The association between novel ST2, BNP, atrial fibrillation and heart failure

Background/Introduction

ST2, a novel marker of fibrosis has been proposed as a novel biomarker for heart failure. There is paucity of data suggesting its association with Atrial Fibrillation (AF), in particular, with regards to the its independent effect after adjustment for clinical factors and traditional biomarkers such as BNP. There is increasing evidence that inflammation and fibrosis are important players in the pathogenesis of AF, the most common arrhythmia that is associated with considerable morbidity.

Purpose

We sought to examine the association of ST2 with AF and its possible incremental value in combination with traditional biomarkers already used in routine clinical practice such as BNP.

Methods

Unselected patients presenting to a Cardiology service who had BNP for clinical reasons, concomitantly had ST2 sent. These patients included those with heart failure, acute coronary syndromes and AF, as well as patients attending cardioversion and cardiac catheterisation. The association between ST2, BNP and clinical factors was examined. ST2 was examined in tertiles as its distribution was highly skewed. Raised BNP was defined as usual (≥100 pg/ml).

Results

Of the 619 patients, the mean age was 69 years and 66% were male. The prevalence of co-morbidities were: Coronary heart disease - CHD (41%), Atrial Fibrillation – AF (30%), Heart Failure - HF (20%), Chronic Kidney Disease – CKD (23%). The mean eGFR was 68 ml/h and the mean LV ejection fraction was 55%. Both ST2 and BNP levels were significantly higher in patients with heart failure, CKD and AF. Mean levels of ST2 were (in ng/ml): HF vs no HF (65 vs. 38, p=0.0001) and in CKD vs. no CKD (49 vs. 41, p=0.001), CAD vs no CAD (43 vs. 42, p=0.3). Mean levels of BNP were (in pg/ml): HF vs no HF (579 vs. 131, p=0.0001), CKD vs. no CKD (379 vs. 173, p=0.0001), CAD vs. no CAD (239 vs. 206, p=0.5).

In patients with AF, levels of both ST2 and BNP were higher, as were their mean ages and prevalence of co-morbidities (see Table 1). Both ST2 and BNP correlated with AF (Pearson r=0.2, p<0.0001 for ST2 and r=0.5, p<0.0001 for BNP). There was also a graded association of ST2 with AF (15%, 33% and 40% across tertiles of ST2, p=0.0001).

Both ST2 and raised BNP were significant associated with AF in both univariable and multi-variable regression models, and remained independent predictors when adjusted for HF, CHD, LV EF and eGFR (Table 2, Model 2 – Relative risk ratio of AF with ST2 across tertiles 1.5, p0.005, and Odds ratio of AF with raised BNP 7.4, p<0.001). However, ST2 loses significance when BNP is added to the model in combination (Table 2 – Model 3).

Conclusions

Both ST2 and BNP are independent predictors of AF even after adjustment for heart failure and other clinical factors. When ST2 is used in combination with BNP, raised BNP appears to be a stronger predictor of AF than ST2.

Funding Acknowledgement

Type of funding sources: None.

Combination of Imaging Features and Clinical Biomarkers Predicts Positive Pathology and Microbiology Findings Suggestive of Spondylodiscitis in Patients Undergoing Image-Guided Percutaneous Biopsy

BACKGROUND AND PURPOSE

Pathology and microbiology results for suspected spondylodiscitis on MR imaging are often negative in up to 70% of cases. We aimed to predict whether MR imaging features will add diagnostic value when combined with clinical biomarkers to predict positive findings of spondylodiscitis on pathology and/or microbiology from percutaneous biopsy.

MATERIALS AND METHODS

In this retrospective single-center institutional review board-approved study, patients with radiologically suspected spondylodiscitis and having undergone percutaneous biopsies were assessed. Demographic characteristics, laboratory values, and tissue and blood cultures were collected. Pathology and microbiology results were used as end points. Three independent observers provided MR imaging-based scoring for typical MR imaging features for spondylodiscitis. Multivariate logistic regression and receiver operating characteristic analysis were performed to determine an optimal combination of imaging and clinical biomarkers in predicting positive findings on pathology and/or microbiology from percutaneous biopsy suggestive of spondylodiscitis.

RESULTS

Our patient cohort consisted of 72 patients, of whom 33.3% (24/72) had spondylodiscitis. The mean age was 63 ± 16 years with a male/female ratio of 41:31. Logistic regression revealed a combination with an area under the curve of 0.72 for pathology and 0.68 for pathology and/or microbiology. Epidural enhancement on MR imaging improved predictive performance to 0.87 for pathology and 0.78 for pathology and/or microbiology.

CONCLUSIONS

Our findings demonstrate that epidural enhancement on MR imaging added diagnostic value when combined with clinical biomarkers to help predict which patients undergoing percutaneous biopsy will have positive findings for spondylodiscitis on pathology and/or microbiology.

