Common Acute Side Effect Research Articles

Comparison of Acute Gastrointestinal Toxicity of Intensity-Modulated Radiotherapy Versus Three-Dimensional Conformal Radiotherapy in Patients of Carcinoma Cervix.

Introduction Cervical cancer is the most common gynaecological malignancy worldwide, with a higher prevalence in middle- and low-income countries. Chemoradiotherapy, followed by intracavitary brachytherapy, is the treatment of choice in locally advanced cervical cancer. The most common acute side effect of external beam radiotherapy (EBRT) is bowel toxicity in the form of diarrhoea and abdominal cramps. The treatment techniques of EBRT were revolutionised with the advent of intensity modulation. This study aims to prospectively analyse whether the dosimetric advantage of intensity-modulated radiotherapy (IMRT) over three-dimensional conformal radiotherapy (3DCRT) is translated clinically into a decrease in acute toxicity. Method Twenty-four patients were randomised into two groups: the 3DCRT and the IMRT. Acute gastrointestinal (GI) toxicity was assessed during treatment using radiation therapy oncology group grading. The factors under consideration were age, stage of the disease, treatment technique, chemotherapy, and the intention of therapy (radical or adjuvant). The mean bowel bag dose of the two techniques was analysed. Result Among the factors under consideration, it was found that the treatment technique was the only factor that had a significant association with acute bowel toxicity in both univariate (p = 0.036) and multivariate analyses (p = 0.028). The mean V25 (the volume receiving 25 Gy), V45, and V50 of the bowel bag in the IMRT arm were significantly less than the 3DCRT arm. Grades 2 and 3 acute bowel toxicities were also higher in the 3DCRT arm. Conclusion The treatment technique is essential to determining acute GI toxicity during pelvic radiotherapy. With IMRT, the dose to the bowel bag and, in turn, the acute bowel toxicity can be reduced.

Scalp Volumetric Modulated Arc Therapy Using 3D Milled Bolus: Dosimetry, Toxicity and Outcome.

Radiotherapy for scalp lesions is frequently challenging due to the competing needs for target volume coverage, sparing of numerous critical nearby OARs, and reproducible bolus setup despite the irregular and highly convex scalp geometry. Here, we evaluate the use of 3D milled bolus in treating such tumors. A retrospective analysis of scalp patients (pts) treated between 2016-2022 using 3D milled bolus and VMAT. All pts were treated with 6 MV photon beams, IGRT via daily CBCT, and 6-degree of Freedom (6-DOF) couch tops. Pts demographics, tumor characteristics, DVHs, toxicities and outcomes were evaluated. Regional control (RC) defined as control of the disease in the rest of the scalp/neck and local control (LC) defined as disease control within the PTV. A total of 23 pts were identified. Median age 74 (46-85), ECOG performance status was 0-1 in 20 pts (87%) and 92% were males. The histopathologies were squamous cell carcinoma (SCC) (61%), angiosarcoma (AS) (35%) and melanoma (4%). 35% of pts were treated with definitive intent to gross disease; the remaining 65% were treated post-operatively, 22% with microscopically positive margins and 43% with negative margins. 21% had perineural invasion (PNI), and none had lymphovascular invasion (LVI). 78% had T3/T4 and 13% had N+ disease. Median radiation dose was 66 Gy (60-69.96Gy). 44% received concurrent systemic therapy (Paclitaxel 22%, Cemiplimab 12%, Temozolomide 5%, Nivolumab 5%). In 40% of pts, the whole scalp was treated; in the remaining 60%, the median ratio of PTV volume to scalp volume was 35% (25-90%). 22% of pts (n = 5) had neck irradiation for prophylactic (3pts)/ neck lymph node involvement (2 pts). The median brain Dmax was 65 Gy (52.5-71.9), median brain mean dose was 15.4Gy (1.4-38.4), median eye Dmax was 10.9Gy (0.23-49), median cochlea mean was 8.4Gy (0.1-20.4), median lacrimal gland mean dose was 6.8Gy (0.11-38), median hippocampus Dmin was 5.9Gy (0.1-14.9) and Dmax was 10Gy (0.3-23). Most common acute side effects were grade 1-2 fatigue (100%), grade 1-2 pain (78%), grade 1 dysgeusia (22%), grade 1-2 dermatitis (74%). The only grade > = 3 adverse event was grade 3 dermatitis in 26%. Regarding long-term side effects, one pt had grade 2 osteoradionecrosis and other one developed grade 2 skin ulcer. 17% developed grade 1 memory impairment. 17% had grade 1 eye dryness. None developed brain radionecrosis. At a median follow-up was 14.4 months (1-73.5), the 1-yr LC was 96%. The 1-yr RC was 75% overall, 100% in angiosarcoma vs 62% in SCC (p = 0.18). Of the 4 regional recurrences, 1 pt had marginal recurrence along V1, 2 had neck nodal recurrence, and 1 had recurrence elsewhere in the scalp. 1-yr DMFS was 62% overall. 1-yr OS was 78% overall, 100% for AS vs 64% for SCC (P = 0.097). VMAT planning with 3D milled bolus permits technically sound radiotherapy for scalp targets with an acceptable toxicity profile and relatively favorable clinical outcomes. This approach warrants further evaluation in a larger prospective study.

