SARS-CoV-2 vaccination willingness and humoral vaccination response in radiation oncology patients

BACKGROUND

SARS-CoV-2 infection has been and, in some parts, still is a threat to oncologic patients, making it crucial to understand perception of vaccination and immunologic responses in this vulnerable patient segment. SARS-CoV-2 vaccines in relation to malignant disease characteristics and therapies have so far not been studied consecutively in larger oncologic patient populations. This study captures SARS-CoV-2 vaccination willingness and humoral immune response in a large consecutive oncologic patient collective at the beginning of 2021.

METHODS

1142 patients were consecutively recruited over 5.5 months at a tertiary department for radiation oncology and were assessed for vaccination willingness via a standardized interview. In already vaccinated patients total SARS-CoV-2 S antibody titres against the spike protein (Anti-SARS-CoV-2 S) and were evaluated 35 days or later after the first dose of SARS-CoV-2 vaccine.

RESULTS

Vaccination willingness was high with a rate of 90 %. The most frequent reasons for rejection were: undecided/potential vaccination after therapy, distrust in the vaccine and fear of interaction with comorbidities. Factors associated with lower vaccination willingness were: worse general condition, lower age and female sex. 80 % of the participants had been previously vaccinated, 8 % reported previous infection and 16 % received vaccination during antineoplastic therapy. In 97.5 % of the vaccinated patients Anti-SARS-CoV-2 S was detected. In a univariable analysis parameters associated with non-conversion were: lower performance status, spread to the local lymphatics (N + ), hematologic disease and diffuse metastases. All patients with oligometastatic disease achieved positive Anti-SARS-CoV-2 S titres. For patients with two vaccinations several risk factors were identified, that were associated with low antibody concentrations.

CONCLUSIONS

SARS-CoV-2 vaccination willingness among oncologic patients was high in the first months after its availability, and most patients had already received one or two doses. Over 97 % of vaccinated patients had measurable anti-SARS-CoV-2 S titres. Our data supports early identification of low humoral responders after vaccination and could facilitate the design of future oncologic vaccine trials (clinicaltrials.gov Identifier: NCT04918888).

Altered fractionation short-course radiotherapy for stage II-III rectal cancer: a retrospective study

Purpose

To report the long-term outcomes of neoadjuvant altered fractionation short-course radiotherapy in 271 consecutive patients with stage II-III rectal cancer.

Patients and Methods: This was a retrospective single institution study with median follow-up of 101 months (8.4 years). Patients who were alive at the time of analysis in 2018 were contacted to obtain functional outcome data (phone interview). Radiotherapy consisted of 25 Gy in 10 fractions of 2.5 Gy administered twice daily. Median time interval to surgery was 5 days.

Results

Local relapse was observed in 12 patients (4.4%) after a median of 28 months. Overall survival after 5 and 10 years was 73 and 55.5%, respectively (corresponding disease-free survival 65.5 and 51%). Of all patients without permanent stoma, 79% reported no low anterior resection syndrome (LARS; 0–20 points), 9% reported LARS with 21–29 points and 12% serious LARS (30–42 points).

Conclusion

The present radiotherapy regimen was feasible and resulted in low rates of local relapse. Most patients reported good functional outcomes.

Feasibility of radiotherapy in nonagenarian patients: a retrospective study

PURPOSE

Specific information about radiation therapy in nonagenarians is limited. In order to shed more light on the feasibility of radiotherapy in this challenging subgroup, a retrospective study was performed.

METHODS

The data of 93 consecutive patients receiving irradiation treatment at the Department of Radiation Oncology, Ordensklinikum Linz Barmherzige Schwestern between June 2005 and December 2016 were analyzed. Patient- and treatment-related factors were extracted from the patient records. Overall survival (OS) was defined as time from irradiation to death or last follow-up. The survival rates were analyzed using the Kaplan-Meier method and log-rank test.

RESULTS

The study population of 93 patients was between 90 and 99 years old (median 91 years). It included 59 women (63%) and 34 men (37%). Of these, 38 (41%) received definitive radiotherapy, 14 (15%) received neoadjuvant or adjuvant radiotherapy, whereas a palliative regimen was prescribed in 44% of the cases (n = 41). In all, 79 patients (85%) were able to complete their prescribed course of radiotherapy. While 16 (17%) patients reported grade 2 toxicities or higher, 4 had ≥grade 3 side effects (4%). The median survival was significantly higher in patients treated with adjuvant, neoadjuvant or definitive radiotherapy (13.8 months) compared to patients treated with palliative radiotherapy (3.6 months; p < 0.001).

