Management of patients with diffuse intrinsic pontine glioma in Australia and New Zealand: Australian and New Zealand Children's Haematology/Oncology Group position statement

INTRODUCTION

The main mission of the Australian and New Zealand Children's Haematology and Oncology Group (ANZCHOG) is to develop and facilitate local access to the world's leading evidence-based clinical trials for all paediatric cancers, including brain tumours, as soon as practically possible. Diffuse intrinsic pontine gliomas (DIPGs) - a subset of a larger group of tumours now termed diffuse midline glioma, H3K27-altered (DMG) - are paediatric brain cancers with less than 10% survival at two years. In the absence of any proven curative therapies, significant recent advancements have been made in pre-clinical and clinical research, leading many to seek integration of novel therapies early into standard practice. Despite these innovative therapeutic approaches, DIPG remains an incurable disease for which novel surgical, imaging, diagnostic, radiation and systemic therapy approaches are needed.

MAIN RECOMMENDATIONS

All patients with DIPG should be discussed in multidisciplinary neuro-oncology meetings (including pathologists, neuroradiologists, radiation oncologists, neurosurgeons, medical oncologists) at diagnosis and at relapse or progression. Radiation therapy to the involved field remains the local and international standard of care treatment. Proton therapy does not yield a superior survival outcome compared with photon therapy and patients should undergo radiation therapy with the available modality (photon or proton) at their treatment centre. Patients may receive concurrent chemotherapy or radiation-sensitising agents as part of a clinical trial. Biopsy should be offered to facilitate consideration of experimental therapies and eligibility for clinical trial participation. After radiation therapy, each patient should be managed individually with either observation or considered for enrolment on a clinical trial, if eligible, after full discussion with the family. Re-irradiation can be considered for progressive disease.

CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE

Every child diagnosed with DIPG should be offered enrolment on a clinical trial where available. Access to investigational drugs without biological rationale outside the clinical trial setting is not supported. In case of potentially actionable target identification with molecular profiling and absence of a suitable clinical trial, rational targeted therapies can be considered through compassionate access programs.

Demographical and Epidemiological Contribution to Cancer Incidence in Delhi and Its Trends from 1991-2015

INTRODUCTION

Cancer incidences are rising worldwide, and India ranked third globally in cancer incidence as of 2020, according to estimates from GLOBOCAN. The three components that contributed to changes in cancer incidence include cancer-related risk factors, population size, and population structure. The present study aim is to derive the contribution of these factors to cancer incidence and to evaluate their trend from 1991 to 2015.

METHODS

The Data were extracted from the Delhi population-based cancer registry published reports. This longstanding registry covers nearly 100% of the Delhi population. The secular trends of cancer incidence from 1991-2015 were assessed for all sites combined as well as top-five cancer sites among males and females. Joinpoint regression and Riskdiff software were performed to assess the trend among the components of cancer incidence change.

RESULTS

Both males and females exhibited nearly equal age-standardised incidence rates over 25 years. Albeit, an overall trend in age-standardised rate was not significant for both sexes (0.68% for males and -0.16% for females) when considering all cancer sites combined. Lung, prostate, oral, and gallbladder cancer exhibits a significant rising trend in the age-standardised rates in males while in females only breast and endometrial cancer showed a rising trend. The cancer counts surged by 252% in males and 208.5% in females from 1991 to 2015. The population size component contributed a 180% increase in males and a 170% increase in females, respectively. The site-specific risk changes were more than 100% for the prostate, oral, and gallbladder cancers in males and endometrial cancer in females. The population structure (aging) contributed to rising cancer incidence varying from 35% to 60% in both genders.

CONCLUSION

A significant contribution to new cancer cases was observed due to a demographical shift in both population size and structure, in addition to plausible cancer-specific risk factors. This transformation could surge a potential burden on the Delhi healthcare system. Persistent endeavours are essential to expand and enhance the existing cancer care infrastructure to meet the rising demand driven by aging and population growth. Implementing a stringent population policy can help to mitigate the impact of population growth on cancer incidence.

Indoximod-based chemo-immunotherapy for pediatric brain tumors: A first-in-children phase I trial

BACKGROUND

Recurrent brain tumors are the leading cause of cancer death in children. Indoleamine 2,3-dioxygenase (IDO) is a targetable metabolic checkpoint that, in preclinical models, inhibits anti-tumor immunity following chemotherapy.

METHODS

We conducted a phase I trial (NCT02502708) of the oral IDO-pathway inhibitor indoximod in children with recurrent brain tumors or newly diagnosed diffuse intrinsic pontine glioma (DIPG). Separate dose-finding arms were performed for indoximod in combination with oral temozolomide (200 mg/m2/day x 5 days in 28-day cycles), or with palliative conformal radiation. Blood samples were collected at baseline and monthly for single-cell RNA-sequencing with paired single-cell T cell receptor sequencing.

RESULTS

Eighty-one patients were treated with indoximod-based combination therapy. Median follow-up was 52 months (range 39-77 months). Maximum tolerated dose was not reached, and the pediatric dose of indoximod was determined as 19.2 mg/kg/dose, twice daily. Median overall survival was 13.3 months (n = 68, range 0.2-62.7) for all patients with recurrent disease and 14.4 months (n = 13, range 4.7-29.7) for DIPG. The subset of n = 26 patients who showed evidence of objective response (even a partial or mixed response) had over 3-fold longer median OS (25.2 months, range 5.4-61.9, p = 0.006) compared to n = 37 nonresponders (7.3 months, range 0.2-62.7). Four patients remain free of active disease longer than 36 months. Single-cell sequencing confirmed emergence of new circulating CD8 T cell clonotypes with late effector phenotype.