Impact of continuous low-dose antibiotic prophylaxis on growth in children with vesicoureteral reflux

BACKGROUND

Continuous antibiotic prophylaxis (CAP) is a mainstay of treatment for children with vesicoureteral reflux (VUR). There has been an increasing focus on the effect of antibiotics on gut microbiota and subsequent repercussions on growth. Continuous antibiotic prophylaxis is generally considered safe; however, its impact on growth in children with VUR remains unknown.

OBJECTIVE

This objective of this study was to determine whether CAP altered height, weight, or body mass index (BMI) in children with VUR.

STUDY DESIGN

Children diagnosed with primary VUR were identified. Demographics including weight and height percentiles, BMI and BMI percentiles, age, gender, antibiotic class, prior antibiotic use, urinary tract infection history, and breakthrough infections were tested in univariate and multivariate analyses. Primary outcome was change in BMI as well as weight, height, and BMI percentiles.

RESULTS

One hundred eighty patients (146 girls, 34 boys) were prescribed CAP at mean age of 29.2 ± 26.2 months. Mean follow-up on CAP was 4.1 ± 3.3 years, with median follow-up of 3.08 years. Mean increase in weight percentile was 1.49 (2.02 males, 1.37 females; P = 0.46). Mean decrease in height percentile was -4.44 (-2.18 males, -4.95 females; P = 0.51). Age at diagnosis (P = 0.004) and history of prior treatment courses of antibiotics (P = 0.007) were associated with a significant BMI increase (Fig. 1). Body mass index percentile increased from 58.4 to 66.5; however, this increase was only significant in children aged above 1 year (P < 0.0001). Of note, children above 1 year of age were significantly more likely to have a history of prior treatment courses of antibiotics (58% vs 32%; P < 0.0001), and when controlling for prior antibiotic use, the increase in BMI percentile in those over 1 year of age did not reach significance.

DISCUSSION

The use of antibiotics has been associated with alterations in pediatric growth parameters in both animal models and clinical studies. However, little information exists on the impact of prophylactic-dosed antibiotics on growth. While this study is limited by the retrospective analysis and small sample size, it was found that the use of CAP did impact growth parameters, with a stronger effect seen in children who had received prior treatment courses of antibiotics before the infection leading to the initiation of CAP.

CONCLUSION

Continuous antibiotic prophylaxis was correlated with significant increase in BMI in children with prior antibiotic usage and a significant increase in BMI percentile in children aged above 1 year. Continuous antibiotic prophylaxis was also associated with decreased height percentiles, particularly in patients aged less than 1 year, though it did not reach statistical significance. Further analysis is needed to investigate whether these effects on weight, height, and BMI are persistent and clinically significant.

Abstract P2-03-08: A retrospective study to identify the frequency of discordant HER2 results using both immunohistochemistry (IHC) and in-situ hybridization (ISH) assays

Background

HER2 targeted therapies have substantially improved survival outcomes for patients with breast cancer and HER2 amplification of their tumour. The recently updated American Society of Clinical Oncology/College of American Pathologists (ASCO CAP) guidelines recommend that HER2 testing to be performed on all invasive breast cancers and that positive HER2 status is defined by either evidence of HER2 protein over-expression measured by immunohistochemistry status (IHC 3+) or by in-situ hybridisation (ISH) amplification. Equivocal results require further testing with the alternative assay.

In Australia, Medicare-funded access to HER2 targeted therapies requires demonstration of HER2 positivity by ISH, regardless of IHC status. Thus, currently most breast units perform IHC and ISH on all breast cancers. Given this discrepancy in practice and significant additional cost of performing ISH, this study evaluated the frequency of discordance and the cost burden in using both assays in a historical series of patients with breast cancer.

Methods

A retrospective audit of HER2 histopathology reports was performed for all breast cancers diagnosed between 2007 and 2016 at a single tertiary hospital in Melbourne, Australia (The Austin Hospital). HER2 IHC results were classified as negative (0 or 1+), equivocal (2+) or positive (3+). An analysis was performed to assess the proportion of concordant (defined as samples with IHC 0/1+ and negative ISH, samples with IHC3+ and positive ISH, and samples with IHC2+ regardless of ISH) and discordant results (defined as IHC 3+ and ISH non-amplified or IHC 0/1+ and ISH amplified). Tumour blocks and slides from discordant cases were reviewed by a breast cancer histopathologist. The cost of additional testing in concordant cases was performed based on the Australian Medicare Benefits Schedule (MBS).

Results

Eight hundred and forty-six histopathology reports were reviewed from 786 patients, all of whom had both IHC and ISH assays. There were 832 (98.8%) concordant cases. There were 10 discordant cases (1.2%) in total, including three cases (0.4%) with a negative IHC (1+) result but positive ISH, and 7 cases (0.8%) with a positive IHC but negative ISH result. A detailed analysis of 10 discordant cases will be presented. HER2 status and subsequent treatment remain unchanged with the addition of ISH testing in 665 (79.0%) cases, which amounted to an additional $209,741 (AUD) being spent on unnecessary ISH testing. Given an estimated incidence of 17,730 new cases of breast cancer per year in Australia, the population cost of performing additional HER2 ISH testing ($315.40 per case) in concordant cases would equate to $4.4 million (AUD) per year.

