A Single-center Experience of Radiotherapy in Pediatric Ewing Sarcoma/Primitive Neuroectodermal Tumor of the Chest Wall

AIM

To evaluate the treatment results, prognostic parameters, and treatment-related toxicity in patients with Ewing sarcoma (ES)/primitive neuroectodermal tumor (PNET) of the chest wall who underwent surgery, chemotherapy, and radiotherapy (RT) in a tertiary referral center.

METHODS

The data of 24 patients under 18 years of age with a histologic diagnosis of ES/PNET in the chest wall that received RT in our department between February 2003 and July 2020 were retrospectively evaluated. RT was applied to the primary site±whole involved chest wall and to the whole lung in patients with lung metastasis.

RESULTS

The median age was 8.5 years (range: 1.5 to 17 y), 15 (63%) patients were female and 9 were male (37%). The tumor localization was extrathoracic in 18 (75%) and intrathoracic in 6 (25%) patients. Mediastinal lymph node and distant metastasis (DM) was present in 5 (21%) and 4 (16%) cases at diagnosis, respectively. The median follow-up after RT was 47 months (range: 11 to 162 mo). The 2-year and 5-year overall survival, event-free survival, local recurrence-free survival, and pleural recurrence-free survival were 83% and 48%, 48% and 42%, 74% and 48%, and 61% and 52%, respectively. The overall local control rate was 83% and the pleural control rate was 67%. RT was well tolerated, with 1 case of grade 3 acute dermatitis and 1 case of grade 3 subacute radiation pneumonitis. Late toxicity was observed in 3 (13%) cases.

CONCLUSION

Long-term survival can be achieved with extended-field RT even in patients with ES/PNET of the chest wall with DM. The low toxicity rates allow us to draw the conclusion that RT with modern techniques is an effective and safe treatment modality for these patients.

Post-induction lymph node delineation in nasopharyngeal cancer: A single-center experience

BACKGROUND

We routinely delineate the gross tumor volume (GTV) for the lymph nodes (LN) based on post-induction chemotherapy (IC) MRI in nasopharyngeal carcinoma (NPC). Herein, we investigated the sufficiency of this method, particularly in high-risk LNs.

METHODS

Eighty-one LNs with a high-risk of clinical extranodal extension and/or ≥3-cm diameter in 58 patients were evaluated. A new GTV covering the pre-IC LN volume was delineated for each LN.

RESULTS

The median volume reduction was 72.5% for the GTV and 53.1% for the planning target volume. After a median 43 months, the overall LN local control rate was 97.5%. The 2- and 5-year LN recurrence-free survival, overall survival, and disease-free survival rate was 88.3% and 84.4%, 92.5% and 85.1%, and 86.8% and 79.2%, respectively.

CONCLUSION

IC yields a significant reduction in nodal target volumes, and post-IC nodal volume-based radiotherapy provides excellent LC in NPC, even in high-risk LNs.

The impact of serum albumin-to-alkaline phosphatase ratio in cervical cancer patients treated with definitive chemoradiotherapy