CONCLUSIONS

Indoximod was well tolerated and could be safely combined with chemotherapy and radiation. Encouraging preliminary evidence of efficacy supports advancing to Phase II/III trials for pediatric brain tumors.

ONC201 in combination with paxalisib for the treatment of H3K27-altered diffuse midline glioma

Diffuse midline gliomas (DMG), including diffuse intrinsic pontine gliomas (DIPGs), are the most lethal of childhood cancers. Palliative radiotherapy is the only established treatment, with median patient survival of 9-11 months. ONC201 is a DRD2 antagonist and ClpP agonist that has shown preclinical and emerging clinical efficacy in DMG. However, further work is needed to identify the mechanisms of response of DIPGs to ONC201 treatment and to determine whether recurring genomic features influence response. Using a systems-biological approach, we showed that ONC201 elicits potent agonism of the mitochondrial protease ClpP to drive proteolysis of electron transport chain and tricarboxylic acid cycle proteins. DIPGs harboring PIK3CA-mutations showed increased sensitivity to ONC201, while those harboring TP53-mutations were more resistant. Metabolic adaptation and reduced sensitivity to ONC201 was promoted by redox-activated PI3K/Akt signaling, which could be counteracted using the brain penetrant PI3K/Akt inhibitor, paxalisib. Together, these discoveries coupled with the powerful anti-DIPG/DMG pharmacokinetic and pharmacodynamic properties of ONC201 and paxalisib have provided the rationale for the ongoing DIPG/DMG phase II combination clinical trial NCT05009992.

Histone H3-wild type diffuse midline gliomas with H3K27me3 loss are a distinct entity with exclusive EGFR or ACVR1 mutation and differential methylation of homeobox genes

Diffuse midline gliomas (DMG) harbouring H3K27M mutation are paediatric tumours with a dismal outcome. Recently, a new subtype of midline gliomas has been described with similar features to DMG, including loss of H3K27 trimethylation, but lacking the canonical H3K27M mutation (H3-WT). Here, we report a cohort of five H3-WT tumours profiled by whole-genome sequencing, RNA sequencing and DNA methylation profiling and combine their analysis with previously published cases. We show that these tumours have recurrent and mutually exclusive mutations in either ACVR1 or EGFR and are characterised by high expression of EZHIP associated to its promoter hypomethylation. Affected patients share a similar poor prognosis as patients with H3K27M DMG. Global molecular analysis of H3-WT and H3K27M DMG reveal distinct transcriptome and methylome profiles including differential methylation of homeobox genes involved in development and cellular differentiation. Patients have distinct clinical features, with a trend demonstrating ACVR1 mutations occurring in H3-WT tumours at an older age. This in-depth exploration of H3-WT tumours further characterises this novel DMG, H3K27-altered sub-group, characterised by a specific immunohistochemistry profile with H3K27me3 loss, wild-type H3K27M and positive EZHIP. It also gives new insights into the possible mechanism and pathway regulation in these tumours, potentially opening new therapeutic avenues for these tumours which have no known effective treatment. This study has been retrospectively registered on clinicaltrial.gov on 8 November 2017 under the registration number NCT03336931 ( https://clinicaltrials.gov/ct2/show/NCT03336931 ).

BRAF-mediated brain tumors in adults and children: A review and the Australian and New Zealand experience

The mitogen-activated protein kinase (MAPK) pathway signaling pathway is one of the most commonly mutated pathways in human cancers. In particular, BRAF alterations result in constitutive activation of the rapidly accelerating fibrosarcoma-extracellular signal-regulated kinase-MAPK significant pathway, leading to cellular proliferation, survival, and dedifferentiation. The role of BRAF mutations in oncogenesis and tumorigenesis has spurred the development of targeted agents, which have been successful in treating many adult cancers. Despite advances in other cancer types, the morbidity and survival outcomes of patients with glioma have remained relatively stagnant. Recently, there has been recognition that MAPK dysregulation is almost universally present in paediatric and adult gliomas. These findings, accompanying broad molecular characterization of gliomas, has aided prognostication and offered opportunities for clinical trials testing targeted agents. The use of targeted therapies in this disease represents a paradigm shift, although the biochemical complexities has resulted in unexpected challenges in the development of effective BRAF inhibitors. Despite these challenges, there are promising data to support the use of BRAF inhibitors alone and in combination with MEK inhibitors for patients with both low-grade and high-grade glioma across age groups. Safety and efficacy data demonstrate that many of the toxicities of these targeted agents are tolerable while offering objective responses. Newer clinical trials will examine the use of these therapies in the upfront setting. Appropriate duration of therapy and durability of response remains unclear in the glioma patient cohort. Longitudinal efficacy and toxicity data are needed. Furthermore, access to these medications remains challenging outside of clinical trials in Australia and New Zealand. Compassionate access is limited, and advocacy for mechanism of action-based drug approval is ongoing.

