Relevance of the time interval between surgery and adjuvant radio (chemo) therapy in HPV-negative and advanced head and neck carcinoma of unknown primary (CUP)

Introduction In contrast to head and neck squamous cell carcinoma (HNSCC), the effect of treatment duration in HNSCC-CUP has not been thoroughly investigated. Thus, this study aimed to assess the impact of the time interval between surgery and adjuvant therapy on the oncologic outcome, in particular the 5-year overall survival rate (OS), in advanced stage, HPV-negative CUPs at a tertiary referral hospital. 5-year disease specific survival rate (DSS) and progression free survival rate (PFS) are defined as secondary objectives. Material and methods Between January 1st, 2007, and March 31st, 2020 a total of 131 patients with CUP were treated. Out of these, 59 patients with a confirmed negative p16 analysis were referred to a so-called CUP-panendoscopy with simultaneous unilateral neck dissection followed by adjuvant therapy. The cut-off between tumor removal and delivery of adjuvant therapy was set at the median, i.e. patients receiving adjuvant therapy below or above the median time interval. Results Depending on the median time interval of 55 days (d) (95% CI 51.42–84.52), 30 patients received adjuvant therapy within 55 d (mean 41.69 d, SD = 9.03) after surgery in contrast to 29 patients at least after 55 d (mean 73.21 d, SD = 19.16). All patients involved in the study were diagnosed in advanced tumor stages UICC III (n = 4; 6.8%), IVA (n = 27; 45.8%) and IVB (n = 28; 47.5%). Every patient was treated with curative neck dissection. Adjuvant chemo (immune) radiation was performed in 55 patients (93.2%), 4 patients (6.8%) underwent adjuvant radiation only. The mean follow-up time was 43.6 months (SD = 36.7 months). The 5-year OS rate for all patients involved was 71% (95% CI 0.55–0.86). For those patients receiving adjuvant therapy within 55 d (77, 95% CI 0.48–1.06) the OS rate was higher, yet not significantly different from those with delayed treatment (64, 95% CI 0.42–0.80; X2(1) = 1.16, p = 0.281). Regarding all patients, the 5-year DSS rate was 86% (95% CI 0.75–0.96). Patients submitted to adjuvant treatment in less than 55 d the DSS rate was 95% (95% CI 0.89–1.01) compared to patients submitted to adjuvant treatment equal or later than 55 d (76% (95% CI 0.57–0.95; X2(1) = 2.32, p = 0.128). The 5-year PFS rate of the entire cohort was 72% (95% CI 0.59–0.85). In the group < 55 d the PFS rate was 78% (95% CI 0.63–0.94) and thus not significantly different from 65% (95% CI 0.45–0.85) of the group ≥55 d; (X2(1) = 0.29, p = 0.589). Conclusions The results presented suggest that the oncologic outcome of patients with advanced, HPV-negative CUP of the head and neck was not significantly affected by a prolonged period between surgery and adjuvant therapy. Nevertheless, oncologic outcome tends to be superior for early adjuvant therapy.

Abstract 13248: The Impact of Instructions for Covering the Mouth and the Nose on Dispatch-Assisted Cardiopulmonary Resuscitation

Introduction: Under the SARS-CoV-2 pandemic, rescuers are recommended to cover their mouth and nose with a facemask or a cloth as well as victim’s mouth and nose when performing cardiopulmonary resuscitation (CPR). However, its impact on dispatch-assisted CPR (DACPR) has not been investigated well. Hypothesis: DACPR including the instruction for covering the rescuer’s and the victim’s mouth and nose can significantly delay the start of the first chest compression. Methods: We retrospectively analyzed DACPR records of the Nara Wide Area Fire Department, covering population of 853,000/3361km 2 , in Japan. We investigated the key time intervals of 505 DACPR records between May 2020 and March 2021. We also compared the results to that of the same period in 2019 (535 records). Results: Dispatchers failed to provide mask instruction in 322 cases (63.8%). The median time interval from the emergency call and the start of CPR instruction was longer in 2020 (197 seconds vs 190 seconds, p=0.641). The time to the first chest compression was also delayed in 2020 (264 seconds vs 246 seconds, p=0.015). Among the cases that dispatchers successfully provided mask instruction (183 cases, 36.2%), median time intervals to the start of instruction and the first chest compression were relatively faster than cases without mask instruction (177 seconds vs 211 seconds and 254 seconds vs 269.5 seconds, respectively). Conclusions: Dispatchers failed to provide mask instruction in the majority of CA cases. However, our study results indicate that the impact of mask instruction on DACPR can be minor in terms of immediate CPR provision.

