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.

Talonavicular-cuneiform arthrodesis in the management of Mueller-Weiss Syndrome: a retrospective case series

Mueller-Weiss Syndrome (MWS), characterized by spontaneous adult-onset tarsal navicular osteonecrosis, is an uncommon cause of chronic midfoot pain that can lead to functional impairment and progressive deformities. This study aimed to present clinical and radiological outcomes of talonavicular-cuneiform (TNC) arthrodesis in the treatment of patients with MWS. A retrospective study was performed on 8 consecutive patients (6 female, 2 male; mean age = 50 years; range = 33-64) who underwent TNC arthrodesis using plate fixation with autologous bone grafting for the treatment of MWS. To evaluate clinical status, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Midfoot Score was performed immediately preoperatively and at the final follow-up. In radiographic evaluation, talus-first metatarsal angle (Meary's angle) was measured preoperatively and at the final follow-up. Solid fusion was also examined on postoperative radiographs and computerised tomography. The mean follow-up was 35 months (range = 24-52). The mean AOFAS improved from 37 (range = 24-53) preoperatively to 85 (range = 80-93) at the final follow-up (p < 0.001). No major intra- operative complications were observed in any of the patients. According to the Maceira and Rochera radiological staging system, 5 feet was stage 3, and 3 feet was stage 4. The mean union time was 10 months (range = 5-15). Radiographic solid fusion was achieved in all but one foot that developed talonavicular non-union. TNC arthrodesis using plate fixation with autologous bone grafting seems to be an effective surgical method for reconstruction of MWS.

Involved-site Radiotherapy Delineation Dilemmas in the Treatment of Adult Hodgkin Lymphoma: Turkish Society for Radiation Oncology Hematological Oncology, Pediatric Oncology and TBI Study Group Case-based Questionnaire Review (TROD 03-005)

AIMS

The International Lymphoma Radiation Oncology Group (ILROG) defined involved-site radiotherapy (ISRT) guidelines. These rules offer a certain variability that allows for autonomous decision-making in diverse clinical settings. However, this flexibility also gives rise to conflicts about the selection of treatment fields in the daily decision-making process. The aim of this study was to show the extent of interobserver variability when ILROG-ISRT recommendations were used in different clinical scenarios.

MATERIALS AND METHODS

The 10-question survey used in our study consisted of two parts (part A and part B) and was prepared by four senior radiation oncologists experienced in the haemato-oncology field. The results were presented by stratifying according to clinical experience (<10 years, ≥10 years). Binomial tests (one-sided) were conducted to assess whether answers for each group and the whole group reached a consensus.

RESULTS

Twenty-six radiation oncologists, 13 of whom had less than 10 years of experience and 13 seniors, participated in the survey. Eighty per cent of respondents thought ILROG did not bring sufficient solutions for all clinical scenarios but offered solutions in some cases. In different case-based scenarios, the consensus among the respondents decreased down to 38%. Senior radiation oncologists were found to have more doubts about the adequacy of current guidelines.

CONCLUSIONS

ILROG guidelines allow for a high degree of variability in real-life clinical scenarios and different interpretation of the recommendations may lead to increased toxicity and recurrences. Therefore, there is a need for refinement in ISRT delineation strategies. On behalf of the Turkish Society for Radiation Oncology Hematological Oncology, Pediatric Oncology and TBI Study Group, we are planning to carry out further educational contouring sessions to detect the interobserver variability in real-life contouring cases.

Radiosensitising Effects of Metformin Added to Concomitant Chemoradiotherapy with Cisplatin in Cervical Cancer

AIMS

The role of metformin on the radiosensitising effect of cisplatin is not clear. Here we investigated the radiosensitising effect of metformin alone and combined with cisplatin in HeLa cells, as well as the implications of the adenosine monophosphate-activated protein kinase (AMPK) pathway on the radiosensitising effect.

MATERIALS AND METHODS

HeLa cells were treated with ionising radiation, metformin, cisplatin, A769662 (AMPK activator) and dorsomorphin (AMPK inhibitor) or in combination. A cell proliferation assay, Western blot and flow cytometry were carried out.

RESULTS

Metformin potentiated cisplatin cytotoxicity when administered 4 h before ionising radiation. Although the radiosensitising effects of metformin and cisplatin alone were observed, which is more apparent at high ionising radiation doses, the metformin-cisplatin combination did not increase the radiosensitivity of cisplatin at any ionising radiation dose. Dorsomorphin alone significantly decreased cell proliferation and potentiated the radiosensitising effects of cisplatin with ionising radiation. Administration of A769662 24 h prior to cisplatin treatment resulted in an increased AMPK level that yielded resistance to cisplatin, but this effect was not observed in HeLa cells concomitantly treated with A769662 and cisplatin.

CONCLUSIONS

Modulation of AMPK may have a role in cervical cancer treatment. Increased AMPK levels result in higher sensitivity to ionising radiation but causes resistance to cisplatin. Dorsomorphin is proven to be a potent radiosensitising agent. The use of metformin alone may be an option as a radiosensitiser during high-dose ionising radiation (e.g. intracavitary brachytherapy).

Revisiting the Radical Radiotherapy-Radiochemotherapy Results in Anal Canal Cancers: (TROD Gastrointestinal Group Study 02-005)

BACKGROUND AND AIM

This study aimed to determine treatment outcomes and factors affecting prognosis in patients diagnosed with anal canal cancer who received radical radiotherapy (RT) or radiotherapy combined with chemotherapy (CT-RT) in radiation oncology centers in Turkey and compare the results with literature.

MATERIAL AND METHOD

The study included 193 patients with anal canal cancer reported between 1995 and 2019, of which 162 had complete data. The study was conducted in 11 radiation oncology centers, and a joint database was shared among them. Patients received radiotherapy doses of 45 Gy to 60 Gy. Data analysis was done using SPSS for Windows version 20.

RESULTS

Median follow-up was 48.51 months (2-214). All patients received radiotherapy, and 140 (86.4%) received concurrent chemotherapy. Radiotherapy doses of 50.4 Gy to 60 Gy were administered to 74 patients (45.7%) using 2-dimensional-3-dimensional (2D-3D) conformal therapy and 70 patients (43.2%) using intensity modulated radiotherapy technique (IMRT). Acute phase hematologic toxicity was observed in 62 patients (38.3%), and nonhematologic toxicity in 123 patients (75.9%). The 5-year overall survival (OS) rate was 75.1% and disease-specific survival (DSS) rate was 76.4%. OS without colostomy was achieved in 79,8 % at 5 years, and complete response in 112 patients (69.1%). OS rate was significantly higher in 142 patients with positive response (P < .000) and 112 with complete response (P < .000). Anemia (P < .002), local progression, and systemic progression (P < .000) resulted in lower OS (P < .002). In univariate analysis, factors affecting OS rate were: gender, age, stage, lymph node status, T stage, RT treatment duration, and treatment planning with PET fusion, which were found to be statistically significant. Completing radiotherapy in less than 45 days, concurrent chemotherapy, and continued administration of mitomycin and 5 FU as chemotherapy had a significant positive effect on overall survival. OS rate was higher in patients receiving RT dose of 58 Gy or less and undergoing IMRT planning in radiotherapy. IMRT was associated with lower acute and late side effects.

