MSD, more than 55 years) is still unanswered. We thus analyzed outcomes in 714 patients aged 55 years and older with AML in first CR (CR1) who received PBSCs after a reduced-intensity conditioning hematopoietic cell transplant from a MUD (n=310) or a MSD (n=404) in a recent period (2005-2010). The 3-year cumulative incidences (CIs) of non-relapse mortality were 17% and 23% with MSD and MUD, respectively (P=0.17). The 3-year CIs of relapse were 37% and 30%, respectively (P=0.12), resulting in a 3-year CI of leukemia-free survival of 46% and 47%, respectively (P=0.51). The 3-year overall survival was 49% with both MSD and MUD. In conclusion, HLA-identical sibling donors aged 55 years or more should not be excluded because of age for patients aged 55 years and older with AML in CR1.

Patterns of practice of regional nodal irradiation in breast cancer: results of the European Organization for Research and Treatment of Cancer (EORTC) NOdal Radiotherapy (NORA) survey

BACKGROUND

Predicting outcome of breast cancer (BC) patients based on sentinel lymph node (SLN) status without axillary lymph node dissection (ALND) is an area of uncertainty. It influences the decision-making for regional nodal irradiation (RNI). The aim of the NORA (NOdal RAdiotherapy) survey was to examine the patterns of RNI.

METHODS

A web-questionnaire, including several clinical scenarios, was distributed to 88 EORTC-affiliated centers. Responses were received between July 2013 and January 2014.

RESULTS

A total of 84 responses were analyzed. While three-dimensional (3D) radiotherapy (RT) planning is carried out in 81 (96%) centers, nodal areas are delineated in only 51 (61%) centers. Only 14 (17%) centers routinely link internal mammary chain (IMC) and supraclavicular node (SCN) RT indications. In patients undergoing total mastectomy (TM) with ALND, SCN-RT is recommend by 5 (6%), 53 (63%) and 51 (61%) centers for patients with pN0(i+), pN(mi) and pN1, respectively. Extra-capsular extension (ECE) is the main factor influencing decision-making RNI after breast conserving surgery (BCS) and TM. After primary systemic therapy (PST), 49 (58%) centers take into account nodal fibrotic changes in ypN0 patients for RNI indications. In ypN0 patients with inner/central tumors, 23 (27%) centers indicate SCN-RT and IMC-RT. In ypN1 patients, SCN-RT is delivered by less than half of the centers in patients with ypN(i+) and ypN(mi). Twenty-one (25%) of the centers recommend ALN-RT in patients with ypN(mi) or 1-2N+ after ALND. Seventy-five (90%) centers state that age is not considered a limiting factor for RNI.

CONCLUSION

The NORA survey is unique in evaluating the impact of SLNB/ALND status on adjuvant RNI decision-making and volumes after BCS/TM with or without PST. ALN-RT is often indicated in pN1 patients, particularly in the case of ECE. Besides the ongoing NSABP-B51/RTOG and ALLIANCE trials, NORA could help to design future specific RNI trials in the SLNB era without ALND in patients receiving or not PST.

Retrospective study of alemtuzumab vs ATG-based conditioning without irradiation for unrelated and matched sibling donor transplants in acquired severe aplastic anemia: a study from the British Society for Blood and Marrow Transplantation

This retrospective national study compared the use of alemtuzumab-based conditioning regimens for hematopoietic SCT (HSCT) in acquired severe aplastic anemia with antithymocyte globulin (ATG)-based regimens. One hundred patients received alemtuzumab and 55 ATG-based regimens. A matched sibling donor (MSD) was used in 87 (56%), matched unrelated donor (MUD) in 60 (39%) and other related or mismatched unrelated donor (UD) in 8 (5%) patients. Engraftment failure occurred in 9% of the alemtuzumab group and 11% of the ATG group. Five-year OS was 90% for the alemtuzumab and 79% for the ATG groups, P=0.11. For UD HSCT, OS of patients was better when using alemtuzumab (88%) compared with ATG (57%), P=0.026, although smaller numbers of patients received ATG. Similar outcomes for MSD HSCT using alemtuzumab or ATG were seen (91% vs 85%, respectively, P=0.562). A lower risk of chronic GVHD (cGVHD) was observed in the alemtuzumab group (11% vs 26%, P=0.031). On multivariate analysis, use of BM as stem cell source was associated with better OS and EFS, and less acute and cGVHD; young age was associated with better EFS and lower risk of graft failure. This large study confirms successful avoidance of irradiation in the conditioning regimens for MUD HSCT patients.