Toxicity of Patients with Ultra-Central Thoracic Tumors Treated with Stereotactic Body Radiotherapy (SBRT) with Dose of 50 Gy in 5 Fractions

The ideal regimen for stereotactic body radiotherapy (SBRT) in ultra-central lung tumors is still to be defined, mostly due to the risk of unacceptable or fatal toxicity. There is not much information on outcomes after SBRT for this group of patients. We summarize here our experience with ultra-central lung cancer patients treated with the dose of 50 Gy delivered in 5 fractions. This study is a retrospective review of all cases of ultra-central thoracic tumors treated with SBRT with the dose of 50 Gy in 5 fractions, delivered every other day, at our institution. In all cases, as we defined ultra-central lung tumor, the PTV overlapped or touched one or more of the following structures: bronchial tree, trachea, great vessels, heart, and esophagus. Metastatic and primary lung lesions were included. The volumes of treatment were defined by 4D-CT to consider breathing motion. Normal organs constraints followed the recommendations of the RTO 0813 trial as follows: Spinal cord: max 30 Gy. Lung right or lung left: V13 Gy[cc] < 1500. Esophagus: max 52 Gy and nonadjacent esophagus: V27.5 Gy[cc] < 5. Heart: V32 Gy[cc] < 15; max 52 Gy. Great vessels: max 52 Gy and non-adjacent great vessels V47 Gy[cc] < 10. Trachea plus bronchus: max 52 Gy and non-adjacent V18 Gy[cc] < 4. Follow-up, at the discretion of the treating MD, included periodic CT scans of the thorax after SBRT and assessment of radiation-induced toxicity scored with CTCv3.0. Between December 2015 and February 2022, 86 patients were eligible for this review. Median follow-up was 17 months (range: 1-76 months); the median age was 74 years (range: 37-98 years). Histology was as follows: 50 patients had biopsy proved NSCLC, 16 had no biopsy, and 20 had metastatic non-lung primaries. Overlapped structures were as follows: with great vessels in 46 cases, heart in 20 cases, trachea/branchial tree in 18 cases, and esophagus in 2 cases. In 16 patients the overlap was present in more than one structure. Overall, 68.6% did not report acute toxicity. The most common acute side effects were fatigue (15.1%), coughing (8.1%), shortness of breath (6.9%), esophagitis (2.3%), and dysphagia (1.1%). No grade 3 or more significant toxicity was described. As acute side effects, many patients had exacerbations of the previous condition, such as shortness of breath (16 pts) or coughing (4 pts) during follow-up. Pneumonitis was found as a late side effect in four cases. One patient had empyema associated with a fistula in the non-irradiated lung, where the patient had previous surgery, but in the irradiated lung no severe complication was detected. There were no deaths attributed to the SBRT treatment. 67.5% of 86 patients were alive at the time of the review; 87.2% had local control, and 65.1% had metastases-free survival. In this cohort of patients, no death or even severe acute or chronic toxicity was attributed to SBRT. SBRT seems safe for ultra-central lesions using the regimen of 50 Gy in 5 fractions with the constraints of the RTOG 0813 trial.

Irradiated peripheral blood mononuclear cells for assessing individual radiosensitivity in laryngeal cancer radiotherapy

In laryngeal cancer radiotherapy (LCRT), dermatitis, dysphagia, and odynophagia are common acute side effects, varying in intensity depending mainly on the patient's radiosensitivity. This study investigated the survival rate of in vitro irradiated peripheral blood mononuclear cells (PBMC) as a pre-therapeutic test to assess individual radiosensitivity and predict the degree of these acute side effects in LCRT. 16 patients diagnosed with early-stage laryngeal cancer undergoing radiotherapy without adjuvant chemotherapy participated as volunteers in this study. Before the beginning of treatment, a sample of PBMC was collected and irradiated with 2.5 Gy using a 6 MV linear accelerator. After 72-h cell incubation, the trypan blue exclusion test was performed to score viable cells through optical microscopy. The percentages of cell viability were compared to the intensity of acute side effects experienced by LCRT patients. Even though no correlation was found regarding the observed degrees of radiation dermatitis, our results indicate that patients with survival rates of in vitro irradiated PBMC higher than 70% are more likely to experience moderate to severe acute odynophagia and dysphagia after LCRT. The proposed and discussed methodology points to a practical and affordable pre-therapeutic test to evaluate individual radiosensitivity in order to prevent or reduce acute side effects in laryngeal cancer radiotherapy.

