Introducing FDG PET/CT-guided chemoradiotherapy for stage III NSCLC in low- and middle-income countries: preliminary results from the IAEA PERTAIN trial.

PURPOSE: Patients with stage III non-small-cell lung cancer (NSCLC) treated with chemoradiotherapy (CRT) in low- and middle-income countries (LMIC) continue to have a poor prognosis. It is known that FDG PET/CT improves staging, treatment selection and target volume delineation (TVD), and although its use has grown rapidly, it is still not widely available in LMIC. CRT is often used as sequential treatment, but is known to be more effective when given concurrently. The aim of the PERTAIN study was to assess the impact of introducing FDG PET/CT-guided concurrent CRT, supported by training and quality control (QC), on the overall survival (OS) and progression-free survival (PFS) of patients with stage III NSCLC. METHODS: The study included patients with stage III NSCLC from nine medical centres in seven countries. A retrospective cohort was managed according to local practices between January 2010 and July 2014, which involved only optional diagnostic FDG PET/CT for staging (not for TVD), followed by sequential or concurrent CRT. A prospective cohort between August 2015 and October 2018 was treated according to the study protocol including FDG PET/CT in treatment position for staging and multimodal TVD followed by concurrent CRT by specialists trained in protocol-specific TVD and with TVD QC. Kaplan-Meier analysis was used to assess OS and PFS in the retrospective and prospective cohorts. RESULTS: Guidelines for FDG PET/CT image acquisition and TVD were developed and published. All specialists involved in the PERTAIN study received training between June 2014 and May 2016. The PET/CT scanners used received EARL accreditation. In November 2018 a planned interim analysis was performed including 230 patients in the retrospective cohort with a median follow-up of 14 months and 128 patients in the prospective cohort, of whom 69 had a follow-up of at least 1 year. Using the Kaplan-Meier method, OS was significantly longer in the prospective cohort than in the retrospective cohort (23 vs. 14 months, p = 0.012). In addition, median PFS was significantly longer in the prospective cohort than in the retrospective cohort (17 vs. 11 months, p = 0.012). CONCLUSION: In the PERTAIN study, the preliminary results indicate that introducing FDG PET/CT-guided concurrent CRT for patients with stage III NSCLC in LMIC resulted in a significant improvement in OS and PFS. The final study results based on complete data are expected in 2020.

Long-term angiographic and histopathologic findings in experimental aneurysms of the carotid bifurcation embolized with platinum and tungsten coils.

PURPOSE: To evaluate the long-term outcome of endovascular occlusion of arterial aneurysms effected with metal coils. METHODS: Microsurgical methods were used to produce carotid bifurcation aneurysms in 20 rabbits and the radiologic and histologic changes were examined. Eight of these aneurysms were occluded with electrically detachable platinum coils (Guglielmi detachable coils [GDCs] and nine were treated with mechanically detachable tungsten coils (mechanical detachable system [MDS]). Three aneurysms remained untreated and served as controls. One animal died of embolic complications 12 hours after endovascular treatment. After observation periods of 3 to 6 months, the remaining animals were examined by intraarterial digital subtraction angiography and subsequent fixation and light and electron microscopy. RESULTS: Large open spaces without signs of thrombosis were found between the loops of the coil baskets in 12 aneurysms (six treated with GDCs and six treated with MDS) regardless of the observation period. In very densely packed aneurysms (four cases with complete occlusion as determined by angiographic criteria), the coil surfaces were for the most part covered by thin cell layers; however, complete endothelialization was never seen. In aneurysms with an initial partial occlusion of 70% to 90%, coil compaction and/or recanalization was a consistent finding. A comparison of the radiologic findings with the histologic aspect revealed that the degree of occlusion was often overrated on the radiographs (in eight of 17 cases). In general, the fibrous tissue reaction appeared to be slightly more pronounced in aneurysms occluded with tungsten coils. CONCLUSIONS: Platinum and tungsten coils were not always effective in causing endoluminal thrombosis leading to long-term occlusion by organized thrombus.

[Endovascular treatment of cerebral aneurysms with selectively detachable platinum coils]. / Endovaskuläre Behandlung zerebraler arterieller Aneurysmen mit selektiv ablösbaren Platinspiralen.

In 14 patients (eight men, six women; mean age 58 [31-72] years) with intracranial aneurysm (basilar artery in nine, anterior branches in five) the aneurysm was occluded by electrically detachable platinum coils, advanced into the aneurysm introduced via a percutaneously introduced catheter system, under local anaesthesia and fluoroscopic control. Ten patients had acute subarachnoid haemorrhage (stage II-IV). In two patients several sessions were required before complete occlusion was achieved. In one patient, with a basilar artery aneurysm, the aneurysmal wall was perforated (angiographically demonstrated contrast-medium extravasation), but this remained clinically asymptomatic. There has been no recurrence or renewed bleeding during a follow-up period of 6-12 months. The method is a highly promising addition to the micro-neurosurgical treatment of such aneurysms. However, as long-term results are still awaited, indications for using the method should be strict and only those patients should be so treated in whom operation would be associated with a high risk or who are inoperable.