United States

Abstract Title
The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Background
Altered Mental Status (AMS) ranges from confusion to coma and is frequently encountered in patients admitted to the Intensive Care Unit (ICU). Etiologies include metabolic disturbances, neurological insults, and systemic illnesses. The precise impact of AMS on in-ICU mortality remains an area of ongoing research, necessitating comprehensive evaluation and elucidation. The objective of our study was to identify significant patterns and outcomes associated with the presence of AMS upon initial Emergency Department (ED) presentation to better inform ICU management and enhance patient care.

Methods
A retrospective cohort study was conducted using patient data from the Northwell Health network, focusing on adult ICU admissions between July 1, 2022, and July 1, 2023. The study included 21,900 unique patients. The primary variables were AMS presence and in-ICU mortality, both recorded as binary outcomes. Descriptive statistics were analyzed for patient demographics and clinical characteristics, including gender distribution and racial composition. The association between AMS and in-ICU mortality was tested using a Chi-square test of independence, with statistical significance set at p &lt; 0.05. The impact of AMS on ICU and hospital stays, treatments (steroids and vasopressors), and acute renal failure incidence was further assessed using Chi-square tests with relative risks and 95% confidence intervals calculated.

Results
Patients with AMS experienced longer ICU and hospital stays, averaging 144.3 hours in the ICU and 13.6 days in the hospital compared to 111.3 hours and 10.1 days for those without AMS, respectively. Patients with AMS were more likely to receive steroids, χ2(1, N = 21,900) = 40.0, p &lt; .001, RR = 1.13, 95% CI [1.08, 1.18]. They were also more likely to be on vasopressors, χ2(1, N = 21,900) = 98.2, p &lt; .001, RR = 1.24, 95% CI [1.18, 1.31], and to develop acute renal failure, χ2(1, N = 21,900) = 53.1, p &lt; .001, RR = 1.15, 95% CI [1.10, 1.20]. The Chi-square test demonstrated a significant association between AMS and in-ICU mortality, χ2(1, N = 21,900) = 111, p &lt; .001, RR = 1.13, 95% CI [1.10, 1.17]. 

Conclusion 
AMS presence was significantly associated with longer ICU and hospital length of stay, more frequent need for vasopressors and steroids, a higher occurrence of acute renal failure, and increased in-ICU mortality rates. These findings underline the importance of AMS as a prognostic indicator in ICU settings and stress the need for increased awareness and proactive management of AMS to potentially improve patient outcomes in the ICU.

AMA Research Challenge 2024 

The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Abstract Title
The Impact of Altered Mental Status on Intensive Care Unit Outcomes: A Retrospective Cohort Study

Background
Altered Mental Status (AMS) ranges from confusion to coma and is frequently encountered in patients admitted to the Intensive Care Unit (ICU). Etiologies include metabolic disturbances, neurological insults, and systemic illnesses. The precise impact of AMS on in-ICU mortality remains an area of ongoing research, necessitating comprehensive evaluation and elucidation. The objective of our study was to identify significant patterns and outcomes associated with the presence of AMS upon initial Emergency Department (ED) presentation to better inform ICU management and enhance patient care.

Methods
A retrospective cohort study was conducted using patient data from the Northwell Health network, focusing on adult ICU admissions between July 1, 2022, and July 1, 2023. The study included 21,900 unique patients. The primary variables were AMS presence and in-ICU mortality, both recorded as binary outcomes. Descriptive statistics were analyzed for patient demographics and clinical characteristics, including gender distribution and racial composition. The association between AMS and in-ICU mortality was tested using a Chi-square test of independence, with statistical significance set at p < 0.05. The impact of AMS on ICU and hospital stays, treatments (steroids and vasopressors), and acute renal failure incidence was further assessed using Chi-square tests with relative risks and 95% confidence intervals calculated.

