Volumetric Response and Survival of Patients With Bulky IDH-Mutated Grade 3 Glioma Managed With FET-FDG-Guided Integrated Boost IMRT.

AIMS: Despite relatively favourable outcomes associated with IDH-mutant grade 3 gliomas, many patients present with diffuse non-enhancing disease involving multiple brain regions, prompting concern over both durable disease control and the morbidity associated with large volume radiation therapy. This study audits volumetric response, survival and functional outcomes in this 'large volume' subgroup that undergoes intensity modulated radiation therapy (IMRT). MATERIALS AND METHODS: From a prospective database of 187 patients with IDH-mutant grade 3 gliomas managed with IMRT between 2008 and 2020, recorded PTV was divided into quartiles. The top quartile, termed the 'large volume cohort' (LVC), was identified. IMRT involved FET-FDG guided integrated boost (59.4/54Gy in 33 fractions). Manual volumetric segmentation of baseline, four months and 13 months post-IMRT tumour were performed for T1, T2 and T1gd MRI sequences. The primary endpoint was volumetric reduction on the T1 and T2 sequences at 13 months and analysed with relapse-free survival (RFS) and overall survival (OS). Morbidity endpoints were assessed at year four post-IMRT and included performance status (ECOG PS) and employment outcomes. RESULTS: The fourth quartile (LVC) identified 44 patients for whom volumetric analysis was available. The LVC had median PTV of 320cm3 compared to 186.2cm3 for the total group. Anaplastic astrocytoma and oligodendroglioma were equally distributed and tumour sites were frontal (54%), temporal (18%) and parietal lobes (16%). Median follow-up for survivors was 71.5 months. Projected 10-year RFS and OS in LVC was 40% and 62%, compared to 53% and 62% respectively in the overall cohort. The RFS (p = 0.06) and OS (p = 0.65) of the LVC was not significantly different to other PTV quartiles; however the impact of PTV volume reached significance when analysed as a continuous variable (RFS p < 0.01; OS p = 0.02). Median T1 volumes were 26.1cm3, 8.0cm3 and 5.3cm3 at months +0, +3 and +12, respectively. The corresponding T2 volumes were 120.8cm3, 29.1cm3 and 26.3cm3. The median T1 and T2 volume reductions were 77% (q1-3: 57-92%) and 78% (q1-3: 60-85%) at 13 months post-IMRT. Initial T2 volume was associated with worse RFS (p = 0.04) but not OS (p = 0.96). There was no association between median T2 volume reduction and RFS (p = 0.77). For patients assessable at year 4 post-IMRT, no late CTCAE Grade 3/4 toxicity events were recognised. 92% of patients were ECOG PS 0-1, 45% were employed at prior capacity and 28% were working with impairment. CONCLUSION: Patients with large volume IDH-mutant Grade 3 glioma demonstrated significant tumour reduction post-IMRT, and good long-term outcomes with respect to survival and functional status. Although larger IMRT volumes were associated with poorer RFS, this was also associated with the initial volume of non-enhancing tumour.

Volumetric response and pattern of failure of histone altered high grade glioma in adults following management with radiation therapy.

PURPOSE: H3K27M- and H3G34R-mutant gliomas are recently-classified subgroups of high-grade gliomas (HGGs) affecting younger adults. This study aimed to describe patterns of infiltration and failure, and the volumetric response of these tumours to radiotherapy. METHODS: Patients with histone-mutant gliomas aged 16-50 years, managed from 2009 to 2021 were identified and clinical, radiological and histopathological characteristics collected. Tumour volume was assessed on MRI at diagnosis, pre-radiotherapy, month + 1, + 3 and + 5 post-radiation and at relapse. RESULTS: Of 538 IDH1/2 wild-type HGGs, 18(15%) had a histone alteration. Eleven were H3K27M- and 7 H3G34R-mutant respectively. Median age at diagnosis was 20 years (range17-48 years). Median overall survival was 20 months (95%CI 14-29 months). Both H3K27M- and H3G34R-mutant tumours exhibited extensive T2F infiltration involving a median of 4 neuroanatomical subsites at diagnosis. Median volume of disease pre-radiotherapy on T1gd and T2F respectively was 0.5cm3 (IQR:0-1.7cm3) and 11.9 cm3 (IQR:7.5-29.6cm3) for H3K27M and 0.9cm3 (IQR:0-8.4cm3) and 43.8cm3 (IQR:25.2-86.6 cm3) for H3G34R tumours. T2F volume reduction > 50% was observed 3-months post-IMRT in 7(64%) patients with H3K27M and 1(14%) with H3G34R tumours. Fourteen patients had relapsed. Relapse was local-only, distant-only and both in 4(44%), 3(33%) and 2(22%) H3K27M-mutant and 1(20%), 2(40%), and 2(40%) H3G34R-mutant tumours. On last scan before death, leptomeningeal spread was present in 4/8(50%) and 1/5(20%) and subependymal spread in 4/8 (50%) and 0/5 H3K27M- and G34R-mutant cases respectively. CONCLUSION: H3K27M-mutant gliomas are highly responsive to radiotherapy but exhibit high propensity for subsequent leptomeningeal and subependymal spread. H3G34R-mutant tumours exhibit lesser early volumetric response to radiotherapy and propensity for distant in-brain failure.

