Impact of the pandemic on surgical oncology in Piedmont, Italy: a retrospective observational study

Background

To prevent the spread of SARS-CoV-2, containment measures were implemented leading to huge healthcare changes worldwide. This study aimed to describe the impact of COVID-19 pandemic on surgical oncology healthcare in a large Italian sample.

Methods

A retrospective observational study included 99651 patients admitted to the hospitals of Piedmont (Northern Italy) to undergo oncological surgery, provided in ordinary hospitalization. We compared data of 2020 with 2016-2019 mean values. Data were stratified by tumor site, year, month and admission way. Chi-squared tests were used to assess differences in the percentage of admission modes between 2020 and 2016-2019.

Results

An overall reduction in oncological surgery (-12.3%) was observed in 2020 (n = 17923) compared to the mean of period 2016-2019 (n = 20432). A relevant decrease began in March (-11%), continued in April (-18%) and peaked in May (-26%). There was a greater reduction in surgery of breast (-19.2%), bladder (-17.5%), colorectal (-16.5%), kidney (-14.2%), prostate (-14%). Little or no difference was observed for liver (-5.2%), body of uterus (-0.54%), ovary (-0.07%), lymphoma (+4.5%). There was a marked reduction of non-emergency admissions (-13.6%), in particular for some tumor sites: colorectal (-19.4%), breast (-19.4%), bladder (-18.7%). The overall volume of surgeries following an emergency access was unchanged (-0.3%). The proportion of hospitalizations with emergency access increased (p < 0.001).

Conclusions

Our results highlight the burden of the reduction in cancer surgery in 2020 and the risk of delays in diagnosis and treatment for time-dependent conditions. For cancers that can be diagnosed early thanks to screening, the reduction in surgery is likely to be an indirect consequence of discontinuing screening activities. Therefore, further studies are needed to assess, as soon as data are available, the trend in 2021, and to compare our results with those reported in other European countries.

Key messages

• The COVID-19 pandemic caused a significant decline in cancer surgeries in 2020 in Piedmont, Italy. It is necessary to compare our results with those reported in other European countries.

• These results show an increase in the proportion of oncological surgical admissions following emergency access in 2020 compared to the average for 2016-2019.

Real-world experience of abiraterone acetate plus prednisone in chemotherapy-naive patients with metastatic castration-resistant prostate cancer: long-term results of the prospective ABItude study

Background

Limited real-world data exist on the effectiveness and safety of abiraterone acetate plus prednisone (abiraterone hereafter) in the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) naive to chemotherapy. Most of the few available studies had a retrospective design and included a small number of patients. In the interim analysis of the ABItude study, abiraterone showed good clinical effectiveness and safety profile in the chemotherapy-naive setting over a median follow-up of 18 months.

Patients and methods

We evaluated clinical and patient-reported outcomes (PROs) of chemotherapy-naive mCRPC patients treated with abiraterone as for clinical practice in the Italian, observational, prospective, multicentric ABItude study. mCRPC patients were enrolled at abiraterone start (February 2016-June 2017) and followed up for 3 years; clinical endpoints and PROs, including quality of life (QoL) and pain, were prospectively collected. Kaplan–Meier curves were estimated.

Results

Of the 481 patients enrolled, 454 were assessable for final study analyses. At abiraterone start, the median age was 77 years, with 58.6% elderly patients and 69% having at least one comorbidity (57.5% cardiovascular diseases). Visceral metastases were present in 8.4% of patients. Over a median follow-up of 24.8 months, median progression-free survival (any progression reported by the investigators), time to abiraterone discontinuation, and overall survival were, respectively, 17.3 months [95% confidence interval (CI) 14.1-19.4 months], 16.0 months (95% CI 13.1-18.2 months), and 37.3 months (95% CI 36.5 months-not estimable); 64.2% of patients achieved ≥50% reduction in prostate-specific antigen. QoL assessed by Functional Assessment of Cancer Therapy—Prostate, the European Quality of Life 5 Dimensions 3 Level, and European Quality of Life Visual Analog Scale remained stable during treatment. Median time to pain progression according to Brief Pain Inventory data was 31.1 months (95% CI 24.8 months-not estimable). Sixty-two patients (13.1%) had at least one adverse drug reaction (ADR) and 8 (1.7%) one serious ADR.

Conclusion

With longer follow-up, abiraterone therapy remains safe, well tolerated, and active in a large unselected population.

•

A prospective real-life study of abiraterone acetate in mCRPC patients.