Analysis of the interaction of induction regimens with p-glycoprotein expression in patients with acute myeloid leukaemia: results from the MRC AML15 trial

Retrospective analyses in non-randomised cohorts suggest that regimens containing fludarabine/Ara C and/or idarubicin/ara C may be more effective than daunorubicin/AraC (DA)-containing regimens in cases of acute myeloid leukaemia (AML) overexpressing p-glycoprotein (Pgp). We prospectively measured Pgp protein and function by flow cytometry in CD45-gated blasts from 434 AML15 trial patients randomised to remission induction therapy with two courses of FLAG-Ida or DA±etoposide (DA/ADE). In all, 34% were positive for Pgp protein and 38% for function. Pgp protein-positive cases had a higher incidence of resistant disease (14% vs 5%), adjusted odds ratio 2.67 (1.14–6.24). There was a trend towards a higher cumulative incidence of relapse at 5 years for Pgp-positive cases (46% vs 55%), adjusted hazard ratio 1.42 (0.98–2.07) (P=0.06). For patients treated with FLAG-Ida, the complete remission (CR) rate was 86% for both Pgp-positive and Pgp-negative patients. In patients treated with DA/ADE, 78% of Pgp-positive and 90% of Pgp-negative cases achieved CR (P=0.06). In analyses of overall survival, there was no interaction between treatment received and Pgp expression. Data for Pgp function followed similar trends. Our data suggest that FLAG-Ida may improve the remission rate for Pgp-positive AML, but the malignant clone is reduced rather than eradicated such that the relapse rate remains high in Pgp-positive patients.

The addition of arsenic trioxide to low-dose Ara-C in older patients with AML does not improve outcome

Most patients with acute myeloid leukaemia (AML) are older, with many unsuitable for conventional chemotherapy. Low-dose Ara-C (LDAC) is superior to best supportive care but is still inadequate. The combination of arsenic trioxide (ATO) and LDAC showed promise in an unrandomised study. We report a randomised trial of LDAC versus LDAC+ATO. Patients with AML according to WHO criteria or myelodysplastic syndrome with >10% blasts, considered as unfit for conventional chemotherapy, were randomised between subcutaneous Ara-C (20 mg b.d. for 10 days) and the same LDAC schedule with ATO (0.25 mg/kg) on days 1-5, 9 and 11, for at least four courses every 4 to 6 weeks. Overall 166 patients were entered; the trial was terminated on the advice of the DMC, as the projected benefit was not observed. Overall 14% of patients achieved complete remission (CR) and 7% CRi. Median survival was 5.5 months and 19 months for responders (CR: not reached; CRi: 14 months; non-responders: 4 months). There were no differences in response or survival between the arms. Grade 3/4 cardiac and liver toxicity, and supportive care requirements were greater in the ATO arm. This randomised comparison demonstrates that adding ATO to LDAC provides no benefit for older patients with AML.

The Role of FDG PET/CT in Patients with Locoregional Breast Cancer Recurrence and a Comparison to Conventional Imaging

Background: The prognosis and clinical management of patients with locoregional recurrence of breast cancer depends on the extent of the disease. Conventional work-up, consisting of bone scintigraphy, liver ultrasound, X-ray or CT of the thorax and MRI of the thoracic wall, may underestimate the local extent or miss the presence of distant metastases. The aim of this study was to evaluate the impact of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) on clinical management in patients with locoregional breast cancer recurrence amenable for locoregional treatment and compare the results with conventional imaging.Material and Methods: We performed a retrospective analysis of all patients referred for FDG PET/CT with locoregional breast cancer recurrence between January 2006 and August 2008. PET/CT findings were compared with results of additional imaging, pathology and follow-up. The impact of FDG PET/CT findings on clinical management of patients, was evaluated on the basis of clinical decisions obtained from patient files.Results: 56 patients were included. In 93% of the patients FDG PET/CT confirmed the locoregional recurrence. In 32 patients (57%) FDG PET/CT revealed additional tumour localisations. Distant metastases were detected in 11 patients on conventional imaging and in 23 patients on FDG PET/CT images (p&lt;0,01). In 25 patients (45%), FDG PET/CT detected additional lesions not visible on conventional imaging. FDG PET/CT had an impact on clinical management in 27 patients (48%) by detecting more extensive locoregional disease or distant metastases. In 20 patients (36%) unnecessary mutilating surgery was prevented and treatment was changed to palliative systemic treatment. The sensitivity, specificity, accuracy, positive and negative predictive values of FDG PET/CT were respectively 97%, 92%, 95%, 94% and 96%.Discussion: FDG PET/CT, in addition to conventional imaging, plays an important role in staging patients with locoregional breast cancer recurrence since its result changed the clinical management in almost half of the patients. FDG PET/CT could potentially replace conventional staging imaging in patients with a locoregional breast cancer recurrence.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5011.