CONCLUSION

Radiochemotherapy is the primary treatment for anal canal cancer and advanced radiotherapy techniques may increase survival by reducing side effects and improving treatment continuation. Higher treatment doses require further investigation. The efficacy of treatment can be improved by including patients treated with modern radiotherapy techniques in multicenter prospective studies using new and more effective chemotherapy and immunotherapy agents.

Simultaneous integrated or sequential boost to clinically involved lymph nodes in patients with locally advanced cervical cancer treated with definitive chemoradiotherapy

OBJECTIVE

The optimal treatment of metastatic lymph nodes (LNs) in locally-advanced cervical cancer (LACC) is controversial. With the widespread use of modern radiotherapy (RT) techniques, it is become possible to perform dose escalation in clinically involved LNs. This study aimed to evaluate the oncologic outcomes of dose escalation to the involved LNs with the simultaneous-integrated (SIB) or sequential boost (SEB) techniques as a part of definitive chemoradiotherapy (CRT) for patients with LACC.

METHODS

The data of 47 patients treated with definitive CRT with either a SIB or SEB technique to the metastatic LNs between 2015 and 2021 were retrospectively analyzed. All patients received 50.4 Gy/28 fractions of external-beam RT and 28 Gy/4 fractions of brachytherapy.

RESULTS

The number of boosted LNs was 146. The median size of the LNs was 2 cm (range, 1-5 cm). The median cumulative equivalent dose in 2-Gy fractions for the LNs was 64.2 Gy (range, 57.6-71.2 Gy). During the median 30 months of follow-up (range, 14-91 months), no boosted LNs recurred and the local control (LC) rate was 100%. The 2-year overall, disease-free, local recurrence-free, and distant metastasis-free survival rate was 83.1%, 70.5%, 77.5%, and 74.4%, respectively. In multivariate analysis, the non-squamous cell histology was the only negative independent prognostic factor for DFS and DMFS. Treatment was well tolerated without any serious acute toxicity. Serious late toxicity developed in three (6%) patients as ureteral stenosis, rectal bleeding and pelvic fracture in one patient each.

CONCLUSIONS

RT dose escalation provides excellent LC for the clinically involved LNs, even for bulky ones, with a low toxicity profile. Routine LN dissection may not be necessary. However, randomized trials are needed to determine the optimal treatment approach.

Applicator-guided proton therapy versus multichannel brachytherapy for vaginal vault irradiation

To dosimetrically compare applicator-guided intensity-modulated proton therapy (IMPT) and multichannel brachytherapy (MC-BRT) for vaginal vault irradiation (VVI) with special focus on dose to organs at risk (OARs) and normal tissues. Ten patients with uterine confined endometrial cancer who received adjuvant vaginal cuff brachytherapy were included in this study. For each patient an additional IMPT treatment plan was created using the same computed tomography dataset and contours segmented for MC-BRT plans. Clinical target volume (CTV) was defined as the proximal 3.5 cm of the vagina including the entire thickness of vaginal wall. Planning target volume for IMPT plans was generated from the CTV with an addition isotropic 3 mm margin. OARs included rectum, bladder, sigmoid, small bowel and femoral heads. The prescribed dose was 21 Gy in 3 fractions. For simplicity, all doses were expressed in Gy and a constant relative biological effectiveness of 1.1 was used for IMPT plans. Plan comparison was performed using dose-volume histogram and treatment planning parameters. A significant improvement of the D98% coverage for CTV was reached by the applicator-guided IMPT plans (p < 0.01). IMPT also provided a dose reduction in all OARs except for femoral heads due to the lateral beam direction, especially significant reduction of V5Gy, D2cc, D0.1 cc, Dmean, V95% values for the rectum and Dmean, D0.1 cc to bladder, sigmoid, small bowel. Additionally, IMPT plans showed a significant reduction of integral dose to normal tissue with respect to MC-BRT (221.5 cGy.L vs. 653.6 cGy.L, p < 0.01). Applicator-guided IMPT has the potential for improving plan quality in VVI while maintaining the high conformity afforded by the state-of-the-art intracavitary brachytherapy.

Inter-observer variation of target volume delineation for CT-guided cervical cancer brachytherapy

Purpose

Delineation is a critical and challenging step in radiotherapy planning. Differences in delineation among observers are common, despite the presence of contouring guidelines. This study aimed to identify the inter-observer variability in the target volume delineation of computed tomography (CT)-guided brachytherapy for cervical cancer.

Material and methods

Four radiation oncologists (ROs) with different expertise levels delineated high-risk (HR) and intermediate-risk (IR) clinical target volume (CTV) according to GYN GEC-ESTRO recommendations, in a blinded manner on every CT set of ten locally advanced cervical cancer cases. The most experienced RO's contours were determined as the index and used for comparison. Dice similarity coefficient (DSC) and pairwise Hausdorff distance (HD) metrics were applied to compare the overlap and gross deviations of all contours.

Results

Median DSC for HR-CTV and IR-CTV were 0.73 and 0.76, respectively, and a good concordance was achieved for both in majority of contours. While there was no difference in DSC measurements for HR-CTV among the three ROs, RO-3 provided improved DSC values for IR-CTV (p = 0.01). Median HD95 was 5.02 mm and 6.83 mm, and median HDave was 1.69 mm and 2.21 mm for HR-CTV and IR-CTV, respectively. There was no significant difference among ROs in HR-CTV for HD95 or HDave; however, IR-CTV value was significantly improved according to RO-3 (p = 0.01). Case-by-case HD analysis showed no significant inter-observer variations, except for two cases.

Conclusions

The inter-observer agreement is generally high for target volumes in CT-guided brachytherapy for cervical cancer. The agreement is lower for IR-CTV than HR-CTV. The individual characteristics of each case and different expertise levels of the ROs may have caused the differences. Despite the good concordance for delineation, dosimetric consequences can still be clinically significant.