We retrospectively analysed the prognostic significance of serum albumin, alkaline phosphatase (ALP) and albumin to ALP ratio (AAPR) and other prognostic factors affecting the overall survival (OS) and progression-free survival (PFS) in 200 cervical cancer patients treated with definitive chemoradiotherapy (CRT). The prognostic factors for OS and DFS, in addition to the predictive factors of albumin, ALP and AAPR, were investigated. Older age, lymph node metastasis, non-complete response (CR) to treatment and low serum albumin levels emerged as predictors of poor OS and PFS in multivariate analysis. However, with a cut-off value of 0.51, AAPR was not a significant prognostic factor of survival in multivariable analysis. There were no significant differences in clinicopathological factors between patients with low and high AAPR, except for lymph node metastasis, where lymph node metastasis rate was significantly higher in patients with a low AAPR compared to those with a high AAPR. Patients with CR had a significantly higher serum albumin level and AAPR compared to patients without CR. The pre-treatment serum albumin level was independent predictive for survival; therefore, it could be a suitable biomarker to guide systemic therapy and predict patient outcomes. Impact StatementWhat is already known on this subject? Two major determinants of tumour progression are nutritional status and inflammation. The albumin-to-alkaline phosphatase ratio (AAPR), which was originally proposed as a marker for nutritional status and immune response, was recently discovered to be a prognostic factor for various cancer types. However, its utility in the treatment of cervical cancer has not been established.What do the results of this study add? Low serum albumin levels were associated with a significantly shorter OS and PFS in cervical cancer patients treated definitively with CRT. AAPR, on the other hand, was not a significant prognostic factor for survival with a cut-off value of 0.51. Regional lymph node metastasis was significantly more common in patients with a low AAPR than in those with a high AAPR.What are the implications of these findings for clinical practice and/or further research? Patients with multiple clinicopathological risk factors and low serum albumin levels had an increased risk of disease recurrence and a poorer prognosis, highlighting the importance of additional adjuvant treatment strategies in these patients. Due to the preliminary nature of our findings, additional research is required to corroborate them.

Uterine papillary serous and clear cell carcinomas: Comparison of characteristics and clinical outcomes

INTRODUCTION

To assess the rate of disease control and survival after adjuvant treatment in patients with uterine papillary serous (PSC) and clear cell carcinoma (CCC) and compare the results between these two subtypes.

METHODS

The medical charts of 199 patients with de novo uterine PSC or CCC who underwent radiotherapy (RT) following surgery between 2001 and 2019 in three radiation oncology departments were retrospectively evaluated. Adjuvant treatment was decided by a multidisciplinary tumor board. All patients were planned to undergo adjuvant 4-6 cycles of chemotherapy with external beam RT (EBRT) and/or vaginal brachytherapy (VBT).

RESULTS

Median age was 63 years for all, 64 years for PSC, and 59 years for CCC, respectively. Complete surgical staging was applied in 98% of patients. Histopathologic subtype was PSC in 142 (71%) and pure CCC in 57 (29%) patients, respectively. FIGO stage was I in 107 (54%), II in 35 (18%), and III in 57 (28%) patients, respectively. Lympho-vascular space invasion and positive peritoneal cytology (PPC) were present in 42% and 10% of patients, respectively. All patients but 23 (12%) underwent adjuvant chemotherapy. Median follow-up was 49.5 months for all patients, 43.9 months for patients with PSC, and 90.4 months for patients with CCC, respectively. During follow-up, 20 (10%) patients developed pelvic recurrence (PR) and 37 (19%) developed distant metastasis (DM). PSC subtype increased the PR and DM rates, although the latter not statistically significant. The 5-year overall survival and disease-free survival rate was 73% and 69% for all patients, 71% and 66% for patients with PSC, and 77% and 75% for patients with CCC, respectively. The difference was more prominent in patients with stage ≥ IB disease. In multivariate analysis, advanced age and PPC significantly decreased all survival rates.

CONCLUSION

PSC has a worse prognosis than CCC with regard to pelvic and distant recurrence with a trend for decreased survival rates. Therefore, a more aggressive therapy is needed for patients with uterine PSC, particularly in patients with stage ≥ IB disease.

Outcome and safety analysis of endometrial cancer patients treated with postoperative 3D-conformal radiotherapy or intensity modulated radiotherapy

BACKGROUND

We sought to analyze the toxicity rates and the treatment outcomes in endometrial cancer (EC) patients treated with postoperative three-dimensional conformal radiotherapy (3DCRT) and intensity-modulated radiotherapy (IMRT).

MATERIAL AND METHODS

The clinical data of 646 EC patients treated with postoperative adjuvant 3DCRT (265 patients, 41%) or with IMRT (381 patients, 59%) between April 2007 and August 2019 were retrospectively analyzed. The primary endpoints were treatment-related acute and late gastrointestinal (GI) and genitourinary (GU) toxicities. The secondary endpoints were LC and overall survival (OS) and disease-free survival (DFS).

