Sole Treatment Modality Research Articles

Immunotherapy as a Complement to Surgical Management of Hepatocellular Carcinoma.

Hepatocellular carcinoma (HCC) is the most common primary liver tumor in adults, and the fourth leading cause of cancer-related deaths worldwide. While surgical and ablative therapies remain the standard of care in early localized disease, late presentation with advanced stages of disease, impaired hepatic function, or local recurrence following surgical resection preclude operative management as the sole treatment modality in a subgroup of patients. As such, systemic therapies, namely immunotherapy, have become an integral part of the HCC treatment algorithm over the past decade. While agents, such as atezolizumab/bevacizumab, have well-established roles as first-line systemic therapy in intermediate- and advanced-stage HCC, the role of immunotherapy in disease amenable to surgical management continues to evolve. In this review, we will discuss the current evidence and aggregate impact of immunotherapy in the context of HCC amenable to surgical management, including its application in the neoadjuvant and adjuvant settings.

Irreversible Electroporation for the Focal Treatment of Prostate Cancer: A Systematic Review.

Irreversible electroporation (IRE) is a promising alternative treatment for low-intermediate-risk localized prostate cancer. In this systematic review we aim to evaluate the safety profile and functional and oncological outcomes of this new technique. A systematic review of the literature was performed on PubMed, EMBASE, and Scopus up to 24 August 2023. Nineteen studies were analyzed, including 12 prospective studies and 7 retrospective studies. A total of 1,452 patients underwent IRE as the sole primary treatment modality. The in-field clinically significant prostate cancer rate was reported between 0%-15.6% in the repeat biopsy. The retreatment rate was reported from 8% to 36.6%. The 3 years failure-free survival was presented between 90%-96.8%. The post-operative pad-free rate ranged between 96.7%-100%. Greater heterogeneity exists considering the change in erectile function. The most common reported complications were urinary tract infection and hematuria. Major complications were rare. These results underline that IRE achieves favorable oncological control with an excellent safety profile, in the meantime preserving patients' urinary and erectile function.

Local steroid injection in severe idiopathic granulomatous mastitis as a new first-line treatment modality with promising therapeutic efficacy.

Intralesional steroid injection has recently evolved as a novel treatment modality for localized idiopathic granulomatous mastitis (= IGM). We aimed to explore the therapeutic efficacy of local steroid injections (LSI) in patients with severe IGM. Fifty-one patients diagnosed with severe IGM were included in the study and treated with either local steroid injection (LSI) alone (n = 25) or combined LSI with systemic oral steroid treatment (OST) (n = 26). The local steroid injection protocol included an intralesional triamcinolone acetonide injection into the palpable granulomas every 4-week, and topical administration of steroid-containing pomades twice a day on the affected surface of the breast. Patients with a combined LSI and OST received low-dose oral methylprednisolone (<16 mg). Patients with LSI alone required more LSI applications than those in the combined LSI with OST group (LSI: 5 ± 2.9; vs. LSI/OST: 3.5 ± 2.5; p = 0.080) to obtain an effective optimum therapeutic response. At a median of 12 months (range, 4-42), no difference was found in complete response rates between patients in the LSI group and the combined LSI group with OST (52 vs. 53.9%, p = 0.999). However, steroid-related systemic side effects were lower in the LSI alone group (p < 0.008). Local steroid injection could be considered as the first-line treatment in patients with severe IGM until a therapeutic response has been obtained either as the sole treatment modality or combined with oral steroids. Compared with systemic oral steroid therapy, local steroid administration can be considered a new treatment modality with fewer side effects.

Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature.

Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.

Are Antibiotics the New Appendectomy?

