Radiotherapy for Liver Cancer: An International Multi-Centre Pooled Analysis of 925 Cases

PURPOSE/OBJECTIVE(S)

Primary and secondary liver cancer incidence is growing and has a poor prognosis. The standard use of radiation has been hampered by studies with a wide range of patients, different management protocols and varied outcomes. To overcome this heterogeneity in the literature, larger and higher-level trials are warranted, but, so far, have been difficult to implement. Therefore, pooled analyses may offer the best way to determine the benefit of radiation, identify treatment parameters needed to optimize treatment techniques, and identify patient factors that allow for better patient selection.

MATERIALS/METHODS

Patients with liver cancer treated by radiotherapy at centers in Canada, United States and Australia was pooled. Patient and treatment characteristics were noted, as well as the clinical outcomes of local control within 1 year, recurrence and mortality. Stepwise Cox proportional hazards models were used to identify significant predictors for recurrence and mortality. Patients were stratified by center, and primary versus metastatic disease.

RESULTS

A total of 925 patients were included in this study. Mean age was 67 years, and 45% had a primary diagnosis of hepatocellular carcinoma. 1-year local control rate was 80%. Median survival was 1.8 years (1.9 years for primary liver cancer, and 1.4 years for metastatic liver cancer). Higher total dose and BED was associated with better survival. Median time to recurrence was 1.5 years. Higher total dose was associated with lower risk of recurrence CONCLUSION: As one of the largest pooled analyses in hepatic cancer, this international multi-center study provides pragmatic data on clinical outcomes of patients receiving radiotherapy for liver cancer. This database may assist in better selection of patients for future studies and answer questions such as what is the optimal dose and which patients benefit from treatment.

Efficacy of Curvilinear Needle Implantation for Prostate HDR Brachytherapy

PURPOSE/OBJECTIVE(S)

High-dose-rate (HDR) brachytherapy is gaining popularity due to better dose distribution, good clinical outcomes, and convenience of the procedure. Conventionally, Rectilinear (straight needle) Method (RLM) is utilized for HDR procedure. However, the efficacy of a newly developed technique, the Curvilinear (curved needle conforming the prostate shape) Method (CLM), for HDR brachytherapy has not yet been explored. In this study, efficacy of the CLM is evaluated. The CLM technique is expected to significantly improve the radiation dose distribution with small number of needles that will potentially improve the clinical outcomes.

MATERIALS/METHODS

Randomly 16 prostate cancer patients were selected (median age: 68.3 yrs, Stage: T1-T2a) from an IRB approved pool of patients. Prostate and OARs (urethra, rectum and bladder) were contoured on T2-weigthed MRI for all the patients. Thirty-two HDR plans, 16 for RLM and 16 for CLM, were prepared using Oncentra treatment planning software with Ir-192 isotope and were optimized using Hybrid Inverse treatment Planning Optimization (HIPO) tool. Prescription dose was 15 Gy in single fraction. Data for relevant parameters (V100, V200, D90, D10, Dmax, etc.) for prostate and OARs were collected using the dose-volume histogram. P-value less than equal to 0.05 was considered statistically significant.

RESULTS

Average prostate volume was 33.1cc (range 17.7-51.3cc, median 30.6cc). In CLM technique the target coverage and dose constraints for OARs were improved by 0.3%-6.4% and 1.6%-34.2%, respectively (see Table below). Certain dose constraints were difficult to meet for some cases with RLM (prostate V100 (4 pts) and V200 (5 pts); rectum Dmax (5 pts) and D12 Gy (10 pts). On average, over 44.6% (average 17.5 vs 9.7 needles) reduction of needles was achieved with CLM (p-value < 0.001).

CONCLUSION

The CLM technique generated significantly improved dosimetric plans using less number of needles. Reduction in number of needles would be associated with potential decrease in toxicity and improved clinical outcomes. Future plan includes clinical implementation of the CLM technique.

Outcomes and toxicities in oligometastatic patients treated with stereotactic body radiotherapy for adrenal gland metastases: A multi-institutional retrospective study

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SBRT to adrenal gland oligometastases achieves a satisfactory local control and OS.

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A minimum PTV dose BED₁₀ > 46 Gy was associated with an improved OS and LRFS.

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A prescribed BED₁₀ > 70 Gy was correlated with improved local control.

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High adrenal metastases volume should not preclude the delivery of SBRT.

Background

Studies reporting SBRT outcomes in oligometastatic patients with adrenal gland metastases (AGM) are limited. Herein, we present a multi-institutional analysis of oligometastatic patients treated with SBRT for AGM.

