Interdisciplinary Tumor Board Research Articles

Current Challenges in the Staging of Oral Cancer.

In the recently published 8th edition of the AJCC Cancer Staging Manual, new pathological elements are required for the N and T category determinations for oral cavity cancers. This includes determination of depth of tumor invasion and assessment of metastatic lymph nodes for extranodal extension. Although definitions and some guidance are provided for the interpretation of these elements, pathologists frequently encounter ambiguous situations that may result in interobserver and intraobserver variability. Pre-existing staging elements, such as assessment of bone invasion, can also be problematic to interpret. Difficulties in the interpretation of depth of invasion, bone invasion and extranodal invasion are discussed, with examples. Communication with the surgeon, proper specimen orientation, gross examination and sampling are crucial to assessment of these elements. Liberal use of deeper levels and submission of additional sections is suggested. Although general staging guidelines encourage clinicians and pathologists to choose the lower category when there is ambiguity, pathologists may choose to discuss difficulties in the interpretation of specific cases at interdisciplinary tumor boards, to allow a more informed choice of treatment on the part of treating physician and patient. More discussion is required among pathologists to develop specific guidelines for the interpretation of these staging elements.

Abstract P4-08-11: First prospective outcome data for the clinico-molecular test Endopredict® in hormone receptor positive, HER2-negative early breast cancer in clinical routine

Abstract Background: The EndoPredict test is a clinico-molecular test that has been validated to predict the likelihood of distant metastases and late relapse inpatients (pts) with hormone receptor positive (HR+), HER2-negative (HER2-) early breast cancer and up to three positive lymph nodes. However, so far prospective outcome results of pts in whom decision on use of adjuvant chemotherapy (CTX) was based on Endopredict has not been available. Here we present three year outcome data of pts, whose adjuvant systemic therapy recommendation was based on EndoPredict test result. Methods: Pts with HR+, HER2- early breast cancer with 0-3 positive lymph nodes were enrolled at a single institution (Interdisciplinary Breast Center of Klinikum rechts der Isar, Munich, Germany). The Endopredict test was carried out on all tumor samples. Demographic, clinical and pathological data as well as EPclin risk class were assessed for each patient at baseline. Therapy recommendations were given during an interdisciplinary tumor board. Pts were evaluated for treatment compliance, local recurrence, distant metastases and survival (cut-off date of last follow up: July 31st 2017). Censored time-to-event outcomes were analysed by cox proportional hazards models. Additional estimates of the event-free-survival were given by the Kaplan-Meier method. Hypothesis testing was conducted on two-sided exploratory 5% significance levels. Results: A total of 373 consecutive pts were enrolled between March 2012 and March 2015. Median age was 59.9 (range: 29.1-88.9) years. In 39% of pts tumorsize was >2cm, 24% of pts were node positive, 16% had G3 tumors, in 21% of pts ki67 was ≥25% and in 13% progesterone receptor was <10%. The EndoPredict test allocated 238 pts (63.8%) in the low-risk group and 135 pts (36.2%) in the high-risk group. 128 of the 373 pts were recommended to undergo adjuvant CTX in addition to endocrine therapy. 92 (72%) of these pts were compliant having received standard of care chemotherapy. After 41.6 months median follow up, 3-year disease free survival (DFS) and distant metastases free survival (DMFS) in the EPclin low risk group was 96.6% (95%CI 94.2-99.1) and 99.6% (95%CI 98.7-100) versus 94.9% (95%CI 90.9-99.0) and 97.6% (95%CI 95.0-100) in the EPclin high risk group. With a hazard ratio (HR) of 2.05 (95%CI 0.85-4.96; p= 0.110) risk for any disease recurrence or death in EPclin high risk patients was two fold higher in comparison with EPclin low risk patients. Patients with EPclin high risk were at significant higher risk of experiencing distant metastases than patients with EPclin low risk (HR 5.18; 95%CI 1.04-25.74; p=0.0443). EPclin high risk patients who actually underwent recommended adjuvant CTX had a 3-year-DFS of 96.3% (95%CI 92.2-100) and were at lower risk for death or recurrence than those EPclin high risk patients without CTX (3-year-DFS: 91.5% (95%CI 82.7-100); HR 0.32; 95%CI 0.10-1.05; p=0.061). Conclusion: These first prospective outcome results show, that EPclin in clinical routine is a valid clinico-molecular marker to predict DFS and guide decision of adjuvant CTX use in HR+, HER2- early breast cancer pts with 0-3 positive lymph nodes. Citation Format: Ettl J, Anders S, Hapfelmeier A, Noske A, Paepke S, Weichert W, Klein E, Kiechle M. First prospective outcome data for the clinico-molecular test Endopredict® in hormone receptor positive, HER2-negative early breast cancer in clinical routine [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-08-11.