Results
Patients with AMS experienced longer ICU and hospital stays, averaging 144.3 hours in the ICU and 13.6 days in the hospital compared to 111.3 hours and 10.1 days for those without AMS, respectively. Patients with AMS were more likely to receive steroids, χ2(1, N = 21,900) = 40.0, p < .001, RR = 1.13, 95% CI [1.08, 1.18]. They were also more likely to be on vasopressors, χ2(1, N = 21,900) = 98.2, p < .001, RR = 1.24, 95% CI [1.18, 1.31], and to develop acute renal failure, χ2(1, N = 21,900) = 53.1, p < .001, RR = 1.15, 95% CI [1.10, 1.20]. The Chi-square test demonstrated a significant association between AMS and in-ICU mortality, χ2(1, N = 21,900) = 111, p < .001, RR = 1.13, 95% CI [1.10, 1.17]. 

Conclusion 
AMS presence was significantly associated with longer ICU and hospital length of stay, more frequent need for vasopressors and steroids, a higher occurrence of acute renal failure, and increased in-ICU mortality rates. These findings underline the importance of AMS as a prognostic indicator in ICU settings and stress the need for increased awareness and proactive management of AMS to potentially improve patient outcomes in the ICU.

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Background
Multiple studies have demonstrated the predictive value of machine learning-based radiomic approaches to CT imaging in colorectal cancer microsatellite instability (MSI) status diagnosis. This study aimed to identify and formulate potential CT-based imaging characteristics available to the general radiologist without access to radiomics, to differentiate MSI status amongst colorectal cancer tumors.


Methods
109 patients with an average age of 61 years (58 male, 51 female) who were diagnosed with MSI-positive colorectal adenocarcinomas between 2011 and 2018 and received imaging at Banner MD Anderson Cancer Center. This was a retrospective analysis where various imaging features of the primary mass and metastasis were analyzed, including location, size, attenuation (compared to the liver and metastases, if present), growth pattern, tumor margin, primary mass area, and mesenteric infiltration. This data was compared with tumor biopsy MSI staging to identify correlations. Patient information (age, sex, tumor staging) was obtained from medical records. Statistical analysis was performed using chi-square, t-test, and Mann-Whitney U tests.

Results
Five tumor characteristics showed a statistically significant relationship with MSI status. Clinical staging differed significantly between MSI groups (p=0.012). CRC tumors with distant metastasis are more likely to be MSI-L, and those with regional metastasis are more likely to be MSI-H (p<0.001). Primary mass area was larger in the MSI-H group compared to the MSI-L group (p<0.001). CRC tumors in the left colon are more likely to be MSI-L, while those in the right colon are more likely to be MSI-H (p<0.001). MSI-H samples had a lower primary tumor Hounsfield Units standard deviation (SD) than MSI-L samples (p=0.002).
Mesenteric infiltration showed no significant difference (p=0.189). Both MSI-L and MSI-H were likely to be well-defined, with no statistical difference in definition (p=1.000). They were also likely to be homogenous, with no statistical difference in homogeneity (p=0.498). Both MSI groups were more likely to exhibit mucosal rather than mass-like growth, with no statistical difference in growth type (p=0.127). The distribution of Mean Primary Tumor Hounsfield Unit: hyperdense region and mean Liver Hounsfield Unit was the same across MSI categories (p=0.162 and p=0.105, respectively). Both MSI-L and MSI-H were more likely to be hypoattenuating, with no significant relationship between tumor enhancement and MSI status (p=0.376).

Conclusion
Multiple CT imaging characteristics were relevant in predicting the classification of MSI in CRC tumors, holding potential clinical relevance in guiding individualized therapy. While these results were statistically significant, more research must be done to validate these findings.

A Retrospective Study of Colorectal Cancer CT Imaging Features Involving Microsatellite Instability (MSI)

Background 
Cryoablation of acetabular bone lesions risks femoral head osteonecrosis and chondrolysis due to ablation zone propagation through the joint. Traditional thermal insulation methods with gases and fluids are inadequate as they fill the joint recess around the neck. A prior case report suggested hip distraction during acetabular cryoablation can prevent femoral head osteonecrosis. This study utilized a cadaveric model to simulate cryoablation propagation and assess the effectiveness of hip joint distraction for thermal protection. 