•

In 481 chemotherapy-naive mCRPC patients (median follow-up: 25 months), abiraterone plus prednisone was effective and safe.

•

QoL, measured with various tools, remained stable during treatment with abiraterone plus prednisone.

•

The median time to pain progression was 31.1 months.

Small Bowel Metastasis from Squamous Cell Carcinoma of the Larynx. A Case Report

Small bowel metastases from squamous cell carcinoma of the head and neck are relatively rare and in some cases asymptomatic. In the case herein reported, small bowel metastasis from a laryngeal carcinoma caused a life-threatening complication. The surgical approach was effective in saving the patient's life. Death occurred for neck tumor progression without abdominal signs of secondary lesions. A review of the previously reported cases is provided.

Head and Neck Metastases of Renal Cancer after Nephrectomy: A Report of 2 Cases

Two cases of metachronous metastases of renal cell adenocarcinoma are reported. One case presented a solitary metastasis of the ethmoid-orbit which was resected. The patient has remained well for the following 12 months. The second case presented with a secondary to the tongue and multiple metastases elsewhere. Electrodissection achieved a good palliative result.

Cisplatin, Epirubicin and 5-Fluorouracil Combination Chemotherapy for Recurrent Carcinoma of the Salivary Gland

Nine patients (5 males, 4 females; median age, 62 years) with recurrent high-grade malignancies of major (7 cases) and minor (2 cases) salivary gland origin (4 adenoid cystic carcinomas, 2 adenocarcinomas, 2 poorly differentiated carcinomas, 1 mixed malignant tumor) were treated with cisplatin (60 mg/m2), epirubicin (50 mg/m2) and 5-fluorouracil (600 mg/m2) (CEF) by intravenous injections on the first day of a 21-day regimen. Previous therapy included surgery (1 case), radiotherapy (1 case), and surgery+radiotherapy (7 cases). There was 1, complete response (11.1%), 3 partial responses (33.3%), 2 unchanged lesions (22.2%) and 3 progressions (33.3%). Patients with local recurrence had a better response. Median remission duration was 7.5 months in CR + PR patients. Median overall survival was 8+ months; 14+ months for responders and 4 months for nonresponders. The major toxic effects were nausea/vomiting and alopecia; myelosuppression was less frequent and usually not severe.

Concomitant Chemoradiotherapy Followed by Adjuvant Chemotherapy in Parotid Gland Undifferentiated Carcinoma

Aims and background

Undifferentiated carcinoma of the parotid gland is a poor-prognosis lesion. Results in unresectable lesions, treated with radiotherapy alone, are very disappointing.

Methods

Six patients with T3-4 N0-1 inoperable lesions were treated with conventional radiotherapy (64-70 Gy, 2 Gy per fraction 5 times a week) and concomitant cisplatin (100 mg/m2, days 1, 22 and 43). Four weeks after radiotherapy, adjuvant chemotherapy (cisplatin, 80 mg/m2, day 1, + VP16, 100 mg/m2, days 1, 3 and 5, q = 3 weeks, for 3 cycles) was given.

Results

A median dose of 66 Gy (range, 64-70 Gy) was delivered, and all patients recived 3 courses of cisplatin during radiotherapy. Five of 6 patients recived all three chemotherapeutic adjuvant courses. Two months after the end of treatment, 3 CR (50%), 2 PR (33%) and 1 NC (16%) was observed. Median CR and PR duration was 26+ and 10 months, respectively. Median overall survival was 18 months. No severe acute or late toxicity was observed.

Conclusions

Concomitant chemoradiotherapy followed by adjuvant chemotherapy in advanced unresectable undifferentiated parotid carcinoma is feasibile and well tolerated. The high percentage of long-lasting CR is encouraging.

Combined Chemo-Radiotherapy for Stage IV Undifferentiated Nasopharyngeal Carcinoma

Undifferentiated nasopharyngeal carcinoma is a chemosensitive lesion, but its role in the management of local advanced disease is under investigation. Twenty-seven untreated stage IV undifferentiated nasopharyngeal carcinoma patients were treated with radiotherapy (median dose, 66.6 Gy, 1.8 Gy/day) and concomitant cisplatin (100 mg/m2 days 1, 22 and 43). After 4 weeks, patients received, every 4 weeks, 3 cycles with cisplatin (80 mg/m2 day 1) + 5-fluorouracil (1000 mg/m2/day continuous infusion for 96 h). After radiotherapy, we observed 74% complete responses and 26% partial responses; after adjuvant chemotherapy 96% had a complete and 4% a partial response. After a median follow-up of 36 months, 81% of the patients were alive (70% with no evidence of disease). Four-year overall and disease-free survival was 70% and 60%, respectively. Concomitant chemotherapy plus radiotherapy was well tolerated, whereas adjuvant chemotherapy was more toxic. Long-term results were significantly better than those observed with radiotherapy alone.

