Background and objective
The oncogenic effect of ionizing radiation is widely known. Sarcomas developing after radiation therapy (RT), termed “iatrogenic disease of success”, represent a growing ...problem, since the advancements in cancer management and screening programs have increased the number of long-term cancer survivors. Although many patients have been treated with radiation therapy, only few data are available on radiation-induced sarcomas (RIS).
Methods
We examined the medical and radiological records of 186 patients with histologically proven soft tissue and bone sarcomas, which referred to IRCCS CROB Centro di Riferimento Oncologico della Basilicata from January 2009 to May 2022. Among them, seven patients received a histological diagnosis of secondary RIS, according to Cahan’s criteria. Clinicopathological features and treatment follow-up data of RIS patients were retrospectively analyzed.
Results
Among these secondary RIS, five arose in irradiated breast cancer (5/2,570, 0.19%) and two in irradiated head and neck cancer (2/1,986, 0.10%) patients, with a mean onset latency time of 7.3 years.
The histology of RIS was one desmoid tumor, two angiosarcomas, one chondrosarcoma, two leiomyosarcomas, and one undifferentiated pleomorphic sarcoma. Out of the seven RIS, one received radiotherapy, one received electrochemotherapy (ECT), one received a second-line chemotherapy, three were subjected to three lines of chemotherapy, and one underwent radiofrequency ablation, chemotherapy, and ECT. Median survival time is 36 months. No significant survival differences were found stratifying patients for age at RT, latency time, and age at RIS diagnosis.
Conclusions
RIS represents a possible complication for long-survivor cancer patients. Therefore, adherence to a strict follow-up after the radiation treatment is recommended to allow early diagnosis and optimal management of RIS patients. After the planned follow-up period, considering the long-term risk to develop a RIS, a specific multispecialty survivorship care plan could be of benefit for patients.
Head and neck cancer (HNC) remains a significant health concern worldwide. Approximately 50% of HNC occur in the elderly patients and this rate is destined to increase over time, due to the aging of ...the population. The treatment of HNC poses unique challenges, as it often requires a combination of surgery, chemotherapy, and radiotherapy (RT). Additionally, age-related comorbidities and frailty may complicate the management of HNC in this setting of patients. RT alone has been one of the treatment options for patients with locally advanced HNC squamous cell carcinoma (SCC) with contraindications to chemotherapy, such as cardiac risk, renal or hepatic impairment, frailty or advanced age, and patient choice. In recent years, hypofractionated RT (HFRT) has emerged as an alternative treatment approach, offering the potential to reduce the overall treatment duration while maintaining or even improving treatment outcomes. Several clinical studies have investigated the efficacy and safety of HFRT in HNC. However, robust data are lacking and mainly concern oropharyngeal and laryngeal carcinoma or palliative treatments. The emergence of the COVID-19 pandemic in late 2019 had a profound impact on healthcare systems worldwide. One significant consequence was the need to adapt cancer treatment protocols to minimize patient exposure to the virus while maintaining treatment efficacy. HFRT, with its potential to shorten treatment duration, became an attractive option during this time. The purpose of this study is to report our preliminary retrospective experience on elderly/frail locally advanced HNC patients treated with HFRT, and to assess how the COVID-19 pandemic influenced treatment duration.
We conducted a retrospective analysis of locally advanced HNC patients aged 70 years and older, not candidate to surgery nor chemotherapy and treated with HFRT alone at our Institution from 2021 to 2022. Gross tumor volume (GTV) was determined according to clinical examination, computed-tomography scan (CT), magnetic resonance imaging (MRI), or positron emission tomography scan (PET). Two clinical target volumes (CTV) were identified (high and low risk). HFRT was delivered with a Linear Accelerator (Trilogy, Varian, Palo Alto, CA, USA) with intensity-modulated (IMRT) or volumetric-modulated (VMAT) RT technique and daily image guidance. HFRT regimens included 60 Gy in 25 fractions over 5 weeks (2.4 Gy per fraction) for CTV-high risk and 50 Gy in 25 fractions over 5 weeks (2.0 Gy per fraction) for CTV-low risk. Patients were evaluated by clinical/endoscopic examination and CT or MRI imaging every 3 months after the completion of HFRT. Response to treatment on imaging (complete or partial response, stable disease), overall survival (OS) and Radiation Therapy Oncology Group (RTOG) Toxicity Criteria were assessed.