Methods 
A cadaver model was used to replicate hip joint distraction during acetabular cryoablation. Three conditions were compared: no intervention (control), intra-articular fluid injection, and hip distraction. The cadaver, warmed to body temperature, underwent 15 pounds of traction to create an 8mm distraction distance. A thermocouple probe placed in the femoral head recorded temperatures every minute during a 10-minute cryoablation treatment. The procedure, using a cryoprobe advanced through a coaxial needle under CT fluoroscopic guidance, simulated a previous case report. 

Results 
Linear regression analysis showed slopes of -1.47, -1.40, and -0.33 for control, liquid, and distraction conditions, respectively. F-tests indicated significant temperature variance differences between control vs. distracted (p<0.0001) and control vs. liquid (p<0.0001), but not between liquid and distraction (p=0.45). The distraction condition maintained a more stable temperature than both the liquid-injected and control conditions. 

Conclusion 
Osteonecrosis and chondrolysis are common complications of cryoablation due to inadequate insulation of the femoral head and acetabulum. This cadaveric study validates hip distraction as a protective method from thermal injury during cryoablation.

Cadaveric Simulation for Hip Protection in Acetabular Tumor Cryoablation

Title: Diagnostic Breast Imaging Performance in Pregnant and Lactating Patients
Purpose: This study aimed to retrospectively assess the diagnostic accuracy of combined mammography and ultrasound (MG+US) in pregnant and lactating women, utilizing the largest sample size to date.
Materials and Methods: A retrospective chart review from January 2013 to June 2024 included pregnant or lactating women who underwent breast imaging at UW Health. Imaging results were classified as true positive, false positive, true negative, or false negative. Reference standards included biopsy or ≥2 years of follow-up for benign cases. The primary outcomes were sensitivity and specificity of MG+US. BI-RADS 3 (probably benign) rates, follow-up adherence, and comparison of BI-RADS 3 utilization between ultrasound alone and MG+US were analyzed using a Z-test for two proportions.
Results: Of 1,000 patients, 756 were lactating and 251 were pregnant, and 7 received additional postpartum imaging. Of the 497 mammograms performed, 57.1% showed extremely dense tissue. The most common symptom prompting imaging was a palpable lump. Fourteen patients were diagnosed with pregnancy-associated breast cancer (PABC), with 13 initially categorized as BI-RADS 4 or 5 by MG+US and 1 by ultrasound alone. BI-RADS 3 recommendation rates were 14% in pregnant patients (71% follow-up adherence) and 12% in lactating patients (62% follow-up adherence). Diagnostic MG+US had 100% sensitivity (13/13), 85% specificity (308/363), 19% positive predictive value (13/63), and 100% negative predictive value (308/308). 
Conclusion: Our study demonstrates that diagnostic breast imaging in pregnant and lactating women is effective and accurate in detecting PABC and should not be delayed. Reduced BI-RADS 3 utilization rates when MG+US is used, compared to ultrasound alone, highlights the added value of mammography in providing a more comprehensive and efficient diagnostic strategy in this patient population. EMR patient reports revealed persistent hesitancy among patients and clinicians about using diagnostic mammography during pregnancy, highlighting the need for clearer communication about its safety. This study contributes to breast imaging research by underscoring the importance of evidence-based imaging algorithms, thereby improving outcomes for pregnant and lactating patients. 
Clinical Relevance: The reduction in BI-RADS 3 utilization with combined mammography and ultrasound helps minimize unnecessary follow-ups and alleviates patient anxiety in pregnant and lactating women. Although combined imaging modalities are generally not recommended for women under 30, revisiting diagnostic imaging protocols for this special population could enhance diagnostic accuracy and improve patient outcomes. Promoting education on safe, evidence-based imaging practices is essential for better management of breast concerns in these patients.


