Very-low Risk Research Articles

Risk assessment for typhoon storm surges using geospatial techniques for the coastal areas of Guangdong, China

Typhoon storm surge (TSS) frequently affects the coastal areas of Guangdong Province, causing casualties, severe economic losses, and environmental damage. A risk assessment model using geospatial techniques combined with a fuzzy complete evaluation principle and coupling coordination method to quantify risk in 14 coastal cities of Guangdong was developed to identify significant risk zones, and targeted disaster prevention strategies were proposed. Four major risk systems were established to obtain the spatial distributions of hazards, exposure, sensitivity, and mitigation capabilities. A TSS risk distribution map was generated based on the interactions between risk systems, and dominant risk factors for different regions were identified. The results showed that the very-high risk zone covered 19.40% of the study area, concentrated in the coastal areas of Zhanjiang, Maoming, and Shanwei. The high-risk zone that accounted for 19.94%, was distributed across the very-high risk zone and encompassed cities such as Maoming, Jiangmen, and Yangjiang. The middle-risk zone accounted for 20.93%. In comparison, the central and inland areas of Guangdong were characterized by low risk and very-low risk. To reduce risk, the top priority should be improving mitigation capacity, especially in the coastal regions of Zhanjiang, Shanwei, and Jieyang. In addition, authorities in Maoming need to reduce the exposure of disaster-bearing bodies, and government officials in Shantou should take measures to avoid aquaculture development in susceptible areas. The results of this study can be used by the relevant authorities to formulate effective disaster-mitigation plans and allocate emergency supplies.

Potential roles of gastroesophageal reflux in patients with superficial esophageal squamous cell carcinoma without major causative risk factors.

Cigarette smoking, alcohol consumption, and Lugol-voiding lesions (LVLs) are the major causative risk factors of esophageal squamous cell carcinoma (ESCC); however, reports on ESCC cases unrelated to these risk factors are very limited. Here, we investigated the clinicopathological features and etiology of such cases. We retrospectively analyzed 704 consecutive superficial ESCC tumors of 512 patients who were treated with endoscopic submucosal dissection. The enrolled patients were divided into two groups-the very low-risk (VLR)-group and risk (R)-group-based on the presence of the abovementioned risks. Clinical, endoscopic, and pathological characteristics and genetic findings were assessed in both groups. The VLR-group consisted of 21 (4.1%) patients, who were characteristically female. Patients in the VLR-group presented gastroesophageal reflux disease (GERD), hiatal hernia, and non-open-type atrophic gastritis, and were negative for Helicobacter pylori. We found unique endoscopic features-frequently observed in the posterior wall of the middle thoracic esophagus-with a linear shape that closely resembled the erosion-like form of GERD. Additionally, histopathological examination showed that these tumors presented atypical nuclei limited to the basal and parabasal layer, sequential to the surrounding changes that presented pathological chronic inflammation of esophagitis. Evaluation of somatic mutations in cancer-related genes using next-generation sequencing revealed that the positive carcinogenic potential (TP53 mutation) of the tumors was relatively frequent in the VLR-group. Our study suggests that ESCC without major causative factors is related to GERD, with no remarkable oncogenic difference.

Prognostic VALUE of EARLY Drop in the Platelet Counts in Patients with VERY Low, Low and Intermediate Risk IPSS-R Myelodysplastic Syndromes. Results from a Single Center Analysis