Abstract P1-17-09: Use of Oncotype DX ® testing in nodal positive breast cancer patients: Real-life data from a single center in Munich, Germany

Abstract Introduction: Despite a large body of prospective studies showing good prognostic and predictive value of the Oncotype DX ® testing in ER+/HER2- early breast cancer patients after breast surgery, the test is currently not reimbursed in Germany by most national health insurance companies. Nevertheless, this multigene assay has been offered to node negative (N-) and increasingly to node positive (N1) patients with 1-3 positive lymph nodes by medical- and gyneco-oncologists for several years. The aim of the present study was to analyze real life data of the test in N1 patients from a German single center with special respect to the intermediate-risk recurrence score (RS) group and event-free survival (EFS). Patients and Methods: Patients with ER+/HER2- node positive breast cancer after breast surgery, to whom Oncotype DX ® testing was consecutively recommended by the interdisciplinary local tumor board from 1/2012 through 12/2016 at the Breast Center of the Red Cross Hospital Munich, Germany, were included in the study. Data was retrospectively retrieved from medical records (e.g. stage and histology), patient interviews as well as from the Munich Cancer Registry (outcome measurements). Patients were stratified according to Oncotype DX ® RS distribution (<11 low-risk, 11-25 intermediate risk and > 25 high-risk). Proportion of patients choosing adjuvant chemotherapy (CT) within the different RS groups and outcome were analyzed. Results: Oncotype DX ® testing was recommended and performed in 500 (17%) out of 2942 patients with ER+/HER2- tumors. Nodal status was positive in 159 (31.8%) of these patients. Patients with more than 3 positive lymph nodes and with missing data on follow-up were excluded, leaving 121 patients for the main analysis. According to RS distribution, n=19 (15.7%) were low-risk, n=83 (68.6%) intermediate-risk and n=19 (15.7%) high-risk, respectively. Although CT was generally discussed with all N1 patients with RS>10, only 39 patients (38.2%) of the intermediate and high-risk RS-group opted for systemic chemotherapy (24.1% of RS 11-25 and 100% of RS>25). In 13 of the patients (11%) within a median follow-up of 40 months an event occurred (4 loco-regional and 2 contralateral relapses, 5 distant metastases (3 bone, 2 visceral) and 2 deaths of other causes). Of those patients with events, three presented with RS <11, six with RS 11-25 and three with RS >25. In the intermediate group (n=83) EFS was 90% for patients receiving CT followed by endocrine therapy (ET) and 91.9% for patients with ET alone (p= 0,583). Conclusions: Using real life data from a large single breast center, only around 25% of patients with 1-3 positive lymph nodes from the intermediate RS group decided to undergo CT after Oncotype DX ® testing. The outcome of patients receiving ET only in this group was not inferior compared to CT followed by ET. Citation Format: Kriegmair A, Szeterlak N, Schrodi S, Stoetzer O, Pölcher M, Braun M. Use of Oncotype DX ® testing in nodal positive breast cancer patients: Real-life data from a single center in Munich, Germany [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-17-09.