RESULTS

Median follow-up time was 37 months. The rates for acute GI and GU toxicities of any grade for the entire group were 55.6% and 46.8%, respectively. Acute grade ≥2 GI toxicity was significantly less in patients treated with IMRT compared to those treated with 3DCRT (11.0% vs. 19.2%, p=.004). However, no significant difference grade ≥2 GU toxicities was observed between the 3DCRT and IMRT groups (15.1% vs. 11.0%; p=.15). Acute grade ≥2 GI and GU toxicities were higher in patients receiving systemic chemotherapy, while paraaortic field irradiation increases only the risk of acute grade ≥2 GI toxicity. Estimated 3-year late grade ≥3 GI toxicity rates in the 3DCRT- and IMRT-treated patients were 4.6% and 1.9% (p= .03), respectively. The patients treated with adjuvant ChT had higher rates of late serious GI complications than those without adjuvant ChT. No significant difference in terms of survival and disease control was observed between the 3DCRT and IMRT treatment groups. No significant factor for LC was found in the multivariate analysis.

CONCLUSION

In this multicentric study involving one of largest patient population, we found that IMRT-treated EC patients showed comparable clinical outcomes but with a lower incidence of GI toxicities compared with those treated with 3DCRT.

Impact of lymph node ratio in patients with stage IIIC endometrial carcinoma treated with postoperative radiotherapy

Aim: To evaluate the prognostic value of the lymph node ratio (LNR) and other clinicopathological factors in patients with stage IIIC endometrial cancer. Methods: Factors affecting overall survival (OS) and progression-free survival (PFS) were assessed in 397 patients with stage IIIC endometrial cancer treated with postoperative radiotherapy. Patients undergoing the removal of at least ten lymph nodes were included in the study. Results: The 5-year OS and PFS rates were 58% and 52%, respectively, with a median follow-up time of 35.7 months. The LNR cutoff value was 9.6%. In the multivariate analysis, advanced age (≥60 years), grade III tumor, presence of cervical stromal invasion, higher LNR and lack of adjuvant chemotherapy were independent predictors for worse OS and PFS. Conclusion: The LNR is an independent predictor for OS and PFS in patients with stage IIIC endometrial cancer treated with postoperative radiotherapy.

Radiation Recall Dermatitis in Patients Treated With Immune Checkpoint Inhibitors: A Case Report and Literature Review

Radiation recall dermatitis (RRD) is defined as a skin reaction in the previously irradiated area triggered by a systemic agent's administration. The use of immune checkpoint inhibitors (ICI) alone and in combination with other treatments is increasing in many cancers. ICI-associated radiation recall reactions such as dermatitis, pneumonia, and myelitis have been reported so far. We report a case of nivolumab (anti-programmed cell death protein-1 antibody) induced RRD in a patient with head and neck cancer and review the publications reporting RRD associated with other ICI in the literature. The patient was diagnosed with neck metastasis of unknown primary origin and underwent surgery followed by adjuvant chemoradiotherapy (CRT). During the follow-up, radiotherapy (RT) was performed to the left parotid region, right neck level 1b, and the left neck skin due to recurrence. After three months of the last RT session, she was started on nivolumab due to the metastatic disease. Four weeks later, she was represented with erythematous squamous plaque-like lesions starting from the left temporomandibular region and spreading to the anterior chest, which corresponded to the previously irradiated area. A biopsy was performed with the differential diagnosis of skin metastases which revealed subacute spongiotic dermatitis. The lesions completely regressed in two weeks with the use of topical steroids and antihistamine tablets. Nivolumab treatment was not interrupted, and no reaction was observed during or after the next cycle. Although RRD is rarely encountered clinically, it is a diagnosis that should be kept in mind while continuing treatment with systemic agents in patients with a history of RT. With the widespread use of ICI, RRD associated with these treatments could be better defined and appropriately managed.

Investigating the Knowledge, Attitudes and Behaviours of Parents Regarding Vaccine Rejection

Background

With an escalating prevalence, vaccine rejection is one of the ten threats to global health as identified by the World Health Organization in 2019. Vaccine rejection and hesitancy can be defined as the hesitancy of individuals to get vaccinated against diseases that can be prevented by vaccination. This study aimed to investigate the knowledge, attitudes and behaviours of parents who use primary healthcare services.