Improving normal tissue sparing using scripting in endometrial cancer radiation therapy planning

The aim of this study was to improve the protection of organs at risk (OARs), decrease the total planning time and maintain sufficient target doses using scripting endometrial cancer external beam radiation therapy (EBRT) planning. Computed tomography (CT) data of 14 endometrial cancer patients were included in this study. Manual and automatic planning with scripting were performed for each CT. Scripts were created in the RayStation™ (RaySearch Laboratories AB, Stockholm, Sweden) planning system using a Python code. In scripting, seven additional contours were automatically created to reduce the OAR doses. The scripted and manual plans were compared to each other in terms of planning time, dose-volume histogram (DVH) parameters, and total monitor unit (MU) values. While the mean total planning time for manual planning was 368 ± 8 s, it was only 55 ± 2 s for the automatic planning with scripting (p < 0.001). The mean doses of OARs decreased with automatic planning (p < 0.001). In addition, the maximum doses (D2% and D1%) for bilateral femoral heads and the rectum were significantly reduced. It was observed that the total MU value increased from 1146 ± 126 (manual planning) to 1369 ± 95 (scripted planning). It is concluded that scripted planning has significant time and dosimetric advantages over manual planning for endometrial cancer EBRT planning.

Stromal or intraepithelial tumor-infiltrating lymphocytes: which one has more prognostic significance in cervical cancer?

PURPOSE

To investigate the effect of tumor-infiltrating lymphocytes (TILs) and tumor associated macrophages (TAMs) on treatment results in patients with cervical squamous cell carcinoma who underwent definitive or adjuvant radiotherapy (RT) or chemoradiotherapy (CRT).

METHODS

Pathological specimens were evaluated from 96 cervical cancer patients who were treated with definitive or adjuvant RT/CRT between April 2001 and January 2020. The percentage of intraepithelial TILs (iTILs) and stromal TILs (sTILs) were calculated, and immunohistochemistry was used for identifying lymphocyte lineage with CD4, CD8, and CD20 antibodies and macrophages with CD68 antibody. Prognostic values of TILs/TAMs on oncological outcomes were evaluated.

RESULTS

Thirty patients had early-stage disease and 66 patients had advanced-stage disease. Sixty-three and 33 patients received adjuvant RT and definitive CRT, respectively. Low number of sCD20 positive cells was associated with large tumor size and parametrial invasion. In multivariate analysis, low percentage of sTILs and advanced-stage disease were independent poor prognostic factors for overall survival, disease-free survival (DFS), and distant metastasis-free survival; low number of sCD4 positive cells was also an independent poor prognostic factor for DFS. Low percentage of sTILs and low number of sCD8 positive cells was correlated with high rates of distant metastasis (p = 0.038 and p = 0.025, respectively).

CONCLUSION

sTILs have superior predictive value than iTILs in terms of prognosis. Stromal compartment should be investigated as a routine practice in TIL studies in cervical cancer. Intensifying the treatment in cervical cancer patients with low number of sTILs should be studied in further investigations.

Multi-institutional study on the role of post-operative radiotherapy in elderly patients with endometrial cancer

OBJECTIVE

To investigate the prognostic factors for survival and toxicities in elderly (≥65 years) patients with endometrial cancer who underwent post-operative radiotherapy. Additionally, to compare the treatment outcomes between the older elderly (≥75 years) and younger elderly (65-74 years) patients.

METHODS

Medical records of patients with enometrial cancer treated between January 1998 and July 2019 were reviewed. Patients with stage IA to IIIC2, all histology subtypes, and any grade were included. All patients underwent total abdominal hysterectomy and received adjuvant radiotherapy with or without chemotherapy. All but 67 (8.4%) of 801 patients had lymph node dissection. Clinicopathological factors and treatment strategies were compared between the two age groups. The prognostic factors for overall survival and progression-free survival were investigated.

RESULTS

A total of 801 patients with enometrial cancer, 627 patients (78.3%) younger elderly and 174 patients (21.7%) in the older elderly group were included. Median follow-up was 74.3 months (range 0.4-224.6). The older elderly patients had significantly higher rates of grade 3 tumors (51.7% vs 40.8%; p=0.04), cervical glandular involvement (21.8% vs 14.0%; p=0.03), and cervical stromal invasion (34.5% vs 27.9%; p=0.04) than the younger elderly patients. The rates of lymph node dissection (p=0.2), radiotherapy modalities (p=0.92), and systemic chemotherapy (p=0.2) did not differ between the two groups. The 5-year locoregional control and distant metastasis rates were 88.3% and 23.8%, respectively. The 5-year cause-specific survival and progression-free survival rates for younger and older elderly patients, were 79.8% vs 74.3% (p=0.04) and 67.5% vs 57.8% (p<0.001), respectively. In multivariate analysis, larger tumor size, non-endometrioid histology, cervical stromal involvement, and stage III disease were associated with poor cause-specific survival and progression-free survival. Age was an independent predictor of worse progression-free survival, but not of cause-specific survival. There was no significant difference in acute and late gastrointestinal and genitourinary toxicities between age groups.

CONCLUSIONS

Post-operative radiotherapy for elderly patients with endometrial cancer is effective and well tolerated. Advanced age should not preclude appropriate treatment, especially in those with adequate quality of life, life expectancy, and functional status.

Stereotactic body radiotherapy boost in patients with cervical cancer

Our aim was to evaluate the oncological outcomes of stereotactic body radiotherapy (SBRT) boost in patients with cervical cancer. The data of 21 patients who received SBRT boost after definitive radiotherapy (RT) or chemoradiotherapy (CRT) between March 2012 and April 2019 were retrospectively evaluated. External beam radiotherapy (EBRT) was applied to patients with a total dose of 50.4 Gy in 28 fractions. Kaplan-Meier method was used for survival analysis (IBM SPSS 23 software) and p < .05 value was considered significant. After definitive RT or CRT, there was a complete response in 9 (43%) patients, partial response in 11 (52%) patients and stable disease in 1 (5%) patient. The median follow-up period was 28 months (range, 7.5-88 months). Two-years cancer-specific survival rate was 80%. While 2-year LC rate was 75% in patients with residual tumour size <4 cm, it was 50% when there was ≥4 cm residual tumour after definitive CRT (p = .1). The treatment was well-tolerated and no acute or late toxicity was observed. Although brachytherapy (BRT) is an essential part of the treatment in locally advanced cervical cancer, SBRT may be used in patients with small residual disease who are not candidate for BRT. IMPACT STATEMENTCervical cancer is one of the most common cancers in the world, and external beam radiotherapy (EBRT) and brachytherapy (BRT) are the main treatment options. However, in rare cases where BRT is not feasible, it has been questioned whether stereotactic body radiotherapy (SBRT) as an alternative to BRT.What is already known on this subject? Nowadays, BRT still appears to be the gold standard treatment. However, studies with a small number of patients and short follow-up periods in the literature show that SBRT can be a good alternative in cases where BRT cannot be performed.What do the results of this study add? Our study is one of the series with the largest number of patients in the literature and with the longest follow-up period. In this area where there is no prospective study, we think that retrospective data with high patient numbers are enlightening.What are the implications of these findings for clinical practice and/or further research? Our study shows that SBRT is an alternative option in cases with small residual disease where BRT cannot be applied, and it provides a basis for a prospective randomised study.

