Malignant Pleural Mesothelioma and Radiotherapy: Lung Toxicity Results of an Interim Analysis in Prospective Pilot Trial

PURPOSE/OBJECTIVE(S)

Malignant Pleural Mesothelioma (MPM) is a rare but aggressive intrathoracic malignancy with an overall poor prognosis. Neoadjuvant chemotherapy, surgery and then radiotherapy is the standard of care in early-stage disease. Our study aim is to evaluate the feasibility and toxicity of the novel adjuvant RT in accelerated hypofractionation. We report the lung toxicity preliminary results of the first patients entreated.

MATERIALS/METHODS

Starting in 2017, 29 MPM patients were enrolled in the trial (IRST trial 163). All patients were treated with accelerated hypofractionated radiotherapy using a helical 3-D CRT and IMRT system and intensity-modulated arc therapy. We conducted a prospective mono-institutional clinical trial enrolling cyto-histological proven, MPM patients. The major exclusion criteria were: previous thorax radiotherapy, contralateral mediastinum involvement (N3) and/or M1, interstitial pneumopathy, active pneumonitis, and fissural disease. The prescription dose was 30 Gy in five daily fractions, while an inhomogeneous dose escalation to 40 Gy was prescribed based solely upon the presence of gross residual tumor. All patients were treated in a 3-D CRT and IMRT system. Patients underwent functional lung study before to start radiotherapy treatment, 2 months and 6 months after the end of the treatment. The organs at risk dose-volume histograms were converted to a 2-Gy equivalent dose, and we closely adhered to the dose constraints of the literature data. We in particular analyzed lung toxicity of the first 20 patients.

RESULTS

No G3/G4 lung toxicity was found. We reported 65.0% G1 pneumonitis and 10% G2 as acute lung toxicity. The majority of the G1 patients had only mild symptoms and pneumonitis was described only for radiologic features with no need for medical therapy. Other respiratory toxicities were G1-G2 cough in 50% of the patients; G1 dyspnea occurred in 65% of the patients and G2 in the 15%. The total lung mean dose was 18 Gy (range 13 Gy-23 Gy), and the contralateral lung mean dose was 2 Gy (range 1 Gy-2 Gy). The median value of Forced Expired Volume in one second (FEV1) recorded was 75.5% (range: 46%-137%) before the treatment was started, the median value of Forced Vital Capacity (FVC) at baseline was 74 (range 46-123) with progressive decreasing values through time. DLCO has also been reported with a progressive decrease over time after radiotherapy treatment. No case of respiratory failure was reported after treatment.

CONCLUSION

Treatment of the intact lung with pleural intensity-modulated arc irradiation is a novel treatment strategy that appears to be safe, feasible, and without a high grade of lung toxicity. More investigations are mandatory. The protocol is ongoing.

Hyperbaric Oxygen Therapy plus Hypofractionated Stereotactic Radiotherapy in Recurrent Glioblastoma

PURPOSE/OBJECTIVE(S)

Hypoxia is thought to play a role in tumor development, angiogenesis and growth, and resistance to chemotherapy, antiangiogenic therapy and radiotherapy (RT) in a large number of human cancers. Brain tumors, especially highly aggressive GBM with its necrotic tissue, are more likely to be affected by hypoxia. The median partial pressure of oxygen (PO2) of high-grade gliomas in patients under anesthesia was approximately 5-7 mmHg, with a significant proportion of PO2 values <2.5 mmHg. The radiosensitivity of brain tumors could potentially be increased by performing hyperbaric oxygenation (HBO) before the RT session. We propose an innovative approach to improve the efficacy of accelerated hypofractionated Stereotactic Radiotherapy (HSRT) after HBO (HBO-RT) for the treatment of recurrent HGG (rHGG). The primary objective of this study is to evaluate the disease control rate (DCR) at 3 months. The secondary Objectives are: - Safety assessment (acute and late toxicity). - Overall Survival (OS), - Progression Free Survival (PFS).