Small Cell Carcinoma of the Esophagus: A Case Report and Review of the Literature

We present a case of small cell esophageal carcinoma (SCEC) treated with alternated chemotherapy (including cisplatin, etoposide, vincristine, cyclophosphamide and doxorubicin) and irradiation (36 Gy) followed by surgery. Despite a pathological complete response, the patient died of regional disease recurrence 29 months after the diagnosis. We reviewed the available literature on SCEC with regard to the incidence, clinical symptoms, radiological signs, diagnostic workup, therapeutic modalities and prognosis of this malignancy.

A randomized, phase 2 study of cetuximab plus cisplatin with or without paclitaxel for the first-line treatment of patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

B490 (EudraCT# 2011-002564-24) is a randomized, phase 2b, noninferiority study investigating the efficacy and safety of first-line cetuximab plus cisplatin with/without paclitaxel (CetCis versus CetCisPac) in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck (R/M SCCHN).

PATIENTS AND METHODS

Eligible patients had confirmed R/M SCCHN (oral cavity/oropharynx/larynx/hypopharynx/paranasal sinus) and no prior therapy for R/M disease. Cetuximab was administered on day 1 (2-h infusion, 400 mg/m2), then weekly (1-h infusions, 250 mg/m2). Cisplatin was given as a 1-h infusion (CetCis arm: 100 mg/m2; CetCisPac arm: 75 mg/m2) on day 1 of each cycle for a maximum of six cycles. Paclitaxel was administered as a 3-h infusion (175 mg/m2) on day 1 of each cycle. After six cycles, maintenance cetuximab was administered until disease progression or unacceptable toxicity. The primary end point was progression-free survival (PFS). We assumed a noninferiority margin of 1.40 as compatible with efficacy.

RESULTS

A total of 201 patients were randomized 1 : 1 to each regimen; 191 were assessable. PFS with CetCis (median, 6 months) was noninferior to PFS with CetCisPac (median, 7 months) [HR for CetCis versus CetCisPac 0.99; 95% CI: 0.72-1.36, P = 0.906; margin of noninferiority (90% CI of 1.4) not reached]. Median overall survival was 13 versus 11 months (HR = 0.77; 95% CI: 0.53-1.11, P = 0.117). The overall response rates were 41.8% versus 51.7%, respectively (OR = 0.69; 95% CI: 0.38-1.20, P = 0.181). Grade ≥3 adverse event rates were 76% and 73% for CetCis versus CetCisPac, respectively, while grade 4 toxicities were lower in the two-drug versus three-drug arm (14% versus 33%, P = 0.015). No toxic death or sepsis were reported and cardiac events were negligible (1%).

CONCLUSION

The two-drug CetCis regimen proved to be noninferior in PFS to a three-drug combination with CetCisPac. The median OS of both regimens is comparable with that observed in EXTREME, while the life-threatening toxicity rate appeared reduced.

CLINICAL TRIAL NUMBER

EudraCT# 2011-002564-24.

Efficacy and safety of Everolimus and Exemestane in hormone-receptor positive (HR+) human-epidermal-growth-factor negative (HER2-) advanced breast cancer patients: New insights beyond clinical trials. The EVA study

BACKGROUND

The BOLERO-2 trial reported efficacy and safety of Everolimus (EVE) and Exemestane (EXE) combination in HR+ advanced breast cancer (ABC) patients. The BALLET trial further evaluated the safety of EVE-EXE in HR+ ABC patients, without reporting efficacy data. Aim of the EVA real-life study was to collect data of efficacy and safety of EVE-EXE combination in the clinical setting, as well as exploring efficacy according to EVE Dose-Intensity (DI) and to previous treatment with Fulvestrant.

PATIENTS AND METHODS

This study aimed to describe the outcome of ABC pts treated with EVE-EXE combination in terms of median duration of EVE treatment and ORR in a real-life setting.

