Multifocal high-grade glioma radiotherapy safety and efficacy

BACKGROUND Multifocal manifestation of high-grade glioma is a rare disease with very unfavourable prognosis. The pathogenesis of multifocal glioma and pathophysiological differences to unifocal glioma are not fully understood. The optimal treatment of patients suffering from multifocal high-grade glioma is not defined in the current guidelines, therefore individual case series may be helpful as guidance for clinical decision-making. METHODS Patients with multifocal high-grade glioma treated with conventionally fractionated radiation therapy (RT) in our institution with or without concomitant chemotherapy between April 2011 and April 2019 were retrospectively analysed. Multifocality was neuroradiologically assessed and defined as at least two independent contrast-enhancing foci in the MRI T1 contrast-enhanced sequence. IDH mutational status and MGMT methylation status were assessed from histopathology records. GTV, PTV as well as the V30Gy, V45Gy and D2% volumes of the brain were analysed. Overall and progression-free survival were calculated from the diagnosis until death and from start of radiation therapy until diagnosis of progression of disease in MRI for all patients. RESULTS 20 multifocal glioma cases (18 IDH wild-type glioblastoma cases, one diffuse astrocytic glioma, IDH wild-type case with molecular features of glioblastoma and one anaplastic astrocytoma, IDH wild-type case) were included into the analysis. Resection was performed in two cases and stereotactic biopsy only in 18 cases before the start of radiation therapy. At the start of radiation therapy patients were 61~years old in median (range 42-84~years). Histopathological examination showed IDH wild-type in all cases and MGMT promotor methylation in 11 cases (55%). Prescription schedules were 60~Gy (2~Gy × 30), 59.4~Gy (1.8~Gy × 33), 55~Gy (2.2~Gy × 25) and 50~Gy (2.5~Gy × 20) in 15, three, one and one cases, respectively. Concomitant temozolomide chemotherapy was applied in 16 cases, combined temozolomide/lomustine chemotherapy was applied in one case and concomitant bevacizumab therapy in one case. Median number of GTVs was three. Median volume of the sum of the GTVs was 26 cm3. Median volume of the PTV was 425.7 cm3 and median PTV to brain ratio 32.8 percent. Median D2% of the brain was 61.5~Gy (range 51.2-62.7) and median V30Gy and V45 of the brain were 59.9 percent (range 33-79.7) and 40.7 percent (range 14.9-64.1), respectively. Median survival was eight months (95% KI 3.6-12.4~months) and median progression free survival after initiation of RT five months (95% CI 2.8-7.2~months). Grade 2 toxicities were detected in eight cases and grade 3 toxicities in four cases consisting of increasing edema in three cases and one new-onset seizure. One grade 4 toxicity was detected, which was febrile neutropenia related to concomitant chemotherapy. CONCLUSION Conventionally fractionated RT with concomitant chemotherapy could safely be applied in multifocal high-grade glioma in this case series despite large irradiation treatment fields

Simultaneous stereotactic radiosurgery of multiple brain metastases using single-isocenter dynamic conformal arc therapy: a prospective monocentric registry trial

BACKGROUND Single-isocenter dynamic conformal arc (SIDCA) therapy is a~technically efficient way of delivering stereotactic radiosurgery (SRS) to multiple metastases simultaneously. This study reports on the safety and feasibility of linear accelerator (LINAC) based SRS with SIDCA for patients with multiple brain metastases. METHODS All patients who received SRS with this technique between November 2017 and June 2019 within a~prospective registry trial were included. The patients were irradiated with a~dedicated planning tool for multiple brain metastases using a~LINAC with a~5 mm multileaf collimator. Follow-up was performed every 3~months, including clinical and radiological examination with cranial magnetic resonance imaging (MRI). These early data were analyzed using descriptive statistics and the Kaplan-Meier method. RESULTS A total of 65~patients with 254 lesions (range 2-12) were included in this analysis. Median beam-on time was 23 min. The median follow-up at the time of analysis was 13~months (95% CI 11.1-14.9). Median overall survival and median intracranial progression-free survival was 15~months (95% CI 7.7-22.3) and 7~months (95% CI 3.9-10.0), respectively. Intracranial and local control after 1~year was 64.6~and 97.5%, respectively. During follow-up, CTCAE grade~I adverse effects (AE) were experienced by 29~patients (44.6%; 18~of them therapy related, 27.7%), CTCAE grade~II~AEs by four patients (6.2%; one of them therapy related, 1.5%), and CTCAE grade~III~by three patients (4.6%; none of them therapy related). Two lesions (0.8%) in two patients (3.1%) were histopathologically proven to be radiation necrosis. CONCLUSION Simultaneous SRS using SIDCA seems to be a~feasible and safe treatment for patients with multiple brain metastases

Exploitation of the Timing Capabilities of Metallic Magnetic Calorimeters for a Coincidence Measurement Scheme

In this report, we compare two filter algorithms for extracting timing information using novel metallic magnetic calorimeter detectors, applied to the precision X-ray spectroscopy of highly charged ions in a storage ring. Accurate timing information is crucial when exploiting coincidence conditions for background suppression to obtain clean spectra. For X-rays emitted by charge-changing interactions between ions and a target, this is a well-established technique when relying on conventional semiconductor detectors that offer a good temporal resolution. However, until recently, such a coincidence scheme had never been realized with metallic magnetic calorimeters, which typically feature much longer signal rise times. In this report, we present optimized timing filter algorithms for this type of detector. Their application to experimental data recently obtained at the electron cooler of CRYRING@ESR at GSI, Darmstadt is discussed