P.037 Benefits of Treatment with OnabotulinumtoxinA in Naive and Non-naive Patients with Cervical Dystonia are Sustained over Time in CD PROBE

Background: The sustained effects of onabotulinumtoxinA in patients with cervical dystonia (CD) who were naïve or non-naïve to botulinum toxin at enrollment in CD PROBE (CD Patient Registry for Observation of BOTOX® Efficacy) were evaluated. Methods: Patients were included if they completed all three treatment cycles and had accompanying data in this prospective, observational study. Assessments included CD severity, Cervical Dystonia Impact Profile (CDIP-58), Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), treatment interval, total dose, and adverse events (AEs). Results: Changes in severity following each onabotulinumtoxinA treatment were generally similar between naïve (n=212) and non-naïve (n=138) patients. Severity scores were maintained or improved in most patients with mild/moderate symptoms, while 30.0-66.7% with the highest severity scores shifted to a lower score across treatments. Sustained improvements were seen in all CDIP-58 subscales and TWSTRS total scores irrespective of baseline CD severity and toxin status. The median time interval between injections was similar in naïve (93.0–98.0 days) and non-naïve patients (96.0–97.0 days); doses tended to be lower in naïve patients. The most common AEs (dysphagia, muscular weakness) were similar. Conclusions: CD severity was attenuated by repeat onabotulinumtoxinA treatments at consistent intervals regardless of prior botulinum toxin exposure. Treatments were well tolerated.

Does Drug Allergy Workup in Children Satisfy Their Parents?

<b><i>Introduction:</i></b> Although drug allergy workup for pediatric patients (skin and drug provocation tests [DPT]) is performed, the procedures are troublesome, painful, and time-consuming. The aim of this study was to assess parents’ perception of and satisfaction with their child’s drug allergy workup. Further, to evaluate parents’ tendency to use the tested drug following a negative DPT and the consequences of re-exposure. <b><i>Methods:</i></b> Parents of children that underwent drug allergy workup from January 2017 to August 2020 in the Pediatric Allergy Department of Trakya University Medical Faculty were included. Satisfaction levels were assessed via a telephone questionnaire (3 open-ended, 7 multiple-choice questions). Satisfaction was scored on a Likert scale (1: very unsatisfied and 5: very satisfied). <b><i>Results:</i></b> A total of 102 parents participated the study. Fifty-two (51%) of patients were male, and median age was 6.2 years and a median time interval between admission and test appointment of 1 month; 16.7% had a positive drug allergy workup, with 88.3% reporting being satisfied (56.9%) or very satisfied (31.4%) with the workup. Satisfaction levels were inversely related to the time between admission and test appointment (rho: −0.254, <i>p</i> = 0.01), with 8.2% reporting they did not use the tested drug when necessary despite a negative result. The tested drug was used by 35 individuals (41.1%), 33 (94.2%) tolerating without reaction. <b><i>Conclusion:</i></b> Most parents were satisfied with the workup, but levels were inversely related to the admission and procedure time interval. Drug allergy workup should be performed as soon as possible to relieve parents’ anxiety and achieve more patient satisfaction.