RESULTS

From July 2013 to December 2015, the EVA study enrolled 404 pts. Median age was 61 years (33-83). Main metastatic sites were: bone (69.1%), soft tissue (34.7%) and viscera (33.2%). Median number of previous treatments was 2 (1-7). 43.3% of the pts had received Fulvestrant. Median exposure to EVE was 31.0 weeks (15.4-58.3) in the whole population. No difference was observed in terms of EVE exposure duration according to DI (p for trend = 0.27) or type of previous treatments (p = 0.33). ORR and Disease Control Rate (DCR) were observed in 31.6% and 60.7% of the patients, respectively, with the lowest ORRs confined in CHT pre-treated patients or in those who received the lowest DI of EVE. Grade 3-4 adverse events (AEs) were reported in 37.9% of the patients. Main AEs were: stomatitis (11.2%), non-infectious pneumonitis - NIP (3.8%), anaemia (3.8%) and fatigue (3.2%).

CONCLUSIONS

The EVA study provided new insights in the use of EVE-EVE combination in HR+ ABC pts many years after the publication of the pivotal trial. The combination is safe and the best response could be obtained in patients receiving the full dose of EVE and/or after hormone-therapy as Fulvestrant in ABC.

Prediction of Virologic Outcome of Salvage Antiretroviral Treatment by Different Systems for Interpreting Genotypic HIV Drug Resistance

The authors assessed the predictive capacity of 3 rule-based algorithms (Bergamo, Stanford University, Rega Institute) for HIV genotypic interpretation. A total of 1132 postgenotypic regimens in 533 patients were considered. The genotypic sensitivity score (GSS) was strongly associated ( P < .0001) with the virologic outcome (1 log HIV-RNA reduction). The 3 algorithms had a highly significant prediction efficiency. The Bergamo algorithm receiver-operating characteristic curve area under the curve (AUC) for the prediction of ≥1 log HIV-RNA reduction was 0.753 (95% confidence interval, 0.725-0.781), testifying that the prediction was significantly different ( P < .0001) from simple chance. The AUCs obtained by the 2 other systems were similar (0.752 Stanford; 0.741 Rega). The predictive capacity of the algorithms was not influenced by the type of antiviral drugs used. The 3 considered rule-based algorithms for the interpretation of HIV genotypic resistance yield congruent results and may effectively predict the virologic outcome of rescue therapy. Their use may help clinicians in interpreting mutational patterns and in making therapeutic choices.

CD4+ T cell depletion, immune activation and increased production of regulatory T cells in the thymus of HIV-infected individuals

Mechanisms by which HIV affects the thymus are multiple and only partially known, and the role of thymic dysfunction in HIV/AIDS immunopathogenesis remains poorly understood. To evaluate the effects of HIV infection on intra-thymic precursors of T cells in HIV-infected adults, we conducted a detailed immunophenotypic study of thymic tissue isolated from 7 HIV-infected and 10 HIV-negative adults who were to undergo heart surgery. We found that thymuses of HIV-infected individuals were characterized by a relative depletion of CD4+ single positive T cells and a corresponding enrichment of CD8+ single positive T cells. In addition, thymocytes derived from HIV-infected subjects showed increased levels of activated and proliferating cells. Our analysis also revealed a decreased expression of interleukin-7 receptor in early thymocytes from HIV-infected individuals, along with an increase in this same expression in mature double- and single-positive cells. Frequency of regulatory T cells (CD25+FoxP3+) was significantly increased in HIV-infected thymuses, particularly in priorly-committed CD4 single positive cells. Our data suggest that HIV infection is associated with a complex set of changes in the immunophenotype of thymocytes, including a reduction of intrathymic CD4+ T cell precursors, increased expression of activation markers, changes in the expression pattern of IL-7R and enrichment of T regulatory cells generation.

One-pill once-a-day HAART: a simplification strategy that improves adherence and quality of life of HIV-infected subjects

OBJECTIVE

The aim of the ADONE (ADherence to ONE pill) study was to verify the effect of a reduced number of pills on adherence and quality of life (QoL) in HIV-infected patients on highly active antiretroviral therapy (HAART).

DESIGN

Prospective, multicenter, study.

METHODS

Patients chronically treated with emtricitabine (FTC) + tenofovir (TDF) + efavirenz (EFV) or lamivudine (3TC) +TDF +EFV and with a HIV-RNA < 50 copies/mL were switched to the single-pill fixed-dose regimen (FDR) of FTC +TDF +EFV. Data were collected with SF-36 using visual analog scales. Results of the final (6 months) primary as-treated analysis are reported.