Lycium barbarum polysaccharide-glycoprotein ameliorates ionizing radiation-induced epithelial injury by regulating oxidative stress and ferroptosis via the Nrf2 pathway.

Radiation-induced oral mucositis (RIOM) is considered to be the most common acute side effect of radiation therapy and occurs during intentional or accidental radiation exposure. Antioxidant synthesis agents have been reported to protect against or alleviate the development of mucositis, but the resulting side effects of chemical synthesis agents limit their use in clinical practice. Lycium barbarum polysaccharide-glycoprotein (LBP), a polysaccharide extract of the Lycium barbarum fruit, has superior antioxidant capacity and biosafety and is a potential option for radiation prevention and treatment. Here, we aimed to investigate whether LBP conferred radioprotection against ionizing radiation-induced oral mucosal damage. We found that LBP exerted radioprotective effects in irradiated HaCaT cells, improving cell viability, stabilizing mitochondrial membrane potential, and decreasing cell death. LBP pretreatment reduced oxidative stress and ferroptosis in radioactivity-damaged cells by activating the transcription factor Nrf2 and promoting its downstream targets, such as HO-1, NQO1, SLC7A11, and FTH1. Knockdown of Nrf2 eliminated the protective effects of LBP, implying the essential role of Nrf2 in LBP activity. Additionally, the topical application of LBP thermosensitive hydrogel on rat mucosa resulted in a significant decrease in ulcer size in the irradiated group, suggesting that LBP oral mucoadhesive gel may be a potential tool for the treatment of irradiation. In conclusion, we demonstrated that LBP attenuates ionizing radiation-induced oral mucosa injury by reducing oxidative stress and inhibiting ferroptosis via the Nrf2 signaling pathway. LBP may be a promising medical countermeasure against RIOM.

Non-Invasive Physical Plasma for Preventing Radiation Dermatitis in Breast Cancer: A First-In-Human Feasibility Study.

Radiation dermatitis (RD) is the most common acute side effect of breast irradiation. More than a century following the therapeutic utilisation of X-rays, potent preventative and therapeutic options are still lacking. Non-invasive physical plasma (NIPP) is an emerging approach towards treatment of various dermatological disorders. In this study, we sought to determine the safety and feasibility of a NIPP device on RD. Thirty patients undergoing hypofractionated whole-breast irradiation were included. Parallel to radiation treatment, the irradiated breast was treated with NIPP with different application regimens. RD was assessed during and after NIPP/radiation, using clinician- and patient-reported outcomes. Additionally, safety and feasibility features were recorded. None of the patients was prescribed topical corticosteroids and none considered the treatment to be unpleasant. RD was less frequent and milder in comparison with standard skin care. Neither NIPP-related adverse events nor side effects were reported. This proven safety and feasibility profile of a topical NIPP device in the prevention and treatment of RD will be used as the framework for a larger intrapatient-randomised double-blind placebo-controlled trial, using objective and patient-reported outcome measures as an endpoint.

Proton Therapy for Primary Bone Malignancy of the Pelvic and Lumbar Region - Data From the Prospective Registries ProReg and KiProReg.

Purpose/Objective(s)Multimodality treatments together with local proton therapy (PT) are commonly used in unresectable primary bone malignancies in order to provide better tumor control rate while maintaining good feasibility. The aim of this study is to provide data on outcome of PT for the challenging cohort of pelvic and lumbar bone tumors.Methods and MaterialsThis retrospective study includes all patients with primary bone malignancy of the pelvis and lumbar spine receiving PT in our institution between May 2013 and December 2019 enrolled in the prospective registries KiProReg and ProReg collecting information on demographics, treatment, tumor characteristics, toxicities, and outcome.ResultsEighty-one patients were enrolled with a median age of 19.7 years (1.3–85.8). The median follow-up time was 27.5 months (1.2–83.2). The majority of patients was male (64.2%), ECOG status of 0–1 (75.2%), underwent only biopsy (50.6%), received chemotherapy (69.1%) and was assigned for definite PT (70.4%). The predominant tumor characteristics were as follows: Ewing’s sarcoma histology (58%), negative nodal involvement (97.5%) and no metastasis at diagnosis (81.5%). Median maximal diameter of tumor was 8 cm (1.4–20). LC, EFS and OS rate were 76.5, 60, and 88.1% at two years and 72.9, 45.7, and 68.9% at three years, respectively. Age over 20 years was a significant negative factor for LC, EFS, and OS. Metastatic disease at initial diagnosis affected OS and ECOG status of 2–4 affected EFS only. Regarding 17 relapsed cases (21%), isolated distant relapse was the most common failure (46.9%) followed by local failure (40.6%). Eleven out of 14 evaluable patients relapsed within high-dose region of radiotherapy. Acute grade 3–4 toxicity was found in 41 patients (50.6%) and all toxicities were manageable. Late grade 3 toxicity was reported in 7 patients (10.4%) without any of grade 4. Most common higher grade acute and late side effects concerned hematologic and musculoskeletal toxicity.ConclusionProton therapy resulted in good oncological outcomes when being part of the multimodality treatment for pelvic and lumbar primary bone malignancies. However, distant metastases and local failures within the high-dose region of radiotherapy are still a common issue. Acute and late toxicities of combined therapy were acceptable.