Prior to the development of laparoscopic procedures, open appendectomy was the standard of care for the majority of appendicitis cases. Recently, studies have debated using antibiotics as a first-line treatment in uncomplicated appendicitis cases. The definition of uncomplicated appendicitis is not always clear-cut; however, with the large-scale accessibility of radiologic techniques, it is becoming increasingly easier to classify patient groups. As suggested by clinical and radiological patient data, this has raised the speculation of considering antibiotic therapy as the sole treatment modality in uncomplicated appendicitis cases. We aim to compare the options of surgery and antibiotics only in terms of efficacy, complications, and financial cost. A range of databases and search strategies were adopted, and various databases were used, including PubMed, ScienceDirect, Google Scholar, and JAMA. Collectively, 30 studies were reviewed, but only 18 were included. Efficacy rates were higher in the appendectomy group. Nevertheless, the antibiotics-only group maintained an efficacy rate greater than 70% at one-year follow-up. Risk factors that decreased the efficacy in medical management included the presence of appendicolith, neoplasm, appendiceal dilatation, peri-appendiceal fluid collection, higher mean temperature, CRP, and bilirubin. Complications were more frequent and significant in the surgery group. These included complications related to anaesthesia, surgical site infections, damage to nearby structures, and pulmonary embolism. Despite several years of follow-up and disease recurrences, higher financial costs were observed in surgically treated patients compared to the antibiotics-only group. Given the high success rates post-appendectomy for acute appendicitis over the decades, the efficacy of conservatively treated acute appendicitis raises a strong argument when choosing one of the two options. The efficacy remained consistently higher across the literature in the surgery group than in the antibiotics-only group. However, it is still arguable that antibiotics may be a preferable option given an efficacy rate of more than 70% at one year and overall higher complications associated with surgery. The argument of missing a neoplasm by avoiding surgery is valid. However, most are carcinoid neuroendocrine neoplasms with a low probability of metastasis (<5%) and are usually considered benign. Given the current practice focused on conservative and minimally invasive treatments and recently the COVID-19 pandemic, with its restrictions and lessons learnt, antibiotics may be the future standard for treating uncomplicated acute appendicitis. Lastly, we noticed higher efficacy rates in articles published recently than those published at least five to ten years earlier. Antibiotics-only therapy for uncomplicated appendicitis is cost-effective with fewer complications than surgery. However, appendectomies have higher efficacy. Thus, surgical treatment prevails as the standard of care. Future literature should yield larger sample sizes and explore the numbers of emergency appendectomies mandated following antibiotics-only therapy.

Real-world program-based lung cancer care.

6581 Background: Low dose CT screening (LDCT) and lung nodule programs (LNP) promote early lung cancer detection, improve survival; Multidisciplinary Care Programs (MDC) promote guideline-concordance. The impact of such program-based care on ‘real-world’ population-level lung cancer survival and mortality is uncertain. We evaluated program-based lung cancer care versus care outside structured programs in a large community healthcare system. Methods: We linked prospective observational databases for LDCT, LNP and MDC with the Tumor Registry of Baptist Cancer Center facilities across Mississippi, Arkansas and Tennessee, categorizing all lung cancer patients between 2011 and 2021, according to program- (LDCT, LNP, MDC) versus non-program-based care. We compared stage distribution, care patterns, survival and mortality by standard statistical methods. Results: Of 12,089 patients, 250 (2%), 1236 (10%), 1045 (7%) and 9558 (79%) were diagnosed through the LDCT, LNP, MDC or no program, respectively; non-program-based care sequentially diminished from 96% in 2011 to 67% in 2021, diagnosis through LDCT increased from 0.3% to 7%, LNP from 0.9% to 21%; and MDC alone decreased from a high of 13% in 2015 to 5% in 2021. Black persons, 28% of the whole cohort, were 13% of LDCT, 25% of LNP, 31% of MDC, and 28% of non-program-based care recipients (p = 0.0005). Median (IQR) tumor size was 20mm (13 – 34), 25mm (17 – 44), 35mm (20 – 55) and 35mm (20 – 55), respectively (p &lt; 0.0001); 40-46% of patients across programs had adenocarcinoma; clinical stage was I or II in 58%, 48%, 38% and 29% and IV in 16%, 27%, 31% and 42% in the respective programs (p &lt; 0.0001). 2609 patients (21.6%) had surgery, including 49.2%, 37.7%, 36.1% and 17.2% in LDCT, LNP, MDC and non-program-based care respectively, among whom aggregate pathologic stage was I in 76%, 71%, 54% and 60% (p = 0.0005). Surgery was the sole treatment modality in 27.6%, 21.5%, 12.9% and 10.6%, respectively (p &lt; 0.0001). Despite higher proportions with more advanced pathologic stage, 30.8% of recipients of non-program-based care received adjuvant therapy, compared to 42% among recipients of program-based care, including 39.0%, 37.1% and 49.3% in LDCT, LNP and MDC, respectively (p &lt; 0.0001); 8.7% of patients in programs received no treatment, compared to 20.1% of non-program-based care. Aggregate 5-year overall survival rates were 60% (95% CI: 52% - 69%), 45% (95% CI: 42% - 49%), 30% (95% CI: 27% - 33%), and 18% (95% CI: 17% - 19%), respectively (p &lt; 0.0001). Adjusting for age, sex, race, patient-level rurality and histology, with non-program-based care as reference, the aHR were 0.3 (95% CI: 0.234 – 0.373), 0.51 (95% CI: 0.464 – 0.556, and 0.66(95% CI: 0.607 – 0.712). Results were consistent even without patients who received no treatment. Conclusions: Program-based care was associated with more favorable lung cancer characteristics, better quality of care and survival. Disseminating program-based care should be explored as a matter of urgent public policy.