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.

Evaluating the effect of tumor size and sidedness on prognosis in stage 2 colon cancer: a retrospective population study

OBJECTIVE

In this study, we aimed to evaluate the effect of tumor size and tumor sidedness on prognosis in patients with stage 2 colon cancer.

PATIENTS AND METHODS

Data of 501 patients diagnosed with stage 2 colon cancer were evaluated retrospectively. It was evaluated whether the patients' age, gender, tumor differentiation, tumor node metastasis (TNM) stage, overall survival rate, and disease-free survival rate had any correlation with horizontal tumor diameter and tumor sidedness. In the ROC analysis performed to determine the cut-off value for the tumor diameter, which we think will predict survival, no significant results were obtained with maximum sensitivity and specificity. Therefore, the median value of the tumor diameter, which is 5 cm, was accepted as the cut-off value.  Kaplan-Meier method and Cox regression analysis were used for survival analysis and determination of prognostic factors.

RESULTS

When the patients were evaluated in terms of tumor localization, 189 (37.7%) patients had right colon tumors and 312 (62.3%) patients had left colon tumors. There was no statistically significant difference in terms of disease-free survival and overall survival according to tumor localization. When the patients were analyzed by dividing them into two groups according to the horizontal tumor size (<5 cm and ≥5 cm), no statistically significant difference was found between the groups in terms of disease-free survival (DFS) and overall survival (OS) p=0.085, p=0.699, respectively.

CONCLUSIONS

Our results suggest that the management of patients with stage 2 colon cancer requires a better understanding of tumor biology rather than features such as tumor size and localization.

Role of radiotherapy in oligometastatic breast cancer: Review of the literature

Metastatic breast cancer has been historically considered as an incurable disease. Radiotherapy (RT) has been traditionally used for only palliation of the symptoms caused by metastatic lesions. However, in recent years the concept of oligometastatic disease has been introduced in Cancer Medicine as a clinical scenario with a limited number of metastases (≤ 5) and involved organs (≤ 2) with controlled primary tumor. The main hypothesis in oligometastatic disease is that locoregional treatment of primary tumor site and metastasis-directed therapies with surgery and/or RT may improve outcomes. Recent studies have shown that not all metastatic breast cancer patients have the same prognosis, and selected patients with good prognostic features as those younger than 55 years, hormone receptor-positive, limited bone or liver metastases, a low-grade tumor, good performance status, long disease-free interval (> 12 mo), and good response to systemic therapy may provide maximum benefit from definitive treatment procedures to all disease sites. While retrospective and prospective studies on locoregional treatment in oligometastatic breast cancer demonstrated conflicting results, there is an increasing trend in favor of locoregional treatment. Currently, available data also demonstrated the improvements in survival with metastasis-directed therapy in oligometastatic breast cancer. The current review will discuss the concept of oligometastases and provide up-to-date information about the role of RT in oligometastatic breast cancer.

Ovarian Carcinoma Presenting With a Large Cervical Mass

Cervical metastasis in ovarian cancer is a rare entity. Therefore, care should be taken in the differential diagnosis of cervical masses as it may mimic a primary tumor. This report aimed to emphasize the importance of a multidisciplinary approach in these tumors. We present a case of a 73-year-old female who presented with post-menopausal vaginal bleeding and cervical mass. The patient was diagnosed with ovarian carcinoma with a multidisciplinary approach. Although cervical metastasis of ovarian cancer is rare, the possibility of secondary cancer should be kept in mind, especially in cervical tumors with atypical clinical course.

Factors affecting prognosis and treatment strategies in metastatic soft tissue sarcomas: twenty years of experience

OBJECTIVE

In this study, we aimed to reveal the general clinicopathological features, treatment features, and factors that could predict overall survival in metastatic soft tissue sarcomas, a very rare and heterogeneous disease group.

PATIENTS AND METHODS

This study was a retrospective cohort study. Patients monitored with metastatic soft tissue sarcoma between January 2001 and January 2021 were evaluated retrospectively. Patients aged 18 years and over, histopathologically diagnosed with metastatic STS, and unsuitable for operations, such as local curative surgery or metastasectomy, were included in the study.

RESULTS

A total of 179 patients in the metastatic stage and monitored in our center were included in the study. The median follow-up period was 8.4 months (IQR, 3.4-14.4). 58 (32.4%) patients were de-novo metastatic, and 121 (67.6%) patients developed metastasis later. The median age was 53.2 (Range: 18.8-87.6 years), and 101 (56.4%) patients were male. The most common primary location was the lower extremity (87) (48.6%). The most common histological subtypes were synovial sarcoma (38) (21.2%), pleomorphic sarcoma (37) (20.7%), and liposarcoma (26) (14.5%). The majority were grade 3 tumors (n=131, 73.2%). Having ECOG PS 2-3 (HR=2.829, 95% CI 1,667-4.800, p<0.001), having tumor grade as 3 (HR=1.748, 95% CI 1.150-2.656, p<0.009), receiving palliative chemotherapy (HR=0.294, 95% CI 0.144-0.600, p<0.001), and receiving two or more lines of chemotherapy among those palliative receivers (HR=2.505 95% CI 1.696-3.700, p<0.001) were independent predictive factors of mortality.

CONCLUSIONS

Survival in metastatic soft tissue sarcoma is better in patients with good ECOG performance status, low tumor grades, and who have received palliative chemotherapy. Receiving more than one line of palliative systemic treatment for progressive disease improves survival.

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.

Pediatric Neuroblastoma with Brain Metastasis: The Prognostic Role of Surgery

AIM

Brain metastasis in pediatric neuroblastoma is uncommon and with poor prognosis. This study was aimed to analyze the prognostic factors and treatment outcomes of neuroblastoma patients with brain metastasis.

MATERIAL AND METHODS

The medical records of 7 patients with brain metastasis among 120 neuroblastoma patients treated with radiotherapy between June 2002 and December 2018 at our department were collected retrospectively. Survival time and prognostic factors were evaluated.

RESULTS

The prevalence of brain metastasis was 7/120 (5.8%). The median age was 35 months (25-64). Three (43%) patients had single brain metastasis. Two (29%) patients with solitary metastases underwent gross total resection and 1 (14%) patient with two lesions underwent subtotal resection for brain metastasis. All patients received chemotherapy and radiotherapy. The median time interval between the initial diagnosis and the brain metastasis was 14 months (0-28 months) in all patients; 12 months (0-28 months) in deceased patients and 23 months (19-26 months) in patients who were still alive at the time of this analysis (p=0.245). The median overall survival time after the treatment of brain metastasis was 14 months (7-22 months). Five patients died from progressive disease and 2 patients who had gross total resection were alive for 164 and 187 months, respectively. While the 5-year overall survival rate was 67% in patients with isolated brain metastasis, the 5-year overall survival rate was 0% in the presence of other metastases (p = 0.221).