Pediatric low-grade glioma: Targeted therapeutics and clinical trials in the molecular era

pLGGs are a group of tumors for which the era of molecular diagnostics has truly shifted treatment paradigms and patient care. The discovery that this group of tumors is driven by single-gene alterations/fusions in the MAPK pathway has resulted in relatively rapid translation into targeted therapy options for patients with this often chronic disease. This translation has been facilitated through efforts of multiple collaboratives and consortia and has led to the development of clinical trials testing the role of targeted therapies in pLGG. Although these developments represent promise, many questions remain regarding these therapies including their long-term toxicities and their potential effects on the natural history of pLGG.

CTIM-32. FIRST-IN-CHILDREN PHASE 1 TRIAL OF INDOXIMOD-BASED CHEMO-IMMUNOTHERAPY FOR PATIENTS WITH PEDIATRIC BRAIN TUMORS: ANALYSIS OF SAFETY, TOLERABILITY, AND 5-YEAR OUTCOME

BACKGROUND

Recurrent brain tumors are the leading cause of cancer death in children. We conducted a first-in-children, two-institution, Phase 1 open-label dose-confirmation study using a 3 + 3 design, with expansion cohorts, to determine the recommended pediatric dose of the IDO pathway-inhibitor indoximod (NCT02502708). DESIGN/

METHODS

Eligible patients were 3-22 years old with either recurrent malignant brain tumor or newly-diagnosed diffuse intrinsic pontine glioma (DIPG). Palliative radiation, surgery or dexamethasone were allowed as needed for patient management. Separate dose-finding arms were performed for indoximod plus temozolomide (200 mg/m2/day orally for 5 days of each 28-day cycle) and for indoximod plus conformal radiation (in patients for whom re-irradiation was planned as standard-of-care). At progression, patients who were otherwise clinically stable were offered crossover to indoximod plus a second-line chemotherapy regimen (cyclophosphamide 2.5 mg/kg/day orally and etoposide 50 mg/m2/day orally for 21 days of each 28-day cycle).

RESULTS

Between December 2015 and January 2019, the study enrolled 81 brain tumor patients, including newly-diagnosed DIPG (n = 13) or recurrent ependymoma (n = 27), glioblastoma/high-grade glioma (n = 19), medulloblastoma (n = 13), or other CNS tumors ( n= 9). Median follow-up was 52 months (range 39-77 months). No dose-limiting toxicities were observed, and the pediatric indoximod dose was determined (19.2 mg/kg/dose, given twice daily). Indoximod was well tolerated and did not affect the ability to deliver chemotherapy or radiation as planned. Median overall survival was 13.6 months (n = 81). Median overall survival was 34.7 months for the subset of patients who continued indoximod with second-line chemotherapy after progression on indoximod plus temozolomide (n = 18).

CONCLUSIONS

Indoximod was well tolerated and could be combined with a variety of standard treatments for pediatric brain tumors. Preliminary anti-tumor activity and overall survival suggest that indoximod with standard therapy should be further evaluated in pediatric brain tumors, and potentially other pediatric solid tumors.

The Trend and Prediction of Cervical Cancer Incidence in Delhi, India: An Age-Period-Cohort Analysis

OBJECTIVE

The objective of the study is to assess the trend of age-standardised incidence rate (ASIRs) of cervical cancer, standardised median age at diagnosis, and projection of cervical cancer incidence rate and the number of new cases up to 2030. The projections help in making strategies for resource allocation to circumvent the future burden.

METHODS

The data were extracted from the Delhi population-based cancer registry from 1990 to 2014. Joinpoint regression analysis was applied to ASIRs to assess the trend. The natural cubic splines age-period-cohort (APC) model was fitted to project the incidence rate and incidence cases. The trend of standardised median age at diagnosis and percentage of cervical cancer to total women cancer was also assessed using regression analysis. Projections of new cases are decomposed into three components aging, the structure of the population, and age-specific incidence rate.

RESULTS

The age-standardised incidence rate of cervical cancer decreased with an annual decline at a rate of 2.98% (95% CI -3.48 to -2.47) from 1990 to 2014. The standardised median age at diagnosis showed an upward trend with an average annual increase of 0.167 per year and the median age increased by 4.18 years during 25-years period, this change was due to the shifting of the peak from 40-44 in 1990 to 60-64 in 2014. The APC model revealed ASIRs would decline by 43.8% in 2030 compared to average ASIRs 2010-2014, albeit a net 12% increase in the incidence cases. An increase in incidence cases is primarily attributed to the aging of the population and population  growth by 38.87% and 33.84% respectively.  The trend analysis of  cervical cancer ASIRs in pre (< 50 years) and post menopause (≥ 50 years) showed a decreasing trend. However, the ratio of cervical to total women increased over time from 1:1 in 1990 to 2:3 in 2014.

CONCLUSION

The declining trend in ASIRs was observed in Delhi and will continue to decrease up to 2030.  The burden of the number of new cases of cervical cancer showed an upward trend primarily due to the aging of the population and shifting of population structure. To counter this big challenge a cost-effective vaccination for vulnerable populations, community-based screening programs, and awareness about cervical cancer prevention might help in eliminating this preventable cancer.

Outcomes after first relapse of childhood intracranial ependymoma

BACKGROUND

Ependymoma is the third most common malignant CNS tumor in children. Despite multimodal therapy, prognosis of relapsed ependymoma remains poor. Approaches to therapy for relapsed ependymoma are varied. We present a single-institution retrospective review of the outcomes after first relapse of intracranial ependymoma in children.