Acrylic "lollipop" for jaw rehabilitation after release of joint ankylosis in paediatric patients.

Falls are a leading cause of injuries to the temporomandibular joint (TMJ) in the paediatric age group. In low- and middle-income nations, after injury to a child's chin, a careful clinical examination of the mandible and TMJ is sometimes omitted. Paediatric mandibular condylar fractures tend to shatter the relatively narrow condylar head, leading to ankylosis to the skull base, which leads to debilitating progressive deformity.1 Early surgical release is then the sole modality of treatment and needs to be followed up by several weeks of active mouth-opening exercises to prevent re-ankylosis, which are crucial in the immediate post-operative period. Unfortunately, as patient cooperation is low owing to uncomfortable jaw mobilization, we fabricated a simple acrylic appliance which is easy to use.

Branchiogenic cyst ‒ a rare finding in vascular surgery.

Branchiogenic cysts are benign lesions caused by anomalous development of the branchial cleft. They are typically detected in individuals aged between their twenties and forties. Ultrasonography is the first-line imaging method of choice. Surgical excision is the sole treatment modality (Tab. 1, Fig. 6, Ref. 25). Keywords: branchiogenic cyst, extirpation, ultrasonography, computed tomography.

Intrapulmonary percussive ventilation for children with bronchiolitis on non-Invasive Ventilation support

Objective: Pediatric Intensive Care (PICU) admission of children with bronchiolitis as well as the use of Non-Invasive Ventilation (NIV) are increasing. The current treatment for bronchiolitis is supportive, and there are no specific studies addressing this group of severe bronchiolitis patients supported with NIV. Intrapulmonary Percussive Ventilation (IPV) is a lung recruitment physical therapy technique used in our PICU to augment lung aeration and improve gas exchange. We hypothesized that IPV treatment can be used to improve the clinical course of infants on NIV support suffering from bronchiolitis. Design: A prospective, open, randomized study. Setting: Single-center Pediatric ICU Patients: Children less than 2 years old admitted to our PICU between November 2016 and April 2018 with a diagnosis of bronchiolitis who were prescribed noninvasive positive pressure ventilation as their sole respiratory treatment modality Interventions: Patients were randomly assigned to two intervention groups: IPV vs. control (standard treatment). Measurements and main results: Thirty-eight infants with bronchiolitis treated with NIV support were randomized into two groups. The probability of a superior outcome (less chance of invasive mechanical ventilation and fewer PICU days) was 62.7% (95% CI, 45%-77%, p = 0.18) in the IPV group compared to the control group. Among the IPV group, there were no failures that required intubation in comparison to three intubations (13.6%) among the control group (p = 0.24). For the IPV group, the PICU length of stay (LOS) was 4.13 ± 2.45 days, compared to 6.18 ± 4.72 for the inhalation group. This difference was not statistically significant. Conclusions: In this single-center study, the use of IPV had no adverse reactions. The study failed to show a statistically significant effect of IPV treatment on the course of hospitalization of patients with bronchiolitis on NIV support in the PICU. Trial registration: Clinical Trials.gov NCT03037801.

