THE ROLE OF FDG-PET IN STAGING AND TREATMENT FOR STAGE III NSCLC IN ONTARIO BETWEEN 2009-2017

Purpose: Fluoro-2-deoxyglucose positron-emission tomography (PET) is now considered standard of care in the staging evaluation for new cases of Stage III NSCLC however, there is not level 3 evidence demonstrating efficacy of PET. Using retrospective population-based data, we sought to examine the role and timing that PET scans play in influencing treatment choice, as well as survival in patients treated with chemoradiation (CRT) for Stage III NSCLC. Materials and Methods: A retrospective cohort of patients diagnosed with Stage III NSCLC from 2009-2017 in Ontario were identified from the Institute of Clinical Evaluative Sciences (ICES). Overall survival (OS), using a landmark analysis of six months, was explored in the entire cohort (PET versus no PET) as well as in patients who received CRT for Stage III disease. Survival time was calculated using Kaplan Meier methods, logistic regression was used to evaluate type of treatment received, and Cox regression was used to evaluate factors prognostic of OS amongst patients who received CRT. Results: A total of 13 796 cases were included in our analysis: 6536 patients underwent PET scanning prior to treatment and 7260 did not. Over time, there was a significantly increased utilization of PET from 12.4% in 2009 to 74.1% in 2017 (p<0.001). In regard to treatment modality, significantly more patients received curative intent therapy in the PET group including: CRT (1472 versus 939 patients;p<0.001), and surgery (1483 versus 734 patients;p<0.001). There was significantly improved OS in the whole cohort with upfront PET versus not with median OS of 17.1 (95% CI=16.3-17.8) versus 11.2 (10.6-11.9) months (p<0.001). In patients specifically receiving CRT, OS was similarly improved in the PET versus no PET subgroups with median OS of 21.7 (19.7-24.2) versus 18.5 (16.8-20.7) months (p=0.004). Examining the timing of PET scan and commencement of therapy, no significant difference was found among patients who had their scan <28 days prior to treatment (median OS =16 months), 2956 days prior to treatment (17.8 months), and >56 days prior to treatment (18.6 months), (p=0.38);these results were similar in the CRT only subgroup. On multivariate analysis, the only factors predicting survival in the CRT group were male gender (HR 1.20;1.08-1.33), increasing age (HR 1.07;1.04-1.10), surgery as part of trimodality therapy (HR 0.60;0.52-0.70), and receipt of PET prior to treatment (HR 0.83;0.72-0.95). Conclusions: Significant differences in treatment received and OS due to receipt of PET may be due to stage migration or unmeasured confounders. However, in a CRT subgroup, receipt of PET was associated with improved OS. Advocating for increased access to PET scans in this patient population is of utmost importance especially now with an additional survival benefit of adjuvant immunotherapy following CRT. The timing of the PET scan relative to initiating treatment did not have an obvious impact on survival, which may be reassuring for centres that may lack the capability to perform timely scans or are experiencing delays due to the COVID-19 pandemic.