CONCLUSION

Even in patients managed without preradiotherapy comprehensive geriatric assessment, carefully planned fractionated radiotherapy was feasible and resulted in acceptable rates of acute toxicities.

Total body irradiation with volumetric modulated arc therapy: Dosimetric data and first clinical experience

BACKGROUND

To implement total body irradiation (TBI) using volumetric modulated arc therapy (VMAT). We applied the Varian RapidArc™ software to calculate and optimize the dose distribution. Emphasis was placed on applying a homogenous dose to the PTV and on reducing the dose to the lungs.

METHODS

From July 2013 to July 2014 seven patients with leukaemia were planned and treated with a VMAT-based TBI-technique with photon energy of 6 MV. The overall planning target volume (PTV), comprising the whole body, had to be split into 8 segments with a subsequent multi-isocentric planning. In a first step a dose optimization of each single segment was performed. In a second step all these elements were calculated in one overall dose-plan, considering particular constraints and weighting factors, to achieve the final total body dose distribution. The quality assurance comprised the verification of the irradiation plans via ArcCheck™ (Sun Nuclear), followed by in vivo dosimetry via dosimeters (MOSFETs) on the patient.

RESULTS

The time requirements for treatment planning were high: contouring took 5-6 h, optimization and dose calculation 25-30 h and quality assurance 6-8 h. The couch-time per fraction was 2 h on day one, decreasing to around 1.5 h for the following fractions, including patient information, time for arc positioning, patient positioning verification, mounting of the MOSFETs and irradiation. The mean lung dose was decreased to at least 80 % of the planned total body dose and in the central parts to 50 %. In two cases we additionally pursued a dose reduction of 30 to 50 % in a pre-irradiated brain and in renal insufficiency. All high dose areas were outside the lungs and other OARs. The planned dose was in line with the measured dose via MOSFETs: in the axilla the mean difference between calculated and measured dose was 3.6 % (range 1.1-6.8 %), and for the wrist/hip-inguinal region it was 4.3 % (range 1.1-8.1 %).

CONCLUSION

TBI with VMAT provides the benefit of satisfactory dose distribution within the PTV, while selectively reducing the dose to the lungs and, if necessary, in other organs. Planning time, however, is extensive.

Local relapse after breast-conserving surgery and radiotherapy: effects on survival parameters

PURPOSE

This retrospective analysis of 1,610 women treated for breast cancer and 88 patients with local relapse aims to show the poor survival parameters after local failure and to evaluate risk factors and compare them with other studies and analyses published.

PATIENTS AND METHODS

Between 1984 and 1997, 1,610 patients presenting with a total of 1,635 pT1-2 invasive and noninvasive carcinomas of the breast were treated at the authors' institution. The mean age was 57.1 years (range 25-85 years). Treatment protocols involved breast-conserving surgery with or without systemic therapy and whole-breast radiotherapy in all women, followed by a boost dose to the tumor bed according to risk factors for local recurrence. All axillary node-positive patients underwent systemic therapy (six cycles of classic CMF or tamoxifen 20 mg/day for 2-5 years). The time of diagnosis of local relapse was defined as time 0 for the survival curves after local failure. The association of clinicopathologic factors was studied using uni- and multivariate analyses. Survival and local control were calculated by the Kaplan-Meier actuarial method and significance by the log-rank test.

RESULTS

After a mean follow-up of 104 months, 88 local failures were recorded (5.4%). Calculated from the time of diagnosis of local relapse, 5-year overall survival (OS) was 62.8%, metastasis-free survival 60.6%, and disease-specific survival 64.2%. In patients with failure during the first 5 years after treatment, the survival parameters were worse (OS 50.6%) compared to those who relapsed after 5 years (OS 78.8%; p < 0.028). Significances were also found for initial T- and N-stage and type of failure (solid tumor vs. diffuse spread).

CONCLUSION

This analysis again shows that the survival parameters are worsening after local relapse, especially in case of early occurrence. In breast cancer treatment, therefore, the goal remains to avoid local failure.