SIRT for downsizing to resection

Background: Different strategies have been developed to achieve resectability in patients initially considered as unresectable. Selective internal radiation therapy (SIRT) has emerged as an effective therapy for patients with primary non-resectable malignancies of the liver. Our group combined SIRT with liver surgery for downsizing for resection. Methods: Starting 2010 all patients with liver malignancies were evaluated in an interdisciplinary tumor board. Patients with marginally resectable liver metastases treated by SIRT followed by liver resection were identified and prospectively documented in a database for subsequent retrospective analysis. Results: Fifteen patients (7 female, 8 male) with marginally resectable liver metastases were planned for liver resection after SIRT. In thirteen patients (87%) liver metastases were from colorectal malignancies, and in two patients from breast cancer. After performing SIRT (90Y resin microspheres, mean administered activity 1260 MBq, range: 600 – 1990 MBq), twelve patients had potentially curative hepatic resection. In three patients liver resection after SIRT could not be performed due to the appearance of new extrahepatic metastases. Analyzing the effect of SIRT, we observed a decrease in tumor size with central scaring. Due to the selectivity of SIRT the future liver remnant was not effected in all patients. Conclusion: The combination of SIRT with modern liver surgery enables new therapeutic options in patients with marginally resectable liver metastases.

SIRT for downsizing to resection

Background: Different strategies have been developed to achieve resectability in patients initially considered as unresectable. Selective internal radiation therapy (SIRT) has emerged as an effective therapy for patients with primary non-resectable malignancies of the liver. Our group combined SIRT with liver surgery for downsizing for resection. Methods: Starting 2010 all patients with liver malignancies were evaluated in an interdisciplinary tumor board. Patients with marginally resectable liver metastases treated by SIRT followed by liver resection were identified and prospectively documented in a database for subsequent retrospective analysis. Results: Fifteen patients (7 female, 8 male) with marginally resectable liver metastases were planned for liver resection after SIRT. In thirteen patients (87%) liver metastases were from colorectal malignancies, and in two patients from breast cancer. After performing SIRT (90Y resin microspheres, mean administered activity 1260 MBq, range: 600 – 1990 MBq), twelve patients had potentially curative hepatic resection. In three patients liver resection after SIRT could not be performed due to the appearance of new extrahepatic metastases. Analyzing the effect of SIRT, we observed a decrease in tumor size with central scaring. Due to the selectivity of SIRT the future liver remnant was not effected in all patients. Conclusion: The combination of SIRT with modern liver surgery enables new therapeutic options in patients with marginally resectable liver metastases.

Resolution of Cardiac Symptoms through Preoperative Intravenous Iron Supplementation in a Cancer Patient

Cardiologic assessment was conducted on a 78-year-old male patient scheduled for elective aortic valve surgery who complained of angina and dyspnea that had arisen over the previous few months. Evaluation showed stable coronary artery disease and iron deficiency anemia (hemoglobin, 7.7 g/dL). Colonoscopy revealed a non-stenosing carcinoma of the right colonic flexure that was causing chronic blood loss. The interdisciplinary tumor board of the hospital decided that his need for an extended right hemicolectomy followed by resection of two pulmonary nodules that were suspicious of metastatic lesions had priority over his cardiac surgery. Prior to abdominal surgery, the patient received 4 × 500 mg intravenous iron (Ferric-Carboxymaltose) over 2 weeks, for correction of iron deficiency and optimization of hemoglobin concentration. This treatment led to rapid improvement of his angina and exertion-induced dyspnea. His hemoglobin concentration continued to rise even after completion of the iron supplementation, and reached normal levels before thoracoscopic removal of the lung nodules, which took place 1 month after resection of the colon tumor. The patient remained in good clinical condition without any need for blood transfusions. As follow-up visits showed persistent abatement of angina and dyspnea, aortic valve surgery and other cardiac interventions were no longer deemed necessary.

