European Protocol Research Articles

CURRENT CHALLENGES OF HEPATITIS A IN UKRAINE DURING WARTIME: A LITERATURE REVIEW

Goal: to analyze the situation of the incidence of hepatitis A in Ukraine during wartime. Materials and methods. The literature review was carried out using search engines on the platforms PubMed and Google Scholar, abstract database of scientific literature Scopus. Articles in both English and Ukrainian languages were sought. Employing bibliographic and analytical methods, approximately 50 literary sources were scrutinized. These included review articles, randomized and cohort studies, as well as international recommendations for antiviral drug prescriptions, directives, Ukrainian and European protocols for managing hepatic infection. Results. Fulminant hepatitis is a rare occurrence, accounting for less than 1% of cases, although cholestatic forms and recurrent hepatitis have also been documented. Recurrent hepatitis typically manifests in about 3–20% of patients, usually occurring 3–12 weeks following the initial episode, with symptoms generally less severe than the initial presentation. Unlike other hepatitis viruses, HAV does not establish chronic infections. While extrahepatic manifestations of acute hepatitis A are uncommon, they may include neurological symptoms such as Guillain-Barré syndrome, rash, pancreatitis, arthritis, myocarditis, acute kidney injury, and hematologic disorders such as hemolysis and cryoglobulinemia. Numerous studies have indicated that disease severity and mortality associated with HAV infection are heightened among individuals with chronic liver disease, encompassing hepatitis B or C virus coinfection, alcoholic cirrhosis, and fatty liver disease. Chronic liver disease is prevalent in HIV patients due to factors such as coinfection with HBV or HCV, hepatotoxicity from antiviral medications, or alcoholic liver disease. This population may also face an elevated risk of acute or chronic liver failure. HAV infections represent the predominant cause of viral hepatitis globally. The epidemiology of HAV has undergone significant changes due to globalization and improved sanitation. Person-to-person transmission, particularly among high-risk populations such as men who have sex with men (MSM), individuals who use psychoactive substances, and those experiencing homelessness, predominates in high-income countries. Conclusion. However, outbreaks still occur despite the availability of safe, effective vaccines and long-term HGA vaccination recommendations for these individuals. Efforts should be made to develop resources aimed at raising awareness of HAV among high-risk populations and promoting vaccination. Additionally, the development of a specific antiviral treatment for HAV could be very helpful in preventing outbreaks of the virus.

Abstract PO2-11-09: European Lobular Breast Cancer Advocates: Bridging the Geographical Gaps in Lobular Breast Cancer Education and Awareness

Abstract Introduction In 2019, Invasive Lobular Cancer (ILC) Patient Advocates attended the 3rd meeting of the European Lobular Breast Cancer Consortium (ELBCC), a scientific community focused on lobular research and treatment. European Lobular Breast Cancer Advocates (ELBCA) now have a network of ILC patient advocates across Europe. ILC is classified by the World Health Organisation as the most common Special Type of Breast Cancer. In 2022 there were 576,300 diagnoses of breast cancer in Europe, 15% ~86,500 were ILC. ILC is a histologically distinct breast cancer with diverse presentations including a tendency to metastasize to unique locations. Current endocrine therapies may have different effectiveness for ILC making treatment challenging. Current imaging tools are often unreliable with up to 30% of ILC tumours not identified on mammograms and detection is often delayed. Challenges There are no standardised European diagnostic or treatment protocols for ILC. ELBCA addresses this with collaborative efforts between ILC medical professionals and researchers. It’s a major challenge because each European country has a different health care system and economic policy structure. It’s also a challenge to streamline the translation of clinically accurate information to European patients in their own language. Not all European countries are members of the EU, there are a minimum of 24 official European languages. Established European breast cancer patient organizations often don’t distinguish between different histological subtypes. Current European policy and administrative processes have hindered the formation of a not-for-profit Advocacy Organization. Without such an organization, fundraising and collaborative efforts with others is difficult. Conclusions ELBCA has made significant progress towards raising awareness and increasing knowledge of ILC across Europe. Our poster will expand on these accomplishments as well as the following goals: Work with European and International ILC research and patient communities to better understand this unique histological subtype. Elevate ILC research priorities and inform European policy to recognize ILC as a distinct disease. Enhance education of ILC among primary HCP’s and patients. Establish a recognized European ILC Advocacy Organization and collaborate with established BC organizations. Attend major BC research and clinical conferences. Lobby to achieve increased funding for ILC research and clinical trials. Citation Format: Siobhan Freeney, Helene Bonval, Esther Geven, Lori Petitti, Rian Terveer, Claire Turner, Cathrin Brisken, Patrick Derksen, Christine Desmedt, Thijs Koorman, ADRIAN LEE, Steffi Oesterreich, Anne Salomon, George Sflomos, Karen Van Baelen, Tone Lien, Damir Vareslija, Sabine Linn. European Lobular Breast Cancer Advocates: Bridging the Geographical Gaps in Lobular Breast Cancer Education and Awareness [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-11-09.