Background: Prognosis of very low, low and intermediate risk myelodosplastic syndromes (MDS) is heterogeneous. Recently, the EUMDS (European Leukemia Net Lower-Risk MDS) described that a 20% drop in platelet counts in the first 6 months after diagnosis of patients with lower risk MDS identifies a poor-risk population independently from the IPSS-R. Herein, we present the impact of an early drop in both platelet and neutrophil counts during the first 6 months after diagnosis in a population of patients with lower and intermediate IPSS-R risk MDS.Patients and Methods: A total of 270 consecutive patients diagnosed with MDS (01/2010-12/2016) at the Catalan Institute of Oncology of Barcelona were included in the study. 201 patients were eligible for the study. Reasons for exclusion were: absence of a medical visit at 6 month or later on (n=9), higher-risk MDS patients (n=40) and patients under treatment with hypomethylating agents, lenalidomide or hydroxycarbamide at the follow up visit (n = 20). Patients were classified into two groups according to the presence or not of a 20% drop in neutrophils and platelets at time of or before the landmark time point. Landmark analysis was conducted at 6 months after diagnosis. We analyzed in our series the prognostic impact of early drop in neutrophils and plateletsin both overall survival (OS) and leukemia free survival (LFS).Results: Median age at diagnosis was 75 years and 135 (67.2%) were male. According to the WHO 2008 classification, 3% of the patients were classified as CRDU, 7.5%RA, 48.8% RCMD, 8.5% RAEB‐1, 1%, RAEB‐2, 27.4% CMML, the remaining 4% were MDS‐U and isolated 5q deletion. Hemoglobin, neutrophiland platelet counts were of 11.2 g/dL (5.6-16.9) [median (range)], 2.71 x109/L (0.3-30), 149 x109/L (1-889), respectively; the percentage of bone marrow blast at diagnosis was 2% (0-13). 47% of the patients were diagnosed with a very low IPSS-R, 42% with a low IPSS-R and the remaining 11% with intermediate IPSS-R. At the time of last follow up, 74 (36.3%) patients had died and 17 (8.5%) had progressed to AML.The median time to the landmark blood test was 188 days (1QR: 160-218). Median follow-up from landmark was 31.4 months. Median relative drop in platelets was 2.4%. In univariate analysis male sex, number of cytopenias, IPSS-R, red blood cell transfusion dependency (RBC-TD) and a platelet drop >20% was associated with poorer OS (Figure 1). In multivariate testing, male sex, RBC-TD and a drop of platelets >20% within 6 months were independent significant parameters affecting survival (Table 1). Number of cytopenias, IPSS-R and RBC-TD were associated to an inferior LFS in univariate analysis. IPSS-R was the only independent adverse prognostic factor for LFS in the multivariate analysis. The combination of both RBC-TD and a platelet drop >20% at 6 month after diagnosis enabled us to identify a small subgroup of patients (6%) with a median OS of 20 months.Conclusion: A 20% drop in platelet counts in the first 6 months after diagnosis is able to identify a poor-risk population of patients with MDS within the very low, low and intermediate-risk IPSS-R groups. As therapeutical decisions are based on prognostic risk assessment, the inclusion of this additional parameter may help to better tailor treatment strategies in these patients. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Can patient decision aids reduce decisional conflict in a de-escalation of breast radiotherapy clinical trial? The PRIMETIME Study Within a Trial implemented using a cluster stepped-wedge trial design

BackgroundFor patients with early breast cancer considered at very-low risk of local relapse, risks of radiotherapy may outweigh the benefits. Decisions regarding treatment omission can lead to patient uncertainty (decisional conflict), which may be lessened with patient decision aids (PDA). PRIMETIME (ISRCTN 41579286) is a UK-led biomarker-directed study evaluating omission of adjuvant radiotherapy in breast cancer; an embedded Study Within A Trial (SWAT) investigated whether PDA reduces decisional conflict using a cluster stepped-wedge trial design.MethodsPDA diagrams and a video explaining risks and benefits of radiotherapy were developed in close collaboration between patient advocates and PRIMETIME trialists. The SWAT used a cluster stepped-wedge trial design, where each cluster represented the radiotherapy centre and referring peripheral centres. All clusters began in the standard information group (patient information and diagrams) and were randomised to cross-over to the enhanced information group (standard information plus video) at 2, 4 or 6 months. Primary endpoint was the decisional conflict scale (0–100, higher scores indicating greater conflict) which was assessed on an individual participant level. Multilevel mixed effects models used a random effect for cluster and a fixed effect for each step to adjust for calendar time and clustering. Robust standard errors were also adjusted for the clustering effect.ResultsFive hundred twenty-one evaluable questionnaires were returned from 809 eligible patients (64%) in 24 clusters between April 2018 and October 2019. Mean decisional conflict scores in the standard group (N = 184) were 10.88 (SD 11.82) and 8.99 (SD 11.82) in the enhanced group (N = 337), with no statistically significant difference [mean difference − 1.78, 95%CI − 3.82–0.25, p = 0.09]. Compliance with patient information and diagrams was high in both groups although in the enhanced group only 121/337 (36%) reported watching the video.ConclusionThe low levels of decisional conflict in PRIMETIME are reassuring and may reflect the high-quality information provision, such that not everyone required the video. This reinforces the importance of working with patients as partners in clinical trials especially in the development of patient-centred information and decision aids.

Twelve-year outcomes of prostate cancer after radical prostatectomy for T3 and/or positive margins managed with surveillance or salvage radiation therapy, based on risk groups.