Conclusion

These results describe an extremely low rate of HER2 IHC/ISH discordance suggesting that routine use of both assays is unnecessary in cases with an unequivocal IHC result. The fiscal burden and potential delays to deciding treatment provide a strong rationale for access to HER2 targeted therapies to be based IHC or ISH, as advised by the ASCO CAP guidelines. Our results will be used to support a national review of IHC and ISH discordance using Australian national registry data.

Citation Format: Balasubramanian A, Ireland-Jenkin K, McDonald A, Khor R, Yeo B, Leong T. A retrospective study to identify the frequency of discordant HER2 results using both immunohistochemistry (IHC) and in-situ hybridization (ISH) assays [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 P2-03-08.

FOLFOX and intensified split-course chemoradiation as initial treatment for rectal cancer with synchronous metastases

BACKGROUND

Optimal initial management of rectal carcinoma with synchronous metastases (RCSM) is controversial - both for patients being treated with curative and palliative intent. This study aims to evaluate the use of an upfront treatment strategy combining FOLFOX chemotherapy with split-course pelvic chemoradiation (FOLFOX + CRT) for patients with RCSM.

MATERIAL AND METHODS

An analysis of all patients who commenced treatment with FOLFOX + CRT at our institutions between January 2009 and June 2014 was performed. The regimen consisted of a total of 12 weeks of treatment with split-course pelvic chemoradiation (50.4Gy with concurrent oxaliplatin and 5-FU) alternating with FOLFOX chemotherapy. Restaging imaging was performed following treatment, with subsequent management as per local standard of care.

RESULTS

78 patients (15 with resectable liver-only metastases) were identified. 77 (99%) completed at least 45Gy of radiation and 87% completed ≥75% of planned dose intensity of both oxaliplatin and 5FU. Two (2.6%) patients died within 30 days of treatment. Rates of radiological complete or partial response for local and metastatic disease were 90% and 66%, respectively. 24% patients had radiological disease progression of metastatic disease. Median overall survival for patients with unresectable metastatic disease at baseline was 23 months (95%CI: 19-28). 12 patients underwent radical surgery to both the rectum and liver and had an estimated 3-year overall survival rate of 62% (95%CI: 37-100). For those patients who did not proceed to rectal surgery, only 7% required palliative re-irradiation or surgery at a later date and all >20months from initial treatment.

CONCLUSIONS

In patients with unresectable metastatic disease, FOLFOX + CRT provides durable pelvic control for the majority without the need for additional local treatment. For patients with an advanced primary tumor and synchronous resectable liver-only metastases, FOLFOX + CRT can be considered a feasible and tolerable upfront treatment option.

The influence of intensive care unit-acquired central line-associated bloodstream infection on in-hospital mortality: A single-center risk-adjusted analysis

OBJECTIVE

To explore the risk-adjusted association between intensive care unit (ICU)-acquired central line-associated bloodstream infection (CLABSI) and in-hospital mortality.

DESIGN

Retrospective observational study.

SETTING

Forty-five-bed adult ICU.

PATIENTS

All non-extracorporeal membrane oxygenation ICU admissions between July 1, 2008, and April 30, 2014, requiring a central venous catheter (CVC), with a length of stay > 48 hours, were included.

METHODS

Data were extracted from our infection prevention and ICU databases. A multivariable logistic regression model was constructed to identify independent risk factors for ICU-acquired CLABSI. The propensity toward developing CLABSI was then included in a logistic regression of in-hospital mortality.

RESULTS

Six thousand three hundred fifty-three admissions were included. Forty-six cases of ICU-acquired CLABSI were identified. The overall CLABSI rate was 1.12 per 1,000 ICU CVC-days. Significant independent risk factors for ICU-acquired CLABSI included: double lumen catheter insertion (odds ratio [OR], 2.59; 95% confidence interval [CI], 1.16-5.77), CVC exposure > 7 days (OR, 2.07; 95% CI, 1.06-4.04), and CVC insertion before 2011 (OR, 2.20; 95% CI, 1.22-3.97). ICU-acquired CLABSI was crudely associated with greater in-hospital mortality, although this was attenuated once the propensity to develop CLABSI was adjusted for (OR, 1.20; 95% CI, 0.54-2.68).

CONCLUSIONS

A greater propensity toward ICU-acquired CLABSI was independently associated with higher in-hospital mortality, although line infection itself was not. The requirement for prolonged specialized central venous access appears to be a key risk factor for ICU-acquired CLABSI, and likely informs mortality as a marker of persistent organ dysfunction.

Phase II trial evaluating the feasibility of interdigitating folfox with chemoradiotherapy in locally advanced and metastatic rectal cancer

BACKGROUND

Patients (pts) with metastatic rectal cancer and symptomatic primary, require local and systemic control. Chemotherapy used during chemoradiotherapy (CRT) is adequate for radiosensitisation, but suboptimal for systemic control. The aim of this phase II study was to assess tolerability, local/systemic benefits, of a novel regimen delivering interdigitating intensive chemotherapy with radical CRT.