PROCEDURE

We performed a retrospective, IRB-approved chart review of patients with recurrent intracranial ependymoma treated at Dana-Farber/Boston Children's Cancer and Blood Disorders Center from 1990 to 2019.

RESULTS

Thirty-four patients with relapsed intracranial ependymoma were identified. At initial diagnosis, 11 patients had supratentorial disease, 22 with posterior fossa disease and one with metastatic disease. Median time-to-first relapse was 14.9 months from initial diagnosis (range 1.4-52.5). Seven patients had metastatic disease at first relapse. Gross total resection (GTR) was associated with improved 5-year progression-free survival (PFS) relative to subtotal resection (STR) and no surgery (p = .005). Localized disease at relapse was associated with improved 5-year overall survival (OS) when compared to metastatic disease (p = .02). Irradiation at first relapse seemed to delay progression but was not associated with statistically prolonged PFS or OS. Tumor location, histology, and chromosomal 1q status did not impact outcome at first relapse, although available molecular data were limited making definitive conclusions difficult. Median time-to-second relapse was 10 months (range 0.7-124). Five-year PFS and OS after first relapse were 19.9% and 45.1%, respectively. Median PFS and OS were 10.0 and 52.5 months after first relapse, respectively.

CONCLUSIONS

Relapsed intracranial ependymoma has a poor prognosis despite multimodal therapy. Novel therapeutic strategies are desperately needed for this disease.

HGG-14. ACT001 – A PROMISING THERAPEUTIC FOR DIFFUSE INTRINSIC PONTINE GLIOMAS

Diffuse Intrinsic Pontine Gliomas (DIPGs) are a subset of Diffuse Midline Gliomas (DMG) and are the most devastating of all brain tumors. There are no effective treatments and all children die of their tumor within 12-months. We performed a high-throughput drug screen with 3,570 biologically active, clinically approved compounds against a panel of DIPG cultures. Parthenolide, a compound derived from the herb T.parthenium, was found to be one of the most effective drugs tested, demonstrating significant anti-tumor activity. However, parthenolide also affected healthy cell viability and showed no in-vivo efficacy. ACT001 is a novel agent in clinical development that is a fumarate salt form of dimethylamino-micheliolide, which is semi-synthesized from parthenolide. ACT001 is blood-brain-barrier permeable and exerts an anti-tumor effect via inhibition of NF-κB and STAT3 pathways. ACT001 demonstrated potent anti-tumor activity against a panel of DIPG-neurospheres, with minimal effect on normal cells and inhibited colony formation in-vitro. To determine whether this activity could be replicated in-vivo, we tested ACT001 in a DIPG-orthotopic model. ACT001 was well tolerated and significantly improved survival of tumor-bearing animals, extending survival by 33% in ACT001 treated mice. We have initiated a Phase 1 paediatric trial of ACT001 for children with relapsed/refractory solid or CNS tumors, with an expansion cohort planned for patients with DIPG/DMG. Eleven patients have been enrolled, and the dose escalated from dose level-1 at 188mg/m2 bd to dose level-4 at 700mg/m2 bd. To date, no dose limiting or Grade 3/4 toxicities have been observed. At the highest dose level, clinical activity has been demonstrated in two patients, one with DIPG with a reduction in tumor burden, and another with DMG with H3K27M mutation with an objective radiographic and clinical response. These combined preclinical and clinical results suggest that ACT001 is an active novel therapy for patients with DIPG/DMG.

Anti-biofilm activity of LC-MS based Solanum nigrum essential oils against multi drug resistant biofilm forming P. mirabilis

Urinary tract infections are second most important diseases worldwide due to the increased amount of antibiotic resistant microbes. Among the Gram negative bacteria, P. mirabilis is the dominant biofilm producer in urinary tract infections next to E. coli. Biofilm is a process that produced self-matrix of more virulence pathogens on colloidal surfaces. Based on the above fact, this study was concentrated to inhibit the P. mirabilis biofilm formation by various in-vitro experiments. In the current study, the anti-biofilm effect of essential oils was recovered from the medicinal plant of Solanum nigrum, and confirmed the available essential oils by liquid chromatography-mass spectroscopy analysis. The excellent anti-microbial activity and minimum biofilm inhibition concentration of the essential oils against P. mirabilis was indicated at 200 µg/mL. The absence of viability and altered exopolysaccharide structure of treated cells were showed by biofilm metabolic assay and phenol-sulphuric acid method. The fluorescence differentiation of P. mirabilis treated cells was showed with more damages by confocal laser scanning electron microscope. Further, more morphological changes of essential oils treated cells were differentiated from normal cells by scanning electron microscope. Altogether, the results were reported that the S. nigrum essential oils have anti-biofilm ability.