Diagnostic Breast Imaging Performance in Pregnant and Lactating Patients

Background 
Prostate cancer (PCa) is the most diagnosed and second-leading cause of cancer-specific mortality among men in the United States. Prostate needle biopsy remains the standard diagnostic test, and MRI- ultrasound-guided fusion prostate biopsy (fBx) has improved the accuracy of Gleason score (GS) findings and thus PCa risk stratification. However, prostate biopsy only samples a small proportion of the prostate and is prone to error, with GS discordance between fBx and final pathology after radical prostatectomy affecting up to 35% of patients. Recent advances with mpMRI have altered diagnosis and staging strategies for PCa. The lesions at MRI are graded with Prostate Imaging Reporting & Data System (PI-RADS) 1 to 5, with PI-RADS 5 indicating the most concerning features of PCa. Exploring which subgroup of PI-RADS scores is more common to have discordance may be important in helping to determine conservative treatment options. This retrospective study aims to compare the rate of the discordance of GS between fBx and surgery as stratified by PI-RADS scores. 

Methods 
After obtaining IRB approval, we retrospectively reviewed records of patients who underwent RP from January 2016 through June 2024 with prior fBx. The rates of concordance and discordance of PCa GS in PI-RADS scores 3, 4 and 5 were compared between the fBx and surgery. Age, PSA, PSA density, and prostate volume were also noted for all patients. Chi-squared statistical analysis was utilized to assess the data.

Results 
Of the 341 patients, 63 were PI-RADS 3, 99 were PI-RADS 4, and 179 were PI-RADS 5. Overall discordance was 27% for PI-RADS 3, 29% for PI-RADS 4, and 40% for PI-RADS 5. Among them, PCa GS 8-9 at surgery in PI-RADS 5 patients (N=31) had a less aggressive PCa GS of 7 at fBx (11/31, 36%), indicating higher possibility of upgrading from fBx. There was a statistically significant difference in GS discordance between PI-RADS 3 and 4 vs. 5 (27% and 29% vs. 40%) (P<0.05).

Conclusion
Discordance in PCa GS between fBx and surgery is not uncommon, particularly for PI-RADS 5 lesions at MRI. In addition, PI-RADS 5 lesions with preoperative fBx GS 7 are prone to pathologic upgrade to GS 8-9 at surgery. This finding may have important implications for treatment options, particularly for patients who decide to pursue conservative management.

Discordance of Prostate Cancer Gleason Scores between Ultrasound-MRI Fusion Biopsy and Radical Prostatectomy as Stratified by PI-RADS Scores

Background
Cigarette smoking (CS) is highly comorbid with alcohol use disorder (AUD). Both are associated with lower white matter (WM) integrity, with potentially additive effects. This study is a starting point to determine the individual and combined effects of CS and AUD on WM integrity.

Methods
Thirty subjects with varying CS and alcohol use (40.0 ± 12.9 years, 13 females, 17 males) underwent structural (T1-weighted) and diffusion weighted magnetic resonance imaging. Indices of WM integrity, fractional anisotropy (FA) and mean diffusivity (MD), were calculated at a voxel-wise level. Parametric maps of FA and MD were spatially normalized to Montreal Neurological Institute space. Average FA and MD values were extracted for 48 WM tracts from the Johns Hopkins University WM tract atlas.

Alcohol drinking and CS were characterized by: DSM-5 AUD symptom checklist, Obsessive Compulsive Drinking Scale (OCDS, including obsessive and compulsive subscales), Timeline Followback (TLFB; drinks/drinking day and drinks/week), Alcohol Use Disorders Identification Test (AUDIT), Fagerstrom Test for Nicotine Dependence (FTND), self-reported pack years, and cigarettes/day. Linear regression was performed between FA and MD with alcohol and CS metrics.

Results
We found significant negative correlations (p<0.01) between bilateral cingulate gyri FA and total OCDS score and subscales, drinks/drinking day, drinks/week, and AUDIT. Right inferior cerebellar peduncle FA was negatively correlated with FTND and cigarettes/day. Bilateral superior cerebellar peduncle MD was positively correlated with FTND and cigarettes/day. Left cingulate hippocampus MD was positively correlated with OCDS compulsivity. 

Conclusion
Alcohol use was negatively correlated with cingulate gyrus WM FA, which is implicated in goal-directed behavior and salience attribution. CS was negatively correlated with cerebellar peduncle FA; however, the interpretation of this is unclear. Our results support the hypothesis that both CS and AUD negatively impact WM integrity. Future work will determine the potentially additive effects of smoking and alcohol use.