Melanoma in Singapore: A 20-year review of disease and treatment outcomes

Introduction: Melanomas in Asians have different clinicopathological characteristics and prognosis from melanomas in Caucasians. This study reviewed the epidemiology and treatment outcomes of cutaneous melanoma diagnosed at a tertiary referral dermatology centre in Singapore, which has a multiracial population. The study also determined whether Asians had comparable relapse-free and overall survival periods to Caucasians in Singapore. Method: This is a retrospective review of cutaneous melanoma cases in our centre between 1996 and 2015. Results: Sixty-two cases of melanoma were diagnosed in 61 patients: 72.6% occurred in Chinese, 19.4% in Caucasians and 3.2% in Indians, with an over-representation of Caucasians. Superficial spreading melanoma, acral lentiginous melanoma and nodular melanoma comprised 37.1%, 35.5% and 22.6% of the cases, respectively. The median time interval to diagnosis was longer in Asians than Caucasians; median Breslow’s thickness in Asians were significantly thicker than in Caucasians (2.6mm versus 0.9mm, P=0.018) and Asians tend to present at a later stage. The mortality rates for Asians and Caucasians were 52% and 0%, respectively. Conclusion: More physician and patient education on skin cancer awareness is needed in our Asian-predominant population for better outcomes. Keywords: Asian, melanoma, nails, skin neoplasm, survival

Introduction of postmortem CT increases the postmortem examination rate without negatively impacting the rate of traditional autopsy in daily practice: an implementation study

AimThe aim of this implementation study was to assess the effect of postmortem CT (PMCT) and postmortem sampling (PMS) on (traditional) autopsy and postmortem examination rates. Additionally, the feasibility of PMCT and PMS in daily practice was assessed.MethodsFor a period of 23 months, PMCT and PMS were used as additional modalities to the autopsy at the Department of Internal Medicine. The next of kin provided consent for 123 postmortem examinations. Autopsy rates were derived from the Dutch Pathology Registry, and postmortem examination rates were calculated for the period before, during and after the study period, and the exclusion rate, table time, time interval to informing the referring clinicians with results and the time interval to the Multidisciplinary Mortality Review Board (MMRB) meeting were objectified to assess the feasibility.ResultsThe postmortem examination rate increased (from 18.8% to 32.5%, p<0.001) without a decline in the autopsy rate. The autopsy rate did not change substantially after implementation (0.2% decrease). The exclusion rate was 2%, the table time was 23 min, and a median time interval of 4.1 hours between PMCT and discussing its results with the referring clinicians was observed. Additionally, more than 80% of the MMRB meetings were held within 8 weeks after the death of the patient.ConclusionsOur study shows that the implementation of a multidisciplinary postmortem examination is feasible in daily practice and does not adversely affect the autopsy rate, while increasing the postmortem examination rate.

P277 Ileo-rectal anastomosis vs. ileoanal pouch in ulcerative colitis: clinical outcome in a real-life experience