TH8.6 Thoracic sarcoma: three-year data from a tertiary referral centre

Abstract Aims The rarity of thoracic sarcomas leads to challenges in their diagnosis and evidence-based management. We aim to investigate the management and outcomes of primary thoracic sarcoma patients under the care of our tertiary centre Sarcoma Service over a three-year period. Methods Data of all thoracic sarcoma patients discussed at the tertiary centre multidisciplinary meetings from 2017–2019 were collected from the local electronic database. Results 65 patients met the inclusion criteria. The most common histological subtypes were chondrosarcomas and spindle cell sarcomas. 60% of cases were high-grade sarcomas. 14 out of 19 deaths occurred in patients with high grade sarcomas (p=0.0586). 78.3% of patients underwent surgical resection, with 35.4% undergoing surgical resection as their sole treatment modality. Surgical intervention was associated with a statistically significant improvement in survival (p &amp;lt; 0.0001*). Clear marginal status was associated with better survival outcomes (p = 0.026*). Local recurrence was seen in 15 cases, and 93.3% of these were in high-grade sarcomas. There was no association between recurrence and marginal status. 8 of the 15 cases with recurrence received surgical intervention for the recurrence. 4 of the cases with recurrence passed away within the study time frame. Conclusion Primary resection should remain the gold standard for treatment of thoracic sarcomas due to its significant improvement in survival. Variability between outcomes and overall survival is likely multifactorial – diversity of histological subtypes, predominance of high-grade sarcomas, and a wide range of age at diagnosis. Prospectively maintained databases and cross-centre collaboration would be beneficial for future study in thoracic sarcomas.

Outcomes of rectal cancer patients with a positive pathological circumferential resection margin.

Evidence-based management of positive pathological circumferential resection margin (pCRM) following preoperative radiation and an adequate rectal resection for rectal cancers is lacking. Retrospective analysis of prospectively maintained single-centre institutional database was done to study the patterns of failure and management strategies after a rectal cancer surgery with a positive pCRM. A total of 86 patients with rectal adenocarcinoma with a positive pCRM were identified over 8years (2011-2018). Majority had low-lying rectal cancers (90.7%) and were operated after preoperative radiotherapy (95.3%). Operative procedures included abdomino-perineal resections, inter-sphincteric resections, low anterior resections and pelvic exenteration in 61 (70.9%), 9 (10.5%), 11(12.8%) and 5 (5.8%) patients respectively. A total of 83 (96.5%) received chemotherapy as the sole adjuvant treatment modality while 2 patients (2.3%) were given post-operative radiotherapy and 1 patient underwent revision surgery. A total of 53 patients (61.6%) had recurrence, with 16 (18.6%), 20 (23.2%), 8(9.3%) and 9 (10.5%) patients having locoregional, systemic, peritoneal and simultaneous local-systemic relapse. Systemic recurrences were more often detected either by surveillance in an asymptomatic patient (20.1%) while local (13.1%) and peritoneal (13.2%) recurrences were more often symptomatic (p = 0.000). The 2-year overall survival (OS) and disease-free survival (DFS) of the cohort was 82.4% and 74.0%. Median local recurrence-free survival (LRFS) was 10.3months. Patients with a positive pCRM have high local and distal relapse rates. Systemic relapses are more often asymptomatic as compared to peritoneal or locoregional relapse and detected on follow-up surveillance. Hence, identification of such recurrences while still salvageable via an intensive surveillance protocol is desirable.

Ocular adnexal lymphoma: A single-institution retrospective study.