BackgroundTo assess 12-year outcomes on radical prostatectomy with T3/positive margins, while categorizing patients into risk groups.MethodsFrom 2004 to 2007, 862 radical prostatectomy patients had T3/positive margins. Management included surveillance (54.8%), salvage radiation therapy (SRT) (36.8%), and primary androgen deprivation therapy (ADT) (8.5%). Freedom from biochemical failure, metastasis-free-survival (MFS), prostate cancer–specific survival (PCSS) were estimated using Kaplan-Meier. Multivariable analysis established prognostic factors that affected PCSS, which were used to form risk groups. Subanalysis was performed on SRT patients.ResultsMedian follow-up was 12.1 years. T3b, Gleason score (GS), and detectable postoperative PSA independently lowered PCSS. Very–low-risk (VLR) were GS 6. Low-risk (LR) were GS 3 + 4 with T3a or positive margins, but undetectable postoperative PSA <0.1. High-risk (HR) were T3b with GS 7-10, or any GS 7-10 with T3a/b and positive margins, but undetectable PSA. Ultra–high-risk (UHR) were detectable PSA with GS 7-10. Median time to first salvage treatment for VLR, LR, HR, and UHR were 11.1, 10.8, 5.3, and 0.6 years, p < 0.001. The 12-year freedom from biochemical failure for VLR, LR, HR, UHR were 60.2%, 52.9%, 28.4%, and 0%, p < 0.001. For 12-year MFS, 99.1%, 97.8%, 88.6%, and 63.6%, p < 0.001. For 12-year PCSS, 99.5%, 99.4%, 93.5%, and 78.9%, p < 0.001. For subanalysis of 317 SRT patients, 10-year MFS were 100.0%, 97.0%, 88.2%, and 84.6%, p = 0.008.ConclusionsOutcomes of VLR/LR yields excellent results using surveillance or SRT as initial management, in which adjuvant radiation therapy or ADT plus SRT can be avoided. For HR, early SRT or adjuvant radiation therapy can be considered reasonable, and UHR patients may benefit from ADT plus immediate SRT.

Considerations for active surveillance in select Gleason grade group 2 patients: A preliminary study.

206 Background: While active surveillance (AS) has become the preferred management strategy for patients with NCCN very-low and low risk prostate cancer, its use in the setting of intermediate risk disease continues to be controversial. Current guidelines state that AS can be considered in favorable intermediate risk disease, but data on outcomes in this cohort of patients is lacking. We aim to report on our experience with AS of Gleason grade group (GG) 2 at the National Cancer Institute (NCI)/National Institutes of Health (NIH). Methods: Our IRB-approved, institutional database was reviewed for men who enrolled on our AS protocol at NIH with GG2 disease from 2007-2020. All patients received MRI-targeted and systematic biopsy at the time of enrollment, diagnosing or confirming GG2 disease. MRI and PSA were performed annually, and majority of patients underwent annual combined MRI targeted and systematic prostate biopsy. If PSA and MRI were stable, annual biopsy was postponed in several patients based on their preference. Differences in PSA and PSAD at enrollment on AS and at progression were compared using Wilcoxon signed rank test. P value &lt; 0.05 was considered significant. Results: 98 patients with GG2 disease enrolled in AS at NIH. Average age at enrollment was 64 years old and the majority of patients were Caucasian. 36/98(37%) of these patients progressed to GG3 or higher while on AS. Median PSA at time of progression was significantly higher than at the time of enrollment on AS (5.2 [IQR 4.0-8.9] vs 8.5 [IQR 5.8-10.9], z = -3.12, p &lt; 0.01). PSAD was also significantly higher at time of progression (0.12[IQR 0.1-0.16] vs 0.13[IQR 0.10-0.22], z = -2.65, p &lt; 0.01). Highest PIRADS score on MRI was largely unchanged. Median time to progression was 71 months. The majority of patients progressed to GG3, and progression was the trigger for definitive treatment. All patients were alive at the end of the follow up period. Conclusions: AS is a reasonable option for compliant patients diagnosed with GG2 prostate cancer. While a significant percentage of these men will progress on AS, they do so at a median of 71 months, avoiding treatment-related harms of definitive therapy for over 5 years. Further research with larger sample sizes are needed to better evaluate the oncologic outcomes of AS for GG2 disease, as well as predictors of more aggressive disease that may be better served with upfront definitive treatment. [Table: see text]

Characteristics and prognosis of jejunoileal gastrointestinal stromal tumours (GISTs) in the era of imatinib: a comparative study with gastric GISTs