Dosimetric Comparison Between Proton and Photon Radiation Therapies for Pediatric Neuroblastoma

PurposeThe aim of this study is to determine the most beneficial radiation treatment technique for pediatric patients with thoracic and abdominal neuroblastoma (NBL), through a dosimetric comparison between photon Volumetric Modulated Arc Therapy and proton Intensity-Modulated Proton Therapy treatment plans. Materials and MethodsA retrospective analysis was conducted on a multicentre case series of 19 patients with thoracic and/or abdominal NBL who underwent radiation therapy, following the recommendations of the European protocol for high-risk NBL (HR-NBL2/SIOPEN). The prescribed dose was 21.6 Gy in 12 fractions (1.8 Gy/fraction) delivered over the preoperative disease volume. The dose volume histograms were analyzed for each patient, and a Wilcoxon signed-rank test with a significance level of 0.01 was employed to assess statistical differences between the dosimetric parameters investigated. Two homogeneity indices (HI and newHI) were compared to evaluate the uniformity in dose, delivered to the adjacent vertebrae (VBs_Adj). ResultsBoth radiation techniques conform to the protocol regarding CTV/PTV coverage for every location. Proton therapy resulted in statistically significant dose sparing for the heart and lungs in supradiaphragmatic locations and for the contralateral kidney, liver, spleen, and bowel in subdiaphragmatic locations. For both techniques, sparing the non-adjacent vertebrae (VBs_NAdj) results more challenging, although promising results were obtained. Furthermore, the dose delivered to the VBs_Adj was not statistically different, in terms of homogeneity, for the 2 radiation techniques that both met the protocol’s requirements. ConclusionThis dosimetric analysis highlights the potential of protons to reduce radiation dose to healthy tissue. These findings apply to all the investigated patients, regardless of primary tumor location, making proton therapy a valuable option for the treatment of neuroblastoma. However, a multidisciplinary assessment of each case is essential to ensure the selection of the most effective and suitable treatment modality.

Cost-Effectiveness of the treatment protocols of pediatrics with Acute Lymphoblastic Leukemia (Decision tree modelling)

Background: Acute lymphoblastic leukemia (ALL) has a high prevalence at early age and in children and regard to life expectancy index this disease cause to losing many years of life in these patients. Two well-known European protocols called United Kingdom (UK-ALL) and Berlin-Frankfurt-Munster (BFM-ALL) protocols are used to treat the disease in most countries of the world and in Iran, so the objective of this study is modelling of the treatment process using both protocols to estimate more cost-effectiveness method. Methods: A decision tree model was applied to depict the real treatment process to calculate costs per quality-adjusted life-year (QALY). Total costs were included to the model. Results: The cost effectiveness ratio of UK-ALL is lower than BFM-ALL (1145.52 USD /3.87 QALY for UK-ALL and 1942.35 USD /3.02 QALY for BFM-ALL). Therefore, the UK-ALL is dominant and BFM-ALL is dominated. Conclusion: The modeling results showed a double difference between the two studied options so to better cancer management, policymakers and oncologist should advocate the economic evaluation methods and modeling to select a real option in the treatment of patients to save resources like UK-ALL.

Obtaining accurate population estimates with reduced workload and lower fish mortality in multi-mesh gillnet sampling of a large pre-alpine lake.