PURPOSE:To characterize demographic, clinical, and histopathologic features of ocular adnexal lymphoma (OAL) at a single institution.METHODS:Retrospective review of all patients with pathologic diagnosis of OAL between 2015 and 2020.RESULTS:There were 133 patients with OAL, with a median age of 65 years (range 23–97) and a slight female predominance (male: female = 1:1.46), (n = 79, 59%). The majority of tumors were non-Hodgkin B-cell lymphomas (n = 131, 99%), most frequently Extranodal Marginal Zone B-Cell Lymphoma (EMZL, n = 93, 70%), followed by follicular lymphoma (n = 21, 16%), chronic lymphocytic leukemia/small lymphocytic lymphoma (n = 7, 5%), diffuse large B-cell lymphoma (n = 5, 4%), and mantle cell lymphoma (n = 5, 4%). The most frequently involved sites included the orbit (n = 85, 64%) and conjunctiva (n = 43, 32%). Information was available on oncologic staging in 78 (59%), treatment in 82 (62%), and follow-up in 75 (56%) patients. By the Ann-Arbor classification system, patients were classified as IE (54/78, 69%), IIE (9/78, 12%), IIIE (6/78, 8%), and IVE (9/78, 12%). The most common treatments included external beam radiotherapy (standard and ultra-low-dose) (48/82, 59%), biologics (22/82, 27%), and surgical excision with cryotherapy (14/82, 17%) (some patients had >1 therapy). Median follow-up time was 24 months (range 0–221 months). Recurrence was observed in 13% (10/75) with a median time to recurrence of 60 months (95% confidence interval 47–73 months). Excision with cryotherapy as a sole treatment modality was associated with earlier recurrence (P = 0.003).CONCLUSION:In this largest single-center study of OAL, we found that most OAL were Ann-Arbor Stage IE EMZL, occurring in older patients with a female predominance. Early recurrence was noted in tumors treated with excision and cryotherapy alone.

Outcomes of open and hybrid treatments in below the knee pathology for critical limb threatening ischemia.

The optimal management of below the knee pathology remains one of the most challenging areas for revascularization in patients presenting with critical limb threatening ischemia. Patients commonly have multilevel lesions and have a high amputation rate and associated mortality. This review aimed to assess the outcomes of below the knee revascularization strategies. An online literature search of medical databases for original articles or review articles was conducted using mesh terms. Bypass surgery remains the gold standard for revascularization with good long-term outcomes with regards to patency, limb salvage, and quality of life but is associated with a higher morbidity than the endovascular approach. Given the increasing frailty of our patients, endovascular treatments have become the preferred strategy with results that are now equal to bypass. Hybrid surgery is an increasingly popular option as it combines the benefits of both endovascular and open surgery and although the evidence base is small the outcomes are encouraging. Hybrid surgery offers promising results and could be considered in the treatment of multi-level lower limb arterial disease especially in high-risk patients or those who are not suitable for either open or endovascular techniques as a sole treatment modality.

Comparison of two different doses of bleomycin in electrochemotherapy protocols for feline cutaneous squamous cell carcinoma nonsegregated from ultraviolet light exposure

Cutaneous squamous cell carcinoma (cSCC) is one of the most common skin tumors in cats due to chronic exposure to ultraviolet light. Local treatments such as electrochemotherapy (ECT) promote disease control or even complete remission. We hypothesize that cats could benefit from treatments using bleomycin at reduced dosages. A prospective nonrandomized single-blind study evaluated the clinical parameters, site lesion, staging, disease-free interval (DFI) and survival time by comparing the standard dose of bleomycin (15,000 UI/m2) (n = 22) with a reduced dose (10,000 UI/m2) (n = 34) in cats with cSCC that underwent ECT as the sole treatment modality. No statistically significant difference in DFI or overall survival was observed between the 2 groups. A higher DFI was found in cats with a small tumor size (less than 0.33 cm3) compared with that for cats with a large tumor size (P = 0.045). Furthermore, a reduced overall survival time for cats with a higher stage in the standard group SG (T3 and T4) (P = 0.004) was observed when compared to that for cats with a lower stage (T1 and T2). In conclusion, ECT using both doses of bleomycin may achieve the same response rate in terms of the overall response, DFI, and overall survival.