Gastrointestinal stromal tumours (GISTs) located in the jejunum or ileum (JI-GIST) are considered worse prognosis compared to those of gastric (G-GIST) location. It has been suggested that this dogma should be revised. The aim of this study was to describe the characteristics of jejunoileal GISTs and its prognosis and to compare them with G-GISTs in the era of imatinib. We retrospectively reviewed the clinical histories of all the patients diagnosed with GISTs between January 2000 and November 2016: Clinical and pathological data, as recurrence, metastatic state, disease-free survival (DFS) as well as overall survival (OS) rates of patients were reviewed. JI-GIST patients comprise 29 cases (37.7%). Compared to G-GIST, JI-GIST patients had undergone emergency surgery more frequently (37.9% vs. 10.4%, p = 0.007). According to the NIH-Fletcher classification, the low or very-low risk group represents 17.2% of JI-GISTs as opposed to 37.6% of G-GISTs (p < 0.005). When the AFIP-Miettinen system was used the low or very-low group represented 17.2% of JI-GISTs vs. 58.4% in the G-GISTs group (p < 0.001). Both local recurrence (24.1% vs. 12.5%, p < 0.05) and metastatic rate (34.5% vs. 22.9%, p < 0.05) were higher in the JI-GIST group than in G-GIST. 5- and 10-year DFS and 10-year OS rate were lower for JI-GIST (54.5% and 39.6% vs. 77.2% and 60.8%, and 57.9% vs. 65%, respectively, p < 0.05). The observed differences between both groups in DFS and OS rates at long term could be attributed to the effect of imatinib.

Reduced-intensity therapy for pediatric lymphoblastic leukemia: impact of residual disease early in remission induction

AbstractLegacy data show that ∼40% of children with acute lymphoblastic leukemia (ALL) were cured with limited antimetabolite-based chemotherapy regimens. However, identifying patients with very-low-risk (VLR) ALL remains imprecise. Patients selected based on a combination of presenting features and a minimal residual disease (MRD) level <0.01% on day 19 of induction therapy had excellent outcomes with low-intensity treatment. We investigated the impact of MRD levels between 0.001% and <0.01% early in remission induction on the outcome of VLR ALL treated with a low-intensity regimen. Between October of 2011 and September of 2015, 200 consecutive patients with B-precursor ALL with favorable clinicopathologic features and MRD levels <0.01%, as assessed by flow cytometry in the bone marrow on day 19 and at the end of induction therapy, received reduced-intensity therapy. The 5-year event-free survival was 89.5% (± 2.2% standard error [SE]), and the overall survival was 95.5% (± 1.5% SE). The 5-year cumulative incidence of relapse (CIR) was 7% (95% confidence interval, 4-11%). MRD levels were between 0.001% and <0.01% on day 19 in 29 patients. These patients had a 5-year CIR that was significantly higher than that of patients with undetectable residual leukemia (17.2% ± 7.2% vs 5.3% ± 1.7%, respectively; P = .02). Our study shows that children with VLR ALL can be treated successfully with decreased-intensity therapy, and it suggests that the classification criteria for VLR can be further refined by using a more sensitive MRD assay.

Successful Therapy Reduction in NCI Standard Risk (SR) Highly Favorable Subgroup of Childhood Acute Lymphoblastic Leukemia

