State of the Art in Combination Immuno/Radiotherapy for Brain Metastases: Systematic Review and Meta-Analysis

Single-Dose Radiation Therapy for Localized Prostate Cancer: Where Does the Evidence Lead?

Prostate cancer (PCa) remains the most prevalent cancer among men and the second leading cause of cancer-related deaths worldwide. Early diagnosis is crucial as it opens up various treatment options with curative intent. Recent advancements confirm that radiotherapy (RT), particularly through modern techniques like stereotactic body RT (SBRT) and single-dose RT (SDRT), is a safe and effective treatment for both localized and advanced PCa. This manuscript reviews the evolution and current state of primary prostate SDRT, focusing on its benefits and limitations. SDRT offers advantages such as reduced treatment time and enhanced patient convenience, showing promising efficacy and safety, especially for low- and intermediate-risk PCa. Challenges include controlling intrafraction variability and organ motion, as well as minimizing urethral toxicity. Next-generation imaging and MR-guided RT are improving treatment accuracy. While SDRT shows potential for cost-effective PCa treatment, further research is needed to address its limitations and refine its clinical application.

Nutritional Assessment and Management of Patients with Brain Neoplasms Undergoing Neurosurgery: A Systematic Review

BACKGROUND/AIM

Nutritional management in neurosurgical patients with brain neoplasms is critical, as optimal nutritional status is potentially associated with improved clinical outcomes. This systematic review aimed to analyze the impact of pre- and postoperative nutritional assessment and effect of prepost interventions on the clinical outcomes.

METHODS

A systematic review was conducted using the PubMed, Cochrane Library, Embase, and CINAHL databases, complemented by a search of grey literature. Study quality was assessed using the Joanna Briggs Institute framework, and the certainty of evidence was graded according to the Oxford Centre for Evidence-Based Medicine levels.

RESULTS

Fourteen studies, encompassing a total of 11,224 adult patients with brain neoplasms, were included. Many of these studies were retrospective, had small sample sizes, and examined diverse nutritional protocols. Preoperative nutritional status assessment, including clinical parameters such as albumin (p < 0.001), Controlling Nutritional Status score (p = 0.001), and Prognostic Nutritional Index (p < 0.010), combined with postoperative oral nutritional supplements (p < 0.001), was significantly associated with postoperative clinical outcomes. Additionally, personalized nutritional counseling contributed to a reduction in complications and facilitated more effective functional recovery.

CONCLUSIONS

Nutritional care is vital in managing neurosurgical patients with brain neoplasms, reducing complications and enhancing postoperative recovery and overall clinical outcomes. A multidisciplinary team is key to optimal outcomes. Future research should aim to standardize protocols for broader applicability.

Case report of the first use of a hydrogel rectal spacer for prostate cancer reirradiation via LDR brachytherapy: applications and technical notes

Introduction

Prostate cancer remains a prevalent malignancy among men, often necessitating innovative therapeutic strategies for effective management of recurrent cases. This article examines the critical role of a biodegradable hydrogel spacer, which creates a temporary interspace between the prostate and the rectum, thus reducing radiation exposure to healthy tissues.

Case description

We present a case of a man with a history of intermediate-risk prostate adenocarcinoma initially treated with external beam radiotherapy in 2015. Despite initial remission, the patient experienced a rise in prostate-specific antigen (PSA) levels indicative of local recurrence in 2022. Salvage treatment with iodine-125 brachytherapy, preceded by the placement of a rectal spacer in January 2024, resulted in a significant reduction of PSA levels. The patient remains asymptomatic with no urinary or gastrointestinal complications 6 months after the salvage treatment.

Discussion

This case illustrates the complexities in managing recurrent prostate cancer and the evolving role of reirradiation strategies. Salvage iodine-125 brachytherapy with the placement of a rectal spacer provided precise radiation delivery while minimizing rectal toxicities. The significant biochemical response observed underscores the efficacy of this approach in controlling disease progression. The rectal spacer enhances treatment safety by reducing radiation exposure to adjacent tissues, highlighting its importance in reirradiation protocols. This case contributes to the growing evidence supporting the rectal spacer's role in enhancing the safety and efficacy of salvage brachytherapy for recurrent prostate cancer.