The EU Water Framework Directive requires monitoring of the ecological status of lakes, with fish as a relevant class of biotic quality indicator, but monitoring fish populations in large lakes is demanding. This study evaluated use in Lake Constance of a novel multi-mesh gillnet modified to reduce catch numbers. In direct comparison with conventional European Committee for Standardization (CEN) nets we achieved 48% reduction in fish mortality with 38% less labour for tasks directly influenced by fish catch numbers, while maintaining comparable species composition and catch per unit effort. Comparison of mesh sizes indicated no significant reduction in species detection in area-reduced panels of the small mesh sizes, while total observed species richness was greater when using the modified nets. Differences in benthic species communities among depth strata were common, while those of pelagic zones were more homogeneous and did not differ significantly with depth. Catches of different net types from the same depth stratum did not exhibit significant differences. The dominance structure of the most common species, relevant to lake assessment, was similar in catches of both net types, suggesting overall superiority of the modified nets in Lake Constance. Sampling conducted according to standard European CEN protocol, while deploying 60% fewer nets, yielded sufficiently precise abundance estimates for monitoring shallow areas of the benthic zone. A 50% difference in the abundance of dominant species was detected among sampling events with a certainty of 95%. The sample did not provide comparable accuracy in deep benthic strata or the pelagic zone, but was adequate to record complete inventories of species present. Based on this trial data, a new stratified sampling design is proposed for monitoring large lake fish communities for ecological assessment. Depth-dependent fish communities were used to calculate the required number of nets, which resulted in a 69% reduction for the entire lake compared to the CEN calculation method. Using the modified nets increases the feasibility of performing WFD surveys, by reducing effort and cost, while the simultaneous halving of fish mortality minimises the negative impact of fish surveys.

Evolution of European prostate cancer screening protocols and summary of ongoing trials.

Population-based organised repeated screening for prostate cancer has been found to reduce disease-specific mortality, but with substantial overdiagnosis leading to overtreatment. Although only very few countries have implemented a screening programme on a national level, individual prostate-specific antigen (PSA) testing is common. This opportunistic testing may have little favourable impact, while stressing the side-effects. The classic early detection protocols as were state-of-the-art in the 1990s applied a PSA and digital rectal examination threshold for sextant systematic prostate biopsy, with a fixed interval for re-testing, and limited indication for expectant management. In the three decades since these trials were started, different important improvements have become available in the cascade of screening, indication for biopsy, and treatment. The main developed aspects include: better identification of individuals at risk (using early/baseline PSA, family history, and/or genetic profile), individualised re-testing interval, optimised and individualised starting and stopping age, with gradual invitation at a fixed age rather than invitation of a wider range of age groups, risk stratification for biopsy (using PSA density, risk calculator, magnetic resonance imaging, serum and urine biomarkers, or combinations/sequences), targeted biopsy, transperineal biopsy approach, active surveillance for low-risk prostate cancer, and improved staging of disease. All these developments are suggested to decrease the side-effects of screening, while at least maintaining the advantages, but Level 1 evidence is lacking. The knowledge gained and new developments on early detection are being tested in different prospective screening trials throughout Europe. In addition, the European Union-funded PRostate cancer Awareness and Initiative for Screening in the European Union (PRAISE-U) project will compare and evaluate different screening pilots throughout Europe. Implementation and sustainability will also be addressed. Modern screening approaches may reduce the burden of the second most frequent cause of cancer-related death in European males, while minimising side-effects. Also, less efficacious opportunistic early detection may be indirectly reduced.