Material/methods

The Consortium for Oligometastases Research (CORE) is among the largest retrospective series of patients with oligometastases. Among CORE patients, those treated with SBRT for AGM were included. Clinical and dosimetric data were collected. Adrenal metastatic burden (AMB) was defined as the sum of all adrenal GTV if more than one oligometastases is present.

Competing risk analysis was used to estimate actuarial cumulative local recurrence (LR) and widespread progression (WP). Kaplan-Meier method was used to report overall survival (OS), local recurrence-free survival (LRFS), and progression-free survival (PFS). Treatment related toxicities were also reported.

Results

The analysis included 47 patients with 57 adrenal lesions. Median follow-up was 18.2 months. Median LRFS, PFS, and OS were 15.3, 5.3, and 19.1 months, respectively. A minimum PTV dose BED₁₀ > 46 Gy was associated with an improved OS and LRFS. A prescribed BED₁₀ > 70 Gy was an independent predictor of a lower LR probability. AMB>10 cc was an independent predictor of a lower risk for WP. Only one patient developed an acute Grade 3 toxicity consisting of abdominal pain.

Conclusion

SBRT to AGM achieved a satisfactory local control and OS in oligometastatic patients. High minimum PTV dose and BED₁₀ prescription doses were predictive of improved LR and OS, respectively. Prospective studies are needed to determine comprehensive criteria for patients SBRT eligibility and dosimetric planning.

Dermoid Cyst with Intracranial Extension Presenting With Headache

Dermoid cysts (DC) are benign cutaneous developmental anomalies comprising of hair follicles, sweat glands and sebaceous glands, and lined by stratified squamous epithelium. They are most commonly found on the face, lower back, and ovaries. We present a case of DC with intracranial extension in a 9 year old boy who presented with headache and a fluctuant scalp swelling. Magnetic resonance imaging revealed a midline scalp mass with intracranial extension. The lesion was excised with superior sagittal sinus preservation; and confirmed as DC by histopathological examination. The boy made good recovery.

Global incidence of caesarean deliveries on maternal request: a systematic review and meta-regression

BACKGROUND

Caesarean delivery on maternal request (CDMR) is considered a significant contributor to the unprecedented increase in caesarean deliveries (CDs) for nonclinical reasons. Current literature lacks a reliable assessment of the rate of CDMR, which hinders the planning and delivery of appropriate interventions for reducing CDMR rates.

OBJECTIVES

To conduct a systematic review of the literature and meta-regression to explore the global incidence of CDMR.

SEARCH STRATEGY

PubMed, Embase, CINAHL, Medline, Google scholar and grey literature were searched from January 1985 to May 2019.

SELECTION CRITERIA

Observational studies that report CDMR data were included. We excluded non-English articles, case notes, editorial reviews and articles reporting elective CDs from pregnancy risk factors.

DATA COLLECTION AND ANALYSIS

Two reviewers independently conducted the screening and quality appraisal using a validated tool. The weighted average of CDMR over total deliveries (absolute proportion) and by total CDs (relative proportion) were generated. Quality-effects meta-regression was used to explain the variability of the CDMR estimates by moderators, including study methodology and demography of study participants.

MAIN RESULTS

We identified 31 articles from 14 countries that include 5 million total births. The absolute proportion of CDMR varies between 0.2 and 42.0%, with significant variations across studies and subgroups. The economic status of the country and study year together explained 84% of the absolute and 76% of the relative proportion of CDMR variation.

CONCLUSIONS

An appropriate reporting of CDMR should be a key priority in maternal health policies and practices.

TWEETABLE ABSTRACT

Globally, the proportion of maternal requested caesarean delivery has mostly been influenced by the economic status of the country.

Survey of current practices from an international task force for gynecological stereotactic ablative radiotherapy

Background

Stereotactic Ablative Radiotherapy (SABR) is an effective treatment that improves local control for many tumours. However, the role of SABR in gynecological cancers (GYN) has not been well-established. We hypothesize that there exists considerable variation in GYN-SABR practice and technique. The goal of this study is to describe clinical and technical factors in utilization of GYN-SABR among 11 experienced radiation oncologists.

Materials and methods

A 63 question survey on GYN-SABR was sent to 11 radiation oncologists (5 countries) who have published original research, conducted trials or have an established program at their institutions. Responses were combined and analyzed at a central institution.