MATERIALS/METHODS

We enrolled 14 patients (aged >18 years) with rHGG detected using MRI. A total dose of 15-25 Gy was administered in daily 5-Gy fractions for 3-5 consecutive days after daily HBO.

RESULTS

Median follow-up from re-irradiation was 22.8 months (range: 2.0-24.2 months). The disease control rate 3-months after HBO-RT was 50% (23.0-76.9). Six- and 12-month Progression-free survival was 35.7% (95% CI: 13-59.4) and 10.7% (95% CI: 0.8-35.4), respectively. Median overall survival of HBO-RT was 10.7 months (95% CI: 6.6-24.2). No acute or late neurologic toxicity >grade (G)2 was observed.

CONCLUSION

HSRT combined to HBO seems effective and safe in the treatment of rHGG.

Locoregional treatment of de novo stage IV breast cancer in the era of modern oncology

Approximately 6% of metastatic breast cancers arise de novo. While systemic therapy (ST) remains the treatment backbone as for patients with metachronous metastases, locoregional treatment (LRT) of the primary tumor remains a controversial method. The removal of the primary has an established role for palliative purposes, but it is unclear if it could also determine a survival benefit. Retrospective evidence and pre-clinical studies seem to support the removal of the primary as an effective approach to improve survival. On the other hand, most randomized evidence suggests avoiding LRT. Both retrospective and prospective studies suffer several limitations, ranging from selection bias and outdated ST to a small sample of patients. In this review we discuss available data and try to identify subgroups of patients which could benefit the most from LRT of the primary, to facilitate clinical practice decisions, and to hypothesize future studies design on this topic.

Oligometastatic breast cancer and metastasis-directed treatment: an aggressive multimodal approach to reach the cure

Metastatic breast cancer (BC) is considered an incurable disease and is usually treated with palliative intent. However, about 50% of metastatic BCs present with only a few metastatic lesions and are characterized by longer overall survival. These patients, defined as oligometastatic, could benefit from a multimodal approach, which combines systemic therapy with metastasis-directed treatment (stereotactic ablative therapy or surgery). The current definition of oligometastatic seems incomplete since it is based only on imaging findings and does not include biological features, and the majority of relevant data supporting this strategy comes from retrospective or non-randomized studies. However, the chance of reaching long-term complete remission or even a cure has led to the development of randomized trials investigating the impact of combined treatment in oligometastatic BC (OMBC). The SABR-COMET trial, the first randomized study to include BC patients, showed promising results from a combination of stereotactic ablative radiotherapy and systemic therapy. Considering the randomized trial's results, multidisciplinary teams should be set up to select OMBC patients who could achieve long-term survival with aggressive multimodal treatment.

Patient-based low dose cone beam CT acquisition settings for prostate image-guided radiotherapy treatments on a Varian TrueBeam linear accelerator

OBJECTIVE

To evaluate the performance of low dose cone beam CT (CBCT) acquisition protocols for image-guided radiotherapy of prostate cancer.

METHODS

CBCT images of patients undergoing prostate cancer radiotherapy were acquired with the settings currently used in our department and two low dose settings at 50% and 63% lower exposure. Four experienced radiation oncologists and two radiation therapy technologists graded the images on five image quality characteristics. The scores were analysed through Visual Grading Regression, using the acquisition settings and the patient size as covariates.

RESULTS

The low dose acquisition settings have no impact on the image quality for patients with body profile length at hip level below 100 cm.

CONCLUSIONS

A reduction of about 60% of the dose is feasible for patients with size below 100 cm. The visibility of low contrast features can be compromised if using the low dose acquisition settings for patients with hip size above 100 cm.

ADVANCES IN KNOWLEDGE

Low dose CBCT acquisition protocols for the pelvis, based on subjective evaluation of patient images.

The role of radiotherapy in elderly women with early-stage breast cancer treated with breast conserving surgery

OBJECTIVE

To analyze the impact of adjuvant radiotherapy (RT) on ipsilateral breast recurrence (IBR) and overall survival (OS) in patients older than 69 years with early-stage breast cancer.