Performance evaluation of six digital mammography systems

The strong advance in digital mammography as a tool for breast cancer screening requires that the new systems be characterized. Quality control protocols describe the methodology to evaluate systems performance. Detective quantum efficiency (DQE) is the most suitable parameter for describing the imaging performance of an X-ray imaging device. The objective of this study was to characterize in terms of DQE six digital mammography systems, at different detector air kerma (DAK) levels for a variety of beam qualities. A Carestream EHR-M3 CR detector, a small field digital mammography system Siemens Opdima, and full field digital mammography systems Planmed Clarity, GE Essential, GE Pristina and GE Crystal Nova were characterized using the European Guidelines protocol. Modulation transfer function (MTF), normalized noise power spectrum (NNPS) and DQE were determined, for an extended detector air kerma range. Attenuated beam qualities (obtained by adding 2 mm Al to the corresponding beam qualities) used were 28 kV with anode/filter combination Mo/Mo for the EHR-M3, Opdima, Essential and Pristina systems; 28 kV W/Ag for the Clarity; 28 kV W/Rh for the Crystal Nova; 28 kV Mo/Rh for the EHR-M3; and 34 kV Rh/Ag for the Pristina. Two groups were identified in MTF analysis, and the group composed of Clarity, Opdima and Essential presented the highest MTF values. In NNPS analysis, three main groups were identified, in which the systems Crystal Nova and Essential presented lower and higher NNPS, respectively. Crystal Nova system also exhibited higher DQE values for low spatial frequencies, while Opdima and Clarity presented higher DQE values for medium to high spatial frequency. Agreement with data from literature indicates that the systems evaluated are operating under typical conditions. Evidence of improvement in detectors performance was found.

The Need for European Surveillance of CDI.

Since the turn of the millennium, the epidemiology of Clostridioides difficile infection (CDI) has continued to challenge. Changes in clinical presentation, severity of disease, descriptions of new risk factors and the occurrence of outbreaks all emphasised the importance of early diagnosis and standardised surveillance systems. However, a lack of consensus on case definitions, clinical guidelines and optimal laboratory diagnostics across Europe has led to the underestimation of CDI and impeded comparison between countries. These inconsistencies have prevented the true burden of disease from being appreciated.Acceptance that a multi-country CDI surveillance program and optimised diagnostic strategies are required has built the foundations for a more robust, unified surveillance. The concerted efforts of the European Centre for Disease Prevention and Control (ECDC) CDI networks led to the development of the European surveillance protocol and an over-arching long-term CDI surveillance strategy for 2014-2020, which has been followed by the development of surveillance systems in at least 20 European countries. However, surveillance activities in individual countries have slowed during the COVID-19 pandemic as resources were diverted to the global health crisis. A renewed and strengthened focus on CDI surveillance and prevention is therefore urgently needed post COVID-19.

Childhood interstitial lung disease: When to suspect and what to do

Childhood Interstitial lung Disease (chILD) is a heterogeneous group of more than 200 respiratory disorders characterized by the impairement of alveolar-capillary gas exchange and lung function. These disorders usually have a chronic course. Morbidity and mortality greatly vary depending on the disorder considered. Interstitial lung disease are associated with respiratory distress. During infancy the most common symptom to pay attention to is tachypnea, whilst in older children clinical presentation may be more insidious. When chILD is suspected, it is advisable to send the patient to a pediatric pulmonology center in order to set up a diagnostic work-up and an adequate treatment. A European protocol called the “Delphi method” has been standardizing empirical treatment since 2015.

Viper envenomation in Central and Southeastern Europe: a multicentre study

Introduction Snakebite incidence varies across Europe. However, there is limited research from Central and Southeastern Europe. These regions are notable for the presence of the common European adder (Vipera berus) and the more venomous nose-horned viper (Vipera ammodytes). No standard European antivenom protocol exists. The aim was to assess the epidemiology and treatment of viper bites in this region, focusing on a comparison of bites from Vipera berus and Vipera ammodytes. Methods We conducted a prospective multicenter study in Central and Southeastern Europe from 2018 to 2020. This study included poison centres and toxicology-associated hospital wards in Poland, the Czech Republic, Slovakia, Hungary, Slovenia, Croatia, Serbia, and Bulgaria. The following data were collected: age, gender, Vipera species, snakebite site, clinical picture, laboratory results, Audebert’s clinical severity grading score, and antivenom therapy. Results The annual incidence of viper bites in Central and Southeast Europe was estimated at 2.55 bites per million population. Within their respective geographical distribution areas, the incidence of Vipera ammodytes bites (1.61 bites per million population) was higher than Vipera berus bites (1.00 bites per million population). Patients bitten by Vipera ammodytes more frequently reported local pain and developed thrombocytopenia. Antivenom treatment was more commonly administered in Vipera ammodytes bites (72%) compared to Vipera berus bites (39%). The incidence of Vipera ammodytes bites treated with antivenom within its geographical distribution area was three times higher than Vipera berus bites treated with antivenom (1.16 bites per million population versus 0.39 bites per million population). No deaths were reported. Conclusions The estimated incidence of viper bites in Central and Southeastern Europe is at least 2.55 per million population. Vipera ammodytes bites are more common and severe, characterized by higher frequencies of pain and thrombocytopenia. Antivenom is needed more often for Vipera ammodytes bites. It is vital that enough European Medicines Agency-approved Vipera ammodytes antivenom is produced and offered affordably.