Conclusions

Our experience advocates for the integration of a hydrogel rectal spacer as a valuable tool in prostate cancer reirradiation protocols, offering a strategic approach to optimize treatment safety by minimizing rectal toxicity.

Evidences on the Use of Hypofractionation in Postoperative/Salvage Radiotherapy for Prostate Cancer: Systematic Review of the Literature and Recent Developments

BACKGROUND

Radical prostatectomy (RP) is one possible curative treatment for localized prostate cancer. Despite that, up to 40% of patients will later relapse. Currently, post-operative radiotherapy (PORT) courses deliver 1.8-2 Gy daily to reach a total dose ranging between 64 and 74 Gy, completed in 7-8 weeks. Several articles reported encouraging data in terms of the effectiveness and the related toxicities using hypofractionation schedules. The objective of the present systematic review was to evaluate the clinical outcomes and toxicity of the use of hypofractionation in adjuvant/salvage prostate cancer treatments.

METHODS

Medline was searched via PubMed and Scopus from inception to July 2024 to retrieve studies on hypofractionation in adjuvant/salvage prostate cancer treatments. This study was conducted under PRISMA guidelines.

RESULTS

A total of 139 articles were identified from the initial search. Subsequently, the 139 studies were reviewed by title and abstract. Ninety-five studies were excluded due to being either abstracts or articles not available in English. In the second step, the full texts of 44 studies were reviewed. Eleven studies were excluded for being reviews, study protocols, or focused on SBRT treatments. Finally, 33 studies were included in our analysis, with a total number of 4269 patients. Of the 33 selected studies, 20 were retrospective trials and 11 were phase I/II prospective trials, while 2 studies were prospective phase III trials. The follow-up ranged from 18 to 217 months. Failure-free survival, for those with the longer follow-up, ranged between 85% and 91% at 3 years, 47 and 78.6% at 5 years and 51.5% at 10 years. Genitourinary (GU) and gastrointestinal acute toxicity was mild to moderate with similar rates across the normofractionated and hypofractionated groups. Acute grade-3 GU toxicity events were unusual, occurring in less than 4% of the cases overall.

CONCLUSION

The present study is the first systematic review of the literature that includes the first two randomized phase III studies published in the literature. Hypofractionated treatment has been shown to be safe, effective, with moderate toxicity and not inferior to conventional RT, with good biochemical control rates.

Radiation drives tertiary lymphoid structures to reshape TME for synergized antitumour immunity

Radiotherapy (RT) plays a key role in the tumour microenvironment (TME), impacting the immune response via cellular and humoral immunity. RT can induce local immunity to modify the TME. It can stimulate dendritic cell maturation and T-cell infiltration. Moreover, B cells, macrophages and other immune cells may also be affected. Tertiary lymphoid structure (TLS) is a unique structure within the TME and a class of aggregates containing T cells, B cells and other immune cells. The maturation of TLS is determined by the presence of mature dendritic cells, the density of TLS is determined by the number of immune cells. TLS maturation and density both affect the antitumour immune response in the TME. This review summarized the recent research on the impact and the role of RT on TLS, including the changes of TLS components and formation conditions and the mechanism of how RT affects TLS and transforms the TME. RT may promote TLS maturation and density to modify the TME regarding enhanced antitumour immunity.

Radiosurgery in Grade II and III Meningiomas: A Systematic Review and Meta-Analysis

BACKGROUND

Meningiomas are the most prevalent benign intracranial tumors. When they are of the invasive subtypes, i.e., grades II and III, they can recur rapidly and present a real challenge for physicians. This study is focused on the use of stereotactic radiosurgery to manage high-grade meningiomas.

METHOD

Medline via PubMed was searched from inception to December 2022 to retrieve studies on stereotactic radiation therapy for patients with grade II-III meningiomas. This study was conducted under PRISMA guidelines.