Treatment outcomes of stereotactic ablative body radiotherapy on oligometastases from colorectal cancer: early results of a single institution service evaluation.

ObjectiveStereotactic ablative radiotherapy (SABR) has been suggested to be an effective non-invasive ablative therapy for oligometastases originated from colorectal cancer (CRC). This study aimed to report CRC oligometastases SABR treatment outcomes in terms of overall survival (OS), progression-free survival (PFS) and post-treatment toxicities.Methods:Treatment records of patients with CRC metachronous oligometastases who underwent SABR at a single institution between February 2015 and December 2018 were retrospectively reviewed. OS and PFS were calculated using Kaplan–Meier statistics and post-RT toxicity data was scored following CTCAE v. 4.0. Analysis of prognostic factors on OS and PFS was performed based on site of primary cancer, types of treatment to primary cancer, number of oligometastases, SABR treatment sites, intervals between treatment to primary cancer and SABR to oligometastases, biological equivalent dose, cumulative gross tumour volume and planning target volume.Results75 patients with 86 CRC metachronous oligometastases (including liver, lung, lymph nodes and bone) were included. The median age was 65.5 years (range 42.5–87.2) with a median follow-up of 23.8 months (range 3.1–46.5). The estimated median PFS was 14.6 months (95% CI 9.6–19.6). and estimated median OS was 33.3 months (95% CI 22.9–43.7). Majority of patients tolerated SABR well with the most common acute side-effects of Grade 1 fatigue. No Grade 3 or higher toxicities were reported at any time points.Only SABR treatment sites (p = 0.03) and cumulative volumes of planning target volume (p = 0.02) were found to be statistically significant independent predictors of PFS and OS respectively.ConclusionThis study showed modest PFS, OS, and post-treatment toxicity outcomes on SABR to metachronous oligometastases from CRC. It has highlighted that cumulative tumour volume may be a stronger prognostic factor of OS comparing to the number of metastases.Advances in knowledge:There are limited data published on the efficacy and post-treatment toxicity of CRC oligometastases SABR with adequate length of follow-up. Our retrospective study suggests that cumulative tumour volume may be a stronger prognostic factor of OS comparing to the number of oligometastases.

Effectiveness and tolerability of radiotherapy for patients with indolent non-Hodgkin\u2019s lymphoma: a monocenter analysis

To analyze the effectiveness and toxicities of radiotherapy in indolent non-Hodgkin’s lymphoma (iNHL) patients treated in our institution. Patients with iNHL treated with radiotherapy between 1999 and 2016 were included. The primary endpoint was progression-free survival (PFS). Secondary endpoints were local control (LC), overall survival (OS) and toxicities. PFS, LC, and OS were analyzed using Kaplan–Meier method. Log-rank test was used to investigate the differences between subgroups. Cox proportional hazard model was used for univariate continuous analysis. Seventy-five patients were identified in our institutional database between 1999 and 2016. Fifty-eight (77.3%) had stage I after Ann-Arbor and 17 patients (22.7%) had stage II. The median follow-up was 87 months (95% CI 72–102 months). Median single dose per fraction was 2.0 Gy (range 1.5–2 Gy) and median total dose was 30.6 Gy (range 16–45 Gy). Radiotherapy was performed in 2D (n = 10; 13.3%), 3D (n = 63; 84.0%) and VMAT (n = 2; 2.7%) techniques, respectively. The median PFS was 14.0 years (95% CI 8.3–19.7 years). The estimated PFS after 5 and 10 years were 73.0% and 65.5% in Kaplan–Meier analysis, respectively. The 5- and 10-year LC were 94.9% and 92.3%, respectively. The 5- and 10-year OS were 88.6% and 73.9%. In univariate analyses of PFS, younger patients (≤ 60 years old) had significantly superior PFS to those older than 60 years old (5-year PFS 81.9% vs. 65.1%, p = 0.021). Dose escalation > 36.0 Gy had no prognostic influence in term of PFS (p = 0.425). Extranodal involvement, stage and histology had no prognostic impact on PFS. Depending on the site of lymphomas, the most common acute side effects were: dermatitis CTCAE° I–II (8.0%), xerostomia CTC° I (8.0%), cataract CTC° I (12.0%) and dry eyes CTC° I–II (14.6%). No adverse event CTC° III was reported. Most acute side effects recovered at 3 to 6 months after radiotherapy except for CTC° I cataract and xerostomia. Local Radiotherapy was highly effective for treatment of early stage iNHL with no serious side effects in our cohort. The most acute CTCAE° I–II side effects recovered 3 to 6 months later. Technique advances seem to have further improved effectiveness and tolerability of radiotherapy.Trial registration: Local ethics committee of Ludwig-Maximilian-University (LMU) Munich approved this retrospective analysis on the May 7th, 2019 (Nr. 19–137).