Effect of Cigarette Smoking and Alcohol Use on White Matter Tract Integrity

Abstract Title:
Evolution of Prostate Cancer Screening in Patients with Elevated PSA

Background:
Prostate cancer (PCa) is the second-leading cause of death in men in the United States. There is uncertainty regarding the most appropriate PCa screening algorithm. Previously, the standard practice for PCa screening was based on prostate-specific antigen (PSA) testing followed by systematic transrectal ultrasound-guided biopsy (TRUS bx). Unfortunately, PCa screening using that method was burdened by a high degree of overdiagnosis of clinically insignificant PCa and by underdiagnosis of up to 35% of clinically significant PCa. The recent advancement of multiparametric prostate MRI (mpMRI) has proven to be an accurate tool in diagnosing PCa, with high positive and negative predictive values in detecting cancer. Patients with elevated PSA may benefit from initial prostate MRI to screen for clinically significant PCa before TRUS bx. Prior studies have demonstrated this screening method has resulted in fewer diagnosis of clinically insignificant PCa without losing sensitivity in detecting clinically significant cancer. Thus, we expect to see a shift from the traditional systematic biopsy toward MRI based screening. This study aims to retrospectively evaluate the change in PCa screening algorithms over a 10-year period at one institution, which may provide insight to the current state of prostate cancer screening and provide guidance for referring physicians. 

Methods:
After obtaining IRB approval, we retrospectively identified and reviewed prostate mpMRI studies performed at VCU Health in the years 2012 and 2022. The study only included patients who had elevated PSA with or without prior prostate TRUS bx. Patient records were also noted for prostate volume, PSA, PSA density, and age. Chi-squared test and two-sample t-tests were used for statistical analysis.

Results:
For clinical indication of PCa screening, there were 196 prostate MRI studies performed in 2012 compared to 1,005 studies performed in 2022. Among them, 89.7% of patients had undergone TRUS bx prior to mpMRI in 2012 compared to 18.2% in 2022 (P < 0.05). Average PSA density decreased from 0.34 in 2012 to 0.22 in 2022 among patients for screening mpMRI (P < 0.05). Average age increased from 63.4 to 66.4 years (P < 0.05).

Conclusion:
The frequency of patients undergoing TRUS Bx for PCa screening prior to mpMRI has significantly decreased from years 2012 to 2022. This demonstrates a change in paradigm among clinicians who prefer prostate mpMRI-based screening over TRUS Bx. This practice has likely reduced diagnosis of clinically insignificant PCa, reduced unnecessary invasive procedures, and increased diagnosis of clinically significant PCa.

Evolution of Prostate Cancer Screening in Patients with Elevated PSA; from TRUS Prostate Biopsy to Prostate MRI

Background
Chronic pain is now the number one reason for medical visits and a major driver of the opioid epidemic. Oftentimes, patients with chronic pain exhaust standard treatment options with little symptomatic relief due to our inability to precisely identify pain generators. 18F-FDG PET/MRI provides a highly sensitive method to identify sites of active inflammation. Our overarching goal is to determine whether 18F-FDG PET/MRI can improve outcomes in patients with challenging pain conditions.

Methods
Twenty-two patients, whose source of chronic pain was unclear, were referred for 18F-FDG PET/MR imaging by their physicians. Potential pain generators were identified as increased FDG uptake on PET and/or T2 abnormalities on MRI. The patients were then followed to determine if their referring physicians altered their management based on the imaging findings.