Results

Most respondents indicated that salvage therapy (non-irradiated or re-irradiated field) for nodal (81%) and primary recurrent disease (91%) could be considered standard options for SABR in the setting of inability to administer brachytherapy. All other indications should be considered on clinical trials. Most would not offer SABR as a boost in primary treatment off-trial without absolute contraindications to brachytherapy. Multi-modality imaging is often (91%) used for planning including PET, CT contrast and MRI. There is a wide variation for OAR tolerances however small bowel is considered the dose-limiting structure for most experts (91%). Fractionation schedules range from 3 to 6 fractions for nodal/primary definitive and boost SABR.

Conclusions

Although SABR has become increasingly standard in other oncology disease sites, there remains a wide variation in both clinical and technical factors when treating GYN cancers. Nodal and recurrent disease is considered a potential indication for SABR whereas other indications should be offered on clinical trials. This study summarizes SABR practices among GYN radiation oncologists while further studies are needed to establish consensus guidelines for GYN-SABR treatment.

Septicemia, Meningitis and Bilateral Subdural Empyema in an Infant Caused by Staphylococcus aureus

Staphylococcus aureus is a global bacterial pathogen. It is an uncommon pathogen causing central nervous system infections, accounting for <1% cases of bacterial meningitis. Sinusitis, trauma and presence of an intracranial device have been reported as risk factors for developing meningitis and brain abscesses. A previously healthy 5-month-old female infant presented to a hospital in North-Eastern India in February 2018 with Staphylococcus aureus sepsis and meningitis and was subsequently detected to have developed bilateral subdural empyema on computed tomography scan of the brain. Burr hole evacuation procedure of subdural empyema was done on day-18 subsequent to which inflammatory markers and temperature gradually normalized. Prolonged course of intravenous antibiotics (5-weeks) and anticonvulsants were needed. This case highlights the importance of considering brain abscess and empyema in a child with meningitis whose temperature do not settle down after being treated appropriately and adequately with intravenous antibiotics and features such as seizures develop. It also reflects the challenges that may be faced by clinicians in resource-limited settings both during acute and follow-up stages.

Abstract P3-03-06: Characterization of HER2-positive breast cancer (BC) cells selected for tolerance to trastuzumab-induced antibody-dependent cell-mediated cytotoxicity (ADCC)

Cellular mechanisms of trastuzumab resistance include alteration(s) in cell signaling pathways (PTEN loss, activation of PI3K/Akt signaling), steric hindrance of antibody binding (by Muc-1/Muc-3), over-activation of alternate receptor kinases (HER3/c-Met/IGF-1R), and proteolysis of HER2 extracellular domain harboring target epitopes for antibody-based therapeutics. Prior studies of trastuzumab resistance have focused largely on cells selected ex vivo with the antibody in absence of human immune effector cells. We developed a selection model, wherein human HER2 positive BC cells (BT474, SKBR3) were subjected to acute ADCC (&gt;90% cell death), trastuzumab concentration 100ug/mL, effector-target ratio 100:1, using human peripheral blood mononuclear cells (PBMCs) as effectors. Surviving cells were allowed to recover to confluence over 8-10 weeks, for 10 total rounds of ADCC selection ex vivo. Mock-treated parent, IgG1 isotype control, trastuzumab, and PBMCs alone were used as controls. ADCC assays based on calcein fluorescent labeling of live target cells, revealed significant reduction (maximum 20%, p&lt;0.005) in cell lysis in immune-selected BT474 cell lines compared to parental controls (immune-selected SKBR3 cells exhibited a non-significant trend towards reduced ADCC). Transcriptome-wide next-generation RNA sequencing (Illumina NextSeq 500, 2 x 75 bp paired-end, median of 46 million paired-end reads/sample), coupled with pathway enrichment analysis (Reactome), followed by q-PCR validation, confirmed significant changes in expression in immune-selected cells (compared to parent control) for genes including: ALDH1, ANK1, TMPRSS3, HINT1, DNM2, TNNC1, COL4A4 in BT474; and ALDH1, ANK1, CAMP1, CPE, IDO1 in SKBR3 cells. Whole-genome sequencing (Illumina HiSeq X, 150 bp paired end, 30x coverage) elucidated 180 genes with single nucleotide variations (SNVs) in immune-selected cells compared to parent in BT474 cells, and 215 genes in SKBR3 cells. Thirty-four SNVs were shared in both cell lines. Further screening and validation confirm genes with SNVs demonstrating significant transcript up-regulation. These include: COL4A3, LEP, SOX-9 in BT474; and HLA-B, TNFRSF10B, HLA-B, PSMA6 in SKBR3. In further phenotypic analysis, ADCC-conditioned BT474 cells exhibit an elongated fibroblast-like morphology with multiple processes, in contrast to control. Immune-selected SKBR3 cells (and not BT474 cells) demonstrate significantly increased motility compared to control in transwell migration assays (p&lt;0.001), and demonstrated increased cell proliferation (MTT assay, 10-15%, 48h; p=0.0242) as compared to parent controls. Our data indicate immune-selection by effector cells contributes to ADCC tolerance in vitro, and is associated with distinct genotypic and phenotypic alterations. Future investigation will determine whether Fc-engineered MAbs (afucosylated), antibody drug conjugates (T-DM1), or potentiation of ADCC by co-stimulatory agonist CD137 antibodies will re-sensitize ADCC-tolerance. This investigation will help to elucidate potentially targetable pathways that emerge from immune-selection with trastuzumab.