Methods

Conducted between August and September 2019, this study adopted a descriptive cross-sectional design. The sample size of the study was calculated to be 378, considering a 95% confidence interval and 80% power. The survey form, the data collection tool of the study, included questions concerning sociodemographic characteristics of individuals and their knowledge, attitudes and behaviours regarding vaccination. The data were analysed on SPSS 22.0. Chi-square test was used in statistical analyses, and the significance level was set as p < 0.05.

Results

In the study group, 15.5% of the parents stated that they were hesitant about vaccines in childhood, 81.3% stated that their source of information on vaccines was healthcare staff and 28% stated that it was the internet. The hesitancy level was significantly high among those who believed that vaccines led to autism and infertility and those who did not trust pharmaceutical companies (p < 0.05). The hesitancy level regarding vaccines was significantly lower among those whose source of information was healthcare staff, whereas it was significantly higher among those whose source of information was the internet (p < 0.05).

Conclusions

Parents' beliefs that vaccines led to autism and infertility increased their hesitancy levels. The inaccurate information on the internet and social media increased their hesitancy levels. Hesitancy levels were lower among the parents who received information from healthcare staff.

Key messages

Healthcare staff should organise public trainings on vaccines to reduce the hesitancy levels of parents. Anti-vaccination statements on the internet and social media influence individuals’ vaccination behaviours.

Knowledge and Behavior of Nurses on Childhood Vaccine Refusal in a Hospital of Eastern Turkey

Background

Among 10 global problems of 2019 determined by the World Health Organization, vaccine refusal was one of the problems mentioned. In this context, health services and health personnel whose main objectives are to keep individuals healthy and to prevent diseases have major responsibilities. This study aims to analyze knowledge and behavior of nurses working in Malatya Turgut Özal Hospital on childhood vaccine refusal.

Methods

This study, conducted between June-July 2019, is a descriptive cross-sectional study and its universe is composed of 850 nurses working in Turgut Özal hospital. Sample size was calculated to be 263 at a confidence interval of 95% and strength of 80%. In the questionnaire, sociodemographic questions on nurses and children as well as questions determining nurses' knowledge and behavior on childhood vaccine refusal were asked. Chi-square test and Fisher's Exact Test were used in statistical analyses. p < 0.05 was determined to be significant.

Results

31.7% of nurses participating in the study stated that they had concerns on childhood vaccines. Two-thirds of nurses stated that their knowledge on vaccines were from their education, one-thirds of them knew that childhood vaccines were mandatory by law while three out of four stated they knew the vaccination schedule recommended by the Ministry of Health. The level of concern in those agreeing to the fact that vaccines caused autism and infertility, those stating that they did not trust vaccine-producing companies, and those stating that catching the disease was a better immunization method than vaccination was significantly higher than those not agreeing to these and those who were indecisive (p < 0.05).

Conclusions

One-thirds of nurses was proven to have concerns on childhood vaccines and this rate is rather high. Nurses, being both health personnel and the communication channel for guiding parents, should be provided necessary trainings and practices in order to ease their concerns on vaccination.

Key messages

In-service trainings should be given importance in order to reduce nurses’ concern. Due to the fact that the information source for nurses on vaccination was their education, subjects that would eliminate their concerns should be highlighted.

Knowledge, Attitudes And Behaviors Of Faculty Members On Childhood Vaccine Refusal A University

Introduction

Vaccines stimulate the immune system and provides protection against a large number of diseases. Although there is a lot of scientific evidence that the benefits of vaccines are higher than their risks, concerns can occur in every segment of the community about the safety of vaccines.In this study, we aimed to examine the knowledge, attitudes and behaviors of the faculty members working at Inonu University regarding vaccine rejection.