Results
All twenty-two cases had 18F-FDG PET/MRI results that directly impacted management after the results were reviewed with referring clinicians. Based on the findings, either a diagnostic injection at a new site was attempted/recommended or surgery was recommended. One patient had endured a proximal fifth metatarsal fracture and subsequently underwent surgical fixation. However, the patient suffered from chronic right lateral foot pain despite an adequate healing period, negative radiographic findings, and eventual removal of the bone screw. 18F-FDG
PET/MRI revealed increased FDG uptake at the site of the previous fracture, suggesting fracture instability and chronic osteitis. Additionally, MRI showed an inflamed and swollen sural nerve entering an area of scarring near the fracture site. This patient has been referred for anesthetic block of the sural nerve and possible surgical correction of the bone inflammation. Another patient had lower back pain initially attributed to Bertolotti’s disease. However, 18F-FDG PET/MRI demonstrated increased FDG uptake in both sacroiliac joints consistent with
sacroiliitis and a lack of uptake at the pseudo-articulation. Bilateral SI joint injections were performed with excellent symptomatic relief.

Conclusion
Chronic pain is a debilitating condition affecting millions worldwide and is difficult to diagnose due to our inability to target pain generators. 18F-FDG PET/MRI has shown groundbreaking promise in identifying pain sources and in preliminarily altering clinical management, leading to improved quality of life for individuals suffering from chronic pain.

Light ‘Em Up! Early Experience Utilizing 18F-FDG PET/MRI to Pinpoint Pain Generators in Patients with Diagnostically Challenging Chronic Pain

Background: Subdural hematoma (SDH) is a common finding in patients with acute traumatic brain injury (TBI). Traumatic meningeal enhancement (TME) of the subdural space is visible on post-contrast MRI following administration of gadolinium. TME has since been described in patients with SDH, suggesting overlapping pathophysiology. It is unclear if TME is in the continuum of a SDH, or if it is a distinct injury. Given the current debate, we explored the relationship of SDH and TME to determine whether TME is a marker of a SDH, or whether TME is a distinct entity. 

Methods: This retrospective analysis included a subset of consented patients (n=151) that were identified to have post-contrast MRI scans within 48 hours of injury who were selected from the Traumatic Head Injury Neuroimaging Classification (THINC) study. One rater reviewed Gradient Echo (GRE), pre-contrast fluid-attenuated inversion recovery (FLAIR) and post-contrast FLAIR axial brain MRI. Cohen’s kappa was performed. Discordant pairs found during the intra-rater agreement analysis were reviewed by a second independent rater. Areas where SDH was present were inspected for TME. SDH presence outside of TME areas was also noted. Following the rating, study data was reviewed to verify accuracy of interpretation. Contingency tables (2x2) were constructed to analyze reading results. 

Results: Cohen’s kappa demonstrated intrareader and interreader agreement for SDH and TME was substantial (Kappa of 0.9, Kappa of 0.8). Initially, 91 SDH were identified. After reviewing radiologist and prior image interpretations, 20 cases were discordant. Of those, 17 were reclassified as SDH absent, 2 were reclassified SDH present, and 1 did not receive contrast and was excluded from analysis. Of the 150 included patients (99 Males, 51 Females, median age 49 [30-63.8]), 107 (71.3%) had TME, 77 (51.3%) had SDH, and 76 (50.7%) had both. 98.7% of patients with SDH also had TME present (p<0.001). Of these, 72 (94.7%) had SDH and TME overlapping in at least one area. Inversely, only 71% of patients with TME also had SDH present (p<0.001). Only 15.9% of patients with TME had no evidence of brain hemorrhage, and 1 showed SDH with no TME (p<0.001). 

Conclusion: In our population TME was seen without SDH in 31 of 107 cases, SDH and TME were seen together in 76 of 77 cases, but seldom is SDH seen without TME. They likely represent very similar pathophysiology, and the discordance may reflect a spectrum of severity of injury.

Subdural Hematoma and Traumatic Meningeal Enhancement in Patients with Acute Traumatic Brain Injury

Background
RTOG 1205 is the only randomized study to evaluate the safety and efficacy of reirradiation (reRT) in recurrent glioblastoma (GBM). While this study showed reRT was safe and improves progression-free survival (PFS), an improved approach for reRT is needed. Here, we report on patterns of failure and outcomes of a cohort of patients with recurrent GBM who underwent reRT. We hypothesize that patients at high risk of leptomeningeal spread (LMS) are not good candidates for reRT due to the risk of treatment-related toxicity without clinical benefit.