BIOLOGICS AND COVID-19 OUTCOMES IN INFLAMMATORY BOWEL DISEASE PATIENTS

Introduction Both clinicians and inflammatory bowel disease (IBD) patients remain concernedthat either their disease or medications—namely biologics, may increase the risk ofsevere adverse outcomes from coronavirus disease-2019 (COVID-19). We performed a systematic review and meta-analysis of the available literature to assess the safety of biologicsin COVID-19 patients with IBD.Methods We performed a systematic review of the databases PubMed/Medline, Embase,Cochrane, Web of Science, LitCOVID-NIH, and WHO COVID-19 from January 1-November3, 2020, to identify relevant articles reporting outcomes in IBD patients with COVID-19.Studies were excluded if they did not report the outcomes of interest (intensive care unit(ICU) admission, mechanical ventilation, and mortality) or excluded data on IBD medications(biologics). Pooled analysis was performed using a random-effects model and multivariateregression was applied.Results The initial search yielded a total of 81 articles, of which a total of 12 studies with2,681 patients were finally included. We found the overall prevalence of outcomes for allIBD patients as: need for mechanical ventilation: 5.1% (95% CI: 3.5%–7.4%, I2 = 52.1%),need for ICU admission: 6.1%, (95% CI: 4.2%-8.8%, I2 = 54.8%), and overall mortality:4.5% (95% CI: 2.8%-7.1%, I2 = 68.0) (Figure 1). Use of biologics did not show a moderatingeffect on the need for mechanical ventilation (coefficient: -0.01, 95% CI -0.08 – 0.05, p =0.68), ICU admission (coefficient: 0.03, 95% CI: -0.02 – 0.08, p = 0.27), or mortality(coefficient: 0.03, 95% CI -0.01 – 0.07, p = 0.20) (Figure 2).Discussion We found the overall prevalence of “severe” COVID-19—mechanical ventilation,ICU admission, and mortality, for all IBD patients with COVID-19 to be 5.1%, 6.1%, and4.5%, respectively. This appears to be fairly low given the impact IBD and its medicationsmay have on the immune-system. We also found that the use of biologics did not predict“severe” COVID-19—as shown upon multivariable analysis from our meta-regression model.This finding is important as it advocates for the ongoing and continued IBD therapy (biologics)in patients during the COVID-19 pandemic. The incidence, severity, and outcomes relatedto COVID-19 in IBD patients needs to be reassessed as data continues to emerge from thepandemic. Additional outcomes data will be required to understand how all classes ofbiologics and/or the use of concomitant immunosuppressants effect COVID-19 outcomesin IBD patients.(Figure Presented)Figure 1. Forrest plot demonstrating the overall prevalence of outcomes—(A) need for mechanical ventilation, (B) need for ICU admission, and (C) overall mortality—in COVID-19 infected inflammatory bowel disease (IBD) patients.(Figure Presented)Figure 2. Scatter plots demonstrating the impact of biologics on outcomes;(A) need for mechanical ventilation, (B) need for ICU admission, and (C) overall mortality.

Socioeconomic factors, not disease severity or treatment regimen, most important in identifying covid-19 vaccine hesitant ibd patients

Introduction: Successful recovery from the COVID-19 pandemic relies on widespread vaccine acceptance. While uptake has improved over recent months, hesitancy and skepticism persist, including in populations who could most benefit from vaccination such as the elderly, chronically ill or those on immunosuppressants. This survey study aims to characterize attributes that correlate and possibly determine vaccine intent or hesitancy among our IBD population. Methods: Subjects were invited to participate in a web-based survey using a patient database from an academic IBD clinic. Survey questions covered disease history, medications, changes to medications and disease management during the COVID-19 pandemic, as well as social, economic, and household characteristics. Positive vaccine intent was defined as having either received a COVID-19 vaccine or planning to do so when it would become available for the participant's age group. Vaccine hesitancy was defined as not having received any portion of a COVID-19 vaccine and not intending to do so. Chi square and logistic binomial regression analysis was performed using SPSS. Results: Of 609 patients invited, 278 (45.6%) completed the survey. 234 (84.2%) had positive vaccine intent;44 (15.8%) were vaccine hesitant. Significant factors are highlighted in Table 1 and were almost exclusively socio-economic. Positive vaccine intent associated variables included college education or above (OR 2.5, p .026), annual income over $150,000 (OR 3.295, p .015), Democratic affiliation (OR 7.193, p<001), CDC information source (OR 5.749, p<.001), and receiving the flu shot in the year prior (OR 3.702, p .002). Variables associated with vaccine hesitancy included African American race (OR .175 p .005), COVID-related financial hardship (OR .480 p .047), in-person employment (OR .403 p .025), and Republican affiliation (OR .259 p .011). Disease-related attributes, comorbidities, or use of immunomodulating drugs were not found to significantly associate with either positive vaccine intent or hesitancy. Discontinuation of biologics during the pandemic was associated with negative vaccine intent, but this relationship disappeared when controlling for race. Conclusion: Vaccine decision making in our population is largely driven by socioeconomic factors, rather than clinical or disease attributes, including among those on immunosuppressant medications. This is important to explore and can help inform public health campaigns when addressing vaccine hesitancy in the community.

The Role of FDG-PET in Staging and Treatment for Stage III NSCLC in Ontario, Canada Between 2009-2017