Background In ulcerative colitis (UC) surgery is required in about 10–20% of patients (patients). Evidence regarding the long-term outcome of Ileo-rectal anastomosis (IRA) vs. the recently proposed ileal pouch (IPAA) are still lacking. In a real-life, retrospective, single-centre study, we aimed to assess the clinical outcome of all UC patients with IRA or IPAA. Methods In a retrospective study, clinical records of UC patients with IPAA or IRA in regular follow-up from January 2001 to September2019 were reviewed. Inclusion criteria: (1) UC diagnosis; (2) Age ≥18 years; (3) IPAA or IRA for UC;4)Detailed clinical history; (5) follow up ≥1 year after surgery. The following parameters were reported: demographic and clinical characteristics, hospitalisation, additional surgery, mortality, dysplasia/cancer of the ileum and/or rectum, number of endoscopies and outpatient visits, stool frequency and treatments. The quality of life (QoL) are being evaluated. Data were expressed as median (range), differences among groups assessed by chi-squared test or unpaired T-test. Results A total 84(4%) UC patients with IPAA (n = 47) or IRA (n = 37) were detected among 2136 UC patients. Among these 84 UC patients, in a preliminary assessment, clinical outcome was evaluated in 31 patients (16 IPAA,15 IRA) with a median follow up of 72 [12–180] months (mos) and a median time interval from surgery of 63 [1–348] mos. Considering the 16 patients with IPAA (8 M, 9 F) vs. the 15 with IRA (5 M,10 F), the median age at first assessment was 44 [range 30–56] vs. 48 [range 23–82] in patients with IPAA or IRA, respectively (p = 0.2123). The median follow up after surgery was 65 [range 12–132] vs. 79 [range 12–180] mos (p = 0.1955). The median time interval from surgery to first clinical assessment after surgery was 48 [range 1–312] vs. 78 [range 2–348] mos (p = 0.1955). Indication for surgery was refractory UC in 30 patients and endoscopic perforation in 1 pt. During the follow up, the following outcomes after surgery were recorded in patients with IPAA vs. IRA: hospitalised patients (n = 6 vs. n = 6 patients, p = 0.8864); additional intestinal surgery (n = 0 vs. n = 4 patients, p = 0.0269), mortality (n = 0 vs. n = 1 patients,p = 0.2938); occurrence of dysplasia/cancer of the ileum and/or rectum (n = 0 vs. n = 2 patients, p = 0.1310), number endoscopies after surgery (mean: 4 vs. n = 3.75, p = 0.316348), number visits after surgery (mean: 2.4/year vs. n = 1.7/year, p = 0.2429), mean stool frequency (n = 8.08 vs. n = 4.36; (p = 0.0005), need of biologics, n = 5 vs. n = 1 (p = 0.0834). Conclusion In a real-life experience, the need for intestinal surgery was significantly higher in patients with IRA vs. IPAA; the mean daily stool frequency was significantly higher in patients with IPAA vs. IRA.No statistically significant differences were found among the two groups in terms of hospitalisation, mortality, cancer/dysplasia and need for biologics.

Predictors of acute intracranial hemorrhage and recurrence of chronic subdural hematoma following burr hole drainage

Objective To investigate predictors of postoperative acute intracranial hemorrhage (AIH) and recurrence of chronic subdural hematoma (CSDH) after burr hole drainage.MethodsA multicenter retrospective study of patients who underwent burr hole drainage for CSDH between January 2013 and March 2019. Univariate and multiple logistic regression analyses were performed to determine the relationship between CSDH recurrence and postoperative AIH and clinical, radiological, and surgical variables. Results A total of 456 CSDH patients (361 males, 95 females) were enrolled in the study. The median (IQR) age was 68 (61–77) years (range: 8–98 years). CSDH recurrence occurred in 63 patients (56 males, seven females), with a recurrence rate of 13.8%. The median time interval between initial burr hole drainage and recurrence was 37 (27–46) days (range: 12–180 days). Postoperative AIH developed in 23 patients (15 males, eight females), with an incidence of 5.0%. The median time interval between initial burr hole drainage and postoperative AIH was 4 (2–6) days (range: 1–10 days). Bilateral hematoma, hyperdense hematoma and anticoagulant drug use were independent predictors of recurrence in the multiple logistic regression analyses. Preoperative headache was an independent risk factor of postoperative AIH in the multiple logistic regression analyses, however, intraoperative irrigation reduced the incidence of postoperative AIH. Conclusions This study found that bilateral hematoma, hyperdense hematoma and anticoagulant drug use were independently associated with CSDH recurrence. Clinical presentation of headache was the strongest predictor of postoperative AIH, and intraoperative irrigation decreased the incidence of postoperative AIH.