Safety and Early Efficacy of Involved Field SBRT for Nodal Oligo-Recurrent Prostate Cancer

<h3>Purpose/Objective(s)</h3> Following definitive treatment for localized prostate cancer a subset of men will unfortunately develop recurrent disease. Newer PET agents have demonstrated that most early recurrences occur in the abdominopelvic nodal basins. The optimal treatment strategy for this patient population is unknown but likely includes a combination of systemic therapy, surgery and/or radiation therapy. For radiation therapy, the optimal treatment volume, fractionation schedule and dose remain unanswered questions. We report early outcomes for patients treated with involved field SBRT for nodal oligo-recurrent prostate cancer. <h3>Materials/Methods</h3> Between January 2018 and January 2020, 21 patients with nodal oligo-recurrent prostate cancer treated with involved field SBRT at a single academic institution were eligible for inclusion in this analysis. Detection of recurrence was ascertained by imaging including: Axumin PET/CT (66%) or MRI/CT (34%) following a PSA rise. All patients were treated with five-fraction involved field SBRT to a dose of 27.5-30 Gy. The treatment volume for involved field was defined as the nodal basin containing the gross nodal disease as well as the immediately adjacent nodal basins. Oligo-recurrence was defined as any volume of disease that could be safely treated within an involved field. Acute and late toxicity data was defined as any treatment related toxicity occurring <b>≤</b> 90 days and > 90 days following treatment, respectively. Toxicity was graded using Common Terminology Criteria for Adverse Events version 4.0. PSA response was defined as any decrease in the PSA following treatment. Local recurrence was defined as any new or growing lesion within the treatment field following treatment. Local control was calculated using the Kaplan-Meier method. <h3>Results</h3> The median pre-salvage PSA was 7.2 ng/ml. The median follow-up for all patients was 25 months (11 – 36 months). The most common acute side effect was grade 1 diarrhea (n = 7, 33%). Acute grade 2 GI toxicity occurred in 14% of patients (n = 3). Two patients had late low grade pelvic pain and 1 patient had late grade 2 lower extremity limb edema. There were no late grade 2+ GI side effects. No grade 3+ side effects occurred at any time following treatment. 88% of patients had a PSA response following treatment. The local control at 1 and 2 years was 100% and 94%, respectively. <h3>Conclusion</h3> With the widespread adoption of novel PET agents the group of patients with oligo-recurrent nodal disease is likely to increase significantly. The optimal combination of local and systemic therapy in this patient population is the subject of ongoing clinical investigation. With a favorable toxicity profile, high rates of local control and PSA response, involved field SBRT represents a feasible as well as convenient local therapy treatment option for an elderly patient population.

Analysis of Applicator Insertion Related Acute Side Effects for Cervical Cancer Treated With Brachytherapy.

PurposeTo report applicator insertion-related acute side effects during brachytherapy (BT) procedure for cervical cancer patients.Materials and MethodsBetween November 2017 and December 2019, 407 BT fractions were performed in 125 patients with locally advanced cervical cancer. Acute side effects recorded comprised anesthesia-related side effects, mechanical-related side effects and infection, whose frequency and degree were recorded. Pain was assessed using numeric rating scale; vaginal bleeding volume was counted by weighing gauze pieces used in packing. The BT procedure comprised eight stages: anesthesia, applicator insertion, image acquisition, transport, waiting for treatment, dose delivery, applicator removal, and removed which denoted 0.5–12.0 h period after removal, with time of each stage recorded. Factors influencing acute side effects were assessed by Spearman correlation and Mann–Whitney U test.ResultsThe most common acute side effect was pain, followed by vaginal bleeding. The mean scores for pain were highest during removal time, 4.9 ± 1.6 points. The mean vaginal bleeding volume was 44.4 ml during removal time. Mean total procedure time was 218.8 (175–336) min, having positive relationship with frequency of acute side effects. The total procedure time with acute side effects was longer than that without acute side effects. The longest procedure time was waiting time, 113.0 (91.0–132.0) min. More needles generated higher pain scores and larger volume of vaginal bleeding.ConclusionPain and vaginal bleeding were the most common acute side effects, especially during removal time, which physicians should focus on. Shortening patients’ waiting time helps to reduce the total procedure time, thus, reduce acute side effects. While meeting dose requirement, less needles are helpful to reduce acute side effects.