CONCLUSION

Isolated brain metastasis and gross total resection of the brain metastasis seems to be favorable prognostic factors. Patients with solitary brain metastasis should be consulted for brain surgery.

Multi-institutional validation of the ESMO-ESGO-ESTRO consensus conference risk grouping in Turkish endometrial cancer patients treated with comprehensive surgical staging

In this study, 683 patients with endometrial cancer (EC) after comprehensive surgical staging were classified into four risk groups as low (LR), intermediate (IR), high-intermediate (HIR) and high-risk (HR), according to the recent consensus risk grouping. Patients with disease confined to the uterus, ≥50% myometrial invasion (MI) and/or grade 3 histology were treated with vaginal brachytherapy (VBT). Patients with stage II disease, positive/close surgical margins or extra-uterine extension were treated with external beam radiotherapy (EBRT)±VBT. The median follow-up was 56 months. The overall survival (OS) was significantly different between LR and HR groups, and there was a trend between LR and HIR groups. Relapse-free survival (RFS) was significantly different between LR and HIR, LR and HR and IR and HR groups. There was no significant difference in OS and RFS rates between the HIR and HR groups. In HR patients, the OS and RFS rates were significantly higher in stage IB - grade 3 and stage II compared to stage III and non-endometrioid histology without any difference between the two uterine-confined stages and between stage III and non-endometrioid histology. The current risk grouping does not clearly discriminate the HIR and IR groups. In patients with comprehensive surgical staging, a further risk grouping is needed to distinguish the real HR group.Impact statementWhat is already known on this subject? The standard treatment for endometrial cancer (EC) is surgery and adjuvant radiotherapy (RT) and/or chemotherapy is recommended according to risk factors. The recent European Society for Medical Oncology (ESMO), European Society of Gynaecological Oncology (ESGO) and European Society for Radiotherapy and Oncology (ESTRO) guideline have introduced a new risk group. However, the risk grouping is still quite heterogeneous.What do the results of this study add? This study demonstrated that the current risk grouping recommended by ESMO-ESGO-ESTRO does not clearly discriminate the intermediate risk (IR) and high-intermediate risk (HIR) groups.What are the implications of these findings for clinical practice and/or further research? Based on the results of this study, a new risk grouping can be made to discriminate HIR and IR groups clearly in patients with comprehensive surgical staging.

Does Internal Mammary Node Irradiation for Breast Cancer Make a Significant Difference to the Diameter of the Internal Mammary Artery? Correlation with Computed Tomography

Objective

Lymphatic irradiation in breast cancer improves locoregional control and has been shown to decrease distant metastasis. However, irradiation also accelerates the formation of atherosclerosis and can cause stenosis, not only in the coronary arteries but also in the internal mammary artery (IMA). The aim of this study was to investigate the effects of radiation on IMAs via computed tomography (CT).

Methods

We reviewed the data of 3,612 patients with breast cancer treated with radiotherapy (RT) between January 2010 and December 2016. We included 239 patients with appropriate imaging and nodal irradiation in the study. All patients were treated with lymphatic irradiation of 46-50 Gy, and a boost dose (6-10 Gy) to the involved internal mammary nodes (IMNs) when imaging studies demonstrated pathological enlargement. Bilateral IMA diameter and the presence of calcification were assessed via thin contrast-enhanced CT and those of ipsilateral irradiated IMAs were compared with those of contralateral nonirradiated IMAs.

Results

The mean diameter of irradiated IMAs was significantly shorter than that of nonirradiated IMAs, regardless of laterality. All vascular calcifications were determined on the irradiated side. A boost dose of radiation to the IMNs and radiation technique did not significantly affect the IMA diameter or the presence of calcification.

Conclusions

The diameter of the IMA is decreased due to RT regardless of laterality, radiation technique, and administration of a boost dose. Evaluation of vessels on CT before coronary artery bypass graft or flap reconstruction can help the surgeon select the most appropriate vessel.

Role of vaginal brachytherapy boost following adjuvant external beam radiotherapy in cervical cancer: Turkish Society for Radiation Oncology Gynecologic Group Study (TROD 04-002)

OBJECTIVE

There are a limited number of studies supporting vaginal brachytherapy boost to external beam radiotherapy in the adjuvant treatment of cervical cancer. The aim of this study was to assess the impact of the addition of vaginal brachytherapy boost to adjuvant external beam radiotherapy on oncological outcomes and toxicity in patients with cervical cancer.

METHODS

Patients treated with post-operative external beam radiotherapy ± chemotherapy ± vaginal brachytherapy between January 2001 and January 2019 were retrospectively evaluated. The treatment outcomes and prognostic factors were analyzed in patients treated with external beam radiotherapy with or without vaginal brachytherapy.

RESULTS

A total of 480 patients were included in the analysis. The median age was 51 years (range 42-60). At least two intermediate risk factors were observed in 51% of patients, while 49% had at least one high-risk factor. The patients in the external beam radiotherapy + vaginal brachytherapy group had worse prognostic factors than the external beam radiotherapy alone group. With a median follow-up time of 56 months (range 33-90), the 5-year overall survival rate was 82%. There was no difference in 5-year overall survival (87% vs 79%, p=0.11), recurrence-free survival (74% vs 71%, p=0.49), local recurrence-free survival (78% vs 76%, p=0.16), and distant metastasis-free survival (85% vs 76%, p=0.09) rates between treatment groups. There was no benefit of addition of vaginal brachytherapy to external beam radiotherapy in patients with positive surgical margins. In multivariate analysis, stage (overall survival and local recurrence-free survival), tumor histology (recurrence-free survival, local recurrence-free survival and distant metastasis-free survival), parametrial invasion (recurrence-free survival and distant metastasis-free survival), lymphovascular space invasion (recurrence-free survival), and lymph node metastasis (distant metastasis-free survival) were found as negative prognostic factors.

CONCLUSION

Adding vaginal brachytherapy boost to external beam radiotherapy did not provide any benefit in local control or survival in patients with cervical cancer.

AB0743 DISEASE CHARACTERISTICS OF PSORIATIC ARTHRITIS PATIENTS MAY DIFFER ACCORDING TO AGE AT PSORIASIS ONSET: CROSS-SECTIONAL ANALYSIS OF PSORIATIC ARTHRITIS-INTERNATIONAL DATABASE

Background:

Psoriasis and psoriatic arthritis (PsA) are heterogenous diseases with various disease manifestations and phenotypes. Psoriasis has a bimodal age of onset being early (before the age of 40, type 1) and late. The impact of this classification on the PsA features is not well understood.