Circulatory soluble LOX-1 is a novel predictor for coronary artery disease patients.

This study investigated the biomarker effect of soluble lectin-like oxidised low-density lipoprotein (sLOX-1) levels for the evaluation of stable and unstable coronary heart disease, correlating it with aging. This case-control study was conducted at the Cardiology Department of Xiangya Hospital between June 2015 and September 2018. Stable coronary artery disease (CAD) patients were confirmed by an invasive coronary angiogram, and American College of Cardiology as well as European Cardiology Society clinical protocols were used for the diagnosis of unstable CAD subjects. Plasma sLOX-1 levels were determined from 226 stable CAD patients, 138 unstable CAD subjects and 75 healthy participants by enzyme-linked immunosorbent assay. Plasma sLOX-1 expressions were significantly elevated in stable CAD patients (4.5-fold) and unstable CAD patients (5.8-fold) above that of volunteer healthy participants. Moreover, between the stable and unstable patient groups, sLOX-1 concentrations were also statistically significantly different (p < 0.001). Levels of plasma sLOX-1 in the healthy female (30-60 years), and stable and unstable CAD female subjects (61-84 years) were markedly elevated compared with healthy male (30-60 years), as well as stable and unstable CAD male patients (61-84 years) (p < 0.001). Besides, in the female unstable CAD (61-84 years) subjects, circulatory sLOX-1 expressions were much higher than in the younger female unstable CAD (30-60 years) patients (p < 0.001). The stable CAD patients were clearly differentiated from healthy subjects with a high sensitivity of the area under the curve (AUC = 0.895). Unstable CAD patients and healthy subjects were also markedly different with a high sensitivity, as shown by AUC (0.902). Stable and unstable CAD subjects were differentiated with an AUC of 0.867. Elevated plasma sLOX-1 levels could be regarded as a novel biomarker for detecting CAD patients and there was a significant association with gender and aging.

Innovate and Stockpile: Respiratory Protection for Essential Workers in a Catastrophic Pandemic.

Innovate and Stockpile: Respiratory Protection for Essential Workers in a Catastrophic Pandemic.

Inter-Rater Reliability of Scoring Systems for Abomasal Lesions in Quebec Veal Calves.

The objective of this study was to determine the inter-rater reliability of current scoring systems used to detect abomasal lesions in veal calves. In addition, macroscopic lesions were compared with corresponding histological lesions. For this, 76 abomasa were retrieved from veal calves in a slaughterhouse in Quebec and scored by four independent raters using current scoring systems. The localisations of the lesions were separated into pyloric, fundic, or torus pyloricus areas. Lesions were classified into three different types, i.e., erosions, ulcers, and scars. To estimate the inter-rater reliability, the coefficient type 1 of Gwet's agreement and Fleiss κ were used for the presence or absence of a lesion, and the intra-class correlation coefficient was used for the number of lesions. All veal calves had at least one abomasal lesion detected. Most lesions were erosions, and most of them were located in the pyloric area. Overall, a poor to very good inter-rater agreement was seen for the pyloric area and the torus pyloricus regarding the presence or absence of a lesion (Fleiss κ: 0.00-0.34; Gwet's AC1: 0.12-0.83), although a higher agreement was observed when combining all lesions in the pyloric area (Fleiss κ: 0.09-0.12; Gwet's AC1: 0.43-0.93). For the fundic area, a poor to very good agreement was also observed (Fleiss κ: 0.17-0.70; Gwet's AC1: 0.90-0.97). Regarding the inter-rater agreement for the number of lesions, a poor to moderate agreement was found (ICC: 0.11-0.73). When using the scoring system developed in the European Welfare Quality Protocol, a poor single random rater agreement (ICC: 0.42; 95% CI: 0.31-0.56) but acceptable average random rater agreement (ICC: 0.75; 95% CI: 0.64-0.83) was determined. Microscopic scar lesions were often mistaken as ulcers macroscopically. These results show that the scoring of abomasal lesions is challenging and highlight the need for a reliable scoring system. A fast, simple, and reliable scoring system would allow for large scale studies which investigate possible risk factors and hopefully help to prevent these lesions, which can compromise veal calves' health and welfare.