A Systematic Review of Low Level Laser (LLLT) Therapy on PainFollowing Orofacial Surgeries

AbstractBackground: Oral Mucositis (OM) is still a common andsevere acute side-effect of many oncologic treatments, espe-cially in patients treated for head and neck cancer. It mayaffect quality of life, require supportive care and impacttreatment planning and its efficacy. Low-Level Laser Therapy (LLLT) seems to promote pain relief and reduces OM incidenceand its severity. It has been recommended for these patientsas a treatment option but without any consensus in the LLLTprocedure. New recommendations and perspectives for clinicaltrials will be discussed.Aim of Study: The aim of this systematic review was toexamine the effectiveness of low level laser therapy on painfollowing oraofacial surgeries patients.Material and Methods: Systematic Review of randomizedcontrolled trials, data bases searched were made in Pubmed,Pedro, Google scholar and Cochrane, all studies were from1996 to 2018. Limits were English language. Included studieswere independently reviewed for methodological quality andassigned a level of evidence (Center for Evidence BasedMedicine).Intervention: Twelve relevant randomized controlled trialsincluded the low level laser such as He Ne, GA As and LEDand its effects on pain in patients with oraofacial surgeries.Results: Twelve studies were selected, included in meta-analysis for the primary outcomes as mucositis and secondaryoutcomes as, ROM and quality of life.Conclusions: Prophylactic LLLT GaALAs” reducedsevere mucositis and pain in post-operative oraofacial surgeries.there are some evidence support its effect on secondaryoutcomes as ROM, cognitive function, and quality of life.

Creation of a chemotherapy-induced nausea/vomiting dashboard to improve outcomes for pediatric cancer patients.

Two of the most common acute side effects of chemotherapy are nausea and vomiting. Nausea and vomiting impact quality of life, nutritional status, and ability to tolerate further chemotherapy. Parents of pediatric oncology patients rank nausea as one of the most bothersome treatment-related symptoms. Utilizing Quality Improvement methodology, we developed a dashboard interface to facilitate extraction of data from the electronic medical record (EMR), which is presented via a visual display that summarizes the type of chemotherapy and antiemetic medications, use of as needed medications, and number of episodes of emesis. This dashboard interface allows for rapid and efficient identification of patients whose antiemetic regimen is mismatched for the emetogenicity of ordered chemotherapy, thus providing a timely opportunity to modify the antiemetic regimen based on published guidelines before administration of chemotherapy drugs. It also allows measurement of the effectiveness of the antiemetic regimen in terms of the number of break through emesis and the need for as needed medications. A novel CINV dashboard was created, which visually conveys complex information about antiemetics, chemotherapy emetogenicity, as needed medications, and breakthrough vomiting for inpatient pediatric oncology patients.

Prognostic factors for lymphedema in patients with locally advanced head and neck cancer after combined radio(chemo)therapy- results of a longitudinal study.

Treatment-associated lymphedema is a common side effect after multimodal therapy for locally advanced head and neck cancer (LAHNC). This study aims to evaluate potential prognostic factors for head and neck lymphedema (HNL) and its potential impact on clinical outcome. This is a prospective data registry analysis on 280 patients treated for locally advanced head and neck cancer (LAHNC). All patients received surgery and risk-adapted platinum-based adjuvant intensity modulated radio(chemo)therapy (R(C)T, IMRT). Treatment- related toxicity was prospectively registered in a data base in regular intervals (baseline 3months after R(C)T, every 3months for 3years, and every 6months thereafter) and documented according to RTOG/EORTC toxicity criteria. Predictive for any grade HNL 3months after R(C)T were age, BMI, number of removed nodes and RT modality. Multivariable logistic regression analysis showed that in the acute toxicity phase (3months after R(C)T) higher body mass index (BMI), extracapsular spread (ECE), linac-based IMRT, bilateral treatment to the neck (surgery and RT), and the addition of chemotherapy increase the risk for grade 2 HNL. For chronic HNL, higher BMI, linac-based IMRT and ECE were predictive for grade 2 HNL. Higher BMI is associated with better local control rates. Advanced age and ECE had a negative impact on OS. HNL is a common acute and late side effect after multimodal therapy for LAHNC. Knowing risk factors for HNL prior to therapy enables caregivers and patients to take measures prior to treatment to prevent or limit the effects of HNL.

Evaluation of The Effectiveness and Side Effects of Radiotherapy in Patients With Primary Nervous System Lymphoma. A Single Center Experience

Aim: In this study, we aimed to evaluate the overall and progression-free survival, the radiotherapy process and the early and late adverse effects in patients who underwent radiotherapy (RT) for primary nervous system lymphoma in our clinic.Method: Between January 2010 and September 2019, 16 patients who received radiotherapy due to primary central nervous system lymphoma in our clinic were examined according to their statistically significant differences in terms of survival and side effects.Results: The median disease-free survival of the patients was 6 months, and the median overall survival was 12.5 months. 18.75% of the patients could not receive chemotherapy but only radiotherapy. Radiotherapy doses were range from 2600 to 5000 cGy. When patients were evaluated in terms of radiotherapy dose, field size and chemotherapy, no statistically significant difference in overall survival was detected. Cognitive disorders were observed as the most common late side effects while the most common acute side effects in patients were headaches.Conclusion: In the treatment of primary central nervous system lymphoma, changes in radiotherapy portals and radiotherapy doses can be predicted in patients who received high-dose methotrexate chemotherapy or not. Furthermore, it has been considered that more comprehensive studies are needed to increase the success of treatment and provide standardization in treatment, especially in patients with elderly and comorbid diseases.