DIPG-75. PRECISION MEDICINE FOR PAEDIATRIC HIGH-GRADE DIFFUSE MIDLINE GLIOMAS - RESULTS FROM THE ZERO CHILDHOOD CANCER COMPREHENSIVE PRECISION MEDICINE PROGRAM

The Australian Zero Childhood Cancer (ZERO) program aims to assess the feasibility of a comprehensive precision medicine approach to improve outcomes for patients with an expected survival &lt;30%. ZERO combines molecular profiling (whole genome sequencing, whole transcriptome sequencing, DNA methylation profiling) with in vitro high-throughput drug screening (HTS) and patient-derived xenograft drug efficacy testing. We report on the cohort of patients with midline high-grade glioma (HGG), including H3-K27M DMG, enrolled on the pilot study (TARGET) and on the ongoing ZERO clinical trial (PRISM). We identified 48 patients with midline HGG. Fresh or cryopreserved samples were submitted in 37 cases and cell culture was attempted in 30/37 cases with 45% success rate. The most commonly mutated genes/pathways identified by molecular profiling include H3-K27M mutations, DNA repair pathway, and PI3K/mTOR pathway. Two targetable fusions (NTRK and FGFR1) were reported. Five patients with germline alterations were identified. Thirty-five (72%) patients received a therapeutic recommendation from the ZERO molecular tumour board and the main recommended therapies were mTOR inhibitors, PARP inhibitors or tyrosine kinase inhibitors. HTS added evidence for the recommended therapy (n=3) or identified novel potential therapy (n=1). Out of the 35 patients, 16 received a recommended drug. Response to treatment was complete response for five months (n=1), partial response for nine months (n=1), stable disease (n=4), and progressive disease (n=10). These results highlight the feasibility of the ZERO platform and the value of fresh biopsy, necessary for pre-clinical drug testing. Targetable alterations were identified leading to clinical benefit in six patients.

Anti-bacterial activity of chitosan loaded plant essential oil against multi drug resistant K. pneumoniae

The development of antibiotic resistant in K. pneumoniae is an emerging thread worldwide due to the poor antimicrobial drugs. To overcome this issue, researchers are focused on plant material and their essential oils to fight against multi drug resistant bacteria. In this context, the current study was concentrated in medicinal plant of guva leaves and their essential oils to combat multi drug resistant bacterial infections. The essential oils were successfully screened and confirmed by HRLC-MS analysis. The anti-bacterial ability of the compounds were loaded into the chitosan nanoparticles and proved by FT-IR analysis. In addition, the chitosan loaded essential oils morphology was compared with chitosan alone in SEM analysis and suggested that the material was loaded successfully. Further, the anti-bacterial ability of the chitosan loaded essential oils were primarily confirmed by agar well diffusion method. At the 100 µg/mL of lowest concentration of chitosan loaded essential oils, the multi-drug resistant K. pneumoniae was inhibited with 96% and confirmed by minimum inhibition concentration experiment. Hence, all the experiments were proved that the essential oils were successfully loaded into the chitosan nanoparticles, and it has more anti-bacterial activity against multi-drug resistant K. pneumoniae.

Feasibility and Results of Cancer Registry and Noncommunicable Disease Cohort Data Linkages in India

Background: Cancer registries worldwide are vital to determine cancer burden, plan cancer control measures, and facilitate research. Population-based cancer registries are a priority for LMICs by the UICC; the National Cancer Registry Program (NCRP) of India oversees 28 such registries. A primary function of registries is to combine data for the same individual from multiple sources. For other disease cohorts where cancer is an outcome of interest, registries can potentially connect information by linking datasets together. Barriers to successful registration and linkages include systems in which cancer is not a notifiable disease, no universal unique individual identifier exists, and lack of trained personnel. This study utilizes technology and infrastructure to develop better linkages, surveillance, and outcomes. Aim: To assess the feasibility of linking large cohorts designed for cardio-metabolic disease research with cancer registries in New Delhi and Chennai; determine additional steps required for linkage accuracy and completeness; and develop detailed protocols for future applications. Methods: A pilot protocol for linkage between a large diabetes cohort and cancer registries in Delhi and Chennai was developed using MatchPro, a probabilistic record linkage program developed for cancer registries. Probabilistic software links datasets together in the presence of uncertainty (eg misspelled or abbreviated names) to identify record pairs with high probability of representing the same individual. For this study, algorithms were developed to address unique aspects of names and demographics in India. The software and algorithms focused on: detecting duplicates in cancer registries; and linking registries with external files from diabetes cohorts. In Delhi, 3 1-year datasets covering 3 years (2010, 2011, 2012) were linked with the diabetes cohort; in Chennai, the linkage included 3 5-year datasets covering 15 years (2000-04, '05-'09, '10-'14). The unique ID (Aadhaar) is not collected or linked systematically between different systems at this point in time. Results: Linkage attempts yielded potential matches ranked according to probabilistic scores; highest scores were reviewed to determine true matches. In Chennai, this process yielded: (2010-2014) 21% self-reported (SR) cases matching perfectly, 36% requiring follow-up, 13 nonreported (NR) cases found; 2005-2009: 33% SR cases matched perfectly, 1 NR case found; 2000-2004: 1 NR case. Also, 2 training workshops on data linkages and software were held. Conclusion: Linkages between cancer registries and other data sources are feasible in LMICs using probabilistic record linkage software augmented by manual matching. Future efforts to use existing epidemiologic resources (cohorts) and cancer research infrastructure (registries and clinical centers) can enhance research including understanding shared risk factors and pathophysiologic mechanisms e.g., between cancer and other NCD.

Trends in incidence of Ewing sarcoma of bone in India - Evidence from the National Cancer Registry Programme (1982-2011)

Background

Ewing sarcoma is a malignant tumour found mainly in childhood and adolescence. The present study aims at analyzing the data on Ewing sarcoma cases of bone from the National Cancer Registry Programme, India to provide incidence, patterns, and trends in the Indian population.