Colorectal metastases - Current treatment strategies

Colorectal metastases - Current treatment strategies Abstract. In the course of their disease, more than 50 % of patients with colorectal cancer develop metastases. They are most frequently localized in the liver, followed by the peritoneum and the lungs. The therapeutic options and prognosis of colorectal metastases have improved markedly in recent years. Modern treatment concepts are multimodal and are customized for the individual patient by interdisciplinary tumour boards that follow widely recognised guidelines and norms. The recommendation of an appropriate treatment option in metastasized patients by an interdisciplinary panel of experts is of paramount importance. Besides technical possibilities, factors such as comorbidities, medical outcomes, quality of processes as well as patient-related outcome are all crucial in the decision-making process. In most patients diagnosed with distant metastases, the prognosis is determined by the extent of the liver burden. Hereby, the resection of the liver metastases is of utmost importance to improve the prognosis of a patient, since only those individuals who have successfully undergone resection have a chance for long-term disease free-survival. Whether liver metastases are resectable depends on sufficient volume and function of the future liver remnant (FLR). Manipulation of the FLR as well as upfront oncological treatment of metastases improves the resectability rates in patients with an advanced tumor load in the liver. Laparoscopic liver resection improves patient outcomes by reducing pain and results in a shortened hospital stay. Lung resection for pulmonary metastases as well as cytoreductive surgery for peritoneal metastases are important mainstays of modern personalized treatment concepts. However, results of ongoing trials are eagerly awaited to help quantify the prognostic effects of those therapies and assess their true therapeutic value.

Radiological imaging procedures in the diagnosis, clarification and treatment of colorectal cancer

Radiological imaging procedures in the diagnosis, clarification and treatment of colorectal cancer Abstract. The therapeutic approaches and possibilities in the treatment of colorectal cancer are becoming increasingly diverse and specialized. This also expands the wishes and requirements for imaging procedures. Radiology and nuclear medicine is an established part of the interdisciplinary tumor board and thus directly involved in the therapy management of patients with colorectal cancer. It is foreseeable that the importance of imaging procedures for increasingly complex and individualized therapy decisions will continue to increase. The article summarizes the current imaging procedures in diagnosis, clarification and further therapy support of colorectal cancer based on current recommendations. In addition, a brief outlook is provided on current developments, expectations and future wishes for imaging procedures.

Comparison of Treatment Recommendations by Molecular Tumor Boards Worldwide.

Precision oncology holds the promise of improving patient outcome. It is based on the idea that the testing of genomic biomarkers can lead to the recommendation of a treatment option tailored to the specific patient. To derive treatment recommendations from molecular profiles, interdisciplinary molecular tumor boards (MTBs) have been established recently in many academic institutions. The recommendation process in MTBs, however, has not been well defined, which limits applicability to larger clinical trials and patient populations. We created four fictional patients on the basis of recent real cases with genomic information on mutations, fusions, copy numbers, and gene expression. We identified 29 tumor boards from nine countries worldwide and asked them to provide treatment recommendations for the sample patients. In addition, a questionnaire regarding the setup and methods used by MTBs was circulated. Five MTBs from four countries provided treatment recommendations and answered the questionnaire. For one patient, three tumor board treatment recommendations were identical, and two tumor boards had identical treatment strategies for the other three patients. There was heterogeneity in the interpretation of tumor and germline aberrations as well as in standards of prioritization. Differences in the interpretation and recommendation process contribute to heterogeneity in MTB recommendations. Additional comparative analyses of recommendations could help improve rational decision making and lead to standardization.

Feasibility, Safety, and Efficacy of Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) for Peritoneal Metastasis: A Registry Study.