Background: Acute Lymphoblastic Leukemia (ALL) is the most common cancer in childhood; it is curable in 80-90% of patients. Current efforts focus on therapy guided by sensitive and specific methods of minimal residual disease (MRD) monitoring, tailoring the type and intensity of chemotherapeutic agents to improve cure rates, quality of life and decrease morbidity. We sought to study the outcome of low risk (LR) ALL treated per modified St Jude total XV Study. Methods: We adopted the modified St Jude total XV study ,B-cell precursor patients with age between 1 and 10 years and presenting leukocyte count &amp;lt;50×10^9/L, leukemic cell DNA index ≥1.16, or TEL-AML1 fusion are classified to have low-risk ALL, provided that they do not have testicular or central-nervous-system (CNS-3) leukemia, hypodiploidy (&amp;lt;45 chromosomes), E2A-PBX1 fusion, or MLL rearrangement, and have a treatment response at day 15 by minimal residual disease (MRD) of &amp;lt;5% and at day 46 of remission-induction &amp;lt;0.01%. We further identified a subgroup of (LR) ALL; defined by presenting age between 2 and 6 years, leukocyte count of &amp;lt;10x 10^9/L and MRD of &amp;lt;0.01% at day 15 of remission induction as Very Low Risk ALL (VLR). Patients with St Jude Low Risk (LR) ALL were treated per St Jude total XV study with several modifications: On 2007; doxorubicin was omitted from reinduction II to lower the total cumulative dose of anthracycline to 80 mg/m2, pulses of dexamethasone and vincristine were stopped at week 72 of maintenance instead of 100. On 2012; for patients identified as VLR; pulses of vincristine /dexamethasone were stopped at week 52 and HDMTX given at week 10 and 12 of maintenance therapy was omitted, frequency of triple Intrathecal chemotherapy remained unchanged (13-18) for LR ALL based on CNS status. Results: We reviewed 184 patients with (LR) between May 2006 to Feb 2018, (the median age at diagnosis, 7.3 years; range, 1.5-9.8). Eighty-two patients (45%) and 102 patients (55%) were treated as VLR and LR ALL respectively. The only significant difference in patients of two groups were age at diagnosis 2-6 years(VLR, 100%; LR, 46%; p&amp;lt;0.001), initial count &amp;lt;10x 10^9/L (VLR, 100%; LR, 65%; p&amp;lt;0.001) and MRD at day 15&amp;lt;0.01%(VLR, 100%; LR, 61%; p&amp;lt;0.001). At median follow up of (48 months; range, 17 to 157), in the subgroups of NCI standard risk defined above; as very low risk(VLR) ALL and low risk (LR) ALL, the 5-year EFS were 92%±3.4; 85%±4 (p=0.12), and the 5-year OS were 98%±1.7; 93%±3.3 (p=0.2) respectively. Conclusion: Chemotherapy was substantially reduced safely in subgroup of children with low risk ALL who were selected on the basis of presenting age, leukocyte count and undetectable MRD levels early at day 15 and at day 46 of remission induction without jeopardizing the survival rate. Patients with St Jude LR ALL maintained outstanding outcomes despite reduction of chemotherapy. Disclosures No relevant conflicts of interest to declare.

Reduced–dose intensity therapy for pediatric lymphoblastic leukemia: long-term results of the Recife RELLA05 pilot study

AbstractTreatment-related mortality is common among children with acute lymphoblastic leukemia (ALL) treated in poor-resource settings. We applied a simplified flow cytometric assay to identify patients with precursor B-cell ALL (B-ALL) at very low risk (VLR) of relapse and treated them with a reduced-intensity treatment plan (RELLA05). VLR criteria include favorable presenting features (age ≥ 1 and < 10 years), white blood cell count of <50 ×109/L, lack of extramedullary leukemia, and minimal residual disease level of <0.01% on remission induction day 19. Except for 2 doses of daunorubicin, treatment of patients with VLR B-ALL consisted of a combination of agents with relatively low myelotoxicity profiles, including corticosteroids, vincristine, L-asparaginase, methotrexate, and 6-mercaptopurine. Cyclophosphamide, systemic cytarabine, and central nervous system radiotherapy were not used. Of 454 patients with ALL treated at the Instituto de Medicina Integral Professor Fernando Figueira in Recife, Brazil, between December 2005 and June 2015, 101 were classified as having VLR B-ALL. There were no cases of death resulting from toxicity or treatment abandonment during remission induction. At a median follow-up of 6.6 years, there were 8 major adverse events: 6 relapses, 1 treatment-related death (from septicemia) during remission, and 1 secondary myeloid leukemia. The estimated 5-year event-free and overall survival rates were 92.0% ± 3.9% and 96.0% ± 2.8%, respectively. The 5-year cumulative risk of relapse was 4.24% ± 2.0%. The treatment was well tolerated. Episodes of neutropenia were of short duration. Patients with B-ALL selected by a combination of presenting features and degree of early response can be successfully treated with a mildly myelosuppressive chemotherapy regimen.