Materials and Methods

The data of five Population Based Cancer Registries (PBCR) of Bangalore, Mumbai, Chennai, Bhopal and Delhi over 30 years period (1982- 2011) were used to calculate the Age Specific and Age Standardized Incidence Rates (ASpR and ASIR), and trends in incidence was analyzed by linear and Joinpoint Regression.

Results

Ewing sarcoma comprised around 15 % of all bone malignancies. Sixty-eight percent were 0-19 years, with 1.6 times risk of tumour in bones of limbs as compared to other bones. The highest incidence rate (per million) was in the 10-14 years age group (male -4.4, female -2.9) with significantly increasing trend in ASpR observed in both sexes. Pooled ASIR per million for all ages was higher in male (1.6) than female (1.0) with an increasing rate ratio of ASIR with increase in age. Trend of pooled ASIR for all ages was significantly increased in both sexes. Twelve percent cases were reported in ≥30 years of age.

Conclusion

This paper has described population based measurements on burden and trends in incidence of skeletal Ewing in India. These may steer further research questions on the clinical and molecular epidemiology to explain factors associated with the increasing incidence of Ewing sarcoma bone observed in India.

Prevalence of HIV in Patients with Malignancy and of Malignancy in HIV Patients in a Tertiary Care Center from North India

BACKGROUND AND OBJECTIVES

People living with HIV/AIDS are at an increased risk of developing cancer. The goals of this study were to obtain data on the prevalence of HIV in the cancer population and vice versa at a major tertiary cancer and HIV center in North India.

METHODS

This cross-sectional study was conducted over a 3-year period from July 2013 to June 2016, wherein successive HIV positive patients from an anti-retroviral therapy (ART) center were screened for malignancy. Simultaneously, successive cancer patients at the cancer center were screened for HIV. Baseline demographic details, risk factors, and laboratory investigations were obtained for all the patients.

RESULTS

Among the 999 HIV-positive patients at the ART center, the prevalence of malignancy was 2% (n=20; 95% confidence interval (CI) 1.13, 2.87). Among the 998 patients with a malignancy, the prevalence of HIV infection was 0.9% (n=9; 95% CI 0.31, 1.49). Weight loss, loss of appetite, and fever were the most common symptoms in patients with HIV and cancer. Among 29 patients with HIV and cancer, AIDS-defining cancer was found in 19 patients; non-Hodgkin's lymphoma was the most common malignancy reported (n=13).

INTERPRETATION AND CONCLUSION

There is a low prevalence of HIV in cancer patients as well as a low prevalence of cancer in HIV patients. AIDS-defining cancers remain much more common than non-AIDS-defining cancers. With the increased coverage of ART, it is expected that non-AIDSdefining cancers will increase, as is evident from data from more developed countries.

Paediatric retinoblastoma in India: evidence from the National Cancer Registry Programme

BACKGROUND

Globally, retinoblastoma is the most common primary intraocular malignancy occurring in children. This paper documents the recent incidence rates of retinoblastoma by age and sex groups from the Population Based Cancer Registries (PBCRs) of Bangalore, Mumbai, Chennai, Delhi and Kolkata using the data from the National Cancer Registry Programme.

MATERIALS AND METHODS

Relative proportions, sex ratio, method of diagnosis, and incidence rates (crude and age standardized) for each PBCR and pooled rates of the five PBCRs were calculated for the years 2005/06 to 2009/10. Standard errors and 95% confidence limits of ASIRs by sex group in each PBCR were calculated using the Poisson distribution. Standardised rate ratios of ASIR by sex group and rate ratios at risk were also calculated.

RESULTS

The maximum retinoblastoma cases were in the 0-4 age group, accounting for 78% (females) and 81% (males) of pooled cases from five PBCRs. The pooled crude incidence rate in the 0-14 age group was 3.5 and the pooled ASIR was 4.4 per million. The pooled ASIR in the 0-4, 5-9 and 10-14 age group were 9.6, 2.0 and 0.1 respectively. The M/F ratio in Chennai (1.9) and Bangalore PBCRs (2.0) was much higher than the other PBCRs. Among the PBCRs, the highest incidence rate in 0-4 age group was found in males in Chennai (21.7 per million), and females in Kolkata (18.9 per million). There was a distinct variation in incidence rates in the PBCRs in different geographic regions of India.

Evaluation of Delhi Population Based Cancer Registry and Trends of Tobacco Related Cancers

BACKGROUND

Tobacco use is the single most important preventable risk factor for cancer. Surveillance of tobacco-related cancers (TRC) is critical for monitoring trends and evaluating tobacco control programmes. We analysed the trends of TRC and evaluated the population-based cancer registry (PBCR) in Delhi for simplicity, comparability, validity, timeliness and representativeness.

MATERIALS AND METHODS

We interviewed key informants, observed registry processes and analysed the PBCR dataset for the period 1988-2009 using the 2009 TRC definition of the International Agency for Research on Cancer. We calculated the percentages of morphologically verified cancers, death certificate-only (DCO) cases, missing values of key variables and the time between cancer diagnosis and registration or publication for the year 2009.