METHODS

Eligible pts had untreated synchronous symptomatic primary/metastatic rectal cancer. A total of 12 weeks of treatment with split-course pelvic CRT (total 50.4 Gy with concurrent oxaliplatin and 5-FU infusion) alternating with FOLFOX chemotherapy. All pts staged with CT, MRI and FDG-PET pre and post treatment.

RESULTS

Twenty-six pts were treated. Rectal primary MRI stage: T3 81% and T4 15%. Liver metastases in 81%. Twenty-four pts (92%) completed the 12-week regimen. All patients received planned RT dose, and for both agents over 88% of patients achieved a relative dose intensity of >75%. Grade 3 toxicities: neutropenia 23%, diarrhoea 15%, and radiation skin reaction 12%. Grade 4 toxicity: neutropenia 15%. FDG-PET metabolic response rate for rectal primary 96%, and for metastatic disease 60%.

CONCLUSIONS

Delivery of interdigitating chemotherapy with radical CRT was feasible to treat both primary and metastatic rectal cancer. High completion and response rates were encouraging.

Role of (chemo)-radiotherapy in resectable gastric cancer

The prognosis of patients with locally advanced gastric cancer remains poor, despite radical surgical resection. Adjuvant therapy has been shown to improve survival and, in Western countries, is delivered either postoperatively (chemoradiotherapy) or perioperatively (chemotherapy). Debate continues as to which of these represents the optimal strategy. High-dose gastric irradiation comes at the expense of significant toxicity, and increasing efforts have focused on attempts to reduce toxicity and normal tissue doses. The development of advancing radiotherapy technologies now allows improved target delineation and coverage. However, gastric irradiation remains technically challenging and requires an understanding of postoperative surgical anatomy, patterns of failure and lymph node drainage, as well as an appreciation of the uncertainties around organ motion and filling. Ongoing trials are examining the optimal strategy in which to incorporate (chemo)-radiotherapy, as well as the addition of targeted therapies, in gastric cancer. This overview discusses the current role and evidence for (chemo)-radiotherapy, as well as the technical challenges encountered in the radiotherapeutic management of resectable gastric cancer.

Augmentation of thrombin generation in neonates undergoing cardiopulmonary bypass

INTRODUCTION

Factor concentrates are currently available and becoming increasingly used off-label for treatment of bleeding. We compared recombinant activated factor VII (rFVIIa) with three-factor prothrombin complex concentrate (3F-PCC) for the ability to augment thrombin generation (TG) in neonatal plasma after cardiopulmonary bypass (CPB). First, we used a computer-simulated coagulation model to assess the impact of rFVIIa and 3F-PCC, and then performed similar measurements ex vivo using plasma from neonates undergoing CPB.

METHODS

Simulated TG was computed according to the coagulation factor levels from umbilical cord plasma and the therapeutic levels of rFVIIa, 3F-PCC, or both. Subsequently, 11 neonates undergoing cardiac surgery were enrolled. Two blood samples were obtained from each neonate: pre-CPB and post-CPB after platelet and cryoprecipitate transfusion. The post-CPB products sample was divided into control (no treatment), control plus rFVIIa (60 nM), and control plus 3F-PCC (0.3 IU ml(-1)) aliquots. Three parameters of TG were measured ex vivo.

RESULTS

The computer-simulated post-CPB model demonstrated that rFVIIa failed to substantially improve lag time, TG rate and peak thrombin without supplementing prothrombin. Ex vivo data showed that addition of rFVIIa post-CPB significantly shortened lag time; however, rate and peak were not statistically significantly improved. Conversely, 3F-PCC improved all TG parameters in parallel with increased prothrombin levels in both simulated and ex vivo post-CPB samples.

CONCLUSIONS

Our data highlight the importance of prothrombin replacement in restoring TG. Despite a low content of FVII, 3F-PCC exerts potent procoagulant activity compared with rFVIIa ex vivo. Further clinical evaluation regarding the efficacy and safety of 3F-PCC is warranted.

Early caffeine therapy and clinical outcomes in extremely preterm infants

OBJECTIVE

To determine if early caffeine (EC) therapy is associated with decreased bronchopulmonary dysplasia (BPD) or death, decreased treatment of patent ductus arteriosus (PDA), or shortened duration of ventilation.

STUDY DESIGN

In a retrospective cohort of 140 neonates ≤1250 g at birth, infants receiving EC (initiation <3 days of life) were compared with those receiving late caffeine (LC, initiation ≥3 days of life) using logistic regression.

RESULT

Of infants receiving EC, 25% (21/83) died or developed BPD compared with 53% (30/57) of infants receiving LC (adjusted odds ratio (aOR) 0.26, 95% confidence interval (CI) 0.09 to 0.70; P<0.01). PDA required treatment in 10% of EC infants versus 36% of LC infants (aOR 0.28, 95%CI 0.10 to 0.73; P=0.01). Duration of mechanical ventilation was shorter in infants receiving EC (EC, 6 days; LC, 22 days; P<0.01).