RESULTS

212 patients (77.4% males) of mean age 45.8 years were enrolled; 202 completed the study. One month post switch to FDR the adherence rate increased significantly to 96.1% from a baseline value of 93.8% (P < 0.01). The increase was steadily maintained throughout the study (96.2% at 6 months). QoL improved over time from 68.8% to 72.7% (P = 0.042) as well, and was significantly associated with the perception of health status, presence of adverse events (AEs) and number of reported AEs (P < 0.0001). QoL significantly influenced adherence (P < 0.0001). During FDR use the mean CD4 count increased from 556 to 605 cells/muL (P < 0.0001). At the end of follow-up 98% of patients maintained HIV-RNA level < 50 copies/mL and 100% <400 copies/mL. Four patients stopped therapy because they were lost to follow-up and 6 because of AEs (insomnia/nervousness 4, allergy 1, difficulties swallowing pills 1).

CONCLUSION

By substituting a one-pill once-a-day HAART, we observed an improvement of both adherence and QoL while maintaining high virologic and immunologic efficacy. HAART simplicity is an added value that favors adherence and may improve long-term success.

Functional and psychological evaluation after exclusive chemoradiation therapy in oral and oropharyngeal cancer

e17012

Purpose: The treatment of head and neck tumours often negatively affects speech, swallowing, body image and quality of life (QoL). Aim of this study was the evaluation of the impact of exclusive chemoradiation therapy (CH-RT) on QoL and psychological functioning. Patients and Methods: Twenty-eight patients, affected by a carcinoma of the oral cavity and oropharynx received exclusive CH-RT. Late effects of CH-RT and psycho-oncological assessment included: Radiation Therapy Oncology Group (RTOG) - European Organisation for Research and Treatment of Cancer (EORTC) late radiation morbidity scoring system, DISCHE morbidity recording scheme, Hospital Anxiety and Depression Scale (HADS), Montgomery Asberg Depression Rating Scale (MADRS), Mini Mental Adjustment to Cancer (MINI MAC), and EORTC QoL Head and Neck 35. Results: After a median follow-up of 42 months (range 12–60 months) moderate-severe late toxicity was as follows: taste impairment (89.20%), salivary function (82.12%), subcutaneous tissue (7.08%). Concerning dysphagia 39% of patients complained some discomfort, 28% had a more severe toxicity whereas 7% could not have an oral feeding; patients with severe dysphagia showed higher levels of anxiety (p < 0.05): dysphagia influences the QoL, fatigue and physical-social functioning. Rates of depression and anxiety were generally low: 78.6% of our sample did not show clinical relevant anxious symptoms and 82.1% of patients did not reach the threshold of an overt depression. Just a fair concordance in rate of depression between self- and hetero-evaluated scale was observed, with higher rates relieved by MADRS compare to HADS depression subscale using 8 or 10 cut-off (Cohen's k test = 0.401) Conclusions: Our data suggest low rates of anxiety and depression, in patients treated with CH-RT, with a different evaluation between self-evaluative and hetero-evaluative scales.

No significant financial relationships to disclose.

Induction chemotherapy with cisplatin and epirubicin followed by radiotherapy and concurrent cisplatin in locally advanced nasopharyngeal carcinoma observed in a nonendemic population

e17040

Background: Chemoradiotherapy (CRT) represents the main therapy choice in the treatment of locoregionally advanced nasopharyngeal carcinoma (NPC). Aim of this study was the clinical evaluation of neoadjuvant chemotherapy (NACT) followed by CRT in a non endemic population affected by advanced NPC. Methods: Patients with locoregionally advanced NPC were treated with three cycles of induction chemotherapy (CHT) with cisplatin (100 mg/m2) plus epirubicin (90 mg/m2), followed by cisplatin (100 mg/m2) and concomitant radiotherapy (70 Gy). Results: In 40 patients treated with such protocol, after the completion of induction CHT and CRT we observed the objective response rates of 90% and 100% respectively. Treatment tolerability and toxicity were easily controllable. With a median follow-up time of 54.5 months 3- and 5-years disease-free survival was 75% and 65.4% and 3- and 5-years overall survival was 84% and 77.5%. 3- and 5-years loco-regional control was 82.4% and 70.3%, and 5-years distant metastases-free survival was 75%. Conclusions: NACT with cisplatin and epirubicin followed by concomitant CRT represents a feasible, efficient treatment for patients with advanced NPC. This regimen ensures an excellent locoregional disease control and overall survival with a low incidence of distant metastases.

No significant financial relationships to disclose.