Methods
In this retrospective study, patients with recurrent GBM who underwent reRT at a single institution from 2015-2023 were included. Sociodemographic, treatment, and outcomes data were collected via chart review. Response assessment in neuro-oncology criteria (RANO) was used to evaluate treatment response. PFS and overall survival (OS) were estimated using the Kaplan-Meier method.

Results
Thirteen patients with recurrent GBM who underwent reRT were identified. Median age at diagnosis was 58. Six patients (46.2%) had tumors that were MGMT methylated, four (30.8%) were MGMT unmethylated, and three (23.11%) had unknown MGMT status. Eight patients underwent repeat resection after recurrence and prior to reRT. Most patients (n=7) received 35 Gy in 10 fractions with concurrent bevacizumab, while other patients were treated with 25-40 Gy in 5-15 fractions with grade 1 or less acute toxicity. Three patients were treated with tumor-treating fields. Median follow up was five months. Median PFS was three months (95% confidence interval [95% CI], 1-4 months) and median OS was five months (95% CI, 1-8 months) as compared to 7.1 months and 10.1 months, respectively, on RTOG 1205. Five patients developed LMS after reRT, one patient died prior to progression, and the remaining seven patients all developed progression within one centimeter of the recurrent tumor. Of the patients who developed LMS, all had tumors abutting the ventricles and three underwent resection 2-17 months prior to reRT.

Conclusion
Patterns of failure suggest a potential treatment selection approach for patients with recurrent GBM, in which patients at high risk of LMS (tumor abutting ventricles with or without recent surgery) should not undergo reRT, while patients at low risk of LMS are good candidates for reRT. Furthermore, reRT could be administered with reduced margins given that all non-LMS recurrences were within 1cm of the original tumor. Additional studies are needed to validate this approach.

The Patterns of Failure and Prognostic Impact of Tumor Location in Patients Undergoing Reirradiation for Glioblastoma

Background
Pulmonary arterial hypertension (PAH) is a life-limiting complication of systemic sclerosis (SSc), with median survival of 3 years. Within PAH therapy, a notable heterogeneity of response exists, leading to identification of a subset of patients termed ‘super-responders’. Although lacking a universally accepted definition, super-responders experience significantly greater benefits compared to the average population. Here, we define super-responders as patients demonstrating a 2-point improvement in their NYHA functional class. In this study, we aim to explore the impact of prostacyclin therapy on SSc-PAH and review the potential clinical and molecular markers that could predict super-responder status.

Methods
This is a retrospective case series with a collection of data of four patients seen at Albany Medical Center between 2010 to 2024 with a diagnosis of SSc and PAH, who were treated with prostacyclin and showed an improvement in their functional status and pulmonary hemodynamics. After obtaining IRB approval, data was extracted that included patient demographics, time of onset of PAH, functional class, and right heart catheterization findings before and after treatment with prostacyclin.

Results
Our study included 3 females and 1 male patient with a median age of 46 years. All patients received prostacyclin therapy: two subcutaneous Treprostinil, one inhaled Treprostinil, and one started subcutaneously before transitioning to oral medication. Clinically, all patients experienced a 2-point improvement in NYHA functional class within approximately a year of prostacyclin therapy. Additionally, all patients had improvements in pulmonary hemodynamics, evidenced by reductions in the mean pulmonary artery pressures (mPAP) and pulmonary vascular resistance (PVR), following prostacyclin therapy as observed via right heart catheterization (table 1). Median survival to date is 9 years.


Conclusion
Our SSc-PAH patients achieved long term survival, notable improvements in functional status and even near normalization of pulmonary hemodynamics after prostacyclin therapy, indicating sustained benefits beyond mere stabilization.

Current studies speculate that prostacyclin therapy not only causes pulmonary artery vasodilation, but also influences vascular remodeling process by potentially recruiting endothelial progenitor cells (EPCs) into the pulmonary vasculature, as well as reducing the number and procoagulant activity of platelet micro-vesicles (PMVs). It will be worthwhile to investigate EPC count and PMVs as surrogate markers for prostacyclin response to address treatment response heterogeneity.



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