CONCLUSION

Infants receiving EC therapy had improved neonatal outcomes. Further studies are needed to determine if caffeine prophylaxis should be recommended for preterm infants.

Effects of in utero antiretroviral exposure on mitochondrial DNA levels, mitochondrial function and oxidative stress

OBJECTIVES

HIV and antiretroviral (ART) exposure in utero may have deleterious effects on the infant, but uncertainty still exists. The objective of this study was to evaluate aspects of mitochondrial DNA (mtDNA) content, mitochondrial function and oxidative stress simultaneously in placenta, umbilical cord blood and infant blood in HIV/ART-exposed infants compared with uninfected controls.

METHODS

HIV-1-infected pregnant women and HIV-1-uninfected healthy pregnant controls were enrolled in the study prospectively. Placenta and umbilical cord blood were obtained at delivery and infant blood was obtained within 48 h of delivery. mtDNA content was determined for each specimen. Nuclear [subunit IV of cytochrome c-oxidase (COX IV)]- and mitochondrial (COX II)-encoded polypeptides of the oxidative phosphorylation enzyme cytochrome c-oxidase were quantified in cord and infant blood. Placental mitochondria malondialdehyde (MDA) concentrations were measured as a marker of oxidative stress.

RESULTS

Twenty HIV-positive/HIV-exposed and 26 control mother-infant pairs were enrolled in the study. All HIV-infected women and their infants received ART. Placental MDA concentration and mtDNA content in placenta and cord blood were similar between groups. The cord blood COX II:IV ratio was lower in the HIV-positive group than in the controls, whereas the infant peripheral blood mtDNA content was higher in the HIV-exposed infants, but the infant peripheral blood COX II:IV ratio was similar. No infant had clinical evidence of mitochondrial disease or acquired HIV infection. In multivariable regression analyses, the significant findings in cord and infant blood were both most associated with HIV/ART exposure.

CONCLUSIONS

HIV-exposed infants showed reduced umbilical cord blood mitochondrial enzyme expression with increased infant peripheral blood mitochondrial DNA levels, the latter possibly reflecting a compensatory mechanism to overcome HIV/ART-associated mitochondrial toxicity.

Chemoradiotherapy in the management of primary squamous-cell carcinoma of the rectum

AIM

To assess the efficacy of chemoradiotherapy in the management of primary squamous-cell carcinoma of the rectum.

METHOD

Nine patients with primary squamous-cell carcinoma of the rectum were treated with chemoradiotherapy from 1985 to 2007. All patients were female, with a mean age of 54 years (range 41-72 years). The mean distance of the tumour from the anal verge was 6 cm (range 4-10 cm). Seven patients were treated with curative intent (two postoperative, three preoperative, two chemoradiotherapy alone). Clinical stages for the curative group were T1N0M0 (1), T3N0M0 (3), T3N1M0 (1) and T4N0M0 (2). Chemoradiotherapy consisted of pelvic radiation 45-54 Gy in 1.8 Gy/fraction and concurrent 5-fluorouracil and mitomycin C. The mean follow-up duration for the curative group was 39 months (range 15-120 months).

RESULTS

All seven patients treated with curative intent achieved local control. A complete pathological response was seen in all patients after preoperative chemoradiotherapy. Two patients did not have surgery and remained free of disease. One patient with gross residual disease after surgery achieved local control. 18-Fluorodeoxyglucose (FDG) avidity was detected in all patients who had FDG-PET scans. Both primary and metastatic tumours demonstrated FDG-avidity.

CONCLUSION

Primary squamous-cell carcinoma of the rectum appears to be very sensitive to chemoradiotherapy. The high complete response rate suggests that chemoradiotherapy alone with salvage surgery for local failure should be further explored. FDG-PET scan may have a role to play in the management of this disease.

What can paper-based clinical information systems tell us about the design of computerized clinical information systems (CIS) in the ICU?

BACKGROUND

Screen designs in computerized clinical information systems (CIS) have been modeled on their paper predecessors. However, limited understanding about how paper forms support clinical work means that we risk repeating old mistakes and creating new opportunities for error and inefficiency as illustrated by problems associated with computerized provider order entry systems.

PURPOSE

This study was designed to elucidate principles underlying a successful ICU paper-based CIS. The research was guided by two exploratory hypotheses: (1) paper-based artefacts (charts, notes, equipment, order forms) are used differently by nurses, doctors and other healthcare professionals in different (formal and informal) conversation contexts and (2) different artefacts support different decision processes that are distributed across role-based conversations.

METHOD

All conversations undertaken at the bedsides of five patients were recorded with any supporting artefacts for five days per patient. Data was coded according to conversational role-holders, clinical decision process, conversational context and artefacts. 2133 data points were analyzed using Poisson logistic regression analyses.

