Evanston Hospital

749 Background: There is mounting data for neoadjuvant chemotherapy use in HG UTUC, but the role of neoadjuvant chemoimmunotherapy remains less clear, including in cisplatin-ineligible pts, representing an unmet need in this population. Our multicenter trial evaluated the efficacy and safety of neoadjuvant gemcitabine/durvalumab (GD) in pts with HG UTUC. Methods: Cisplatin-ineligible pts with localized cN0 HG UTUC planned for radical nephroureterectomy (NU) were assigned to 4 GD cycles. Primary endpoint was pCR (ypT0N0/x); accrual goal was 29 pts; 18% pCR was considered worthy of further study, while 4% pCR would not justify further pursuit. Simon’s two stage design was used and if ≥1 out of the first 14 pts (13 evaluable) had pCR in stage I, another 15 pts (14 evaluable) would be accrued. With 27 evaluable (eligible and treated) pts, success was defined as ≥3 pCRs. Secondary endpoints included safety/tolerability, event-free survival (EFS) and overall survival (OS) both measured from registration and disease-free survival (DFS) measured from NU. Results: From 2022–2025, 31 pts enrolled (19 men) with median age 79 (44-88), including 15 renal pelvis, 15 ureteral, and 1 multifocal tumor; 5 with sessile appearance. Thirty pts were eligible and received ≥ 1 therapy dose and 23 completed all 4 planned cycles. Three patients achieved pCR (10%; 90%CI: 3.0 - 25.2%), 10 achieved pathologic stage < ypT2N0/x (33%, 90%CI: 19.3 – 49.9%). All 30 pts experienced treatment-related adverse events (TRAEs), 13 experienced G3-4 TRAEs (most common were anemia and neutropenia: 4 pts each), with no G5 TRAE. Among pts who underwent NU, median time from last neoadjuvant dose to NU was 10 weeks (range 5-22 weeks); 6 pts did not have lymph node dissection; 5 treated pts did not undergo NU: 1 due to progression before NU, 1 due to unresectable tumor, 1 due to cancer-related death, 1 due to refusal of further intervention, 1 due to deconditioning. With median follow-up of 11 months, the estimated 1-year EFS was 77.4% (60.9 – 98.3%). Conclusions: Neoadjuvant GD was feasible and relatively well tolerated in pts with HG UTUC; associated with 10% pCR, 33% < ypT2N0/x and promising 1-year EFS. Follow-up continues to further assess EFS, DFS, OS, while biomarker analysis is planned. Lymph node dissection for pts with HG UTUC is standard of care. The addition of durvalumab to accelerated MVAC chemotherapy is being evaluated in the randomized phase 3 part of this trial for cisplatin eligible patients (cohort A vs B; NCT04628767). Clinical trial information: NCT04628767 .

Preterm infants are at risk for white matter brain injury characterized by periventricular leukomalacia (PVL) with exposure to in-utero inflammation. Our aim was to correlate placental pathology with PVL in a cohort of preterm infants. All infants born <1500 g between Jan 1, 2017 and July 31, 2022 with placental pathology reports and neonatal outcome data on PVL were included in this study. Placental pathology findings were divided into 4 major categories (acute inflammation (AI), chronic inflammation (CI), fetal vascular malperfusion (FVM), and maternal vascular malperfusion (MVM)); each category was graded as absent, low-grade, or high-grade. We identified 263 infants with data for PVL and placental pathology. Gestational age (GA) averaged 28 completed weeks and mean birthweight was 1050 g. 11/263 (4.2%) infants had PVL. Acute inflammation was seen in 9/11 (82%) infants with PVL and only 101/252 (40%) of those without PVL (P = .01). Eight of the nine infants with PVL and AI (89%) had high-stage AI. In analyses adjusted for gestational age, the prevalences of CI, FVM and MVM were not significantly different between infants with or without PVL. In a large cohort of preterm infants, we demonstrate a strong association between AI in the placenta (histologic chorioamnionitis) and PVL in infants born <1500 g.