METHODS

From January 2007 to June 2015, we analyzed retrospectively 137 women with estrogen receptor-positive T1-2 invasive breast cancer, with negative axillary lymph nodes, dividing them into 2 subgroups: 70 to 79 years and older than 79 years.

RESULTS

After a median follow-up of 43.2 months, the 3-year IBR-free survival in patients treated with surgery plus RT was 98.8% and 92.1% in patients treated with surgery alone, with a significant difference (p = .01). Radiotherapy did not impact overall survival (p = .10). A higher percentage of patients aged between 70 and 79 years received RT after conservative surgery if compared with the older subgroup (p < .01).

CONCLUSIONS

In elderly women, adjuvant RT reduced the IBR, but did not improve OS.

Pathological and molecular diagnosis of bilateral inguinal lymph nodes metastases from low-grade endometrial adenocarcinoma: a case report with review of the literature

BACKGROUND

Extra-abdominal metastases in low grade endometrial carcinoma are rare events. Inguinal lymphatic spread occurs usually in advanced disease and is associated with abdominal lymph nodes involvement. To our knowledge, isolated inguinal lymph node metastases in patients with early endometrial carcinoma have never been described thus far.

CASE PRESENTATION

We present an uncommon case of inguinal lymph node metastasis in a 51-year old patient with early endometrial disease without other metastatic involvement. The metastatic loci were analyzed with the recently validated method of mitochondrial DNA sequencing to demonstrate clonality of the lesions.

CONCLUSIONS

We describe the first case of inguinal metastasis from intramucous endometrial carcinoma; this case confirms the unpredictable spread of endometrial neoplasia and the importance of both patient's history and physical examination in good clinical practice.

Concurrent chemoradiation with volumetric modulated Arc therapy of patients treated for anal cancer-acute toxicity and treatment outcome

BACKGROUND

to report the acute toxicity and clinical results in patients with anal cancer treated with volumetric modulated arc therapy (VMAT) concomitant with chemotherapy.

METHODS

A cohort of 21 patients with histologically confirmed squamous cell carcinoma of the anal canal was treated with VMAT and chemotherapy. Dose prescription was 39.6 Gy, 1.8 Gy/ fraction for the elective nodal PTV, the macroscopic (tumor and involved lymph nodes) PTV doses were 14.4 Gy up to a total dose of 54 Gy in 4 patients and 19.8 up to 59.4 Gy in 15 patients. One patient received a boost dose of 18 Gy up to a total dose of 57.6 Gy and another one was treated with 36 Gy and boost of 19.8 Gy up to a total dose of 55.8 Gy. Chemotherapy with MMC and 5-FU/Capecitabine was administered concomitantly. End points were local control (LC), disease-free survival (DFS) and overall survival (OS).

RESULTS

Median follow-up time was 35.5 months. Two year OS was 91%, DFS was 73% and LRC was 81%. Acute dermatological toxicity G3 was recorded in one patient, ten patients (47.6%) experienced a G2 skin toxicity, while G1 toxicity was registered in eight patients (38%). One patient developed Grade 3 acute gastrointestinal (GI) toxicity, two patients (9.5%) experienced grade 2 acute GI toxicity and ten patients (47.6%) G1 toxicity. Acute genitourinary toxicity G1 was recorded in ten patients (47.6%).

CONCLUSIONS

Our results support VMAT as standard radiotherapy technique in the treatment of patients with anal cancer.

Advanced gastric cancer: What we know and what we still have to learn

Gastric cancer is a common neoplastic disease and, more precisely, is the third leading cause of cancer death in the world, with differences amongst geographic areas. The definition of advanced gastric cancer is still debated. Different stadiating systems lead to slightly different stadiation of the disease, thus leading to variations between the single countries in the treatment and outcomes. In the present review all the possibilities of treatment for advanced gastric cancer have been analyzed. Surgery, the cornerstone of treatment for advanced gastric cancer, is analyzed first, followed by an investigation of the different forms and drugs of chemotherapy and radiotherapy. New frontiers in treatment suggest the growing consideration for intraperitoneal administration of chemotherapeutics and combination of traditional drugs with new ones. Moreover, the necessity to prevent the relapse of the disease leads to the consideration of administering intraperitoneal chemotherapy earlier in the therapeutical algorithm.