A UK consensus on the management of the bladder in multiple sclerosis

Bladder symptoms in multiple sclerosis (MS) are common and distressing but also highly amenable to treatment. A meeting of stakeholders involved in patients' continence care, including neurologists, urologists, primary care, MS nurses and nursing groups was recently convened to formulate a UK consensus for management. National Institute for Health and Clinical Excellence (NICE) criteria were used for producing recommendations based on a review of the literature and expert opinion. It was agreed that in the majority of cases, successful management could be based on a simple algorithm which includes using reagent sticks to test for urine infection and measurement of the post micturition residual urine volume. This is in contrast with published guidelines from other countries which recommend cystometry. Throughout the course of their disease, patients should be offered appropriate management options for treatment of incontinence, the mainstay of which is antimuscarinic medications, in combination, if necessary, with clean intermittent self-catheterisation. The evidence for other measures, including physiotherapy, alternative strategies aimed at improving bladder emptying, other medications and detrusor injections of botulinum toxin A was reviewed. The management of urinary tract infections as well as the bladder problems as part of severe disability were discussed and recommendations agreed.

Resistance to FLT3 inhibition in an in vitro model of primary AML cells with a stem cell phenotype in a defined microenvironment

Relapse in acute myeloid leukaemia (AML) is mediated by survival of leukaemic stem cells following remission-induction chemotherapy. It would therefore be useful to identify therapeutic agents that target leukaemic stem cells. We devised a flow cytometric chemosensitivity assay allowing 48 h culture of leukaemic blasts in a defined microenvironment followed by enumeration of viable CD34+CD38-CD123+ leukaemic stem and progenitor cells (LSPC). The assay was used to investigate the LSPC response to cytosine arabinoside (Ara-C) and to the FLT3 inhibitor AG1296. There was a 3.6-fold increase in Ara-C-treated LSPC survival under defined 'niche-like' conditions compared to culture without microenvironmental support. Nine AML samples with internal tandem duplications of FLT3 (FLT3/ITDs) were treated with AG1296. Three samples were very sensitive (>50% kill) and 4 were moderately sensitive (10-50% kill) in bulk suspension culture without microenvironmental support. However, under defined 'niche-like' conditions, the survival of LSPC was enhanced rather than inhibited by AG1296 treatment. We conclude that an interaction between LSPC and a defined in vitro microenvironment models a chemoresistant niche. Our data point to a need to investigate more novel chemotherapeutic agents under these stringent conditions to identify agents that may be suitable to target minimal residual disease in AML.

A novel murine model of allogeneic vaccination against prostate cancer

Prostate cancer continues to be a major cause of death in men. Surgical and medical treatments of the disease have improved, but metastasic disease remains a significant clinical problem. Novel therapies such as whole cell vaccination offer the potential of treating disease by stimulating the immune system. To study the efficacy of a whole cell vaccine in prostate cancer two strains of mice were used: C57BL/6 (H-2Kb) and C3H/HeJ (H-2K(k)) in combination with four different cell lines. Thus, a model was constructed of allogeneic and syngeneic vaccine, as well as a challenge tumour for each strain. Two novel cell lines were developed during this study. Firstly, the non tumourigeneic PMC-1 was derived from a normal mouse prostate and immortalized with HPV16. Secondly, the tumourigeneic PMC-1 C6ras1p1 was transformed with human ras gene which formed tumours in both SCID and C3H/HeJ mice. Protection, and the nature of the immune response to syngeneic and allogeneic vaccine, in males and females was examined in both strains. Vaccination with both syngeneic and allogeneic irradiated whole cell vaccines induced protection from syngeneic challenge in females. However, no protection was observed when allogeneic vaccine was given to male mice. This correlated with the immune response. Two types of cellular immune responses were generated in females. A NK-mediated response was observed in C57BL/6 mice, whilst C3H/HeJ mice developed a CTL response. Little or no cellular immune response was observed in males. The cytokine profile in C3H/HeJ females was a mixture of Th1 and Th2 whilst a mainly Th1 profile was observed in C57BL/6 mice. Male mice showed a diminished cytokine secretion compared to females which was further depressed after challenge. The difference in immunity was largely as expected, since tolerance to prostate antigens should not normally develop in female mice. However, this makes this model particularly relevant clinically since it directly mimics the human situation and thus may accelerate the development of whole cell vaccines for clinical use.