Citation Format: Biswas T, Fritzemeier R, Mark A, Meißner T, Young B, Jones BL, Pegram M. Characterization of HER2-positive breast cancer (BC) cells selected for tolerance to trastuzumab-induced antibody-dependent cell-mediated cytotoxicity (ADCC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-03-06.

Overweight and obesity among children and adolescents in Bangladesh: a systematic review and meta-analysis

OBJECTIVES

The increasing prevalence of overweight and obesity among children (0-12 years) and adolescents (13-19 years) has emerged as a major public health threat in Bangladesh. Unfortunately, there is a serious paucity of credible data on these issues that can be used for policy and programmatic development. This article presents a systematic review of studies on overweight and obesity to present a more accurate estimate by pooling results.

STUDY DESIGN

Systematic review.

METHODS

The study systematically reviewed relevant literature published between 1998 and 2015 using predefined inclusion/exclusion criteria. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist was used to identify relevant studies. Measures of heterogeneity and variability were calculated, and a random effect model was used to report pooled prevalence rates of overweight and obesity.

RESULTS

The findings show that prevalence rates of overweight and obesity among children and adolescents varied widely from 1.0% to 20.6% and 0.3% to 25.6%, respectively. The pooled prevalence rates of overweight and obesity were 7.0% (95% confidence interval [CI] 5.0-10.0) and 6.0% (95% CI 4.0-8.0), respectively. The pooled prevalence rate of overweight increased substantially over the years, from 3.6% during 1998-2003 (95% CI 0.3-29.2) to 5.7% during 2004-2009 (95% CI 0.8-30.2) and 7.9% by 2010-2015 (95% CI 5.1-12.1). However, the pooled prevalence rate of obesity registered a sharp decline between 1998-2003 and 2004-2009 - from 9.7% (95% CI 5.7-16.2) to 2.0% (95% CI 0.3-11.1) - and subsequently increased significantly to 9.0% by 2010-2015 (95% CI 5.3-14.6).

CONCLUSIONS

This review identified increasing trends in the prevalence of overweight and obesity among children and adolescents in Bangladesh. This study underscores the urgent need to promote healthy lifestyles among children and adolescents with a view to effectively address the increasing problem of overweight and obesity. This would also help to prevent the development of chronic non-communicable diseases in adulthood.

Increasing prevalence of diabetes in Bangladesh: a scoping review

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly in Bangladesh. However, studies documenting the increasing trend of diabetes prevalence are scarce. The aim of this study was to conduct a scoping review of published literature to ascertain the changing patterns of diabetes prevalence in Bangladesh.

METHODOLOGY

We conducted a scoping review based on York scoping reviews framework and performed a comprehensive search of published literature through Medline, BanglaJOL, and Google Scholar published between 1994 and 2013. We summarised and calculated the time trends and pooled prevalence for type 2 diabetes among adults (≥18 years) in both urban and rural areas in Bangladesh.

RESULTS

Of 152 studies identified, we included 22 studies for the scoping review which met the inclusion criteria. Overall, 11 studies (50%) were conducted in rural areas, eight in urban (36%) and three (14%) in semi-urban, semi-rural and tribal areas. The overall prevalence of type 2 diabetes ranged between 4.5% and 35.0%. The final estimate of diabetes prevalence obtained after pooling of data from individual studies among 51,252 participants was 7.4% (95% CI 7.2-7.7%). The prevalence of diabetes was higher in males compared to females in urban areas and vice-versa in rural areas. Analyses of exponential trend revealed an increasing trend of diabetes prevalence among urban and rural population at a rate of 0.05% (R = 0.18) and 0.06% (R = 0.35) per year, respectively.

CONCLUSION

The prevalence of type 2 diabetes showed an increasing trend in both urban and rural population in Bangladesh. Our findings suggest the need for an all-out effort by the government and stakeholders to implement preventive strategies for diabetes in Bangladesh.