Testicular tumors in children and adolescents: long-term endocrine and fertility issues.

The treatment modalities for testicular tumors (surgery, chemotherapy, and radiotherapy), have different associated gonadotoxic risks and the overall survival for most pediatric patients with testicular tumors is very good. However, necessary treatments may lead to the development of lasting gonadal dysfunction and subsequent negative health and quality of life impact. Research with long-term follow-up for patients who have undergone surgery as the sole treatment modality for testicular tumors in childhood are lacking. It is currently unclear if surgery leads to long-term negative functional outcomes. Alkylating agents (e.g., cyclophosphamide) have long been known to increase risk of infertility; platinum-based therapies used frequently for patients with germ-cell tumors (GCTs) also seem to carry some risk of gonadotoxicity, although they have not been as well studied. Radiotherapy to the gonads is toxic and Leydig cells are particularly sensitive to high doses of radiation (>12 Gy). Long-term fertility and hormonal impact vary based on the patient’s age, as well as the type and intensity of the oncological treatment prescribed. Counselling regarding fertility risk and preservation options should ideally take place before initiating potentially gonadotoxic treatments. Hypogonadism in peri-pubertal boys can present as delayed onset or failure to progress through puberty. Sperm cryopreservation should be offered for post-pubertal boys who are able to provide a semen sample. For prepubertal boys or young males who cannot provide a semen sample, only experimental options are currently available. Much of the data reviewed here is extrapolated from research done on adult males whose reproductive and hormonal outcomes may not be comparable to younger patients who do not yet have fully developed reproductive systems. Currently, a lack of good quality evidence in this age range causes this restriction to be unavoidable. Patients and their families want to be informed of the risks and treatment options for preserving testicular function. As research continues in this field, it grows more important for urologists to be aware of the outcomes and options for their patients.

3097 Reduction of a Hiatal Hernia Using Osteopathic Treatment

INTRODUCTION: Hiatal hernia describes superior herniation of abdominal contents through the diaphragm. This type of herniation occurs when the esophageal hiatus weakens and the positively pressurized abdominal cavity forces contents into the negatively pressurized thoracic cavity. Risk factors include conditions that either increase intra-abdominal pressure (e.g., obesity) or weaken the hiatus and associated structures (e.g., fibromuscular degeneration associated with normal aging). Multiple types and classifications of hiatal hernias encumber assessments of disease prevalence; however, hiatal hernias are broadly classified as either sliding or paraesophageal. While many sliding hernias are asymptomatic, patients may experience reflux-like symptoms due to weakening of the lower esophageal sphincter. Paraesophageal hernias are more serious and can lead to volvulus, bleeding, and respiratory compromise. Surgical repair of the hernia is indicated in symptomatic patients refractory to conservative management and to manage complications; however, surgical intervention is a risk factor for more serious complications such as stenosis and perforation. CASE DESCRIPTION/METHODS: Here we present a case of a 71-year-old female with reflux symptoms diagnosed with a 3 cm hiatal hernia on esaphagogastroduodenoscopy (EGD). After four osteopathic manipulative treatments (OMT), follow-up EGD showed no evidence of hernia or gastritis and the patient reported complete relief of symptoms. DISCUSSION: To our knowledge, this is the first case confirmed by EGD to show a complete reduction of a 3 cm hiatal hernia with OMT being the sole treatment modality. This case demonstrates that hiatal hernias can be managed using OMT, without the use of medications or the need for surgical intervention.

Impact of Travel Distance on Radiation Treatment Modality for Central Nervous System Disease.