Fluoro-2-deoxyglucose positron-emission tomography (PET) is now considered standard of care in the staging evaluation for new cases of stage III NSCLC however, there is not level 3 evidence demonstrating efficacy of PET. Using retrospective population-based data, we sought to examine the role and timing that PET scans play in influencing treatment choice, as well as survival in patients treated with chemoradiation (CRT) for stage III NSCLC. A retrospective cohort of patients diagnosed with stage III NSCLC from 2009-2017 in Ontario, Canada were identified from the Institute of Clinical Evaluative Sciences (ICES). Overall survival (OS), using a landmark analysis of 6 months, was explored in the entire cohort (PET versus no PET) as well as in patients who received CRT for stage III disease. Survival time was calculated using Kaplan Meier methods, logistic regression was used to evaluate type of treatment received, and Cox regression was used to evaluate factors prognostic of OS amongst patients who received CRT. A total of 13 796 cases were included in our analysis: 6536 pts underwent PET scanning prior to treatment and 7260 did not. Over time, there was a significantly increased utilization of PET from 12.4% in 2009 to 74.1% in 2017 (P < 0.001). In regards to treatment modality, significantly more pts received curative intent therapy in the PET group including: CRT (1472 vs 939 pts;P < 0.001), and surgery (1483 vs 734 pts;P < 0.001). There was significantly improved OS in the whole cohort with upfront PET vs not with median OS of 17.1 (95% CI = 16.3-17.8) vs 11.2 (10.6-11.9) mos (P < 0.001). In pts specifically receiving CRT, OS was similarly improved in the PET vs no PET subgroups with median OS of 21.7 (19.7-24.2) vs 18.5 (16.8-20.7) mos (P = 0.004). Examining the timing of PET scan and commencement of therapy, no significant difference was found among pts who had their scan ≤28 days prior to treatment (median OS = 16 mos), 29-56 days prior to treatment (17.8 mos), and > 56 days prior to treatment (18.6 mos), (P = 0.38);these results were similar in the CRT only subgroup. On multivariate analysis, the only factors predicting survival in the CRT group were male gender (HR 1.20;1.08-1.33), increasing age (HR 1.07;1.04-1.10), surgery as part of trimodality therapy (HR 0.60;0.52-0.70), and receipt of PET prior to treatment (HR 0.83;0.72-0.95). Significant differences in treatment received and OS due to receipt of PET may be due to stage migration or unmeasured confounders. However, in a CRT subgroup, receipt of PET was associated with improved OS. Advocating for increased access to PET scans in this patient population is of utmost importance especially now with an additional survival benefit of adjuvant immunotherapy following CRT. The timing of the PET scan relative to initiating treatment did not have an obvious impact on survival, which may be reassuring for centers that may lack the capability to perform timely scans or are experiencing delays due to the COVID pandemic. [ABSTRACT FROM AUTHOR] Copyright of International Journal of Radiation Oncology, Biology, Physics is the property of Pergamon Press - An Imprint of Elsevier Science and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Air on the side of caution: A case of gastric emphysema

INTRODUCTION: Gastric pneumatosis, the presence of intramural gas in the stomach, is a rare but alarming radiographic finding. Gastric emphysema (GE) and emphysematous gastritis remain the two most important differential diagnoses of gastric pneumatosis, both differing vastly in their management and prognosis. Due to these differences, it is essential to reach an accurate clinical diagnosis early. Here we describe the case of a young male with GE due to severe gastroparesis from uncontrolled diabetes. CASE DESCRIPTION/METHODS: A 36 year-old COVID-19 positive male with a history of uncontrolled Type 1 Diabetes, Hepatitis C, and Hirschsprung disease presented with generalized weakness, fatigue, polyuria, and polydipsia for two days. Laboratory work revealed diabetic ketoacidosis which improved with intravenous (IV) fluids and insulin. However, his course was complicated by persistent nausea, inability to tolerate oral diet, abdominal distension, and worsening leukocytosis. Computed Tomography (CT) of the abdomen demonstrated a markedly distended stomach containing air and undigested food, air in the gastric wall, gas and thrombus in the left portal vein, and pancolitis. He remained afebrile, hemodynamically stable with negative blood cultures and was initially treated conservatively with fluconazole and piperacillin-tazobactam, nasogastric suction and supportive care. Repeat CT of the abdomen two days later showed improvement in gastric pneumatosis and portal venous gas. Subsequent EGD revealed retained gastric contents, an open pylorus, and large necroticappearing ulcerations extending most of the lesser curvature and fundus of the stomach. These findings were consistent with GE, likely a chronic issue from longstanding gastroparesis. However microvascular thrombi related to COVID remain on the differential as there is a known propensity for a procoagulable state in these patients. DISCUSSION: GE can be due to an increase in intraluminal pressure or mucosal injury that leads to intramural gas formation. In our patient, we suspect his GE was due to uncontrolled diabetes, causing severe gastroparesis and gastric wall distention. GE is benign and managed with observation and conservative treatment. Comparatively emphysematous gastritis is often associated with systemic toxicity, is potentially fatal, and often requires more aggressive therapy including surgery. As in the majority of GE cases, our patient's symptoms improved with conservative treatment and follow-up imaging revealed interval improvement.