Macrophage-Mediated Bystander Effects after Different Irradiations through a p53-dependent Pathway.

The goal of this work was to elucidate the mechanisms of bystander effects outside the localized irradiation field and their potential hematological toxicity. In this study, an in vitro multicellular co-culture system was used to investigate the intercellular commutation and related signaling pathways between either irradiated A549 cells or Beas-2B cells and bystander lymphoblast TK6 cells with or without macrophage U937 cells as an intermediator. Results showed that the proliferation ability of bystander TK6 cells was inhibited after co-culture with A549 cells irradiated with γ rays rather than carbon ions. When macrophages were contained in the co-culture system, the cell viability damage to the bystander TK6 cells were further enhanced. However, the proliferation inhibition of bystander TK6 cells after co-culture with irradiated Beas-2B cells was observed only when intermediator macrophages existed in the cell co-culture system. More serious cell injury was detected after carbon-ion irradiation compared with γ-ray irradiation. The p53-relevant apoptosis pathway was activated in both irradiated A549 and Beas-2B cells, each to a different extent. When the p53 pathway of irradiated cells was inhibited by PFT-α, PFTµ or p53 siRNA, the bystander damage to TK6 cells were clearly alleviated. In conclusion, the bystander lymphoblast damage was induced in different cells using different LET radiations. An amplified bystander response was modulated by the intermediator macrophage. The underlying molecular mechanisms of these bystander effects were dependent on the activation of p53 and its relevant apoptosis pathway in the irradiated cells. These results suggest that the bystander and macrophage-mediated bystander effects contribute to the common acute side effect of lymphocytopenia after local irradiation.

Determination of Radiotherapy-Related Acute Side Effects; A Starting Point for the Possible Implementation of a Clinical Pharmacy Services in the Radiological Unit in Turkey

Background: Although it is considered as important part in cancer therapy, radiotherapy is associated with many acute side effects. The clinical pharmacist in clinical oncology practice provides a well-defined role in the assessment and monitoring of side effects during treatment. Aims and Objectives: The aim of this study was to explore Radiotherapy-Related Acute Side Effects (RRASEs) in a real-life setting at the radiology unit and whether there is a possibility for providing radiology unit-based clinical pharmacy supportive services in collaboration with other healthcare professionals for cancer patients admitted for radiotherapy application. Methods: A retrospective descriptive study was carried out on cancer patients admitted for radiotherapy application at the radiology unit. During the study, detection of RRASEs incidence and their outlined treatments were assessed. Results: RRASEs observed was 494 with a mean number of 6.175±2.88 per patient. A high incidence of RRASEs was encountered among male patients 61.3%. Nausea and vomiting were the most common acute side effects encountered 82.5% followed by loss of appetite 73.8%. There was a significant correlation between the incidence of RRASEs and a number of factors that were related to age greater than 60 years ( P =0.0003), cigarette smoking ( P =0.0084), comorbidities ( P =0.0328), carcinoma type and stage ( P =0.0098) and ( P =0.0001) respectively. Conclusion: Radiotherapy application is associated with the incidence of different acute side effects that require proper treatment and follow-up. This could be further achieved through the introduction of the clinical pharmacist services in collaboration with other healthcare professionals for better patient-related health outcomes. Key words: Acute Side Effects, Cancer, Clinical Pharmacy Services, Radiology Unit, Turkey.

Radiotherapy in the treatment of primary or recurrent unresectable desmoid tumors of the neck

Purpose: Desmoid tumors are locally aggressive nonmalignant soft tissue tumors, which frequently recur after therapy. The optimal treatment is still controversial because of the lack of large research. A few studies have reported the effects of other treatments in one lesion when surgery is not possible or would cause notable functional impairment. Our aim was to examine the outcome of radiotherapy (RT) in the treatment of primary or recurrent unresectable desmoid tumors of the neck.Materials: A retrospective analysis was performed on 30 patients between 1/2008 and 12/2017, with 3 primary and 27 recurrent unresectable desmoid tumors of the neck. All cases were reviewed by pathologists.Results: The median follow-up time was 50.5 months (range 2–126 months). Radiotherapy doses varied from 50 to 66 Gy (median 60 Gy, 23/30 patients) with all fraction size of 2 Gy. The objective response rate (ORR: CR or PR) to definitive RT was 56.7% (17/30 patients). On Chi-square statistic, ORR was significantly influenced by tumor size (≤5 cm versus >5 cm) (p = .046). Age (≤ 40 versus >40 years) (p = .804), gender (p = .629), and RT dose (≤60 versus >60 Gy) (p = .613) were not significantly associated with ORR. The most common acute side effects of the radiation-related complication were grade 1–2 skin toxicities.Conclusion: Radiotherapy is a valuable option in the management of primary or recurrent unresectable DTs of the neck with good local control. Multi-institutional and prospective studies are warranted to further validate our findings.