RESULTS

The number of new cancer cases increased from 5,854 to 15,244 (160%) during 1988-2009. TRC constituted 58% of all cancers among men and 47% among women in 2009. The age-adjusted incidence rates of TRC per 100,000 population increased from 64.2 to 97.3 among men, and from 66.2 to 69.2 among women during 1988-2009. Data on all cancer cases presenting at all major government and private health facilities are actively collected by the PBCR staff using standard paper-based forms. Data abstraction and coding is conducted manually following ICD-10 classifications. Eighty per cent of cases were morphologically verified and 1% were identified by death certificate only. Less than 1% of key variables had missing values. The median time to registration and publishing was 13 and 32 months, respectively.

CONCLUSIONS

The burden of TRC in Delhi is high and increasing. The Delhi PBCR is well organized and generates high-quality, representative data. However, data could be published earlier if paper-based data are replaced by electronic data abstraction.

Descriptive epidemiology of primary brain and CNS tumors in Delhi, 2003-2007

The Delhi Population Based Cancer Registry data during the period 2003-2007 were used to describe the epidemiology of primary malignant brain and central nervous system tumors in Delhi. A total of 1989 brain and CNS tumors cases in 1291 males and 698 females were registered during the period 1st January 2003 to 31st December 2007. The age adjusted (world population) incidence rates were 3.9 per 100,000 for males and 2.4 per 100,000 for females. Gliomas were the most frequently reported histology both in males (26.6%) and females (23.2%). A male predominance in incidence was observed for all histological classifications. The rates in Delhi are low compared to the incidences reported from developed countries.

Cancer incidences in rural Delhi--2004-05

There are no data available on cancer incidence pattern in rural Delhi. This is the first report on cancer incidence among Delhi Rural population during 2004-05 which gives the first hand information on cancer incidence. The data for this report has been collected by Delhi Population based cancer registry. The sources for cancer registration are more than 162 Government Hospitals/centers and 250 private hospitals and nursing homes. A total of 594 cancer cases with 317 males and 277 females were registered during the period 1st January 2004 to 31st December 2005. The age adjusted (world population) incidence rates for all sites were 55.2 per 100,000 for males and 47.7 per 100,000 for females. The leading sites of cancer among Delhi Rural males was oral cavity (ASR: 8.0 per 100000) followed by lung (ASR: 6.5), larynx (ASR: 4.0) and bladder (ASR: 4.1). In females cervix uteri (ASR: 10.3 per 100,000) was the most common site of cancer followed by breast (ASR: 7.8), gallbladder (ASR: 3.5) and ovary (ASR: 3.3). The overall incidence rates of cancer in Delhi Rural were comparatively very less than Delhi Urban. A statistically significant difference was also found between Delhi Rural and Delhi Urban in incidence rates (ASR) for first four common sites. The rates in Delhi Rural are also comparatively lower than other rural registries situated in India.

Antibacterial copper-nickel bilayers and multilayer coatings by pulsed laser deposition on titanium

Biofouling, especially microfouling, is a major concern with the use of titanium (Ti) in the marine environment as a condenser material in cooling water systems. Earlier, copper-nickel (Cu/Ni) alloys were extensively used in marine environments due to their high corrosion and biofouling resistance. However, the choice of condenser material for the new fast breeder reactor in Kalpakkam is Ti to avoid steam side corrosion problems, which may pose a threat to steam generator parts having sodium as the secondary coolant. This study evaluates the surface modification of Ti using nano films of copper (Cu) and nickel (Ni) to utilize the antibacterial property of copper ions in reducing microfouling. The surface modification of Ti was carried out by the deposition of a Cu/Ni bilayer and (Cu/Ni)(10) multilayer films using a pulsed laser deposition technique. Various surface characterization studies revealed that the deposited Cu/Ni films were thin and nanocrystalline in nature. The antibacterial properties were evaluated using total viable count and epifluorescence microscopic techniques. The results showed an apparent decrease in bacterial attachment on multilayered and bilayered Cu/Ni thin films on Ti surfaces. Comparative studies between the two types of films showed a bigger reduction in numbers of microorganisms on the multilayers.

Surface modification of titanium using nanothin films of copper for biofouling control

Biofouling is one of the major impediment in the use of titanium, which is otherwise excellent material with respect to corrosion resistance and mechanical properties, for seawater-cooled condensers of power plants. The routine chlorination treatment and sponge ball cleaning may not be successful to keep the titanium condenser tube clean over a period extending to years. This brings into focus the relevance of surface modification of titanium to improve the antimicrobial properties, which can effectively supplement the present treatment programmes. In this study antimicrobial thin film of copper (Cu) is developed on titanium surfaces, as copper is known to be very toxic to microorganisms and effectively kills most of the microbes by blocking the respiratory enzyme system. The preparation of nanocrystalline thin films of copper on titanium surfaces was done by pulsed DC magnetron-sputtering technique. Then this thin film was characterized using Glancing Incidence X-ray Diffraction (GIXRD) and Atomic Force Microscopy (AFM). Antimicrobial properties of these specimens were evaluated by exposure studies in seawater. Results showed two order decrease in the bacterial density on copper coated surface and epifluorescence micrographs depicted very few fluorescing cells and no biofilm formation clearly demonstrating the superior antibacterial capability of this nanocrystalline copper thin film.