Use of beta-blocker types and risk of incident prostate cancer in a multiethnic population

PurposeIncreased adrenergic innervation is observed in prostate cancer (CaP) and is associated with aggressive disease. Emerging evidence suggests that beta-adrenergic blockade inhibits CaP progression. However, the association between type of beta-blocker use and risk of incident CaP on initial prostate biopsy has not been investigated in multiethnic populations. Materials and methodsA retrospective study of racially/ethnically diverse men (64% African-American and Hispanic), who underwent initial prostate biopsy between 2006 and 2016 in a large healthcare system was performed. Oral use of beta-blocker type was assessed by reviewing active prescriptions within the 5-year period preceding initial biopsy. Patient demographics and clinical factors were collected. ResultsOf 4,607 men who underwent initial prostate biopsy, 4,516 met criteria and 2,128 had a biopsy positive for CaP; 20% high-risk, 41% intermediate-risk, and 39% low or very-low risk (National Comprehensive Cancer Network classification). Overall, 15% of patients were taking a beta-blocker prior to initial biopsy, with Metoprolol, Atenolol, and Carvedilol accounting for the majority. Of beta-blocker types, Atenolol alone was associated with a 38% reduction in odds of incident CaP (P= 0.01), with a 40% and 54% reduction in risks of National Comprehensive Cancer Network intermediate and high-risk CaP (P = 0.03 and P = 0.03, respectively) compared to men not taking a beta-blocker. Furthermore, longer duration of Atenolol use (3–5 years) was associated with a 54% and 72% reduction in intermediate and high-risk disease, (P = 0.03 and P = 0.03, respectively). ConclusionsAmong beta blocker types, long-term Atenolol use is associated with a significant reduction in incident CaP risk on initial prostate biopsy for clinically-significant intermediate and high-risk disease compared to men not taking a beta-blocker.

Redefining the role of adjuvant versus salvage radiation therapy for prostate cancer after radical prostatectomy for T3 disease and/or positive margins.

367 Background: SWOG 8794 recommends adjuvant radiation therapy (ART) after radical prostatectomy (RP) for T3 and/or positive margins. Our purpose was to assess 12-year outcomes on 862 RP patients who had either T3 and/or positive margins who underwent surveillance, salvage radiation therapy (SRT), or hormonal therapy (HT), while categorizing these patients into very low risk (VLR), low risk (LR), high risk (HR), and ultra high risk (UHR) groups. Methods: From 2004 - 2007, 862 RP patients had adverse factors of extracapsular penetration (T3a), seminal vesicle invasion (T3b), positive margins, and/or detectable post-operative PSA. Management included surveillance (54.8%), SRT (36.8%), and HT (8.5%) as first salvage therapy, and 21.5% eventually received hormonal therapy. Twenty patients underwent ART, and were excluded from this analysis. We assessed prognostic factors using multivariable analysis, and 12-year estimates of freedom from biochemical failure (FFBF), freedom from salvage therapy (FFST), distant metastases-free survival (DMFS), prostate cancer-specific survival (PCSS), and overall survival (OS). VLR were those with Gleason Score (GS) of 6. LR were GS 3+4 with only T3a or positive margins, but an undetectable postoperative PSA &lt;0.1. HR were T3b with GS 7-10, any GS 7-10 with T3a/b and positive margins, but an undetectable PSA. UHR were those with a detectable PSA with a GS 7-10. Results: Median follow-up was 12.1 years. Median age was 61.6 years. Median time to first salvage treatment for VLR, LR, HR, and UHR were 10.8, 11.1, 5.3, and 0.6 years, p&lt;0.001. 12-year estimates of FFBF for VLR, LR, HR, and UHR were 60.2%, 52.9%, 28.4%, and 0%, p&lt;0.0001. For FFST, 70.9%, 68.6%, 40.5%, and 0%, p&lt;0.0001. For DMFS, 99.1%, 97.8%, 88.6%, and 63.6%, p&lt;0.0001. For PCSS, 99.4%, 99.5%, 93.5%, and 78.9%, p&lt;0.0001. For OS, 91.8%, 91.8%, 81.0%, and 69.9%, p&lt;0.0001. Conclusions: Outcomes of T3 and/or positive margins using surveillance or SRT as initial management yields excellent outcomes for VLR and LR groups, in which ART should be avoided. For HR, ART can be considered reasonable, since FFBF is only 28.4%. For VHR, these patients may benefit from combined hormonal therapy and ART.