RESULT

A total of 29 articles involving 1446 patients with grade II-III meningiomas treated with stereotactic radiation therapy were included in the present study. Of these studies, 11 were conducted exclusively on patients with atypical meningiomas (grade II), 1 targeted anaplastic meningiomas (grade III), and 17 articles were carried out on both grade II and III meningiomas. The pooled 1, 2, 3, 5, and 10-year overall survival (OS) of grade II meningiomas was 0.96 [p < 0.01], 0.89 [p = 0.01], 0.90 [p = 0.09], 0.81 [p < 0.01], and 0.66 [p = 0.55], respectively. The pooled 2, 5, and 10-year OS of grade III meningiomas was 0.64 [p = 0.01], 0.41 [p = 0.01], and 0.19 [p < 0.01], respectively.

CONCLUSIONS

Although long-term prospective studies are still required, the outcomes of stereotactic radiation therapy appear promising regarding overall outcome and progression-free survival.

'Immunotherapeutic Strategies for Intra-cranial Metastatic Melanoma - a Meta-analysis and Systematic Review'

Immune-activating anti-CTLA4 and anti-PD1 monoclonal antibodies (alone or in combination) are being used to treat advanced melanoma patients and can lead to durable remissions, and long-term overall survival may be achieved in between 50-60% of patients. Although intracranial metastases are very common in melanoma (about 50-75% of all patients with advanced disease), most of the pivotal prospective clinical trials exclude patients with intra-cranial metastases, certainly if their lesions are symptomatic and steroid-requiring and the degree of sensitivity of intra-cranial melanoma to immunotherapy remains uncertain, and requires further investigation especially in view of the demonstrable activity of RAF-MEK inhibitors in this clinical setting and the emergence of stereotactic radiotherapy. Our study aimed to evaluate the efficacy and toxicity of immunotherapy against advanced melanoma patients with brain metastases. In terms of comparative studies, only retrospective analyses could be identified. Based on 3 retrospective studies, treatment of patients with melanoma brain metastases with immunotherapeutic approaches improves overall survival substantially compared with supportive measures alone (no active anticancer treatment). The efficacy of targeted therapy appeared to be comparable to that of immune therapy in terms of overall survival, based on a small number of patients. The combination of concurrent radiation therapy to the brain and systemic immunotherapy led to improved overall survival compared to radiotherapy alone, suggesting potential synergism between the approaches, and combination treatment could be delivered safely. Our review supports the use of immunotherapeutic strategies for these patients although treatment efficacy appears to be lower for symptomatic lesions. In view of the extremely high efficacy of stereotactic radiotherapy approaches in the brain, understanding the interaction between radiotherapy and immunotherapy is vital and should be an area of active investigation.

Role of radiotherapy in the management of brain oligometastases

The management of patients with brain oligometastases is complex and relies on specific reasoning compared to extracranial oligometastases. The levels of evidence are still low because patients with brain oligometastases are frequently excluded from randomized clinical trials. Stereotactic radiotherapy should be preferred in this indication over whole brain irradiation, both for patients with metastases in place and for those who have undergone surgery. The decision of local treatment and its timing must be a multidisciplinary reflection taking into account the histological and molecular characteristics of the tumor as well as the intracranial efficacy of the prescribed systemic treatments. Great caution must be observed when using stereotactic radiotherapy and concomitant systemic treatments because interactions are still poorly documented. We present the recommendations of the French society of radiation oncology on the management of brain oligometastatic patients with radiotherapy.