Outcome of patients with undifferentiated embryonal sarcoma of the liver treated according to European soft tissue sarcoma protocols.

To assess the outcomes of pediatric patients with undifferentiated embryonal sarcoma of the liver (UESL) and treatment including at least surgery and systemic chemotherapy. This study included patients aged up to 21years with a pathological diagnosis of UESL prospectively enrolled from 1995 to 2016 in three European trials focusing on the effects of surgical margins, preoperative chemotherapy, use of radiotherapy (RT), and chemotherapy. Out of 65 patients with a median age at diagnosis of 8.7years (0.6-20.8), 15 had T2 tumors, and one had lymph node spread, 14 were Intergroup Rhabdomyosarcoma Study (IRS) I, nine IRS II, 38 IRS III, and four IRS IV. Twenty-eight upfront surgeries resulted in five operative spillages and 11 infiltrated surgical margins, whereas 37 delayed surgeries resulted in no spillages (p=.0119) and three infiltrated margins (p=.0238). All patients received chemotherapy, including anthracyclines in 47. RT was administered in 15 patients. With a median follow-up of 78.6months, 5-year overall and event-free survivals (EFS) were 90.1% (95% confidence interval [CI]: 79.2-95.5) and 89.1% (95% CI: 78.4-94.6), respectively. Two out four local relapses had previous infiltrated margins and two out of three patients with metastatic relapses received reduced doses of alkylating agents. Infiltrated margins (p=.1607), T2 stage (p=.3870), use of RT (p=.8731), and anthracycline-based chemotherapy (p=.1181) were not correlated with EFS. Multimodal therapy improved the outcome of UESL. Neoadjuvant chemotherapy for pediatric patients increases the probability of complete surgical resection. The role of anthracyclines and RT for localized disease remains unclear.

Metastatic adult-type non-rhabdomyosarcoma soft tissue sarcomas in children and adolescents: A cohort study from the European paediatric Soft tissue sarcoma Study Group.

Limited data exist on the clinical behavior of pediatric non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) with distant metastases at onset, and a clear standard of care has not yet been defined. This cohort study reports on pediatric adult-type metastatic NRSTS enrolled in two concurrent prospective European studies, i.e., the randomized BERNIE study and the single-arm MTS 2008 study developed by the European paediatric Soft tissue sarcoma Study Group. Treatment programs were originally designed for patients with metastatic rhabdomyosarcoma, i.e., nine courses of multidrug chemotherapy (with or without bevacizumab in the BERNIE study), followed by 12 cycles of maintenance therapy, whereas radiotherapy and/or surgery (on primary tumor and/or metastases) were delayed until after seven courses of chemotherapy had been administered. The study included 61 patients <21years old treated from July 2008 to December 2016. The lung was the site of metastases in 75% of the cases. All patients received multi-agent chemotherapy, 44% had local therapy to primary tumor, and 18% had treatment of metastases. Median time to progression/relapse was 6months. A high rate of tumor progression was observed during the initial part of the chemotherapy program. With a median follow-up of 41.5months (range, 2-111months), 3-year event-free survival and overall survival were 15.4% (95% confidence interval [CI], 7.6-25.7) and 34.9% (95% CI, 22.7-47.5), respectively. There were no statistically significant differences in outcome depending on the type of treatment administered. The study confirmed the overall poor outcome for patients with metastatic NRSTS, whose treatment remains a challenge. Pediatric non-rhabdomyosarcoma soft tissue sarcomas form a heterogeneous group of rare tumors. Although recent international studies have defined the standard of care for patients with localized disease, limited data are available on the clinical behavior of patients with distant metastases. This study on 61 metastatic cases treated on two prospective European protocols confirms that the chances of survival of such patients are often dismal and a standard treatment is still lacking.