Objectives:

To compare the PsA characteristics of patients with early- and late-onset psoriasis in a large, multicenter database

Methods:

PSART-ID (Psoriatic Arthritis-International Database) is a prospective, multicenter web-based registry (www.trials-network.org) of patients with PsA. A detailed data collection was performed including demographics (sex, age, duration of education, smoking status, BMI), skin features (psoriasis onset date, type, initially involved site of skin, nail involvement (ever) and family history) and PsA characteristics (type of articular involvement and presence of axial, dactylitis (ever), enthesitis (ever), family history) and indices for disease activity and function (DAPSA, Leeds enthesitis index, BASDAI, BASFI, patient and physician global assessment, pain, HAQ-DI). We grouped according to the age at psoriasis onset (early onset, psoriasis before the age of 40 (EOPsO); late-onset, psoriasis after the age of 40 (LOPsO)), patient and disease characteristics of the groups were compared (1). Due to the differences among groups, following adjustments weer made: BMI for age, nail involvement for PsO disease duration, axial PsA for PsA disease duration.

Results:

A total of 1634 (62.8% females; EOPsO, 1108 (67.8%); LOPsO, 526 (32.2%)) patients with PsA was recruited. Rate of over-weight patients was higher in LOPsO group (66.8% vs. 86.8%, p<0.001; adjusted for age - aOR 1.55 (1.11-2.20; % 95 CI)). The EOPsO group had the scalp involvement as the initial site of skin disease more often than the LOPsO group (56.7% vs. 43.0%, p<0.001), whereas extremity involvement was more frequent as the initial finding in the LOPsO group (EOPsO vs. LOPsO 63.8% vs. 74.2%, p<0.001). Nail involvement (ever) was more prominent in EOPsO group, however, the significance was disappeared when adjusted for psoriasis duration. Interaction between gender and both axial disease and psoriatic disease family history were found (axial disease in man; EOPsO vs LOPsO; 38.0% vs. 25.4%; p=0.005; adjusted for PsA duration - aOR 0.56 (0.38-0.84; %95 CI) // psoriatic disease family history in females; EOPsO vs LOPsO; 39.5% vs. 30.1%; p=0.003; OR 0.65 (0.50-0.86; %95 CI)). Duration between PsO and PsA was significantly longer in EOPsO group (148 vs. 24 months, p<0.001). In EOPsO group, more patients had PsO preceeding PsA than LOPsO group (81.8% vs. 60.6%, p<0.001), however, synchronous disease -defined as the diagnosis of PsO and PsA within the same year- was more common in LOPsO group (16.6% vs. 30.3%, p<0.001) (Table 1). Psoriatic disease activity parameters, patient and physician reported outcomes and HAQ-DI scores were similar in both groups.

Table 1.

Comparison of psoriatic arthritis patients‘ characteristics according to age at psoriasis onset

Conclusion:

Clinical features of PsA may be affected by the age at the onset of psoriasis. As the genetic background is different in early and late-onset psoriasis, this may suggest a different pathogenetic mechanism based on the psoriasis phenotype, also affecting the PsA features. Further prospective studies are needed to define whether the classification of PsA requires including psoriasis phenotypes as well.

References:

[1]Henseler T, Christophers E. Psoriasis of early and late onset: characterization of two types of psoriasis vulgaris. J Am Acad Dermatol. 1985;13(3):450-6.

Disclosure of Interests:

Emre Bilgin: None declared, Özün Bayindir: None declared, esen kasapoğlu: None declared, Sibel Bakirci: None declared, Dilek Solmaz: None declared, Gezmiş Kimyon: None declared, Atalay Doğru: None declared, Ediz Dalkiliç: None declared, Cem Özişler: None declared, Meryem Can: None declared, Servet Akar: None declared, Emine Figen Tarhan: None declared, Şule Yavuz: None declared, Levent Kiliç: None declared, Orhan Küçükşahin: None declared, Ahmet Omma: None declared, Emel Gönüllü: None declared, Fatih Yildiz: None declared, Duygu Ersözlü: None declared, abdurrahman tufan: None declared, Muhammet Çinar: None declared, Abdulsamet Erden: None declared, Sema Yilmaz: None declared, Seval Pehlevan: None declared, Tuncay Duruöz: None declared, Sibel Aydin: None declared, Umut Kalyoncu Consultant of: Abbvie, Amgen, Janssen, Lilly, Novartis, UCB

AB0761 DEMOGRAPHIC AND CLINICAL FEATURES OF JUVENILE-ONSET PSORIATIC ARTHRITIS: RESULTS FROM PsART-ID REGISTRY

Background:

Although psoriatic arthritis (PsA) may be seen at any decades, juvenil onset PsA is relatively rare. Moreover, there were no more data about clinical features, treatments, and course in juvenile PsA when they reached to adult age.

Objectives:

The objective of this study was to assess and compare demographic and clinical features for juvenile onset PsA and adult onset PsA.

Methods:

PsART-ID is a multicenter, international database, investigating the disease characteristic in real life (1). Briefly, demographic data, PsA subtypes, uveitis, enthesitis, dactylitis, Co-morbidities, disease activity scores (TJC, SJC, VAS-pain, VAS patients and physician global assessments, VAS-fatigue, BASDAI), and functional status (HAQ-DI, BASFI) were recorded. Psoriasis and PsA starting age were noted, as well. Patients were classified as juvenile PsA or juvenile PsO (under 18 years old). Results were compared regarding to juvenile versus adult onset age.

Results:

Overall, 1644 PsA patients were included to study, 301/1644 (18.3%) patients had juvenile onset psoriasis. Of 39/1644 (2.4%) patients had juvenile onset PsA, as well. As expected, juvenile onset PsA patients were younger, however PsA disease duration were longer than adult onset PsA patients. There were no any difference between demographic and clinical data, except BMI and enthesitis were less frequently at the juvenile onset PsA groups. Although, ever csDMARD using were similar between two groups, however, juvenile onset PsA patients were used more frequently bDMARDs.

Table.

Comparison of demographic and clinical characteristics of juvenile and adult-onset psoriatic arthritis

Juvenile onsetAdult onsetpN (%)39 (2.4)1605 (97.6)Female Sex n (%)24 (61.5)1006 (62.7)0.884PsA beginning age mean (SD)13.3 ± 3.8542.3 ± 12.9<0.001Current age mean (SD)26.6 ±10.747.3 ±13.07<0.001Duration of psoriasis (years)17.10 ± 11.2614.75 ± 11.780.124Duration of psoriatic arthritis (years)13.5 ±115.06 ± 6.7<0.001Cigarette smoking (ever) n (%)15/38641/14940.72Education duration/year (mean,SD)10.09 ± 3.679.52 ± 4.810.464BMI (kg/m2) (mean, SD)24.5 ±5.128.3 ± 5.21<0.001Family history of PsO/PsA n (%)15 (38.5)559 (34.9)0.642Nail involvement n (%)18 (46.2)762 (47.5)0.864Dactilitis n (%)9 (23.7)367 (24)0.958Entesitis n (%)3 (7.9)384 (25.7)0.013Uveitis n (%)-13 (4.3)0.713Axial involvement (%)15 (38.5)464 (29)0.199Methotrexate36 (92.3)1348 (84)0.162Sulfasalazine17 (43.6)612 (38.1)0.488Leflunomide14 (35.9)379 (23.6)0.076Biologic DMARDs102 (33.9)358 (26.8)0.013

Conclusion:

Although psoriasis may be seen frequently in the juvenile age, juvenile onset PsA was not so frequent in our PsA cohort. Although, ever csDMARD using were similar between two groups, however, juvenile onset PsA patients were used bDMARDs more frequently.