Introduction Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is a novel drug delivery system with superior pharmacological properties for treating peritoneal metastasis (PM). Safety and efficacy results of PIPAC with cisplatin/doxorubicin or oxaliplatin from a registry cohort are presented. Methods IRB-approved registry study. Retrospective analysis. No predefined inclusion criteria, individual therapeutic recommendation by the interdisciplinary tumor board. Safety assessment with CTCAE 4.0. Histological assessment of tumor response by an independent pathologist using the 4-tied peritoneal regression grading system (PRGS). Mean PRGS and ascites volume were assessed at each PIPAC. Results A total of 142 PIPAC procedures were scheduled in 71 consecutive patients with PM from gastric (n = 26), colorectal (n = 17), hepatobiliary/pancreatic (n = 9), ovarian (n = 6), appendiceal (n = 5) origin, pseudomyxoma peritonei (n = 4), and other tumors (n = 3). Mean age was 58 ± 13 years. Patients were heavily pretreated. Mean PCI was 19 ± 13. Laparoscopic nonaccess rate was 11/142 procedures (7.7%). Mean number of PIPAC/patient was 2. All patients were eligible for safety analysis. There was no procedure-related mortality. There were 2.8% intraoperative and 4.9% postoperative complications. 39 patients underwent more than one PIPAC and were eligible for efficacy analysis, and PRGS could be assessed in 36 of them. In 24 patients (67%), PRGS improved or remained unchanged at PIPAC#2, reflecting tumor regression or stable disease. Ascites was present in 24 patients and diminished significantly under therapy. Median survival was 11.8 months (95% CI: 7.45–16.2 months) from PIPAC#1. Conclusion PIPAC is feasible, safe, and well-tolerated and can induce histological regression in a significant proportion of pretreated PM patients. This trial is registered with NCT03210298.

Impact of the Interdisciplinary Tumor Board of the Cooperative Ewing Sarcoma Study Group on local therapy and overall survival of Ewing sarcoma patients after induction therapy.

The Interdisciplinary Tumor Board (ITB) of the Cooperative Ewing Sarcoma Study (CESS) Group was investigated to assess its impact on the overall survival (OAS) of Ewing sarcoma (EwS) patients. The ITB functions as a reference center for the international institutions participating in the clinical trials of the CESS group, but is also available internationally to patients who have not been treated within an appropriate clinical trial. The value of tumor boards in terms of benefit for the patients and the health care system in general is not well documented and is also the subject of controversial discussions. A review of the representative literature is included. Data were analyzed from 481 patients who had been registered into the European Ewing Tumor Working Initiative of National Groups (EURO E.W.I.N.G.-99) clinical trial via the CESS data center between 2006 and 2009; this included 331 patients with localized disease and another 150 individuals with metastases at diagnosis. Median follow-up time was 3.2 years. Improved OAS was observed for patients with metastases who had received recommendations from the ITB compared with those who had not received recommendations. In patients with localized disease, a recommendation from the ITB had no influence on OAS. As a reference center for a rare disease, recommendations from our ITB impacted local therapy and led to higher OAS in patients with metastatic disease. To our knowledge, this is the first analysis that examines the value of a reference tumor board on a rare disease.

Patterns of care analysis for head & neck cancer of unknown primary site: asurvey inside the German society of radiation oncology (DEGRO).

Due to the absence of randomized trials, the optimal management for squamous cell cancer of unknown primary in the head and neck region (SCCHNCUP) remains controversial. Current strategies are based on retrospective studies, clinical experience, and institutional policies. An anonymous questionnaire with atotal of 24questions was created and distributed by the use of an online version (Google Forms®, Google, Mountain View, CA, USA) as well as aprintout version as equivalent option. An email with alink to the survey and the questionnaire as attachment was sent to 361 DEGRO(German Society of Radiation Oncology)-associated departments. Frequency distributions of responses for each question were calculated. The data were also analyzed by type of practice. Representativity of the sample size for the DEGRO was also evaluated. 66responses were received including answers from 20 (30%) university departments, 16 (24%) non-university institutions, and 30 (46%) radiation oncology practices. 95% of the participants routinely present these cases in an interdisciplinary tumor board and use intensity modulated radiotherapy (IMRT) techniques for SCCHNCUP treatment. Surgery includes neck dissection in 83% and tonsillectomy in 73% of the cases. Human papilloma virus (HPV) status is routinely determined in 82% of the departments. Statistically significant differences between universities and institutions and clinics and practices could be found with respect to positron emission tomography-computed tomography (PET-CT) utilization, indications for chemotherapy, radiotherapy volumes, and cumulative doses. Diagnostics and treatment for SCCHNCUP within the DEGRO remain heterogeneous. Aprospective register trial with standard operation procedures is warranted to homogenize and possibly improve management.