An Overview of Systemic Targeted Therapy in Renal Cell Carcinoma, with a Focus on Metastatic Renal Cell Carcinoma and Brain Metastases

The most commonly diagnosed malignancy of the urinary system is represented by renal cell carcinoma. Various subvariants of RCC were described, with a clear-cell type prevailing in about 85% of all RCC tumors. Patients with metastases from renal cell carcinoma did not have many effective therapies until the end of the 1980s, as long as hormonal therapy and chemotherapy were the only options available. The outcomes were unsatisfactory due to the poor effectiveness of the available therapeutic options, but then interferon-alpha and interleukin-2 showed treatment effectiveness, providing benefits but only for less than half of the patients. However, it was not until 2004 that targeted therapies emerged, prolonging the survival rate. Currently, new technologies and strategies are being developed to improve the actual efficacy of available treatments and their prognostic aspects. This article summarizes the mechanisms of action, importance, benefits, adverse events of special interest, and efficacy of immunotherapy in metastatic renal cell carcinoma, with a focus on brain metastases.

The Evolution of the Sentinel Node Biopsy in Melanoma

The growing repertoire of approved immune-checkpoint inhibitors and targeted therapy has revolutionized the adjuvant treatment of melanoma. While the treatment of primary cutaneous melanoma remains wide local excision (WLE), the management of regional lymph nodes continues to evolve in light of practice-changing clinical trials and dramatically improved adjuvant therapy. With large multicenter studies reporting no benefit in overall survival for completion lymph node dissection (CLND) after a positive sentinel node biopsy (SLNB), controversy remains regarding patient selection and clinical decision-making. This review explores the evolution of the SLNB in cutaneous melanoma in the context of a rapidly changing adjuvant treatment landscape, summarizing the key clinical trials which shaped current practice guidelines.

Linac-based stereotactic salvage reirradiation for intraprostatic prostate cancer recurrence: toxicity and outcomes

BACKGROUND

The rates of local failure after curative radiotherapy for prostate cancer (PC) remain high despite more accurate locoregional treatments available, with one third of patients experiencing biochemical failure and clinical relapse occurring in 30-47% of cases. Today, androgen deprivation therapy (ADT) is the treatment of choice in this setting, but with not negligible toxicity and low effects on local disease. Therefore, the treatment of intraprostatic PC recurrence represents a challenge for radiation oncologists. Prostate reirradiation (Re-I) might be a therapeutic possibility. We present our series of patients treated with salvage stereotactic Re‑I for intraprostatic recurrence of PC after radical radiotherapy, with the aim of evaluating feasibility and safety of linac-based prostate Re‑I.

MATERIALS AND METHODS

We retrospectively evaluated toxicities and outcomes of patients who underwent salvage reirradiation using volumetric modulated arc therapy (VMAT) for intraprostatic PC recurrence. Inclusion criteria were age ≥ 18 years, histologically proven diagnosis of PC, salvage Re‑I for intraprostatic recurrence after primary radiotherapy for PC with curative intent, concurrent/adjuvant ADT with stereotactic body radiation therapy (SBRT) allowed, performance status ECOG 0-2, restaging choline/PSMA-PET/TC and prostate MRI after biochemical recurrence, and signed informed consent.

RESULTS

From January 2019 to April 2022, 20 patients were recruited. Median follow-up was 26.7 months (range 7-50). After SBRT, no patients were lost at follow-up and all are still alive. One- and 2‑year progression free survival (PFS) was 100% and 81.5%, respectively, while 2‑year biochemical progression-free survival (bFFS) was 88.9%. Four patients (20%) experienced locoregional lymph node progression and were treated with a further course of SBRT. Prostate reirradiation allowed the ADT start to be postponed for 12-39 months. Re‑I was well tolerated by all patients and none discontinued the treatment. No cases of ≥ G3 genitourinary (GU) or gastrointestinal (GI) toxicity were reported. Seven (35%) and 2 (10%) patients experienced acute G1 and G2 GU toxicity, respectively. Late GU toxicity was recorded in 10 (50%) patients, including 8 (40%) G1 and 2 (10%) G2. ADT-related side effects were found in 7 patients (hot flashes and asthenia).

CONCLUSION

Linac-based SBRT is a safe technique for performing Re‑I for intraprostatic recurrence after primary curative radiotherapy for PC. Future prospective, randomized studies are desirable to better understand the effectiveness of reirradiation and the still open questions in this field.