References:

[1]Kalyoncu U et al. The Psoriatic Arthritis Registry of Turkey: results of a multicenter registry on 1081 patients. Rheumatology. 2017;56:279-286.

Disclosure of Interests:

Serpil ERGULU EŞMEN: None declared, Ozun Bayindir: None declared, esen kasapoğlu: None declared, Sibel Bakirci: None declared, Dilek Solmaz: None declared, Gezmiş Kimyon: None declared, Atalay Doğru: None declared, Ediz Dalkiliç: None declared, Cem Özişler: None declared, Meryem Can: None declared, Servet Akar: None declared, Emine Figen Tarhan: None declared, Sule Yavuz: None declared, Levent Kiliç: None declared, Orhan Küçükşahin: None declared, Ahmet Omma: None declared, Emel Gönüllü: None declared, Fatih Yildiz: None declared, Duygu Ersözlü: None declared, abdurrahman tufan: None declared, Muhammet Çinar: None declared, Abdulsamet Erden: None declared, Sema Yilmaz: None declared, Seval Pehlevan: None declared, Mehmet Tuncay Duruöz: None declared, Sibel Aydin: None declared, Umut Kalyoncu Consultant of: Abbvie, Amgen, Janssen, Lilly, Novartis, UCB

Female genital tract rhabdomyosarcoma in childhood and adolescence: A single center experience

e22518

Background: Rhabdomyosarcoma is a rare tumor in children and adolescents, presenting 3% to 4% of all pediatric cancers. The female genital tract is considered as a favorable site of childhood RMS. The outcome has improved significantly during the last two decades, attributed to risk stratification and multimodality management of these challenging tumors. Here we present the clinical features and treatment results of girls with genital tract rhabdomyosarcoma to discuss. Methods: Fourteen girls with vaginal and uterine servical rhabdomyosarcoma younger than 18 years of age diagnosed and followed up between the years of 1995 and 2019 were included in this analysis. The clinical features and treatment results of patients were recorded from patient files and hospital information system retrospectively. Results: There were seven cases with vaginal and seven with uterin cervical carcinoma. All patients presented with polypoid masses protruding from the vagina. Median age of patients at diagnosis was 71 months (range 8-200 months). The IRS modified TNM staging was stage I for all the patients. All cases had embryonic type of RMS except one with alveolar type. All patients were treated with surgery and adjuvant chemotherapy, three received radiotherapy additionally. All achieved complete remission. Four patients experienced tumor relapse, 1 patient died with progressive disease. The median follow-up time was 75 months (7-271 months) for 13 patients who were alive with remission. Conclusions: Rhabdomyosarcoma is a rare sarcoma with a higher incidence in children and adolescents. With current treatment strategies, female genital tract rhabdomyosarcomas have a good prognosis. Favorable prognostic factors such as early stage at diagnosis and a favorable histology may contribute to the excellent observed survival. All parties who had involved on the care of these girls must be aware of the high survival with proper treatment to avoid treatment related morbidities and mortalities. Because of the rareness of the disease we wanted to share our experience.

Economic burden of severe asthma in Turkey: a cost of illness study from payer perspective

Summary

Objective. To estimate economic burden of severe asthma in Turkey from payer perspective based on expert panel opinion on practice patterns in clinical practice. Methods. This cost of illness study was based on identification of per patient annual direct medical costs for the management of sever easthma in Turkey from payer perspective. Average per patient direct medical cost was calculated based on cost items related to outpatient visits, laboratory and radiological tests, hospitalizations and interventions, drug treatment and equipment, and co-morbidities/complications. Results. Based on total annual per patient costs calculated for outpatient admission ($ 177.91), laboratory and radiological tests ($ 82.32), hospitalizations/interventions ($ 1,154.55), drug treatment/equipment ($ 2,289.63) and co-morbidities ($ 665.39) cost items, total per patient annual direct medical costrelated to management of severe asthma was calculated to be $ 4,369.76 from payer perspective. Drug treatment/equipment (52.4%) was the main cost driver in the management of severe asthma in Turkey, as followed by hospitalizations/interventions (26.4%) and co-morbidities (15.2%). Conclusions. In conclusion, our findings indicate that managing patients with severe asthma pose a considerable burden to health economics in Turkey, with medications as the main cost driver.

Stereotactic radiotherapy in patients with oligometastatic or oligoprogressive gynecological malignancies: a multi-institutional analysis

INTRODUCTION

Data supporting stereotactic body radiotherapy for oligometastatic patients are increasing; however, the outcomes for gynecological cancer patients have yet to be fully explored. Our aim is to analyze the clinical outcomes of stereotactic body radiotherapy in the treatment of patients with recurrent or oligometastatic ovarian cancer or cervical cancer.

METHODS

The clinical data of 29 patients (35 lesions) with oligometastatic cervical cancer (21 patients, 72%) and ovarian carcinoma (8 patients, 28%) who were treated with stereotactic body radiotherapy for metastatic sites were retrospectively evaluated. All patients had <5 metastases at diagnosis or during progression, and were treated with stereotactic body radiotherapy for oligometastatic disease. Patients with ≥5 metastases or with brain metastases and those who underwent re-irradiation for primary site were excluded. Age, progression time, mean biologically effective dose, and treatment response were compared for overall survival and progression-free survival.

RESULTS

A total of 29 patients were included in the study. De novo oligometastatic disease was observed in 7 patients (24%), and 22 patients (76%) had oligoprogression. The median follow-up was 15.3 months (range 1.9-95.2). The 1 and 2 year overall survival rates were 85% and 62%, respectively, and the 1 and 2 year progression-free survival rates were 27% and 18%, respectively. The 1 and 2 year local control rates for all patients were 84% and 84%, respectively. All disease progressions were observed at a median time of 7.7 months (range 1.0-16.0) after the completion of stereotactic body radiotherapy. Patients with a complete response after stereotactic body radiotherapy for oligometastasis had a significantly higher 2 year overall survival and progression-free survival compared with their counterparts. In multivariate analysis, early progression (≤12 months) and complete response after stereotactic body radiotherapy for oligometastasis were the significant prognostic factors for improved overall survival. However, no significant factor was found for progression-free survival in the multivariable analysis. No patients experienced grade 3 or higher acute or late toxicities.