The Electron Capture in 163^{163} Ho Experiment - a Short Update

The definition of the absolute neutrino mass scale is one of the main goals of the Particle Physics today. The study of the end-point regions of the β- and electron capture (EC) spectrum offers a possibility to determine the effective electron (anti-)neutrino mass in a completely model independent way, as it only relies on the energy and momentum conservation. The ECHo (Electron Capture in 163Ho) experiment has been designed in the attempt to measure the effective mass of the electron neutrino by performing high statistics and high energy resolution measurements of the 163 Ho electron capture spectrum. To achieve this goal, large arrays of low temperature metallic magnetic calorimeters (MMCs) implanted with with 163Ho are used. Here we report on the structure and the status of the experiment

Towards an Intrinsic Doppler Correction for X-ray Spectroscopy of Stored Ions at CRYRING@ESR

We report on a new experimental approach for the Doppler correction of X-rays emitted by heavy ions, using novel metallic magnetic calorimeter detectors which uniquely combine a high spectral resolution with a broad bandwidth acceptance. The measurement was carried out at the electron cooler of CRYRING@ESR at GSI, Darmstadt, Germany. The X-ray emission associated with the radiative recombination of cooler electrons and stored hydrogen-like uranium ions was investigated using two novel microcalorimeter detectors positioned under 0∘ and 180∘ with respect to the ion beam axis. This new experimental setup allowed the investigation of the region of the N, M → L transitions in helium-like uranium with a spectral resolution unmatched by previous studies using conventional semiconductor X-ray detectors. When assuming that the rest-frame energy of at least a few of the recorded transitions is well-known from theory or experiments, a precise measurement of the Doppler shifted line positions in the laboratory system can be used to determine the ion beam velocity using only spectral information. The spectral resolution achievable with microcalorimeter detectors should, for the first time, allow intrinsic Doppler correction to be performed for the precision X-ray spectroscopy of stored heavy ions. A comparison with data from a previous experiment at the ESR electron cooler, as well as the conventional method of conducting Doppler correction using electron cooler parameters, will be discussed

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Oral abstracts 3: RA Treatment and outcomesO13. Validation of jadas in all subtypes of juvenile idiopathic arthritis in a clinical setting

Background: Juvenile Arthritis Disease Activity Score (JADAS) is a 4 variable composite disease activity (DA) score for JIA (including active 10, 27 or 71 joint count (AJC), physician global (PGA), parent/child global (PGE) and ESR). The validity of JADAS for all ILAR subtypes in the routine clinical setting is unknown. We investigated the construct validity of JADAS in the clinical setting in all subtypes of JIA through application to a prospective inception cohort of UK children presenting with new onset inflammatory arthritis. Methods: JADAS 10, 27 and 71 were determined for all children in the Childhood Arthritis Prospective Study (CAPS) with complete data available at baseline. Correlation of JADAS 10, 27 and 71 with single DA markers was determined for all subtypes. All correlations were calculated using Spearman's rank statistic. Results: 262/1238 visits had sufficient data for calculation of JADAS (1028 (83%) AJC, 744 (60%) PGA, 843 (68%) PGE and 459 (37%) ESR). Median age at disease onset was 6.0 years (IQR 2.6-10.4) and 64% were female. Correlation between JADAS 10, 27 and 71 approached 1 for all subtypes. Median JADAS 71 was 5.3 (IQR 2.2-10.1) with a significant difference between median JADAS scores between subtypes (p < 0.01). Correlation of JADAS 71 with each single marker of DA was moderate to high in the total cohort (see Table 1). Overall, correlation with AJC, PGA and PGE was moderate to high and correlation with ESR, limited JC, parental pain and CHAQ was low to moderate in the individual subtypes. Correlation coefficients in the extended oligoarticular, rheumatoid factor negative and enthesitis related subtypes were interpreted with caution in view of low numbers. Conclusions: This study adds to the body of evidence supporting the construct validity of JADAS. JADAS correlates with other measures of DA in all ILAR subtypes in the routine clinical setting. Given the high frequency of missing ESR data, it would be useful to assess the validity of JADAS without inclusion of the ESR. Disclosure statement: All authors have declared no conflicts of interest. Table 1Spearman's correlation between JADAS 71 and single markers DA by ILAR subtype ILAR Subtype Systemic onset JIA Persistent oligo JIA Extended oligo JIA Rheumatoid factor neg JIA Rheumatoid factor pos JIA Enthesitis related JIA Psoriatic JIA Undifferentiated JIA Unknown subtype Total cohort Number of children 23 111 12 57 7 9 19 7 17 262 AJC 0.54 0.67 0.53 0.75 0.53 0.34 0.59 0.81 0.37 0.59 PGA 0.63 0.69 0.25 0.73 0.14 0.05 0.50 0.83 0.56 0.64 PGE 0.51 0.68 0.83 0.61 0.41 0.69 0.71 0.9 0.48 0.61 ESR 0.28 0.31 0.35 0.4 0.6 0.85 0.43 0.7 0.5 0.53 Limited 71 JC 0.29 0.51 0.23 0.37 0.14 -0.12 0.4 0.81 0.45 0.41 Parental pain 0.23 0.62 0.03 0.57 0.41 0.69 0.7 0.79 0.42 0.53 Childhood health assessment questionnaire 0.25 0.57 -0.07 0.36 -0.47 0.84 0.37 0.8 0.66 0.4