The role of immune checkpoint inhibitors in patients with intracranial metastatic disease

Intracranial metastatic disease (IMD) complicates the course of nearly 2-4% of patients with systemic cancer. The prevalence of IMD has been increasing over the past few decades. Historically, definitive treatment for brain metastases (BM) has been limited to radiation therapy or surgical resection. Chemotherapies have not typically proven valuable in the treatment of IMD, with the exception of highly chemotherapy-sensitive lesions. Recent data have supported a role for systemic targeted therapies and immune checkpoint inhibitors (ICIs) in the treatment of select patients with IMD. There remains, however, a clear clinical need for further investigation to delineate the role of ICIs in patients with BM. In this review, we outline and describe recent and current efforts to identify the efficacy of ICI therapy in patients with IMD.

Clinical Effects of Immuno-Oncology Therapy on Glioblastoma Patients: A Systematic Review

The most prevalent and deadly primary malignant glioma in adults is glioblastoma (GBM), which has a median survival time of about 15 months. Despite the standard of care for glioblastoma, which includes gross total resection, high-dose radiation, and temozolomide chemotherapy, this tumor is still one of the most aggressive and difficult to treat. So, it is critical to find more potent therapies that can help glioblastoma patients have better clinical outcomes. Additionally, the prognosis for recurring malignant gliomas is poor, necessitating the need for innovative therapeutics. Immunotherapy is a rather new treatment for glioblastoma and its effects are not well studied when it is combined with standard chemoradiation therapy. We conducted this study to evaluate different glioblastoma immunotherapy approaches in terms of feasibility, efficacy, and safety. We conducted a computer-assisted literature search of electronic databases for essays that are unique, involve either prospective or retrospective research, and are entirely written and published in English. We examined both observational data and randomized clinical trials. Eighteen studies met the criteria for inclusion. In conclusion, combining immunotherapy with radiochemotherapy and tumor removal is generally possible and safe, and rather effective in the prolongation of survival measures.

Radiotherapy improves the outcomes of immunotherapy with Sintilimab in non-small-cell lung cancer: A real-world analysis

Introduction

Radiotherapy may augment systemic antitumor responses to immunotherapy. We did a retrospective study to infer whether radiotherapy improves outcomes to immunotherapy in patients with stage III and IV non-small-cell lung cancer (NSCLC).

Methods

This retrospective study conducted at Enze Medical Center enrolled 259 patients with histopathology confirmed NSCLC from December 2018 to December 31, 2021. All were treated with Sintilimab, some patients received radiotherapy at an appropriate time point. Radiation type includes conventional radiotherapy and stereotactic body radiotherapy. The progression-free survival (PFS), and overall survival (OS) were the primary endpoint.

Results

A retrospective analysis was performed on 259 patients, of whom 140 had been treated with immunotherapy lonely and 119 had been remedied with immunotherapy plus radiotherapy. Baseline variables were well balanced between the two groups, including gender, age, smoking status, TNM staging, number of metastases, ECOG score, pathological type and lines of previous systemic therapy. The median PFS in the immunotherapy alone group was 5.00 months (95%CI 4.38-5.62) versus immunotherapy plus radiotherapy was 9.00 months (5.95-12.05; p<0.001). The median OS in the immunotherapy alone group was 16.00 months (12.59-19.42) versus immunotherapy plus radiotherapy was 30.00 months (20.75-39.25; p=0.027). PFS was finer in the radiotherapy plus immunotherapy group than the immunotherapy group alone in both stage III(P=0.0069) and Stage IV(P=0.006) patients. In the univariate analysis, radiotherapy, male, ECOG=0 and <2 lines of previous systemic therapy were connected with an observably better PFS (P<0.001; P=0.03; P=0.002;P=0.021). In a multivariate analysis, radiotherapy, ECOG=0 and <2 lines of previous systemic therapy were independent prognostic factors with a markedly better PFS (P<0.001; P=0.006;P=0.009). An univariate analysis, radiotherapy, male, stage III, non-metastasis, ECOG=0 and squamous carcinoma were associated with a significantly better OS (P=0.032, P=0.036,P=0.002,P<0.001,P=0.002,P=0.025). A multivariate analysis, non-metastasis was a standalone prognostic indicator with a significantly better OS (P=0.006). However, radiotherapy was a tendency indicator with a better OS (HR0.70 95% CI 0.47-1.06). There were also no obvious increases in adverse events in the combination group.