CONCLUSIONS

Patients with early detection of oligometastasis (≤12 months) and with complete response observed at the stereotactic body radiotherapy site had a better survival compared with their counterparts. Stereotactic body radiotherapy at the oligometastatic site resulted in excellent local control rates with minimal toxicity, and can potentially contribute to long-term survival.

Stereotactic ablative radiotherapy for bone metastasis of gastrointestinal stromal tumor: Case report and review of the literature

Background

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. These tumors are rare and only make bone metastases at a rate of 5%.

Case summary

A 31-year-old male with a GIST presented with solitary bone metastasis at the right iliac bone. We performed stereotactic ablative radiotherapy (SABR) and achieved excellent local control. Herein, our case is presented, and a short review of the literature is carried out.

Conclusion

SABR should be considered as a treatment option in GIST with bone metastasis.

A multi-institutional analysis of sequential versus 'sandwich' adjuvant chemotherapy and radiotherapy for stage IIIC endometrial carcinoma

Objective

To analyze the outcomes of sequential or sandwich chemotherapy (ChT) and radiotherapy (RT) in patients with node-positive endometrial cancer (EC).

Methods

Data from 4 centers were collected retrospectively for 179 patients with stage IIIC EC treated with postoperative RT and ChT (paclitaxel and carboplatin). Patients were either treated with 6 cycles of ChT followed by RT (sequential arm; 96 patients) or with 3 cycles of ChT, RT, and an additional 3 cycles of ChT (sandwich arm; 83 patients). Prognostic factors affecting overall survival (OS) and progression-free survival (PFS) were analyzed.

Results

The 5-year OS and PFS rates were 64% and 59%, respectively, with a median follow-up of 41 months (range, 5–167 months). The 5-year OS rates were significantly higher in the sandwich than sequential arms (74% vs. 56%; p=0.03) and the difference for 5-year PFS rates was nearly significant (65% vs. 54%; p=0.05). In univariate analysis, treatment strategy, age, International Federation of Gynecology and Obstetrics (FIGO) stage, pathology, rate of myometrial invasion, and grade were prognostic factors for OS and PFS. In multivariate analysis, non-endometrioid histology, advanced FIGO stage, and adjuvant sequential ChT and RT were negative predictors for OS, whereas only non-endometrioid histology was a prognostic factor for PFS.

Conclusion

Postoperative adjuvant ChT and RT for stage IIIC EC patients, either given sequentially or sandwiched, offers excellent clinical efficacy and acceptably low toxicity. Our data support the superiority of the sandwich regimen compared to the sequential strategy in stage IIIC EC patients for OS.

Is there any benefit of paraaortic field irradiation in pelvic lymph node positive endometrial cancer patients? A propensity match analysis

We evaluated the survival outcomes and recurrence patterns of endometrial cancer (EC) patients with pelvic lymph node metastases who received postoperative radiotherapy (RT) to the pelvis (P-RT) or to the pelvis plus paraaortic lymph nodes (PA-RT) with or without systemic chemotherapy (ChT). The data from 167 patients with stage IIIC1 EC treated with postoperative RT or RT and ChT were collected retrospectively. Those patients with pelvic lymph node metastases were treated with either P-RT (106 patients, 63%) or PA-RT (61 patients, 37%). The median follow-up time for the entire cohort was 49 (range = 5-199) months. The patients receiving adjuvant ChT and RT had significantly higher 5-year OS rates (77% vs. 33%, p < .001) and 5-year PFS rates (71% vs. 30%, p < .001) when compared to those receiving adjuvant RT alone. The patients receiving P-RT and ChT had significantly higher 5-year OS rates and 5-year PFS rates when compared to those treated with adjuvant PA-RT in the entire cohort and matched cohort. Adjuvant ChT together with RT is the strongest predictor of the OS and PFS. Prophylactic PA-RT is unnecessary, even if ChT is used together with P-RT in EC patients with pelvic lymph node metastasis.Impact statementWhat is already known on this subject? Local and distant recurrence risks are relatively higher in patients with stage IIIC disease, postoperative adjuvant treatment is required to reduce the recurrence risk. Adjuvant RT is a common approach for patients with locally advanced EC. Optimal target volume for RT in patients with stage IIIC EC remains controversial. We demonstrated that extended field RT is unnecessary, even if ChT is used together with pelvic RT in stage IIIC EC patients.What do the results of this study add? We demonstrated that adjuvant ChT together with RT is the strongest predictor of the OS and PFS for EC patients with pelvic lymph node metastases. Extended field RT is unnecessary, even if ChT is used together with pelvic RT in EC patients with pelvic lymph node metastases.What are the implications of these findings for clinical practice and/or further research? Although adjuvant treatment modalities are associated with improvements in survival, distant metastasis still remains the most common site of recurrence in advanced EC patients. Thus, further research is warranted to identify improved combined modality strategies to optimise the outcomes for EC patients with pelvic lymph node metastasis.

Dosimetric comparison of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for left-sided chest wall and lymphatic irradiation

Introduction

The aim of this study was to compare five different techniques for chest wall (CW) and lymphatic irradiation in patients with left‐sided breast carcinoma.

Methods

Three‐dimensional conformal radiotherapy (3DCRT), forward‐planned intensity‐modulated radiotherapy (FP‐IMRT), inverse‐planned IMRT (IP‐IMRT; 7‐ or 9‐field), and hybrid IP‐/FP‐IMRT were compared in 10 patients. Clinical target volume (CTV) included CW and internal mammary (IM), supraclavicular (SC), and axillary nodes. Planning target volumes (PTVs), CTVs, and organs at risks (OARs) doses were analyzed with dose–volume histograms (DVHs).

Results

No differences could be observed among the techniques for doses received by 95% of the volume (D95%) of lymphatics. However, the FP‐IMRT resulted in a significantly lower D95% dose to the CW‐PTV compared to other techniques (P = 0.002). The 9‐field IP‐IMRT achieved the lowest volumes receiving higher doses (hotspots). Both IP‐IMRT techniques provided similar mean doses (Dmean) for the left lung which were smaller than the other techniques. There was no difference between the techniques for maximum dose (Dmax) of right breast. However, FP‐IMRT resulted in lower Dmean and volume of right breast receiving at least 5 Gy doses compared to other techniques.

Conclusion

The dose homogeneity in CW‐CTV was better using IMRT techniques compared to 3DCRT. Especially 9‐field IP‐IMRT provided a more homogeneous dose distribution in IM and axillary CTVs. Moreover, the OARs volumes receiving low radiation doses were larger with IP‐IMRT technique, while volumes receiving high radiation doses were larger with FP‐IMRT technique. Hybrid IMRT plans were found to have the advantages of both FP‐ and IP‐IMRT techniques.