Palliative electro-chemotherapy in elderly patients with vulvar cancer: A phase II trial

OBJECTIVE

The primary endpoint of this trial was to assess clinical response (cCR) of squamocellular vulvar cancer (V-SCC) in elderly patients treated with electro-chemotherapy (ECT). Secondary endpoints were symptoms relief and local tumor control.

METHODS

A phase II study was designed and elderly patients with V-SCC unfit for other treatments were treated. Response Evaluation Criteria in Solid Tumors (RECIST criteria) were applied to evaluate tumor response. Quality of life (QoL) was evaluated by visual analogue score (VAS) for pain and four items of vulvar cancer subscale (VCS), of functional assessment of vulvar cancer therapy (FACT-V) [16], before, one month after the procedure and during follow-up.

RESULTS

Median age was 85 years (range 66-96 years). One month after treatment complete response was observed in 13 patients (52%), partial response in 7 (28%), stable disease in 3 (12%), and progressive disease in 2 (8%). Local tumor control at 1 and 6 months was 91% and 53%, respectively. Symptom free survival at 1 and 6 months was 78% and 40%, respectively, with significant reduction of pain (P < 0.01). One-year overall survival was 34%.

CONCLUSIONS

Our study showed that ECT produces high response rate with significant reduction of pain and improvement of local symptoms.

General issues on microbial translocation in HIV-infected patients

The lumen of the gastrointestinal tract is home to an enormous quantity of different bacterial species that thrive in an often symbiotic relationship with the host. It is the principal source of microbial products because of its massive bacterial load. Injury to the immune component of the gastrointestinal mucosal surface, along with damage to the intestinal epithelial microenvironment with its antimicrobial functions, may affect systemic immune activation during the chronic phase of HIV infection through the increased translocation of luminal microbial products. Moreover, microbial translocation, which is defined as "the passage of both viable and nonviable microbes and microbial products such as endotoxin across anatomically intact intestinal barrier", may be a fundamental mechanism through which HIV accelerates progression of chronic viral hepatitis. Improvements in the tools available to microbiota research, and especially advancement of our knowledge in this area may help us in controlling the evolution of HIV disease, although population complexity and diversity between individuals make this challenging.

Risk of venous thromboembolism associated with single and combined effects of Factor V Leiden, Prothrombin 20210A and Methylenetethraydrofolate reductase C677T: a meta-analysis involving over 11,000 cases and 21,000 controls

Genetic and environmental factors interact in determining the risk of venous thromboembolism (VTE). The risk associated with the polymorphic variants G1691A of factor V (Factor V Leiden, FVL), G20210A of prothrombin (PT20210A) and C677T of methylentetrahydrofolate reductase (C677T MTHFR) genes has been investigated in many studies. We performed a pooled analysis of case-control and cohort studies investigating in adults the association between each variant and VTE, published on Pubmed, Embase or Google through January 2010. Authors of eligible papers, were invited to provide all available individual data for the pooling. The Odds Ratio (OR) for first VTE associated with each variant, individually and combined with the others, were calculated with a random effect model, in heterozygotes and homozygotes (dominant model for FVL and PT20210A; recessive for C677T MTHFR). We analysed 31 databases, including 11,239 cases and 21,521 controls. No significant association with VTE was found for homozygous C677T MTHFR (OR: 1.38; 95 % confidence intervals [CI]: 0.98-1.93), whereas the risk was increased in carriers of either heterozygous FVL or PT20210 (OR = 4.22; 95 % CI: 3.35-5.32; and OR = 2.79;95 % CI: 2.25-3.46, respectively), in double heterozygotes (OR = 3.42; 95 %CI 1.64-7.13), and in homozygous FVL or PT20210A (OR = 11.45; 95 %CI: 6.79-19.29; and OR: 6.74 (CI 95 % 2.19-20.72), respectively). The stratified analyses showed a stronger effect of FVL on individuals ≤ 45 years (p value for interaction = 0.036) and of PT20210A in women using oral contraceptives (p-value for interaction = 0.045). In this large pooled analysis, inclusive of large studies like MEGA, no effect was found for C677T MTHFR on VTE; FVL and PT20210A were confirmed to be moderate risk factors. Notably, double carriers of the two genetic variants produced an impact on VTE risk significantly increased but weaker than previously thought.