Patient satisfaction with nutrition services amongst cancer patients treated with autologous stem cell transplantation: a comparison of usual and extended care.

BACKGROUND: This study aimed to determine patient satisfaction with clinical nutrition services delivered by an accredited practicing dietitian amongst cancer patients treated with autologous stem cell transplantation that was provided with usual and extended care at 100 days post-transplantation. METHODS: Patients were randomised to receive usual nutrition care or extended nutrition care during the course of their stem cell transplantation. After hospital discharge, usual care patients received no further nutrition support, whereas extended care patients received telephone dietary counselling from the same dietitian for up to 100 days post-transplantation. The patient satisfaction with clinical nutrition service questionnaire was completed anonymously at 100 days post-transplantation. Group comparisons were made using independent t-tests. RESULTS: Thirty-seven patients consented to participate in the study (54% male; mean age 58.7 ± 9.5 years; median body mass index 26.8 kg m(-2) , range 16.4-47.6 kg m(-2) ); 33 patients completed the study and 28 patients returned the questionnaire (response rate = 85%). All components of the questionnaire were rated highly by both groups; there was no significant difference between the groups (P > 0.05). Although not statistically significant, extended care patients who received at least three telephone calls rated a higher overall satisfaction compared to those who received less calls; this difference was clinically important (score difference = 0.56). CONCLUSIONS: Cancer patients treated with autologous stem cell transplantation were satisfied with usual and extended nutrition care. Extended care patients who received at least three telephone calls after hospital discharge were more satisfied than those with less frequent intervention. Further exploration regarding the frequency and intensity of nutrition service is required.

Nutritional status of long-term patients in the acute care setting.

The nutritional status of 926 patients (51.4% female) at an acute tertiary private hospital with a length of stay ≥14 days was assessed using Subjective Global Assessment. The prevalence of malnutrition was 42.5% (37.2% length of stay of 14-27 days, 51.6% ≥28 days). From logistic regression analysis, length of stay and age were independent predictors of malnutrition. It is important that the nutritional status of longer stay patients is monitored and appropriate nutrition support is commenced.

Nutritional status of patients who have fallen in an acute care setting.

BACKGROUND: Falls may result in injury, loss of independence and higher healthcare costs. The aim of this study was to examine the nutritional status of patients who had fallen in an acute care setting. METHODS: Forty-nine patients who had experienced a fall while admitted at an Australian private hospital participated in the study (age: 71.2 (SD 14.1) years; 21 male: 28 female). Nutritional status was assessed using subjective global assessment. Protein and energy intake was determined by dietary history and analysed using Australian computerised food composition data. RESULTS: According to subjective global assessment, 27 patients were well nourished and 22 malnourished (21 moderately, one severely malnourished). Well nourished fallers had significantly higher BMI (mean difference 3.7 kg/m(2), CI: 1.2-6.2), dietary protein (mean difference 19.8 g, CI: 2.0-37.5) and energy intake (mean difference 1751 kJ, CI: 332-3170) compared to malnourished fallers. There was no difference in severity of falls based on nutritional status, weight or BMI. CONCLUSIONS: There was a high prevalence of malnutrition and poor intake in this sample of patients who had fallen in hospital. Nutrition assessment and intervention for patients who have fallen in the acute care setting should be considered.

Poor nutritional status prior to peripheral blood stem cell transplantation is associated with increased length of hospital stay.

The nutritional status of patients prior to peripheral blood stem cell transplantation (PBSCT) and its impact on length of hospital stay is not well described in the literature. The nutritional status of 66 consecutive patients (46 m:20 f); and the mean age 58.7+/-12.0 years was determined a maximum of 2 weeks pre-transplantation using the scored Patient-Generated-Subjective Global Assessment (PG-SGA). According to the global assessment, 73% patients were well nourished, 23% moderately malnourished and 4% severely malnourished. There was a significant difference in post transplant length of stay (mean difference+/-s.e.m. -7.0+/-2.1 days) between well-nourished and malnourished patients and a trend towards higher mortality in the malnourished group (2 vs 20%). Although 89% of patients described no problems eating, two or more nutrition impact symptoms were reported in 30% of patients. From stepwise multiple regression analysis, nutritional status as determined by PG-SGA score was significantly associated with length of stay, accounting for 12% of the variance. In conclusion, malnutrition prior to PBSCT is associated with increased length of stay. Routine nutrition assessment of patients prior to PBSCT should be undertaken.

Positive Women Victoria: supporting women with HIV / AIDS.

PIP: Positive Women Victoria (PWV) is a support group for women with HIV/AIDS run by women with HIV/AIDS. It is the only group of its kind in Australia which is directly funded by government, through the National/State AIDS Matched Funding Program. The group is also the contact point for the National Network of Positive Women, an organization which keeps positive women across Australia informed and connected through its newsletter with a list of representatives in each state. PWV has since 1994 received funding for one paid worker and has office space donated by the main AIDS hospital in Melbourne. The group provides the following free and confidential support services for HIV-positive women: individual contact, group support meetings, a drop-in center, free massages offered by volunteers, information and referrals, and a monthly newsletter. Gender issues in HIV/AIDS, advocacy on behalf of individuals and groups, and the Federal Government's national 3-year HIV/AIDS strategy are discussed.^ieng