Costs and quality of life of multiple sclerosis in the United Kingdom

This cost-of-illness analysis for the United Kingdom is part of a Europe-wide study on the costs of multiple sclerosis (MS). The objective was to analyze the costs and quality of life (utility) related to the level of disease severity. People with MS from a database administered by a UK charity (the MS Trust) were asked to participate in the survey by answering a postal questionnaire. In addition to details on the disease (type of disease, relapses, level of functional disability), the questionnaire asked for information on all resource consumption, medical, non-medical, work absence and informal care as well as utility. The response rate was 19%, and a total of 2048 people were included. The mean age of the cohort was 51 years, and 23% of people were > or =60 years of age. Disease severity was concentrated in people with moderately severe MS (Expanded Disability Status Scale [EDSS] score of 4 to 6.5), with 21, 60 and 19% of people reporting mild, moderate and severe disease, respectively. Costs and utility are highly correlated with disease severity. Mean annual costs for all people in the study increase from approximately pound 12.000 at an EDSS score <4 to almost pound 60.000 at an EDSS score > or =7. In particular, employment rates are reduced from 82% in early disease to 2% at an EDSS score of 8, while the costs of inpatient care, investments, informal care and productivity losses increase by more than tenfold between an EDSS score of 0-1 and a score > or =7. Utility decreases from 0.92 at an EDSS score of 0 to a state worse than death in the most severe state (-0.18 at an EDSS score of 9). Compared to the results in an earlier cost study in the United Kingdom using a comparable methodology, costs have substantially increased, by roughly 40%. Part of the increase is due to a higher use of disease-modifying drugs and, possibly linked with this, a higher use of ambulatory care and services. Another part of the increase is most likely due to an increased age in the current sample, with more patients on early retirement due to MS and more intense use of informal care. However, another reason may lie in the methodology, e.g. different unit costs or differences in the sample distribution, despite a similar mean EDSS score of 5.1.

Clofarabine in previously untreated elderly (>65 yrs) AML patients with an unfavourable cytogenetic profile who are considered unfit for standard intensive chemotherapy

6513

Background: Elderly AML patients (>65 yrs) are a very poor prognostic population. Standard treatment achieves an 18% overall response (OR) rate (low dose Ara-C, U.K. AML 14 trial) with no little or no responses observed in high-risk cytogenetic patients. BIOV-121 is a Phase II non-randomized study of clofarabine, a novel, next generation purine nucleoside analogue, in older patients (>65 yrs) with previously untreated acute myeloid leukemia (AML) for whom standard intensive chemotherapy is not considered suitable. Methods: 66 patients aged > 65 yrs with untreated AML were enrolled in study BIOV-121. All patients were considered unfit for standard intensive chemotherapy based primarily on age (> 65 years) and/or performance status. All patients received clofarabine 30mg/m2 for 5 consecutive days repeated every 28 days (1 course) for a maximum of 6 courses. The primary study endpoint was overall response rate (ORR) defined as the number of patients achieving a CR, CRi, or PR according to the international working group guidelines. A preliminary analysis was conducted on both patients with an unfavourable cytogenetic profile (11/44 patients), for whom data was available, and on patients > 70 years of age (36/66 patients). Unfavourable cytogenetic prognostic risk was defined as the presence of a complex karyotype, monosomies of chromosome 5 (del [5q]/5q-), or 3q abnormalities as reported by Grimwade et al (U.K. MRC AML 10 trial). Results: Of 44 patients for whom cytogenetic data was available, 25% (11/44) had an unfavourable cytogenetic prognostic risk profile. The median number of clofarabine courses administered in this patient group was one. With a median age of 68 years the overall response rate (ORR) in this unfavourable cytogenetic patient group was 36% (4/11) with a 27% complete response (CR) rate. 55% (36/66) of patients were aged >70 years. The ORR and CR rate was 56% and 44% respectively in patients aged >70 years. The toxicity of clofarabine was acceptable and manageable in elderly AML patients. Conclusions: Clofarabine appears superior to current standard treatment (low-dose Ara-C) in both unfavourable cytogenetic AML (>65 years) and AML patients > 70 years (all cytogenetic risk groups).

[Table: see text]