Usefulness of 124I PET/CT imaging to predict absorbed doses in patients affected by metastatic thyroid cancer and treated with 131I

AIM

The aim of this work was the evaluation of the usefulness of 124I PET/CT sequential scans to predict absorbed doses to metastatic thyroid cancer in patients undergoing 131I therapy.

METHODS

From July 2011 until April 2012 8 patients affected by metastatic thyroid cancer were enrolled. Each patient underwent 4 PET/CT scans at 4, 24, 48, 72 h after the administration of about 74 MBq of 124I. Blood samples and whole body exposure measurements were obtained to calculate blood and red marrow doses. Activity concentrations and lesion volumes obtained from PET/CT images were used to evaluate tumour doses with MIRD formalism and spheres model. The average administered 131I therapeutic activity was 6475 MBq (range: 3700-9250 MBq).

RESULTS

124I PET/CT images showed, with a very good resolution, all 131I avid lesions detected by post therapy whole body scans. The average dose rates for blood, red marrow and lesions were respectively: 6.58E-02 ± 1.64E-02 mGy/MBq, 5.73E-02 ± 1.57E-02 mGy/MBq, 2.22E+01 ± 1.62E+01 mGy/MBq. Three out of eight patients did not show any uptake of 124I in all PET/CT scans, despite high level of TSH and CT detectable lesions. Post-therapy 131I whole body scan confirmed the absence of focal iodine uptake.

CONCLUSION

Negative 124I PET/CT images probably could be used as predictive of real absence of iodine avidity, avoiding all toxicity from useless 131I therapy. A higher number of patients is necessary to validate these preliminary results and a project is ongoing to compare MIRD results to voxel dosimetry based on Monte Carlo simulation.

Comparison of peginterferon pharmacokinetic and pharmacodynamic profiles

The pharmacokinetics and in dosing regimens of the currently available pegylated interferon (peginterferon) alfa molecules differ greatly, depending on the size and nature of their polyethylene glycol (PEG) moiety. Peginterferon alfa-2a has a branched 40 kDa PEG chain covalently attached to lysine residues and circulates as an intact molecule. On the other hand, peginterferon alfa-2b has a linear 12 kDa PEG chain covalently attached to interferon-a-2b via an unstable urethane bond that is hydrolysed after injection, releasing native interferon alfa-2b. The difference in pegylation between the two peginterferons has a significant impact on their pharmacokinetic properties. Data from comparative and non-comparative studies indicate that peginterferon alfa-2b has a shorter half-life in serum than peginterferon alfa-2a, and a significant proportion of patients receiving peginterferon alfa-2b may have trough concentrations below the limit of detection during the latter part of the 7-day dosing schedule. However, the pharmacodynamic parameters of the two drugs appear to be similar.

Sulfated K5 Escherichia coli polysaccharide derivatives inhibit human immunodeficiency type-1 (HIV-1) infection: candidate microbicides to prevent sexual HIV transmission

The ideal microbicide must fulfill a number of criteria including a broad and potent activity against transmission of HIV and other sexually transmitted agents in the absence of toxicity and inflammation. We have described that derivatives of K5 polysaccharide from Escherichia coli inhibit HIV entry in target cells. K5 derivatives have a structure that resembles that of heparin, but they are devoid of the anticoagulant activity typical of heparin. Moreover, in contrast to heparin, they inhibit a broad spectrum of HIV-1 laboratory-adapted and primary isolates that use either CCR5 or CXCR4 or both coreceptors in terms of their infection and replication in primary CD4+ lymphocytes and monocytes-derived macrophages (MDM). Therefore, these compounds could be developed as candidate microbicides for preventing sexual HIV transmission, a predominant modality of HIV spreading in both the developed and underdeveloped world.