Background Stereotactic body radiation therapy (SBRT) has emerged as a popular alternative to conventional radiation therapy (RT) over the past 15 years. Unfortunately, the impact of patient distance from radiation treatment centers and utilization of SBRT versus conventional RT has been sparsely investigated. This report represents the first analysis of the impact of patient distance on radiation treatment modality for central nervous system (CNS) disease. Materials and Methods Since the inception of our RADIation oncology And Neuro-Surgery (RADIANS) multidisciplinary clinic at a community hospital in 2016, 27 patients have received either SBRT or conventional RT as their sole radiation treatment modality for CNS disease. Twenty-four (88.9%) presented with metastatic disease. Fisher’s exact test evaluated the relationship between patient residence from treatment (in miles) and radiation treatment modality received. Results Mean patient distance from our RADIANS clinic was 50.6 miles (median = 15.3). Twenty-one patients (77.8%) received SBRT; the remaining six received conventional RT. Mean patient distance from SBRT was 63.6 miles, and mean patient distance for conventional RT was 5.1 miles; this finding was statistically significant ( p = 0.0433; 95% confidence interval = 1.9–115.1). Conclusion Our findings indicate that patients with CNS disease who receive SBRT over conventional RT are statistically more likely to reside further from treatment centers. This is similar to findings of national studies comparing proton versus photon treatment for pediatric solid malignancies. The results from our work have implications for neuro-oncology treatment and the development of community hospital-based clinic models similar to RADIANS in the future.

PB2119 CLINICAL PRESENTATION AND OUTCOMES OF SOLITARY PLASMACYTOMA IN A LARGE TERTIARY HOSPITAL: A RETROSPECTIVE COHORT STUDY

Background:Solitary plasmacytoma is a rare neoplasm of monoclonal plasma cells presenting as either Solitary Bone Plasmacytoma (SBP) or Solitary Extramedullary Plasmacytoma (SEP), without evidence of systemic disease. Standard treatment typically involves radical radiotherapy resulting in prolonged remissions in the majority of cases. However, previous studies have identified a high‐risk group of patients with an increased risk of progression to multiple myeloma. Due to the rarity of this plasma cell dyscrasia, there are few published clinical trials.Aims:To identify risk factors for progression to myeloma, evaluate survival outcomes and determine the incidence of secondary malignancies in a cohort of solitary plasmacytoma patients.MethodsWe retrospectively reviewed case records of adult patients with plasmacytoma treated in a 15‐year period (2002‐2017) at Addenbrookes Hospital, the regional tertiary hospital for the Eastern region of England. Patients with multiple plasmacytomas or meeting the criteria for multiple myeloma at the time of diagnosis were excluded. Clinical, laboratory and radiological features at diagnosis and during the course of treatment were analyzed. Time to progression to myeloma were recorded and survival outcomes analyzed using the Kaplan‐Meier method. The data cut off date was the 1st of July 2018.Results:Thirty‐three (33) cases of solitary plasmacytoma were identified (Table 1): 26 (79%) SBP and 7 (21%) SEP. The mean age at diagnosis was 63 years with a 2:1 male preponderance. The thoracic vertebrae were the commonest sites for SBP while SEP occurred most frequently in skin and soft tissue. Pain and spinal cord compression were the most frequent presenting symptoms. A paraprotein was detectable in 19 (58%) patients at the time of diagnosis, predominantly IgG (68%). The majority of patients received radiotherapy alone (79%) while two patients received wide local excision as the sole modality of treatment. The median total dose of radiation received was 50 gray in 25 fractions (range: 40Gy‐65 Gy). Over a median follow up of 48 months, 13 patients (39%) progressed to multiple myeloma. Median time of progression to myeloma was 22 months but notably, two patients progressed more than 5 years after radiotherapy. There was a trend towards progression for patients with non‐IgG paraprotein and paraproteinemia &gt;10 g/l (relative risk 2.2, 95% CI 0.8‐5.8). From pooled analysis of overall survival, 5‐and 10‐year survival rates were 80% and 57% respectively (Figure 1). The median progression‐free survival was 85 months (Figure 2). Following progression to myeloma, the median survival was 48 months. Over the course of follow up, 5 patients (15%) developed a second malignancy with lung cancer being the most frequent.Summary/Conclusion:Solitary plasmacytoma generally has a good prognosis but progression to multiple myeloma predicts inferior survival. Previous studies have suggested a number of predictive factors for progression but these have not been validated in large prospective studies. In this retrospective cohort, the presence of a significant (&gt;10 g/l) paraprotein and non‐IgG type appeared to increase the likelihood of progression to myeloma but this observation was limited by the relatively small sample size. In the era of novel therapies for myeloma, there is a need for clinical trials investigating adjuvant therapies for high risk solitary plasmacytoma. We also suggest long‐term monitoring of solitary plasmacytoma patients due to the finding of late progression (&gt;5 years) and the incidence of secondary cancers in this study.image