P04.02 Postponing the medical treatment is possible in selected cases of diffuse low-grade glioma with foci of WHO grade III-IV after total or subtotal resection

BACKGROUND Diffuse low-grade gliomas (DLGG) are defined by a continuous growth and an unavoidable malignant transformation. Foci of malignant transformation may be found within DLGG samples obtained from surgical resections. As the medical management is classically based on the higher tumor grade, an immediate adjuvant treatment is usually proposed (radiotherapy [RT] with Temozolomide or PCV), whatever the extent of resection. Yet, early RT has no impact on overall survival compared with late RT, and is associated with cognitive toxicity. An alternative approach consists in postponing the medical treatment in selected patients. MATERIAL AND METHODS We conducted a monocentric retrospective analysis of a consecutive series of patients managed with this conservative approach. Inclusion criteria were: DLGG (WHO 2016 grade II) with at least one focus of malignant transformation (grade III-IV); no previous chemotherapy or RT; no less than a subtotal resection of the FLAIR tumor volume; no intention of treating with immediate adjuvant therapy; at least two years of postoperative follow-up. The time interval to the next medical treatment (chemotherapy and/or radiotherapy) was assessed, as well as the functional and survival results. RESULTS Forty-five DLGG patients, of median age 36.5 years, were included in the analysis (median time interval from diagnosis: 7.3 months). The histo-molecular diagnosis was diffuse astrocytoma, IDH mutant in 46.7% of cases, astrocytoma, IDH wild-type in 13.3% and oligodendroglioma, IDH mutant and 1p/19q codeleted in 40.0%. Ten tumors presented with grade IV foci. The quality of resection was subtotal (FLAIR tumor residue ≤15 cm3) in 73.3%, total (no FLAIR tumor residue) in 24.4% and supratotal in 2.2%. After surgery, patients were managed with regular clinical and radiological follow-up. With a median postoperative follow-up of 6.3 years, 75.5% of patients received a subsequent medical treatment, after a median time interval of 3.7 years. The first treatment after surgery consisted of repeated surgery in 11 patients, Temozolomide in 28 patients, RT in one patient. At the time of analysis, 19 patients (42.2%) had been treated with RT, after a median time interval of 9.5 years. Nine patients (20.0%) had died (median overall survival not reached, 5-years and 7-years survival rates: 95.2% and 67.0%). Most surviving patients were still active professionally (69.4%), with a median Karnofsky performance status of 90, and no or rare seizures. CONCLUSION In this series, total or subtotal resection of DLGG with a least one focus of grade III-IV glioma radically changed the natural history of these tumors and allowed delaying the following medical treatment by several years. This strategy is feasible in selected patients and should be considered on a case-by-case basis in patients with foci of malignant transformation following total or subtotal resection.

Development of clinically apparent synovitis: a longitudinal study at the joint level during progression to inflammatory arthritis

IntroductionSubclinical inflammation, detected by MRI, in patients with arthralgia is predictive for development of inflammatory arthritis (IA). However, within patients that develop IA, the course of inflammation at the joint level during this transition is unknown. This longitudinal study assessed progression of inflammation at the joint level.Methods350 joints (unilateral metacarpophalangeals (MCPs), wrist, metatarsophalangeal (MTP) joints) of 35 patients presenting with clinically suspect arthralgia (CSA) that progressed to IA were studied at presentation with CSA and subsequently when clinical synovitis was first identified at joint examination (median time interval 17 weeks). At both time points, subclinical inflammation (bone marrow oedema, synovitis, tenosynovitis) was evaluated with MRI and joint examination was performed.ResultsAt presentation with CSA, 71 joints showed subclinical inflammation. During progression to IA, 20% of these joints had resolution of inflammation, 60% had persistent inflammation and 20% progressed to clinical synovitis. Of all joints that had developed clinical synovitis (n = 45), no prior subclinical inflammation was detected in 69%. Similar results were observed for anticitrullinated protein antibodies (ACPA)-positive and ACPA-negative patients.ConclusionsThis longitudinal study demonstrated moderate correlations between joints with subclinical inflammation and joints that developed clinical synovitis. These data imply that IA development is a more systemic rather than a locally outgrowing process.