RESULTS

Results show significant interactions between artefacts used during different professional conversations in different contexts (chi(2)((df=16))=55.8, p<0.0001). The interaction between artefacts used during different professional conversations for different clinical decision processes was not statistically significant although all two-way interactions were statistically significant.

CONCLUSIONS

Paper-based CIS have evolved to support complex interdisciplinary decision processes. The translation of two design principles - support interdisciplinary perspectives and integrate decision processes - from paper to computerized CIS may minimize the risks associated with computerization.

A phase I trial of Capecitabine+Gemcitabine with radical radiation for locally advanced pancreatic cancer

Standard chemoradiotherapy with infusional 5FU for locally advanced pancreatic cancer (LAPC) has limited efficacy in this disease. The combination of Capecitabine (Cap) and Gemcitabine (Gem) are synergistic and are potent radiosensitisers. The aim of this phase I trial was thus to determine the highest administered dose of the Cap plus Gem combination with radical radiotherapy (RT) for LAPC. Patients had LAPC, adequate organ function, ECOG PS 0–1. During RT, Gem was escalated from 20–50 mg m⁻² day⁻¹ (twice per week), and Cap 800–2000 mg m⁻² day⁻¹ (b.i.d, days 1–5 of each week). Radiotherapy 50.4 Gy/28 fractions/5.5 weeks, using 3D-conformal techniques. Three patients were entered to each dose level (DL). Dose-limiting toxicity(s) (DLTs) were based on treatment-related toxicities. Twenty patients were accrued. Dose level (DL) 1: Cap/Gem; 800/20 mg m⁻² day⁻¹ (3 patients), DL2: 1000/20 (12 patients), DL3: 1300/30 (5 patients). Dose-limiting toxicities were observed in DL3; grade 3 dehydration (1 patient) and grade 3 diarrhoea and dehydration (1 patient). Dose level 2 was the recommend phase 2 dose. Disease control rate was 75%: PR=15%, SD=60%. Median overall survival was 11.2 months. The addition of Cap and Gem to radical RT was feasible and active and achieved at relatively low doses.

Utility of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in the staging, radiotherapy planning and prognostication of anal cancer

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Background: Accurate inguinal and pelvic nodal staging in anal cancer is important for prognosis and planning of (chemo)radiation fields. There is strong evidence for the impact of FDG-PET in staging and management of cancer, with early reports of an increasing role in outcome prognostication for a number of tumours. We aimed to determine the impact of FDG-PET on the nodal staging, radiotherapy planning and prognostication of patients with primary anal cancer. Methods: Sixty-two consecutive patients with anal cancer referred to a single tertiary oncology centre between August 1997 and November 2005 were staged with conventional imaging (CIm), computed tomography, magnetic resonance imaging and chest x-ray and by FDG-PET. The stage determined by CIm and the proposed management plan was prospectively recorded and changes in stage and management as a result of FDG-PET assessed. Patients were treated using uniform radiotherapy technique and dose. The accuracy of changes and prognostication of FDG-PET was validated by subsequent clinical follow-up. Kaplan-Meier survival analysis was used to assess survival for the cohort and by FDG-PET and CIm stage. Results: The TNM stage group was changed in 23% (14/62) as a result of FDG-PET (15% up-staged, 8% down-staged). Fourteen percent of T1 patients (3/22), 42% of T2 patients (10/24) and 38% of T3–4 patients (6/16), assessed using CIm, had a change in their N or M stage following FDG-PET. Sensitivity for nodal disease by FDG-PET and CIm was 92% and 72% respectively. The staging FDG-PET scan altered management intent in 3% (2/62), and altered radiotherapy fields in 13% (8/62). Estimated 5 year overall survival and progression free survival (PFS) for the cohort was 77.3% (95% CI 55.3%-90.4%) and 72.2% (95% CI 51.5%-86.4%) respectively. Estimated 5 year PFS for FDG-PET and CIm staged N2–3 disease was 70% (95% CI 42.8%-87.9%) and 55.3% (95% CI 23.3%-83.4%) respectively. Conclusions: FDG-PET shows increased sensitivity over CIm for staging nodal disease in anal cancer and changes treatment intent or radiotherapy fields in a significant proportion of patients. Improved 5 year PFS for FDG-PET staged N2–3 disease could be consistent with more accurate nodal staging and radiotherapy targeting.

No significant financial relationships to disclose.

Increasing the use of an existing medical emergency team in a teaching hospital

Cultural barriers in hospital ward staff may limit the use of a Medical Emergency Team (MET) service. In December 2000 the role of the existing Code Blue team in our hospital was expanded to incorporate review of patients fulfilling commonly employed MET criteria. Between January 2001 and June 2003, the average call rate was only 9.8 calls/ 1000 admissions. Anecdotal feedback and a group-administered questionnaire conducted in July 2003 demonstrated a number of obstacles to initiating calls and the system was modified in October 2004. Specifically, emergency response calls were separated into Code Blue calls (for cardiorespiratory arrests) and MET calls (with physiological and worried criteria). Further loud overhead chimes as well as anaesthetist and cardiologist attendance were used only in the case of Code Blue calls (suspected arrests). Finally, the heart rate and respiratory rate criteria for MET service activation were modified. In the 12 months before the intervention (October 2003 to September 2004) there were 817 emergency response calls and 51,963 admissions (15.7 calls/1000 admissions). In the 12 months after the intervention there were 1349 emergency response calls (Code Blue plus MET calls) and 54,593 admissions (24.7 calls/1000 admissions [OR 1.59; 95% CI=1.45-1.73; P<0.0001]). Our findings suggest that increasing the use of an existing service to review patients fulfilling MET criteria requires repeated education and a periodic assessment of site-specific obstacles to utilization.