Methods

This study is a descriptive cross-sectional study, conducted between July and August 2019. The universe of this study consists of 799 faculty members working at Inonu University. Sample size was calculated as 258 with 95% confidence interval and 80% power. The questionnaire used in the study consists of the questions including the sociodemographic characteristics of the faculty members and their knowledge, attitudes and behaviors about childhood vaccine rejection. Chi-square test was used for statistical analysis. p < 0.05 was determined to be significant.

Results

99.1% of the faculty members had their children vaccinated during their childhood. 31.8% of faculty members stated that they were worried about childhood vaccines.As a source of information about vaccines, faculty members stated the scientific articles in highest rate (49.4%).It was found in comparison that parents who applied alternative medicine for their children were more worried about vaccines than those who did not, and those who did not read scientific publications about vaccines were more worried than to those who read (p < 0.05).The levels of anxiety are significantly lower in those who do not think that vaccines cause autism and infertility, and those who trust vaccine producing companies (p < 0.05).

Conclusions

Almost all of the faculty members have their children vaccinated, but their level of anxiety about vaccines is high. In our study, we observed that those who obtained their knowledge about vaccines from scientific articles were less anxious.

Key messages

Faculty members, who are among the most educated groups of the society, have a high level of anxiety about childhood vaccination. By keeping faculty members informed about the scientific publications about vaccines, their concerns about the vaccine can be eliminated.

Posterior Reversible Encephalopathy Syndrome in the Emergency Service

Posterior reversible encephalopathy syndrome (PRES) is an entity characterized by headache, altered mental status, seizures, visual disturbances, and focal neurological signs. The most common etiologies of PRES are hypertension and renal failure, and the most frequent pathophysiology is hyperperfusion. PRES is generally symmetrical, often in the occipital and parietal lobes, and is typically characterized by vasogenic edema in the subcortical white matter. This study involves a 38-year-old female patient who had hypertension, used immunosuppressive drugs and was also found to have nephropathy. After 3 months of treatment for PRES, the patient's symptoms had declined.

Usefulness of C1 esterase inhibitor protein concentrate in the management of hereditary angioedema of oropharyngeal tissue

Hereditary angioedema is an autosomal-dominant disorder caused by mutation of the gene encoding the C1 esterase inhibitor (C1-INH). It manifests as painless, nonpruritic, nonpitting episodic swelling of the subcutaneous tissues, gastrointestinal, and upper respiratory tracts in the absence of urticaria. An attack typically takes 24 h to peak and resolves over 48-72 h. The most serious manifestation is a laryngeal attack associated with upper airway swelling. The aim of this case report is to describe the lifesaving use of a novel C1-INH protein concentrate in a patient with mild-to-moderate dyspnea caused by swelling of the upper airway (larynx) and tongue.

Assessment of respirable dust exposures in an opencast coal mine

All major opencast mining activities produce dust. The major operations that produce dust are drilling, blasting, loading, unloading, and transporting. Dust not only deteriorates the environmental air quality in and around the mining site but also creates serious health hazards. Therefore, assessment of dust levels that arise from various opencast mining operations is required to prevent and minimize the health risks. To achieve this objective, an opencast coal mining area was selected to generate site-specific emission data and collect respirable dust measurement samples. The study covered various mining activities in different locations including overburden loading, stock yard, coal loading, drilling, and coal handling plant. The dust levels were examined to assess miners' exposure to respirable dust in each of the opencast mining areas from 1994 to 2005. The data obtained from the dust measurement studies were evaluated by using analysis of variance (ANOVA) and the Tukey-Kramer procedure. The analyses were performed by using Minitab 14 statistical software. It was concluded that, drilling operations produce higher dust concentration levels and thus, drill operators may have higher incidence of respiratory disorders related to exposure to dust in their work environment.

The amino terminus of the coat protein of Turnip crinkle virus is the AVR factor recognized by resistant arabidopsis

We have isolated three naturally occurring strains of Turnip crinkle virus (TCV) that break resistance in Di-17 Arabidopsis. Two mutations in the N terminus of the TCV coat protein, D4N and P5S, were shown to confer this phenotype. Thus, this region of the coat protein is involved in eliciting resistance responses in Arabidopsis.