The plasma membrane-associated protein RS1 decreases transcription of the transporter SGLT1 in confluent LLC-PK1 cells

Previously we cloned RS1, a 67-kDa polypeptide that is associated with the intracellular side of the plasma membrane. Upon co-expression in Xenopus laevis oocytes, human RS1 decreased the concentration of the Na(+)-D-glucose co-transporter hSGLT1 in the plasma membrane (Valentin, M., Kühlkamp, T., Wagner, K., Krohne, G., Arndt, P., Baumgarten, K., Weber, W.-M., Segal, A., Veyhl, M., and Koepsell, H. (2000) Biochim. Biophys. Acta 1468, 367-380). Here, the porcine renal epithelial cell line LLC-PK1 was used to investigate whether porcine RS1 (pRS1) plays a role in transcriptional up-regulation of SGLT1 after confluence and in down-regulation of SGLT1 by high extracellular D-glucose concentrations. Western blots indicated a dramatic decrease of endogenous pRS1 protein at the plasma membrane after confluence but no significant effect of D-glucose. In confluent LLC-PK1 cells overexpressing pRS1, SGLT1 mRNA, protein, and methyl-alpha-D-glucopyranoside uptakes were drastically decreased; however, the reduction of methyl-alpha-D-glucopyranoside uptake after cultivation with 25 mm D-glucose remained. In confluent pRS1 antisense cells, the expression of SGLT1 mRNA and protein was strongly increased, whereas the reduction of SGLT1 expression during cultivation with high D-glucose was not influenced. Nuclear run-on assays showed that the transcription of SGLT1 was 10-fold increased in the pRS1 antisense cells. The data suggest that RS1 participates in transcriptional up-regulation of SGLT1 after confluence but not in down-regulation by D-glucose.

Breast cancer: primary treatment with external-beam radiation therapy and high-dose-rate iridium implantation

PURPOSE

To evaluate a treatment for breast cancer and to demonstrate the safe use of iridium-192 high-dose-rate (HDR) implantations.

MATERIALS AND METHODS

In December 1984, the authors began to use HDR Ir-192 brachytherapy to deliver an interstitial boost to the primary site in conservative breast cancer treatment. By December 1989, 212 patients with 216 tumors were treated with external-beam irradiation of 45-50 Gy to the whole breast, which was followed by an interstitial 10-Gy boost. Median follow-up was 62 months (range, 36-101 months).

RESULTS

Ten patients (10 of 216 breasts, 4.6%) developed local tumor recurrences, and 36 (17.0%) had distant metastases. At 5 years, overall survival was 88%, local tumor control was 96%, and disease-free survival was 81%. There were no serious complications.

CONCLUSION

The use of an HDR source as a boost to the primary tumor site after external-beam radiation therapy with a dose of 10 Gy in one fraction is a safe procedure and does not negatively affect cosmetic appearance.

Case report: salvage fractionated high dose rate after-loading brachytherapy in the treatment of a recurrent tumour in the middle ear

Re-irradiation of previously irradiated head and neck sites is associated with a high complication rate. In an attempt to reduce this complication risk, multiple fractions of high dose rate (HDR) intracavitary irradiation were used in a young patient who had developed recurrent transitional cell carcinoma in the tympanic cavity one year after radical radiotherapy. After gross surgical removal of the tumour, an afterloading probe was placed into the middle ear by a surgical approach. In 11 treatments of 3 Gy each over 4 days, a total dose of 33 Gy was delivered to a spherical volume, 1.7 cm in diameter. The patient was 24 months free of disease at the start of 1993. Audiometry shows no severe deterioration of hearing. We concluded that fractionated HDR brachytherapy can be used to achieve local control in small volume recurrences at previously irradiated sites, without the inevitability of complications.

[External irradiation and interstitial HDR brachytherapy in the treatment of breast cancer]

PURPOSE

In the breast conserving management of mammary cancer a high-dose-rate (HDR)-Iridium-192 source is used for interstitial boosting of the primary tumor site after external radiotherapy. We want to show the clinical results and side effects and to demonstrate the safe use of a HDR source.

PATIENTS AND METHOD

From December 1984 until November 1988, 154 patients with breast cancer stage T1-2, N0-1 were treated by conservative surgery and radiation. A dose of 45 to 50 Gy was given to the whole breast by external radiotherapy, and the previous tumor area was boosted by an interstitial implant with Iridium-192 HDR. We applied 10 Gy in one or two fractions.

RESULTS

The mean follow-up period of survivors is 76 months (range 57 to 107 months). In 36 patients failures occurred: eight patients (5%) developed local recurrences, 31 patients (20%) had distant metastases, and 19 (12%) died with cancer. The Kaplan-Meier estimation for five year overall survival is 86.9%, for disease-specific survival 89.3%, for local control 95.8%, and for disease free survival 80.1%. The most frequent late effects were telangiectasia (11%), fibrotic masses in the previous tumor area (6.5%), and lymphedema of the arm (6.5%). No serious complications could be observed.