Clinical outcome after high-precision radiotherapy for skull base meningiomas: Pooled data from three large German centers for radiation oncology

PurposeTo evaluate outcome in patients with base of skull meningiomas treated with modern high precision radiation therapy (RT) techniques. Patients and methods927 patients from three centers were treated with either radiosurgery or fractionated high-precision RT for meningiomas. Treatment planning was based on CT and MRI following institutional guidelines. For radiosurgery, a median dose of 13 Gy was applied, for fractionated treatments, a median dose of 54 Gy in 1.8 Gy single fractions was prescribed. Follow-up included a clinical examination as well as contrast-enhanced imaging. All patients were followed up prospectively after radiotherapy in the three departments within a strict follow-up regimen. The median follow-up time was 81 months (range 1–348 months). ResultsMedian local control was 79 months (range 1–348 months). Local control (LC) was 98% at 1 year, 94% at 3 years, 92% at 5 years and 86% at 10 years. There was no difference between radiosurgery and fractionated RT. We analyzed the influence of higher doses on LC and could show that dose did not impact LC. Moreover, there was no difference between 54 Gy and 57.6 Gy in the fractionated group. Side effects were below 5% in both groups without any severe treatment-related complications. DiscussionBased on the pooled data analysis this manuscript provides a large series of meningiomas of the skull base treated with modern high precision RT demonstrating excellent local control and low rates of side effects. Such data support the recommendation of RT for skull base meningiomas in the interdisciplinary tumor board discussions. The strong role of RT must influence treatment recommendations keeping in mind the individual risk–benefit profile of treatment alternatives.

Added value of diffusion-weighted imaging in hepatic tumors and its impact on patient management

BackgroundTo investigate the added diagnostic value of diffusion-weighted imaging (DWI) of the liver and its impact on therapy decisions in patients with hepatic malignancy.MethodsInterdisciplinary gastrointestinal tumorboard cases concerning patients with hepatic malignancies discussed between 11/2015 and 06/2016 were included in this retrospective, single-center study. Two radiologists independently reviewed the respective liver MR-examination first without, then with DWI. The readers were blinded regarding number, position and size of hepatic malignancies. Cases in which DWI revealed additional findings concerning the hepatic tumor status as compared to conventional sequences alone were presented to experienced members of the interdisciplinary tumor board. In this retrospective setting changes in treatment decisions based on these additional findings in the DWI sequences were recorded.ResultsA total of 87 patients were included. DWI revealed additional findings in 12 patients (13,8%). These new findings had a direct effect on the therapy in 8 patients (9,2%): In 6 patients (6,9%) the surgical/interventional treatment was adapted (n = 5: extended resection, n = 1: with transarterial chemoembolization of a single hepatocellular carcinoma only detectable in DWI); 2 patients (2,3%) received systemic therapy (n = 1: neo-adjuvant, n = 1: palliative) based on the additional findings in DWI. In 4 patients (4.6%) additional DWI findings did not affect the therapeutic decision.ConclusionsDWI is a relevant diagnostic tool in oncologic imaging of the liver. By providing further information regarding tumor load in hepatic malignancies it can lead to a significant change in treatment.

Canadian Neurosurgery Educators' Views on Stereotactic Radiosurgery in Residency Training.

Despite the increasing prominence of stereotactic radiosurgery (SRS) in treating intracranial and spinal pathologies, there is currently a dearth of exposure to this modality in the neurosurgical residency. To address this gap, the aim of this study is to assess neurosurgery educators' views regarding the current state of SRS exposure, and to identify potential approaches to improve residency education in this domain. Qualitative thematic analysis and constructivist grounded theory methodology were employed. Semistructured telephone-based interviews were conducted with current or past residency program directors, as well ascurrent departmental chairs across neurosurgical departments in Canada. Interviews were transcribed and subjected to thematic analysis using open and axial coding. Of the 34 eligible participants, the overall response rate was 41.1% (14/34), with a 35.3% participation rate (12/34). Participants represented 9 of the 12 Canadian institutions surveyed. The majority of participants were current program directors (n= 8), followed by past program directors (n= 2), and departmental chairs (n= 2). Most respondents 75% (9/12) view an increasing role for SRS in neurosurgery. Unanimously, respondents endorse greater exposure to SRS during residency through formal residency rotations and engagement in interdisciplinary tumor boards to facilitate involvement in clinical decision-making. This is the first study to systematically collate neurosurgery educators' views on SRS in residency in Canada and demonstrates recognition of the discordance between SRS in practice and residency training. Neurosurgery educators broadly endorse increased exposure to this modality. Future work is needed to delineate the requirements necessary to achieve adequate competency in SRS.