Cancer incidences in urban Delhi - 2001-05

The Delhi Population based cancer registry collects data on new cancer cases diagnosed among Delhi urban resident population. The sources for cancer registration are more than 162 government hospitals/centers and 250 private hospitals and nursing homes. During the period 1st January 2001 to 31st December 2005 a total of 54,554 cases were registered of which 28,262 were males and 26,292 were females. The age adjusted (world population) incidence rates were 116.9 per 100,000 for males and 116.7 per 100,000 for females. The leading sites of cancer among Delhi males was lung (ASR: 13.8 per 100,000) followed by oral cavity (ASR: 11.4), prostate (ASR: 9.0) and larynx (ASR: 7.9). In females, breast (ASR: 30.2 per 100,000) was the most common site of cancer, followed by cervix uteri (ASR: 17.5), ovary (ASR: 8.5) and gallbladder (ASR: 7.4). The incidence of prostate cancer in males and ovary cancer in females in Delhi were the highest among the Indian registries, while larynx among males was the second highest and the gallbladder cancer in females was the highest among Indian metropolitan cities.

Breast dose heterogeneity in CT-based radiotherapy treatment planning

The aim of this study was to evaluate the breast dose heterogeneity in CT-based radiotherapy treatment planning and to correlate with breast parameters. Also, the number of slices required for treatment planning in breast cancer by tangential field technique has been assessed by comparing the treatment plans according to International Commission on Radiation Units and Measurement (ICRU) 50 guidelines (1993) for single-slice, three-slice, and multi-slice (3D) planning . Sixty women who underwent isocentric tangential field breast radiotherapy were included in this study. The plans were optimized and analyzed with dose volume histograms. Sixty-three percent of the single-slice plans and 26.7% of the three-slice plans showed poor dose homogeneity as compared to the 3D plans. Dose inhomogeneity correlated better with breast volume (r² = 0.43) than the chest wall separation (r² = 0.37) and breast area product (r² = 0.36). Similarly, breast volume correlated better with breast area product (r² = 0.80) than with chest wall separation (r² = 0.56). Breast volume can be approximated to breast area product from the relation, breast volume = [(breast area product × 8.85) − 120.05]. The results of this study showed that most of the cases require 3D planning for breast cancer. It also showed that patients with large breast are prone to have more dose inhomogeneity with standard tangential field radiotherapy. In centers where 3D planning is not possible due to lack of facilities or workload, three slices–based planning can be performed to approximate the dosimetric advantage of 3D planning.

Trends of Cancer Prevalence in Some Districts of West Bengal

An attempt has been made to understand the cancer prevalence in eight districts of West Bengal. Special emphasis was on the types of cancer most prevalent among the male and female populations. In this study we have represented the frequency by age and sex of different tumors among 9034 cancer cases registered over five years. Our findings indicate that liver cancer is predominant among males and cancer of the cervix uteri is most prevalent among females. The valuesby age indicate that cancer incidence increased during this study period, especially in Kolkatta.

The Madurai Intraocular Lens Study. II: Clinical outcomes

PURPOSE

To evaluate the safety and efficacy of extracapsular cataract extraction with posterior chamber intraocular lens (ECCE/PC-IOL) compared with intracapsular cataract extraction with aphakic glasses (ICCE-AG).

METHODS

In a nonmasked randomized controlled clinical trial, 3,400 bilaterally vision-impaired patients aged 40 to 75 years with operable cataract were randomly assigned to receive either ICCE-AG or ECCE/PC-IOL at the Aravind Eye Hospital in India. The surgery was performed by one of four study surgeons. Patients were hospitalized for 5 postoperative days, with follow-up visits at 2, 6, and 12 months after discharge. Postsurgery evaluations were conducted by two independent study ophthalmologists.

RESULTS

At any single postoperative follow-up time point, there were no statistically significant differences of clinical relevance between treatment groups for any complication of a serious nature except cystoid macular edema, which was more common with ICCE (4.2% vs 1.6%). In general, whether of a trivial, intermediate, or serious nature, complication rates were low at each evaluation time point. Cumulatively, the incidence of serious complications of all types throughout the 1-year study period was 14.5% for patients in the ICCE-AG group and 7.7% in the ECCE group (P < .001). Best-corrected visual acuity of 20/40 or better at 12 months was attained by 90.7% of ICCE-AG patients and 96.3% of ECCE/PC-IOL patients (P < .001).

CONCLUSION

Although both operative procedures are safe and effective for cataract patients with bilateral impairment, ECCE/PC-IOL is superior to ICCE-AG in terms of both visual acuity restoration and safety.

Lens induced glaucomas--visual results and risk factors for final visual acuity

Lens induced glaucomas are a common occurrence in India. An attempt was made to understand the clinical modes of presentation and post operative visual results in 93 patients with lens induced glaucoma, 49 phacomorphic and 44 phacolytic, attending our institute during 1994. All these patients were subjected to a planned extracapsular cataract extraction. Forty four percent had a posterior chamber intraocular lens implantation following surgery. Fifty seven percent eyes with phacomorphic glaucoma and 61% with phacolytic glaucoma recovered visual acuity of 6/12 or better. There was no significant difference in the final visual acuity between those patients who had an intraocular lens implanted and those who did not (P = 0.18). Univariate analysis was performed for selected risk factors such as age, sex and duration of glaucomatous process as predictors of final visual acuity and odds ratios with 95% confidence intervals were calculated. Patients with age more than 60 years (OR = 2.7, 95% CI = 1.04-6.93) and in whom the glaucoma was present for more than 5 days (OR = 3.1, 95% CI = 1.21-8.13) had a significantly higher risk of poor visual outcome post-operatively.