A phase I/II trial of celecoxib with chemotherapy and radiotherapy in the treatment of patients with locally advanced oesophageal cancer

BACKGROUND

The study's aim was to determine the maximum tolerated dose (MTD) of celecoxib combined with chemoradiotherapy (CRT) for locally advanced oesophageal cancer (OC).

METHODS

CRT comprised of 5FU (1000 mg/m(2)/day, days 1-4, weeks 1 & 5), cisplatin (75 mg/m(2), days 1 & 29) and radiotherapy (50 Gy in 25 fractions or 50.4 Gy in 28 fractions). Celecoxib was given daily during CRT at one of five doses (200 mg bd to 600 mg bd). Three to six patients were assigned per dose.

RESULTS

Thirteen patients were recruited before trial closure due to external safety concerns regarding celecoxib. Median follow up was 17 months (95% CI 9 - >39). The highest administered dose was 400 mg bd (n=4) with one dose-limiting toxicity at this level: grade 3 rash. Five (38%) and 8(62%) patients had grade 3 non-haematological and haematological toxicities respectively. No grade 4 toxicities occurred. Radiological response rate was 54% (n=7: all CR). Six patients had resection with one pathological CR. Median progression-free and overall survival were 8.8 (95% CI 5.1 - >24.8) and 19.6 months (95% CI 7.3 - >39) respectively.

CONCLUSIONS

A MTD was not reached. The regimen was tolerable, indicating that celecoxib can be safely administered with CRT for locally advanced OC.

Influence of 18F-fluorodeoxyglucose-positron emission tomography on computed tomography-based radiation treatment planning for oesophageal cancer

The addition of positron emission tomography (PET) information to CT-based radiotherapy treatment planning has the potential to improve target volume definition through more accurate localization of the primary tumour and involved regional lymph nodes. This case report describes the first patient enrolled to a prospective study evaluating the effects of coregistered positron emission tomography/CT images on radiotherapy treatment planning for oesophageal cancer. The results show that if combined positron emission tomography/CT is used for radiotherapy treatment planning, there may be alterations to the delineation of tumour volumes when compared to CT alone. For this patient, a geographic miss of tumour would have occurred if CT data alone were used for radiotherapy planning.

Oxaliplatin combined with infusional 5-fluorouracil and concomitant radiotherapy in inoperable and metastatic rectal cancer: a phase I trial

The aim of this study was to define the recommended dose of oxaliplatin when combined with infusional 5-fluorouracil (5-FU) and concurrent pelvic radiotherapy. Eligible patients had inoperable rectal cancer, or symptomatic primary rectal cancer with metastasis. Oxaliplatin was given on day 1 of weeks 1, 3 and 5 of radiotherapy. Dose level 1 was oxaliplatin 70 mg m(-2) with 5-FU 200 mg m(-2) day(-1) continuous infusion 96 h week(-1). On dose level 2, the oxaliplatin dose was increased to 85 mg m(-2). On dose level 3, the duration of the 5-FU was increased to 168 h per week. Pelvic radiotherapy was 45 Gray (Gy) in 25 fractions over 5 weeks with a boost of 5.4 Gy. Fluorine-18 fluoro deoxyglucose and Fluorine-18 fluoro misonidazole positron emission tomography (FDG-PET and FMISO-PET) were used to assess metabolic tumour response and hypoxia. In all, 16 patients were accrued. Dose-limiting toxicities occurred in one patient at level 2 (grade 3 chest infection), and two patients at level 3 (grade 3 diarrhoea). Dose level 2 was declared the recommended dose level. FDG-PET imaging showed metabolic responses in 11 of the 12 primary tumours assessed. Four of six tumours had detectable hypoxia on FMISO-PET scans. The addition of oxaliplatin to infusional 5-FU chemoradiotherapy was feasible and generally well tolerated. For future trials, oxaliplatin 85 mg m(-2) and 5-FU 200 mg m(-2) day(-1) continuous infusion 96 h week(-1) is the recommended dose when combined with 50.4 Gy of pelvic radiotherapy.