A total of five elderly/frail locally advanced HNC patients were included. The median age was 78 years (range 72-82 years). Patients were staged according to seventh edition of TNM system. Of five patients, three patients had cT3-4 cN2-3 oral cavity SCC, one patient had cT4 parotid gland cancer with cutaneous ulceration and one patient had cT3 cN3b (ipsilateral large lymph node with extracapsular invasion) oropharyngeal SCC. All patients completed the full planned course of HFRT. Acute toxicities according to RTOG scale were grade 2/3 skin toxicity, grade 1/2 dryness of mouth and grade 2 oral mucositis. After a median follow-up of 6.3 months, four patients were alive, one patient with complete response (patient with oropharyngeal SCC), one patient with partial response and two patients with stable disease on imaging. Late toxicities sec. RTOG scale were grade 1/2 skin toxicity and grade 1/2 salivary gland toxicity.
In conclusion, HFRT is an evaluable option in the management of elderly/frail HNC patients. With a growing elderly population and the challenges posed by the COVID-19 pandemic, there is a need to explore new treatment strategies that optimize clinical outcomes in this subgroup of patients. This experience has recently been adopted in our daily clinical practice to treat very selected elderly/frail HNC patients not fit to chemo-radiotherapy or access difficulties to our radiation unit center. Future research should focus on HFRT protocols to assess long-term survival and quality of life in elderly/frail HNC patients.
•We report the long-term results of addiction of gefitinib to preoperative chemoradiotherapy in locally advanced rectal cancer.•We wanted to see if the hight rate of pCR, already shown in previous ...studies, influenced survival outcomes.•The first promising results have not been confirmed by a significant improvement in outcomes.
The aim of this study is to evaluate the long term survival of the addition of gefitinib to chemoradiotherapy (CRT) in locally advanced rectal cancer (LARC).
This previously published multicentre, open-label, phase I-II study, enrolled patients (pts) with LARC to receive CRT with concurrent 5-fluorouracil continuous intravenous infusion and a dose escalation of orally administered gefitinib, followed 6–8 weeks later by surgery. An intra-operative radiotherapy boost of 10 Gy was planned. Adjuvant chemotherapy was administrated in ypN1-2 pts. After a median f/u of >10 years, we analyzed Local Control (LC), Metastasis Free Survival (MFS), Disease Free Survival (DFS), Disease Specific Survival (DSS) and Overall Survival (OS). Predictive endpoints of clinical outcomes were tested by univariate and multivariate analysis. Variables analyzed included: age, gefitinib dose and interruptions, adjuvant CT, surgery type, ypT, ypN, and TRG grade. We have also analyzed late toxicity according to CTCAEv4.
Of the 41 initially enrolled pts, 39 were evaluable (27M, 12F). With a median f/u of 133 months, LC, MFS, DFS, OS and DSS at 5 years were 84%; 71%; 64%; 87% and 92%, respectively. The OS and DSS at 10 years were 61,5% and 76%, respectively. Grade 3-4 late toxicity occurred in 38% of pts: sexual (28,2%) and gastrointestinal toxicities (10,2%).
Long term outcomes and late toxicity were similar to previously reported series. The addition of gefitinib did not improve outcomes in LARC. Gefitinib is not recommended for rectal cancer patients who received 5-FU based preoperative CRT. Further studies may identify if gefitinib is beneficial in selected group of patients.
We administered a new breast cancer (BC) adjuvant therapy sequence that delivered postoperative radiotherapy (PORT) before chemotherapy (CT). Our aim was to assess the gain in time to start PORT and ...the G2-G3 acute-subacute toxicity rate of whole breast adjuvant hypofractionated radiotherapy (AH-RT) administered up-front to the third-generation adjuvant CT (A-CT) in high-risk nodal positive BC in a preliminary report at 2 years.PurposeWe administered a new breast cancer (BC) adjuvant therapy sequence that delivered postoperative radiotherapy (PORT) before chemotherapy (CT). Our aim was to assess the gain in time to start PORT and the G2-G3 acute-subacute toxicity rate of whole breast adjuvant hypofractionated radiotherapy (AH-RT) administered up-front to the third-generation adjuvant CT (A-CT) in high-risk nodal positive BC in a preliminary report at 2 years.This retrospective study analysed the duration of treatment and safety of AH-RT administered up-front to A-CT in high-risk nodal positive BC patients (pts). Data on 45 pts treated between 2022-2023 were collected. All pts underwent the third-generation A-CT after AH-RT 15-5 fractions with or without a boost. Acute toxicity was scored according to CTCAE v5.0 for skin, pulmonary, and cardiac adverse events. Univariate and multivariate analyses were conducted to assess significant prognosticators for skin/lung/heart acute toxicities in the AH-RT 5-15 fractions arms and CT (p < 0.005).MethodsThis retrospective study analysed the duration of treatment and safety of AH-RT administered up-front to A-CT in high-risk nodal positive BC patients (pts). Data on 45 pts treated between 2022-2023 were collected. All pts underwent the third-generation A-CT after AH-RT 15-5 fractions with or without a boost. Acute toxicity was scored according to CTCAE v5.0 for skin, pulmonary, and cardiac adverse