Conclusions

Radiotherapy with addition of immunotherapy was observably linked to a better outcome in patients with III and IV staging NSCLC.

Stereotactic Body Radiation Therapy (SBRT) for Oligorecurrent/Oligoprogressive Mediastinal and Hilar Lymph Node Metastasis: A Systematic Review

Simple Summary

This paper is a review of the literature on oligorecurrent/oligoprogressive mediastinal and hilar lymph node metastasis treated with SBRT. The use of mediastinal SBRT had historically been not feasible in view of the expected toxicity due to the proximity of critical structures such as the airways and esophagus. Despite the heterogeneity and lack of some data in the studies analyzed, this literature review is the first published and can be a valid guide for the radiotherapist in the management of oligometastatic/oligoprogressive patients, with particular regard to the radiotherapy doses, dose constraints for organs at risk, and clinical outcomes.

Abstract

Introduction: Mediastinal or hilar lymph node metastases are a challenging condition in patients affected by solid tumors. Stereotactic body radiation therapy (SBRT) could play a crucial role in the therapeutic management and in the so-called “no-fly zone”, delivering high doses of radiation in relatively few treatment fractions with excellent sparing of healthy surrounding tissues and low toxicity. The aim of this systematic review is to evaluate the feasibility and tolerability of SBRT in the treatment of mediastinal and hilar lesions with particular regard to the radiotherapy doses, dose constraints for organs at risk, and clinical outcomes. Materials and methods: Two blinded investigators performed a critical review of the Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA), starting from a specific question: What is the clinical impact of SBRT for the treatment of oligorecurrent/oligoprogressive mediastinal and hilar metastasis? All retrospective and prospective clinical trials published in English up to February 2022 were analyzed. Results: A total of 552 articles were identified and 12 of them were selected with a total number of 478 patients treated with SBRT for mediastinal or hilar node recurrence. All the studies are retrospective, published between 2015 and 2021 with a median follow-up ranging from 12 to 42.2 months. Studies following SBRT for lung lesions or retreatments after thorax radiotherapy for stage III lung cancer were also included. The studies showed extensive heterogeneity in terms of patient and treatment characteristics. Non-small cell lung cancer was the most frequently reported histology. Different dose schemes were used, with a higher prevalence of 4–8 Gy in 5 or 6 fractions, but dose escalation was also used up to 52 Gy in 4 fractions with dose constraints mainly derived from RTOG 0813 trial. The radiotherapy technique most frequently used was volumetric modulated arc therapy (VMAT) with a median PTV volume ranging from 7 to 25.7 cc. The clinical outcome seems to be very encouraging with 1-year local control (LC), overall survival (OS) and progression-free survival (PFS) rates ranging from 84 to 94%, 53 to 88% and 23 to 53.9%, respectively. Half of the studies did not report toxicity greater than G3 and only five cases of fatal toxicity were reported. CONCLUSIONS: From the present review, it is not possible to draw definitive conclusions because of the heterogeneity of the studies analyzed. However, SBRT appears to be a safe and effective option in the treatment of mediastinal and hilar lymph node recurrence, with a good toxicity profile. Its use in clinical practice is still limited, and there is extensive heterogeneity in patient selection and fractionation schedules. Good performance status, small PTV volume, absence of previous thoracic irradiation, and administration of a high biologically effective dose (BED) seem to be factors that correlate with greater local control and better survival rates. In the presence of symptoms related to the thoracic lymph nodes, SBRT determines a rapid control that lasts over time. We look forward to the prospective studies that are underway for definitive conclusions.