Abstract Objective To evaluate whether induction of fetal asystole (IFA) during second‐trimester termination induction of labor (2T termination IOL) is associated with duration of labor and adverse health outcomes. Study design We analyzed a retrospective cohort of individuals undergoing second‐trimester termination IOL (2T termination IOL) between 14 0/7 to 27 6/7 weeks of gestation of a singleton at four centers from 2009 to 2019. Individuals with prelabor rupture of membranes, preterm labor, intrauterine fetal demise, or cervical insufficiency were excluded. The primary exposure was IFA. The primary outcome was duration of labor, treated continuously and dichotomously (i.e., upper quartile of the duration of labor for the cohort vs. all other quartiles). The secondary outcomes were composite morbidity and its components (uterine rupture, need for blood transfusion, clinical chorioamnionitis, intensive care unit admission, or need for readmission). Bivariate and multivariate analyses were performed, comparing individuals who underwent IFA to individuals who had fetal cardiac activity (FCA) at the time of 2T termination IOL. A priori, the receipt of mifepristone was chosen as a confounding covariate. A Kaplan–Meier curve was generated, censoring at the time of delivery. Subgroup analyses for the primary outcome were performed based on parity. A sensitivity analysis was conducted, with the use of propensity score matching, to assess for differences in all outcomes. Results A total of 358 participants were analyzed of which 83 (20.8%) underwent IFA with potassium chloride and 275 (76.8%) had FCA. There were no significant differences in the duration of labor between the two groups (13.1 h in the IFA group vs. 12.0 h in the FCA group, p = 0.84) or the frequency of experiencing the highest quartile of labor duration (26.5% vs. 24.7%, p = 0.70). There was also no difference in the composite secondary outcome (21.7% vs. 17.4%, p = 0.42) or its components (i.e., uterine rupture ( p = 0.053), need for blood transfusion ( p = 0.10), clinical chorioamnionitis ( p = 0.96), ICU admission ( p = 0.41), or need for hospital readmission ( p = 1.0)). A similar pattern was noted in the sensitivity analysis. On subgroup analysis, there was no difference in the duration of labor based on parity. Conclusion IFA is not associated with increased duration of labor when compared to FCA during 2T termination IOL. It is also not associated with adverse outcomes including uterine rupture, need for blood transfusion, clinical chorioamnionitis, ICU admission, or need for hospital admission.

The ideal resection strategy for rectal neoplasms extending to the dentate line (RNDLs) remains unclear. Transanal surgical approaches and endoscopic mucosal resection (EMR) have their limitations related to inadequate visualization, device maneuverability, and securing an adequate margin on the anal side. Endoscopic submucosal dissection (ESD) appears to overcome some of the limitations of transanal surgical and snare-based endoscopic techniques. Therefore, we evaluated the safety and efficacy of ESD for resection of distal rectal lesions within 2cm of the dentate line. This is a large-scale multicenter retrospective study of patients who underwent ESD for RNDLs between 2015 and 2023. The primary outcomes were the rates of R0 and en bloc resection. Secondary outcomes were immediate and delayed adverse events. A total of 255 patients across 20 institutions were included (mean age 63.60, women 52.20%). The median lesion size was 40mm (IQR: 30 to 55), and the median resection time was 110 minutes (IQR: 81 to 169). The en bloc resection rate was 93.70% (n=236), and the rate of R0 resection was 85.40% (n=216). The rate of overall adverse events was 8.70% (n=22, 95% CI: 5.22% to 12.17%), with 13 cases of bleeding (5.10%), 4 cases of full-thickness perforation, and 1 case of postprocedural pain requiring intervention. All AEs were managed conservatively without the need for subsequent surgical or endoscopic interventions. ESD is safe and effective for resecting RNDLs with high en bloc and R0 resection rates, offering the potential for complete resection with minimal morbidity. It offers advantages over TEN, TAMIS, and other forms of transanal surgery due to the anatomy being less conducive to the equipment required for these techniques, lower cost, and lower rates of complications. However, careful patient selection, meticulous procedural planning, and close follow-up are essential to ensure optimal outcomes and minimize the risk of complications. Long-term follow-up studies and additional prospective controlled trials are warranted.

BackgroundRadiolucent head immobilization (RHI) devices have recently been introduced to the neurovascular space for the purpose of procedural efficiency and safety. However, limited data exists to support its efficacy. In this study, we assessed the potential benefits of RHI. We hypothesized that RHI use is associated with improved procedural efficiency without loss of angiographic image quality or increase in radiation exposure.MethodsA single-institution single-physician retrospective cohort study of patients who underwent cerebral digital subtraction angiography (DSA) or middle meningeal artery embolization (MMAE) under conscious sedation over a 1-year period was conducted. Comparative analyses of fluoroscopy time, image quality, and radiation dosage were performed.ResultsSignificantly shorter fluoroscopy times were observed for patients with RHI undergoing DSA (p < 0.05) and bilateral MMAE (p < 0.05). There was no significant difference in fluoroscopy time for patients undergoing a unilateral MMAE. No difference was found in total radiation dose between patients with RHI compared to patients without RHI. A blinded image quality comparison found no differences in image quality or presence of artifact upon review of DSA images.ConclusionUse of RHI devices was associated with significantly lower fluoroscopy times for DSA and bilateral MMAE without sacrificing image quality. RHI may prove beneficial for decreasing procedural times, particularly during longer, conscious sedation procedures.