Recommandations de la SFCE pour la prise en charge du lymphome de Hodgkin nodulaire à prédominance lymphocytaire de l’enfant et de l’adolescent

Nodular Lymphocyte predominant Hodgkin lymphoma (NLPHL) are rare lymphomas in pediatric patients comprising less than 10% of all Hodgkin lymphoma (HL). They are for the most part diagnosed at stage I or II and indolent with lymphadenopathy often preceding the diagnosis by many months/years. Survival is excellent. Historically, patients were treated according to classical HL protocols. Due to high toxicity and excellent prognosis, management of NLPHL shifted to de-escalation protocol with good results. No treatment beyond surgical resection was proposed for localized unique nodal disease completely resected. The closed European protocol (EuroNet PHL LP1) evaluated the efficacy of low intensity chemotherapy protocol based on CVP courses (cyclophosphamide vinblastine prednisone) for stage IA/IIA not fully resected. Final results are not yet available. Advanced stage NLPHL are rare and there is no clinical trial and no consensus treatment in children. The SFCE lymphoma committee recently established recommendations for staging and treatment of limited and advanced NLPHL in children based on current practices and published results. The goal was to allow homogeneous practice on a national scale. If incomplete resection for patients with stage I/IIA combination of low intensity chemotherapy (CVP) and rituximab is recommended. For intermediary and advanced stage intensification with AVD (adriamycine vinblastine dacarbazine) or CHOP courses (cyclophosphamide doxorubicine vincristine prednisone) combined with rituximab are advocated. In children, there is no indication for first-line local treatment with radiotherapy.

Evaluation of patient dose during a digital breast tomosynthesis

IntroductionWhen the patient dose in mammography is assessed, it is important to evaluate both average glandular dose (AGD) and entrance surface dose (ESD). A dose survey on both AGD and ESD in mammography has never been studied in Sri Lanka. Therefore, the present study aimed to evaluate the patient dose received during a full-field digital breast tomosynthesis (DBT) examination by determining both AGD and ESD. MethodsThe study was performed on 140 patients who underwent DBT examination. The AGD, ESD, compression breast thickness (CBT), half-value layer (HVL), target/filter combination, kVp, and mAs values were obtained from the machine, and AGD for each projection was calculated using the equation proposed by the Dance 2011. ResultsThe measured mean AGDs and ESDs of both the breasts were statistically significantly lower than the reference values given by European protocol (p < 0.05). There were no statistically significant differences in both AGDs and ESDs between the right and left breast, between right craniocauidal (RCC) and left craniocaudal (LCC), and between right mediolateral oblique (RMLO) and left mediolateral oblique (LMLO) examinations (p > 0.05). The measured median AGDs and ESDs received for MLO projections of both breasts were statistically significantly higher than that of CC projections (p < 0.05). ConclusionThe patients receive a low radiation dose during their DBT examination with both lowered AGD and ESD than the recommended values. Implications for practiceThe results can be used as a baseline to optimize the radiation dose in mammography in Sri Lanka

Nonmetastatic Rhabdomyosarcoma in Children and Adolescents: Overall Results of the European Pediatric Soft Tissue Sarcoma Study Group RMS2005 Study.

Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.The RMS2005 study included two phase III randomized trials for high-risk (HR) and observational trials for low (LR), standard (SR), and very high-risk (VHR) patients who have been partially reported. Herein, we present a comprehensive report of results achieved for the complete unselected nonmetastatic cohort and analyze the evolution of treatment in comparison with previous European protocols. After a median follow-up of 73.1 months, the 5-year event-free survival (EFS) and overall survival (OS) of the 1,733 patients enrolled were 70.7% (95% CI, 68.5 to 72.8) and 80.4% (95% CI, 78.4 to 82.3), respectively. The results by subgroup: LR (80 patients) EFS 93.7% (95% CI, 85.5 to 97.3), OS 96.7% (95% CI, 87.2 to 99.2); SR (652 patients) EFS 77.4% (95% CI, 73.9 to 80.5), OS 90.6% (95% CI, 87.9 to 92.7); HR (851 patients) EFS 67.3% (95% CI, 64.0 to 70.4), OS 76.7% (95% CI, 73.6 to 79.4); and VHR (150 patients) EFS 48.8% (95% CI, 40.4 to 56.7), OS 49.7% (95% CI, 40.8 to 57.9). The RMS2005 study demonstrated that 80% of children with localized rhabdomyosarcoma could be long-term survivors. The study has established the standard of care across the European pediatric Soft tissue sarcoma Study Group countries with the confirmation of a 22-week vincristine/actinomycin D regimen for LR patients, the reduction of the cumulative ifosfamide dose in the SR group, and for HR disease, the omission of doxorubicin and the addition of maintenance chemotherapy.

Management of Patients Diagnosed with Endometrial Cancer: Comparison of Guidelines.

Endometrial cancer is the most common gynecological malignancy in Europe and its management involves a variety of health professionals. In recent years, big discoveries were made concerning the management of patients diagnosed with endometrial cancer, particularly in the field of molecular biology and minimally invasive surgery. This requires the continuous updating of guidelines and protocols over the years. In this paper, we aim to summarize and compare common points and disparities among protocols for management of patients diagnosed with endometrial cancer by leading international gynecological oncological societies. We therefore systematically report the parallel among the guidelines based on the various steps patients with endometrial cancer usually undergo. The comparison between American and European protocols revealed some relevant disparities, in particular regarding surgical staging, molecular biology application as a prognostic tool and follow up regimens. This could possibly cause differences in interpreting and applying protocols in clinical practice in small centers, leading to a lack of adherence to guidelines or even prompting a confusing mix of them.

Analysis of prognostic factors and histopathological response to neoadjuvant chemotherapy in osteosarcoma.

This study aims to examine the clinical results of patients who underwent medical and surgical treatment for osteosarcoma, to determine the overall survival (OS) and disease-free survival (DFS) rates, and to examine the effects of prognostic factors on these rates. Between January 2005 and January 2020, a total of 64 patients (38 males, 26 females; mean age: 20.9±11.5 years; range, 6 to 70 years) who received medical and surgical treatment for osteosarcoma were retrospectively analyzed. Demographic characteristics, follow-up period, tumor location and size, tumor stage and necrosis rate, metastatic disease, surgical treatments, postoperative complications, local recurrence, and metastasis were recorded. The relationship of these factors with the survival was examined. The median follow-up was 51.6 (range, 3 to 156) months. The most common tumor localization was in the distal femur with 42 (65.6%) patients and the most common histopathological subtypes were conventional osteosarcoma in 50 (78.1%) patients. The OS rates were 91.6% at one year, 65.9% at five years, and 51.6% at 10 years. With the exception of two patients who died during neoadjuvant chemotherapy, all patients underwent surgical treatment. The addition of chemotherapy + radiotherapy in the treatment did not provide any benefits in terms of survival and recurrence compared to the group that was not added, and the five-year OS rate was 79.3% compared to 20.7%, respectively. The overall 10-year survival rates were 83.9% and 37.2% in the group with a good response (≥90%) and poor response (<90%) to treatment (p=0.012). The mean survival time of three patients who presented with pathological fractures was shorter than the others (p>0.05). Surgical margin was ≤2 mm in 27 (42.2%) patients, >2 mm in 30 (46.9%) patients, and surgical margin was positive in five (7.8%) patients. The mean OS in the group with a surgical margin closure of >2 mm was 10.8±1.9 years and was longer than the other groups (p=0.047). Metastasis at the time of diagnosis, <90% tumor necrosis, a tumor size of ≥10 cm, and metastasis development were significantly associated with poor survival and were found to be independent prognostic factors. The OS rate in the patient group with Stage III-IV response after neoadjuvant chemotherapy given the cisplatin + doxorubicin protocol was found to be better than those given the European and American Osteosarcoma Studies (EURAMOS) protocol. More research is needed to determine the most optimal chemotherapy protocols in this patient population. In addition, a multidisciplinary approach in treatment is of utmost importance to improve oncological outcomes.