CONCLUSION

With the HDR-Boost of 10 Gy in addition to external beam radiotherapy in the treatment of breast cancer we obtained good clinical results without serious side effects.

[Quality assurance of interstitial irradiation in the breast-conserving therapy of breast cancer]

PURPOSE

The purpose of this communication is to describe the procedure of interstitial implant planning in definitive irradiation of early breast cancer. There are some reports about localization techniques of the boost volume for external irradiation. Less has been reported about the target volume localization of HDR implants of the breast.

METHODS

Conservative surgery and following radiation therapy have become a standard treatment in the management of early breast cancer. The use of a boost irradiation in the area of the primary tumour seems to be promising in decreasing local recurrence rates. Most of our patients received a boost dose by interstitial HDR iridium-192 therapy. Therefore we have improved the method of interstitial implantation by CT under general anesthesia. The implant is planned in the simulator room by localizing the radiopaque clips of the tumor bed, the entrance and exit points of the needles are determined by marking the skin. Then the implantation is done in the operating and afterloading room. A device for patient transportation between brachytherapy unit and CT has been constructed. So patients can be shifted under general anesthesia between the different devices without any problems. The implanted needles and the clips are visualized by the means of CT. The target volume can be defined and the source dwell positions determined.

CONCLUSION

This method improves the accuracy of target localization. Therefore the treated volume can be adapted and minimized, resulting in less side effects and may contribute to maximize local control.

Combined external and high dose rate intracavitary radiotherapy in the primary treatment of cancer of the uterine cervix

From August 1980 to December 1985, 153 patients with stage I, II and III carcinomas of the uterine cervix were treated with external beam irradiation and high dose rate (HDR) Cs-137 and Ir-192 Curietherapy at the Barmherzige Schwestern Hospital in Linz, Austria. Complete remission was achieved in 146 patients (95.4%). The 5-year overall survival probabilities (Kaplan-Meier) in stages I, II and III were 79.3%, 62.6% and 40.8%, respectively. The 5-year recurrence-free survival rates were 91.5%, 59.6% and 52.9%. These results are equivalent to those achieved by treatments incorporating low dose rate (LDR) Ra-226 applications in regard to the limitations of historical comparisons. Use of the high dose rate afterloading methods lead to similar rates of local failures and complications.

[MCA and CA 15-3 in the follow-up of patients with breast cancer]

After surgery and radiotherapy circulating serum levels of the tumour markers MCA and Ca 15-3 were evaluated in 226 clinically disease-free breast cancer patients. 15 of them presented with local recurrences and/or distant metastases after a follow-up period of twelve months. Six patients belonged to the group of 180 with both markers negative, two belonged to the 32 patients with only one marker positive, and seven to the group of 14 with both markers positive. After twelve months the probability of disease-free survival (calculated by the method of Kaplan-Meier) is 96% in patients with negative tumour markers and only 51.4% in patients with both markers positive (p less than 0.001). After 16 months these values are 96% versus 25.7% with the same statistical significance. The value of tumour marker examinations in the regular follow-up of patients with breast cancer lies in the early detection of tumour activity and therefore in a better chance of response to subsequent treatment. The diagnostic sensitivity of MCA was 75.5%, and for Ca 15-3 70.24%.

[Combined external and interstitial radiotherapy of vocal cord carcinoma]

Since 1984 an Ir-192 source with a high dose rate has been used for interstitial implants, and since 1986 in the treatment of the tumor-bearing vocal cord in the organ-preserving management of larynx carcinoma. The combined percutaneous and interstitial treatment has been administered either as the primary treatment or after incomplete removal of the tumour. So fat 16 patients have been treated, two of them presented with tumours on both cords. All patients refused radical surgical interventions, four of them refused cord stripping too. The treatment method included external radiotherapy with a dose of 4600 to 5000 cGy to the larynx. One to two weeks after external XRT an interstitial implant into the vocal cord followed. Using two needles per cord, a boost dose of 1000 cGy was given to the tumour area. The median follow-up time is 21.3 months (range five to 49, calculated October 1990). So far no local or regional failures occurred. None of the patients had intra- or postoperative complications. All patients have preserved their voice. No severe late effects could be observed. The number of patients is very low, but the preservation of voice is high psychosocial value.