99m Tc-MIP-1404-SPECT/CT for the detection of PSMA-positive lesions in 225 patients with biochemical recurrence of prostate cancer.

99m Tc-MIP-1404 (Progenics Pharmaceuticals, Inc., New York, NY) is a novel, SPECT-compatible 99m Tc-labeled PSMA inhibitor for the detection of prostate cancer. We present results of its clinical use in a cohort of 225 men with histologically confirmed prostate cancer referred for workup of biochemical relapse. From April 2013 to April 2017, 99m Tc-MIP1404-scintigraphy was performed in 225 patients for workup of PSA biochemical relapse of prostate cancer. Whole-body planar and SPECT/CT images of the lower abdomen and thorax were obtained 3-4 h p.i. of 710 ± 64 MBq 99m Tc-MIP-1404. Images were visually analyzed for presence and location of abnormal uptake. In addition, quantitative analysis of the SPECT/CT data was carried out on a subset of 125 patients. Follow-up reports of subsequent therapeutic interventions were available for 59% (139) of all patients. Tracer-positive lesions were detected in 77% (174/225) of all patients. Detections occurred at the area of local recurrence in the prostate in 25% of patients (or a total of 56), with metastases in lymph nodes in 47% (105), bone in 27% (60), lung in 5% (12), and other locations in 2% (4) of patients. Detection rates were 90% at PSA levels ≥2 ng/mL and 54% below that threshold. Lesional SUVmax values were, on average, 32.2 ± 29.6 (0.8-142.2), and tumor-to-normal ratios 146.6 ± 160.5 (1.9-1482.4). The PSA level correlated significantly with total uptake of MIP-1404 in tumors (P < 0.001). Furthermore, total tumor uptake was significantly higher in patients with Gleason scores ≥8 compared to those with Gleason scores ≤7 (P < 0.05). In patients with androgen deprivation therapy, the detection rate was significantly higher compared to patients without androgen deprivation therapy (86% vs 71%, P < 0.001). Based on 99m Tc-MIP-1404-imaging and other information, an interdisciplinary tumor board review recommended changes to treatment plans in 74% (104/139) of those patients for whom the necessary documentation was available. SPECT/CT with 99m Tc-labeled MIP-1404 has a high probability in detecting PSMA-positive lesions in patients with elevated PSA. Statistical analysis disclosed significant relationship between quantitative 99m Tc-MIP-1404 uptake, PSA level, and Gleason score.

Therapeutic approach in oligometastatic gastric and esophageal cancer

The therapeutic approach to patients with oligometastatic gastric cancer and esophageal cancer is currently undergoing ashift towards amore aggressive therapy including surgical resection. In the current GermanS3 guidelines surgical treatment of metastatic disease is not recommended; however, nowadays interdisciplinary tumor boards have to evaluate such patients increasingly more often. On an individual basis a radical surgical resection of the primary tumor and the metastases is considered and performed in patients who respond well to multimodal chemotherapy concepts. In this review article the currently available data from the literature are discussed and afoundation for individually extended surgical approaches is presented. Together with the currently available results of the FLOT 3 study and the mostly retrospective studies, it seems to be possible to identify patients who would profit from such an aggressive treatment. In the future randomized prospective studies, such as the RENAISSANCE/FLOT 5 study and the GASTRIPEC study will have to evaluate whether an aggressive surgical therapy within multimodal therapy concepts of metastatic gastric and esophageal carcinomas is warranted.

Clival chordoma: a single-centre outcome analysis.