Decompressive Craniectomy for Traumatic Brain Injury: Postoperative TCD Cerebral Hemodynamic Evaluation.

Background: There are no studies describing the cerebral hemodynamic patterns that can occur in traumatic brain injury (TBI) patients following decompressive craniectomy (DC). Such data have potentially clinical importance for guiding the treatment. The objective of this study was to investigate the postoperative cerebral hemodynamic patterns, using transcranial Doppler (TCD) ultrasonography, in patients who underwent DC. The relationship between the cerebral circulatory patterns and the patients' outcome was also analyzed.Methods: Nineteen TBI patients with uncontrolled brain swelling were prospectively studied. Cerebral blood circulation was evaluated by TCD ultrasonography. Patients and their cerebral hemispheres were categorized based on TCD-hemodynamic patterns. The data were correlated with neurological status, midline shift on CT scan, and Glasgow outcome scale scores at 6 months after injury.Results: Different cerebral hemodynamic patterns were observed. One patient (5.3%) presented with cerebral oligoemia, 4 patients (21%) with cerebral hyperemia, and 3 patients (15.8%) with cerebral vasospasm. One patient (5.3%) had hyperemia in one cerebral hemisphere and vasospasm in the other hemisphere. Ten patients (52.6%) had nonspecific circulatory pattern. Abnormal TCD-circulatory patterns were found in 9 patients (47.4%). There was no association between TCD-cerebral hemodynamic findings and outcome.Conclusion: There is a wide heterogeneity of postoperative cerebral hemodynamic findings among TBI patients who underwent DC, including hemodynamic heterogeneity between their cerebral hemispheres. DC was proved to be effective for the treatment of cerebral oligoemia. Our data support the concept of heterogeneous nature of the pathophysiology of the TBI and suggest that DC as the sole treatment modality is insufficient.

P18 - Impact of Travel Distance on Radiation Treatment Modality for Central Nervous System Disease

Background Stereotactic body radiation therapy (SBRT) has emerged as a popular alternative to conventional radiation therapy (RT) over the past 15 years. Unfortunately, the impact of patient distance from radiation treatment centers and utilization of SBRT versus conventional RT has been sparsely investigated. This report represents the first analysis of the impact of patient distance on radiation treatment modality for central nervous system (CNS) disease. Materials and Methods Since the inception of our RADIation oncology And Neuro-Surgery (RADIANS) multidisciplinary clinic at a community hospital in 2016, 27 patients have received either SBRT or conventional RT as their sole radiation treatment modality for CNS disease. Twenty-four (88.9%) presented with metastatic disease. Fisher’s exact test evaluated the relationship between patient residence from treatment (in miles) and radiation treatment modality received. Results Mean patient distance from our RADIANS clinic was 50.6 miles (median = 15.3). Twenty-one patients (77.8%) received SBRT; the remaining six received conventional RT. Mean patient distance from SBRT was 63.6 miles, and mean patient distance for conventional RT was 5.1 miles; this finding was statistically significant (p = 0.0433; 95% confidence interval = 1.9–115.1). Conclusion Our findings indicate that patients with CNS disease who receive SBRT over conventional RT are statistically more likely to reside further from treatment centers. This is similar to findings of national studies comparing proton versus photon treatment for pediatric solid malignancies. The results from our work have implications for neuro-oncology treatment and the development of community hospital-based clinic models similar to RADIANS in the future.