A phase I trial of preoperative radiotherapy and capecitabine for locally advanced, potentially resectable rectal cancer

The purpose of the study was to determine the maximum-tolerated dose (MTD) of oral capecitabine, combined with concurrent, standard preoperative pelvic radiotherapy, when given twice daily, from Monday to Friday throughout the course of radiotherapy, for locally advanced potentially resectable rectal cancer. Maximum-tolerated dose was defined as the total (given in two equally divided doses) oral dose of capecitabine that caused treatment-related grade 3 or 4 toxicity in one-third or more of the patients treated. Radiotherapy involved 50.4 Gy given in 28 fractions in 5 weeks and 3 days. Eligible patients had a newly diagnosed clinical stage T3–4 N0–2 M0 rectal adenocarcinoma located within 12 cm of the anal verge suitable for curative resection. Surgery was performed 4–6 weeks from completion of preoperative chemoradiotherapy. In all, 28 patients were enrolled in the study at predefined dose levels: 850 mg m⁻² day⁻¹ (n=3), 1000 mg m⁻² day⁻¹ (n=6), 1250 mg m⁻² day⁻¹ (n=3), 1650 mg m⁻² day⁻¹ (n=3), 1800 mg m⁻² day⁻¹ (n=8) and 2000 mg m⁻² day⁻¹ (n=5). The mean age was 62.3 years (range: 33–80 years). Five patients were female and 23 male. The median distance of tumour from the anal verge was 6 cm (range: 1–11 cm). Endorectal ultrasound was performed in 93% of patients. A total of 26 patients (93%) had T3 disease and two patients had resectable T4 disease. Dose-limiting toxicity (DLT) developed in one patient at dose level 1000 mg m⁻² day⁻¹ (RTOG grade 3 cystitis). Two of the five patients at dose level 2000 mg m⁻² day⁻¹ had a total of three DLT (grade 3 perineal skin reaction, grade 3 diarrhoea and grade 3 dehydration). Dose escalation of capecitabine was ceased at 2000 mg m⁻² day⁻¹ after reaching MTD. None of the eight patients at dose level 1800 mg m⁻² day⁻¹ developed DLT. All except one patient underwent surgery. A total of 15 patients had the clinical T stage reduced by at least one stage in pathologic specimens. Five patients (19%) achieved a pathologic complete response. We conclude that the MTD of capecitabine was reached at a dose level of 2000 mg m⁻² day⁻¹, given as 1000 mg m⁻² twice daily, from Monday to Friday throughout the course of preoperative pelvic irradiation of 50.4 Gy. For patients with resectable rectal cancer receiving concurrent, full dose radiotherapy, the recommended dose of capecitabine for further study is 1800 mg m⁻² day⁻¹ when given in this schedule.

Clinical and cellular radiosensitivity in inherited human syndromes

AIMS

It has been proposed that in-vitro measurements of radiosensitivity might allow individualisation of patient radiotherapy schedules, with concomitant increases in the therapeutic ratio between tumours and normal tissues. Most predictive assay research on normal tissues to date has been based on the radiosensitivity of normal lymphocytes and skin fibroblasts as determined by clonogenic cell-survival assays. Studies comparing the radiosensitivity of fibroblasts or lymphocytes with acute or late radiation damage have reported variable results.

METHODS

In this study, we measured the radiosensitivity of lymphocytes from three patients displaying clinical radiation hypersensitivity who were known or suspected to carry germline mutations in genes that have been linked to increased radiosensitivity (a BRCA2 mutation carrier, a patient with Bloom's syndrome and a patient with a Fanconi anaemia-like condition), to investigate whether there is a correlation between cellular radiosensitivity and normal tissue response.

RESULTS

We found no association between lymphocyte radiosensitivity and the development of adverse radiation reactions in this group of patients, as is observed in the paradigm radiosensitivity syndrome, ataxia-telangiectasia.

CONCLUSIONS

Our results, and those of others, show that, at present, the evidence is not strong enough to justify routine clinical use of clonogenic cell survival assays to predict radiation response.

Adjuvant and neoadjuvant therapy for gastric cancer using epirubicin/cisplatin/5-fluorouracil (ECF) and alternative regimens before and after chemoradiation

Chemoradiation is now used more commonly for gastric cancer following publication of the US Intergroup trial results that demonstrate an advantage to adjuvant postoperative chemoradiotherapy. However, there remain concerns regarding the toxicity of this treatment, the optimal chemotherapy regimen and the optimal method of radiotherapy delivery. In this prospective study, we evaluated the toxicity and feasibility of an alternative chemoradiation regimen to that used in the Intergroup trial. A total of 26 patients with adenocarcinoma of the stomach were treated with 3D-conformal radiation therapy to a dose of 45 Gy in 25 fractions with concurrent continuous infusional 5-fluorouracil (5-FU). The majority of patients received epirubicin, cisplatin and 5-FU (ECF) as the systemic component given before and after concurrent chemoradiation. The overall rates of observed grade 3 and 4 toxicities were 38 and 15%, respectively. GIT grade 3 toxicity was observed in 19% of patients, while haematologic grade 3 and 4 toxicities were observed in 23%. Our results suggest that this adjuvant regimen can be delivered safely and with acceptable toxicity. This regimen forms the basis of several new studies being developed for postoperative adjuvant therapy of gastric cancer.