Flood Risk Assessment Based on Fuzzy Synthetic Evaluation Method in the Beijing-Tianjin-Hebei Metropolitan Area, China

Flooding is one of the most devastating natural events and leads to enormous and recurring loss of life, properties, and resources around the globe. With climate change and accelerating urbanization, flood disasters in China have increasingly affected the sustainable development of metropolitan areas. Risk assessment is an essential step in flood management and disaster mitigation, which provide a quantitative measure of flood risk. However, the difficulty of flood risk zoning is dealing with the uncertainty of the evaluation process and the complicated non-linear relationship between indicators and risk levels. To address this issue, a fuzzy synthetic evaluation (FSE) method based on combined weight (CW) was utilized in this paper to generate flood risk maps at a grid-scale (1 × 1 km). For the case study in the Beijing-Tianjin-Hebei metropolitan area (BTH) in China, fourteen indicators were selected to construct the flood risk assessment model based on the FSE approach integrated with ArcGIS. The research demonstrates that moderate, high, and very high risk zones are distributed in the southeast fluvial plain of the BTH area, accounting for 31.36% of the total land area. Meanwhile, low and very-low risk zones occupy 68.64% of the total land area, and are primarily located in the high plateau and mountain regions in the northwest. We analyzed the risk level of each county and proposed risk mitigation measures based on field investigations. The verified risk assessment results were spatially consistent with the historical flood disaster records and loss positions, indicating the accuracy and reliability of the risk assessment map using the FSE approach. Compared with the IPCC (Intergovernmental Panel on Climate Change) TAR (Third Assessment Report) and AR5 (Fifth Assessment Report) methods, FSE has significant advantages in handling uncertainty, complexity, and the non-linear relationship between indices and risk grades. This study provides a novel quantitative method for flood risk assessment in metropolitan areas and practical implications for urban flood management.

Somatic Mutations Improve Risk Classification By Cytogenetic Abnormalities in Patients with Myelodysplastic Syndrome after Hematopoietic Stem Cell Transplantation

Somatic Mutations Improve Risk Classification By Cytogenetic Abnormalities in Patients with Myelodysplastic Syndrome after Hematopoietic Stem Cell Transplantation

Radiotherapy Utilization for Patients Over Age 60 With Early Stage Breast Cancer

IntroductionRecent studies have questioned the relative benefit of radiotherapy (RT) for older patients with favorable breast cancer given the lack of survival benefit and marginal local control benefit. Despite the 2004 National Comprehensive Cancer Network (NCCN) guidelines advocating for the option of hormonal therapy alone, trends in utilization rates of RT in this group are not well-documented. We analyzed our institutional experience with implementation of the guidelines over time. Material and MethodsWe identified 564 patients aged ≥ 60 years with favorable breast cancer treated with breast conserving surgery from 2000 to 2017. Patients met criteria for Cancer and Leukemia Group B (CALGB) 9343, Postoperative Radiotherapy in Minimum Risk Elderly (PRIME II), or the very-low risk cohort identified in the Toronto-British Columbia study. Multivariable logistic regression analysis was performed to assess the magnitude of association between omission status, grade, and tumor size while controlling for age and year of diagnosis. ResultsOverall RT omission rates were 17.6% prior to the 2004 NCCN update and 45% after the publication of the 10-year CALGB data in 2013. The overall RT omission rate was 29%. Patients with grade 1 to 2 histology (odds ratio, 3.2; 95% confidence interval, 1.3-7.7; P = .01) and tumors < 1 cm (odds ratio, 1.60; 95% confidence interval, 0.4-0.9; P = .007) were more likely to omit RT than those with higher grade or larger tumors. ConclusionsWe observed a slight decrease in the use of RT over time, suggesting a move towards adoption of the NCCN guidelines. There remains a fundamental need to continue to individualize breast cancer care based on risk stratification and make evidenced-based treatment recommendations with equitable use of health care resources.

Combination of left ventricular reverse remodeling and brain natriuretic peptide level at one year after cardiac resynchronization therapy predicts long-term clinical outcome

IntroductionThe aim of this study was to investigate the predictors of long-term clinical outcome of heart failure (HF) patients who survived first year after initiation of cardiac resynchronization therapy (CRT).MethodsThis was a single-center observational cohort study of CRT patients implanted because of symptomatic HF with reduced ejection fraction between 2005 and 2013. Left ventricle (LV) diameters and ejection fraction, New York Heart Association (NYHA) class, and level of N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) were assessed at baseline and 12 months after CRT implantation. Their predictive power for long-term HF hospitalization and mortality, and cardiac and all-cause mortality was investigated.ResultsA total of 315 patients with left bundle branch block or intraventricular conduction delay who survived >1 year after CRT implantation were analyzed in the current study. During a follow-up period of 4.8±2.1 years from CRT implantation, 35.2% patients died from cardiac (19.3%) or non-cardiac (15.9%) causes. Post-CRT LV ejection fraction and LV end-systolic diameter (either 12-month value or the change from baseline) were equally predictive for clinical events. For NT-proBNP, however, the 12-month level was a stronger predictor than the change from baseline. Both reverse LV remodeling and 12-month level of NT-proBNP were independent and comparable predictors of CRT-related clinical outcome, while NT-proBNP response had the strongest association with all-cause mortality. When post-CRT relative change of LV end-systolic diameter and 12-month level of NT-proBNP (dichotomized at -12.3% and 1230 ng/L, respectively) were combined, subgroups of very-high and very-low risk patients were identified.ConclusionThe level of NT-proBNP and reverse LV remodeling at one year after CRT are independent and complementary predictors of future clinical events. Their combination may help to improve the risk stratification of CRT patients.