The treatment of clival chordomas remains challenging. Total tumour resection is often impossible without hampering adjacent anatomical structures and causing functional sequelae. On the other hand, chordomas show limited response to non-surgical treatment modalities. Up to now, no well-established interdisciplinary treatment algorithms for clival chordomas exist. In this regard, we analysed the data from all patients that underwent interdisciplinary treatment for clival chordoma in our institution over the last 10years. Retrospective report of all patients treated at the authors' institution from 2005 to 2015. Thirteen patients underwent 24 surgeries, of which 2 (8%) were gross total resections and 22 (92%) incomplete resections. Neurological deterioration, endocrinological disturbances and other surgical complications were observed in six (25%), three (13%) and nine (38%) cases, respectively. Three surgeries (13%) led to an improvement of the initial preoperative neurological condition. All patients were discussed on the interdisciplinary tumour board and all underwent one type of radiotherapy following initial surgery: proton beam in 11 cases (85%) and photon beam in two (15%) cases. In the course of their recurrent disease, three patients (23%) received systemic therapy (imatinib, pazopanib and nivolumab). One patient received a personalised cellular immunotherapy. One patient (8%) was lost to follow-up. Of the remaining 12 patients, four patients (33%) died in the period of analysis; all deaths were chordoma-related. The 5-year cumulative survival rate was 83% (52-97%, CI 95%), 5-year progression-free survival rate was 53% (26-79%, CI 95%). The eight patients (66%) still alive had favourable outcome (KPS, 90±10.7%). SF36 analysis among the survivors revealed 43 points for the Physical Component Summary (12% above, 38% at and 50% below the general population norm) and 47 points for the Mental Component Summary (25% above, 38% at and 38% below). Our patients show a low rate of gross total resection but an outcome well comparable to other published results. This emphasises the importance of interdispiplinary treatment strategies, with surgery supplying maximal safe resection and avoiding severe neurological deficit, allowing patients to undergo adjusted radiotherapy and other treatment options in a good condition.

Critical aspects to achieve a high-quality melanoma clinic.

With incidence of melanoma growing worldwide and new therapies prolonging the survival of patients with advanced disease, complex medical care is needed. Best care of complicated melanoma cases is achieved in specialized referral centers. Aims to provide optimized melanoma therapy, best patient-reported treatment outcome, and successful clinical and translational research, necessitate a dedicated interdisciplinary team. We report on critical aspects of the interaction between patients, medical care givers, clinical trial and biobanking teams, and emphasize the importance of interdisciplinary tumor boards. Specialized skin cancer nurses and local patient advocacy groups should be involved in patient care and could be the binding link between the patients and the treatment team.

Multidisciplinary Tumor Boards: Facts and Satisfaction Analysis of an Indispensable Comprehensive Cancer Center Instrument

Background The established standard to ensure State-of-the-art cancer treatment - as a prerequisite in the national cancer plan and for comprehensive cancer centers (CCCs) today - is through interdisciplinary tumor boards (TBs). Methods This analysis assessed a newly founded CCC-TB for multiple myeloma (MM) patients, namely a) questions solved therein, b) level of compliance and c) evidence, d) frequency of clinical trial (CT) inclusion, d) progression free (PFS) and overall survival (OS) and e) satisfaction of TB-participants, referring physicians and MM patients. Results With initiation of the MM-TB, patients discussed therein substantially increased. TB-questions mostly involved symptomatic patients and recommendations on best treatment. The level of compliance and evidence were 94 % and 96.5 %, respectively; all noncompliance being coherently justified. CT inclusion was improved through the TB, leading to 18.8 % of patients being treated therein. Median PFS and OS were 2.9 and 4.7 years, respectively; also those of substantially pretreated, relapsed/refractory patients were favorable. The satisfaction of 58 participants, 33 referring physicians and 100 MM patients with the MM-TB was rewarding. Conclusion The detailed assessment of this CCC-TB on TB-questions, compliance and evidence levels, survival and satisfaction responses could serve as a valuable example for other TBs and CCCs and excite subsequent analyses on TBs.