events. Univariate and multivariate analyses were conducted to assess significant prognosticators for skin/lung/heart acute toxicities in the AH-RT 5-15 fractions arms and CT (p < 0.005).A reduction in the time to PORT initiation and overall adjuvant treatment time was recorded. RT was initiated 5 median weeks after surgery, and A-CT was performed 9 median weeks after surgery. The median duration of the entire adjuvant treatment was 35 weeks after surgery. At 6 months mean follow-up, no significant differences in G2-G3 toxicity were noted between the different hypofractionated RT arms, irrespective of the CT schedules, irradiated volumes, or boost (SIB or sequential) in univariate and multivariate analyses. In the multivariate analysis, no significant effects in CT schedules and AH-RT 5-15 arms for skin/lung acute toxicities (p = 0.077 and p = 0.68; 0.67 and 0.87, respectively) were recorded.ResultsA reduction in the time to PORT initiation and overall adjuvant treatment time was recorded. RT was initiated 5 median weeks after surgery, and A-CT was performed 9 median weeks after surgery. The median duration of the entire adjuvant treatment was 35 weeks after surgery. At 6 months mean follow-up, no significant differences in G2-G3 toxicity were noted between the different hypofractionated RT arms, irrespective of the CT schedules, irradiated volumes, or boost (SIB or sequential) in univariate and multivariate analyses. In the multivariate analysis, no significant effects in CT schedules and AH-RT 5-15 arms for skin/lung acute toxicities (p = 0.077 and p = 0.68; 0.67 and 0.87, respectively) were recorded.As a new PORT approach in BC, AH-RT up-front to the third-generation A-CT appeared safe with a low acute toxicity profile, providing an advantage in shortening the time from surgery to PORT initiation and the overall adjuvant treatment time.ConclusionAs a new PORT approach in BC, AH-RT up-front to the third-generation A-CT appeared safe with a low acute toxicity profile, providing an advantage in shortening the time from surgery to PORT initiation and the overall adjuvant treatment time.
Background: The treatment of breast cancer (BC) remains a constant and rapidly evolving issue for multidisciplinary breast cancer teams. Considering the emerging understanding and advances in the ...biological course of this disease, new trends in radiotherapy fractionation, systemic therapies, and oncoplastic surgical techniques are revolutionizing adjuvant treatment approaches to BC. Novel challenges are questioning the integration of adjuvant radiotherapy (ART) into the real-world clinical setting.
Methods: PubMed literature search was conducted in order to extract data supporting the role of new trends in breast cancer adjuvant approach according to rising issues in the multidisciplinary team discussion such as sequencing with chemotherapy (CT) plus whole breast hypofractionated radiotherapy (HF-WBRT); the role of ART after neoadjuvant CT (NACT) followed by breast conservative surgery (BCS) in early BC achieving pathological complete remission (pCR); and the integration of ART in immediate autologous breast oncoplastic reconstruction after mastectomy (a-IBR). Furthermore, there are still several concerns about toxicity with adjuvant trastuzumab emtansine (T-DM1) or breast re-irradiation after BCS relapse in long-term survivors refusing mastectomy.
Results: Among 40 hits, only 12 studies answered to these issues. Many of them were retrospective studies. Less than 500 patients met the criteria for these issues and several conclusions were found exhaustive.
Conclusion: Few issues seem to have literature solutions, while there are still open questions in regard to these new trends. Novel strategies through prospective or randomized studies and new consensus guidelines are required.
The COVID-19 pandemic has opened several new disease scenarios, yielding novel syndromes that have never been seen before and resurrecting old inflammatory phenomena that are no longer recorded, such ...as radiation recall (RR) syndromes. Radiation recall syndrome is a limited field inflammatory reaction that occurs in a volume that was irradiated several months or years previously before being induced by a triggering factor. The most frequently reported phenomena are skin reactions; however, other organs could be involved, such as the lungs in radiation recall pneumonitis (RRP). It is a well-described inflammatory reaction that occurs within a pulmonary volume that was irradiated several months or years previously via radiotherapy (RT), triggered by factors such as drugs, including chemotherapy agents, immunotherapy, or vaccination. Indeed, during the COVID-19 pandemic, RRP following anti-COVID -19 vaccination or SARS-CoV2 infection was recently reported. ACE receptor-rich tissues such as lung or skin tissues were mainly involved. Herein, we present a case of RRP triggered by COVID-19 pulmonary infection in a woman who previously underwent adjuvant breast cancer radiotherapy. Although symptoms were typical, pulmonary CT findings depicted a unique distribution of ground-glass opacities (GGOs) throughout the previous radiation portals and mirror-like the radiation fields. Anamnesis and radiation plan evaluation were crucial in the diagnosis of RRP. Keywords: recall syndromes, adjuvant radiotherapy, immune memory, ACE receptors
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