A revised international prognostic score system for Waldenström's macroglobulinemia.

A staging system was developed a decade ago for patients with Waldenström's macroglobulinemia (WM), however, since then WM treatments have changed. A revised staging system could better capture prognosis of WM patients in the chemoimmunotherapy era. We developed a revised system based on data from 492 symptomatic patients with at least 3 years and a median of 7 years of follow up while an independent validation cohort included 229 symptomatic patients. We identified age (≤65 vs 66-75 vs ≥76 years), b2-microglobulin ≥ 4 mg/L, serum albumin <3.5 gr/dl, and LDH ≥ 250 IU/L (ULN < 225) to stratify patients in five different prognostic groups and identify a very-low risk as well as a very-high risk group with a 3-year WM-related death rate of 0, 10, 14, 38, and 48% (p < 0.001) and 10-year survival rate of 84, 59, 37, 19, and 9% (p < 0.001). We evaluated this staging system separately in patients >65 years and <65 years, according to the reason for initiation of treatment, among patients receiving frontline rituximab or in patients treated primarily without rituximab. With further validation before clinical use, this revised IPSSWM could improve WM patient risk stratification, is easily available and may be used in the everyday practice to provide prognostic information.

A novel clinical risk prediction model for myocardial infarction, coronary revascularization, and cardiac death according to clinical, exercise, and gated SPECT variables (VH-RS).

To create a risk score for cardiac events (CE) according to clinical, exercise, and gated SPECT variables. We analysed 5707 consecutive patients; 3181 patients (age 64.2 ± 11 years, male 59.6%) with suspected coronary artery disease (CAD) [without previous myocardial infarction (MI) or coronary revascularization (CR)] and 2526 patients (age 63.3 ± 11 years, male 81.7%) with established CAD (with previous MI or CR). To create the Vall d'Hebron Risk Score (VH-RS), first we analyse the predictors of CE (non-fatal MI, CR, and/or cardiac death), then the probability of CE for every patient according to the predictive variables. According to risk we stratified patients into four risk levels: very low risk (VLR), low risk (LR), moderate risk (MR), and high risk (HRi) using Multiple Cox Regression analysis models. Finally, we validate the VH-RS in another prospective cohort of 734 patients. In patients with suspected CAD; age (P < 0.001); gender (P = 0.001); hyperlipidaemia (P < 0.001); nitrates (P = 0.04); ejection fraction (EF) (P = 0.001); summed stress score (P < 0.001); METs (P < 0.001); exercise angina (P = 0.006); and mm of ST segment depression (P = 0.004) were the independent predictors of CE (C-statistic: 0.8; P < 0.001). In patients with established CAD, EF (P < 0.001); summed difference score (P = 0.001); age (P < 0.001); smoker (P = 0.002); nitrates (P = 0.003); exercise angina (P = 0.001); METs (P < 0.001); and mm of ST segment depression (P = 0.011) were the independent predictors of CE (C-statistic: 0.7; P < 0.001). The risk score obtained from these variables allows the stratification of patients into four risk levels: VLR, LR, MR, and HRi. The cardiac risk stratification by mean of clinical, exercise, and gated SPECT variables is an objective aid to assessing an individual's cardiac risk.

MP48-12 ACTIVE SURVEILLANCE OF VERY LOW AND LOW RISK PROSTATE CANCER: LONG-TERM OUTCOMES FROM A LARGE PROSPECTIVE COHORT

INTRODUCTION AND OBJECTIVES:Active surveillance (AS) is a first-line management option for men with very low risk (VLR) and low risk (LR) prostate cancer. We sought to assess and describe long-term...

Landscape of TP53 Abnormalities and Their Clinical Relevance in Patients with Myelodysplastic Syndromes and Acute Myeloid Leukemia

Landscape of TP53 Abnormalities and Their Clinical Relevance in Patients with Myelodysplastic Syndromes and Acute Myeloid Leukemia