Hypofractionated intensity-modulated radiotherapy in locally advanced unresectable pancreatic cancer: A pilot study

PurposeTo test feasibility and safety of hypofractionated intensity modulated radiotherapy (H-IMRT) in pancreatic adenocarcinoma (PAC) treatment. MethodsPatients with unresectable nonmetastatic PAC were prospectively enrolled on a pilot study. Patients received H-IMRT to gross tumor volume to a total dose of 52 Gy (4 Gy/fraction). Toxicity rates, duodenal dosimetric parameters, and clinical outcomes were evaluated. ResultsTen patients received H-IMRT regimen. Objective tumor response was recorded in all patients but one. Gastrointestinal toxicity was the most common acute side effect and its severity moderately correlated with duodenal maximum dose (ρ = 0.46) and percentage of duodenal volume exposed to 5 Gy (ρ = 0.46). The 1-year overall and disease-free survival were 83.3% and 68.6%, respectively. ConclusionH-IMRT seems to guarantee a high local control rate without severe toxicity. Its use in unresectable nonmetastatic PAC needs to be further investigated.

Hypofractionated Regional Nodal Irradiation (HF-RNI) in Early Breast Cancer (BC) after Breast-Conserving Surgery (BCS): A Single Institution Comparative Study

Hypofractionated whole-breast radiotherapy without RNI has recently become the standard of care for early BC after BCS. A hypofractionated radiation (HF-RT) schedule can be considered for RNI in an attempt not to dissociate the overall treatment time when RNI is indicated. However, limited data are available. We aimed to compare outcome of HF-RNI to conventional fractionated (CF) RNI in patients treated during the same period. Among the 767 BC patients treated in our department between January 2013 and December 2016, 39 patients were included in this study, 13 of whom had HF-RNI (40Gy in 15 fractions or 45Gy in 20 fractions) while 26 (control group; ratio 2:1) patients were treated in the same period using a CF-RNI schedule (46Gy in 23 fractions). All patients received RT after BCS with sentinel lymph node biopsy procedure (SLN, n=11) or axillary lymph node dissection (ALND, n=28). RNI included irradiation to at least supraclavicular fossa and internal mammary chain (IMC) ± axillary lymph nodes (n=6). Boost was delivered at a dose of 10-15Gy (2.5Gy/fraction) in the HF group, and 16Gy (2Gy/fraction) in the CF group. Systemic treatments were indicated according to prognostic factors (n=17, 43.6%). Disease control and treatment-related toxicity were analyzed at each follow-up visit. Dosimetric data were reviewed retrospectively regarding the heart, lungs, and brachial plexus. After a median follow-up of 24.8 (range, 1-52) months, only one patient in the HF-RNI group had local recurrence at 12 months. Patients in the HF-RNI group were older than those in the CF-RNI group (70 vs. 62 years, p=0.03). There was a trend to have more left-side breast RT in the CF-RNI group (46.2 vs. 23.1%, p=0.051). IMC RT was more common in the CF-RNI group (80.8 vs. 23.1%, p=0.001), resulting in a higher equivalent (EQD2) mean dose to the heart (3.96 vs. 2.24Gy, p=0.046). Lung dose was similar in both groups, except for EQD2 V30 which was higher in the HF-RNI group (21.3 vs. 14.9%, p=0.03). The most common acute side effects in both groups were skin reactions, including erythema and patchy moist desquamation (CF-RNI 57.7 vs. HF-RNI 53.9%, p=0.83) and moderate hyperpigmentation (CF-RNI 34.6 vs. HF-RNI 46.2%, p=1.0). Only one patient presented lymphedema in the CF-RNI group. Two (7.7%) patients in the CF-RNI group had moderate breast fibrosis versus none in the HF group (p=0.54). We did not observe other late complications, such as plexopathy, rib fracture, pneumonitis, and cardiac events. Scanographic evaluation of potential lung fibrosis is ongoing. Results will be presented during the meeting. HF-RNI seems to be a safe and reasonable alternative in early breast cancers after BCS. However, younger patients were more likely to receive a CF schedule and IMC-RT than the elderly. Our schedule that allows completing the whole treatment in 19 fractions including the boost is safe, however with short term follow-up. More prospective studies are needed to confirm the long term safety of HF-RNI.