Median Tumor Volume Research Articles

Preoperative growth dynamics of untreated glioblastoma: Description of an exponential growth type, correlating factors, and association with postoperative survival.

Little is known about the growth dynamics of untreated glioblastoma and its possible influence on postoperative survival. Our aim was to analyze a possible association of preoperative growth dynamics with postoperative survival. We performed a retrospective analysis of all adult patients surgically treated for newly diagnosed glioblastoma at our center between 2010 and 2020. By volumetric analysis of data of patients with availability of ≥3 preoperative sequential MRI, a growth pattern was aimed to be identified. Main inclusion criterion for further analysis was the availability of two preoperative MRI scans with a slice thickness of 1mm, at least 7 days apart. Individual growth rates were calculated. Association with overall survival (OS) was examined by multivariable. Out of 749 patients screened, 13 had ≥3 preoperative MRI, 70 had 2 MRI and met the inclusion criteria. A curve estimation regression model showed the best fit for exponential tumor growth. Median tumor volume doubling time (VDT) was 31 days, median specific growth rate (SGR) was 2.2% growth per day. SGR showed negative correlation with tumor size (rho = -0.59, P < .001). Growth rates were dichotomized according to the median SGR.OS was significantly longer in the group with slow growth (log-rank: P = .010). Slower preoperative growth was independently associated with longer overall survival in a multivariable Cox regression model for patients after tumor resection. Especially small lesions suggestive of glioblastoma showed exponential tumor growth with variable growth rates and a median VDT of 31 days. SGR was significantly associated with OS in patients with tumor resection in our sample.

Stereotactic radiosurgery of brain metastases: a retrospective study

BackgroundSingle-fraction stereotactic radiosurgery (SRS) is an established standard for radiation therapy of brain metastases although recent developments indicate that multi-fractionated stereotactic radiotherapy (FSRT) results in lower radiation necrosis especially for larger metastases, and the same or even better local control in comparison to SRS.MethodsSeventy-two patients with 111 brain metastases received SRS with a single dose of 18 Gy between September 2014 and December 2021. The dose prescription was either 18 Gy given to the enclosing 80% isodose with a normalization to Dmax = 100% of 22.5 Gy (part I) or 18 Gy = D98, while D0.03 cc of 21.6–22.5 Gy was accepted (part II). The study retrospectively evaluated local progression-free survival (LPFS), response on the first follow-up magnetic resonance imaging (MRI), and radiation necrosis.ResultsMelanoma brain metastases (n = 44) were the most frequent metastases. The median gross tumor volume (GTV) was 0.30 cm³ (IQR, 0.17–0.61). The median follow-up time of all patients was 50.8 months (IQR, 30.4–64.6). Median LPFS was 23.5 months (95%CI 17.2, 29.8). The overall LPFS rates at 12-, 18-, 24- and 30 months were 65.3%, 56.3%, 46.5%, and 38.8%. Brain metastases with radioresistant histology (melanoma, renal cell cancer, and sarcoma) showed a 12-month LPFS of 60.2%, whereas brain metastases with other histology had a 12-month LPFS of 70.1%. The response of brain metastases on first follow-up MRIs performed after a median time of 47 days (IQR, 40–63) was crucial for long-term local control and survival. Eight brain metastases (7.2%) developed radiation necrosis after a median time of 18.4 months (IQR, 9.4–26.5). In multivariate analyses, a GTV > 0.3 cm³ negatively affected LPFS (HR 2.229, 95%CI 1.172, 4.239). Melanoma, renal cell cancers, and sarcoma had a lower chance of LPFS in comparison to other cancer types (HR 2.330, 95%CI 1.155, 4.699).ConclusionsOur results indicate a reasonable 1-year local control of brain metastases with radiosensitive histology. Radioresistant metastases show a comparatively poor local control. Treatment refinements merit exploration to improve local control of brain metastases.Trial registrationThis study is retrospectively registered (ethics approval number 23-3451-104).

Correlations Between Preoperative Indicators and Postoperative Histopathological Outcomes in Prostate Cancer Patients

Objective: Prostate cancer continues to pose a significant health challenge, with diverse prognoses influenced by preoperative and postoperative assessments. This study aims to elucidate the correlation between preoperative clinical indicators and postoperative histopathological outcomes to enhance prognostic models. The primary objective of this study is to investigate the predictive value of preoperative factors, such as age, Prostate-Specific Antigen (PSA) level, prostate volume (PV), and tumor volume (TV), on postoperative outcomes, specifically focusing on extracapsular invasion (ECI), seminal vesicle invasion (SVI), and positive surgical margins (PSM). Materials and Methods: We retrospectively analyzed the data of 63 patients with prostate cancer who underwent radical prostatectomy. Preoperative clinical data, including age, PSA level, PV, and TV, were collected. Postoperative histopathological data were gathered for ECI, SVI, and PSM. Statistical analyses, including correlation coefficients and median comparisons, were employed to identify significant predictors of postoperative outcomes. Results: The cohort had a mean age of 64.1 years, with PSA levels ranging from 3.65 to 112 ng/ml. Patients with ECI had a median PSA of 14.9 ng/ml, whereas those without had 8.2 ng/ml (p=0.001). Median PV and TV were significantly higher in patients with ECI (PV: 55 cc, TV: 8.07 cc) than in those without ECI (PV: 49 cc, TV: 4.25 cc, p=0.001). Similar significant differences were noted for SVI and PSM, with higher PSA, PV, and TV values in patients with these features (p≤0.042). Age did not significantly affect the outcomes. Conclusion: Preoperative PSA level, prostate volume, and tumor volume were significant predictors of adverse postoperative histopathological features in patients with prostate cancer. These findings highlight the need for a multifactorial approach in preoperative evaluation and advocate the development of enhanced predictive models for improved clinical decision-making and patient management.

Solitary Fibrous Tumours of the Orbit - Clinical Pathology, Therapy and Prognosis.

Solitary fibrous tumours are rare. The aim of this study is to describe the clinical features, therapy and outcome of affected patients and to identify factors associated with recurrence. Retrospective study of a cohort of 20 patients who underwent surgery for orbital solitary fibrous tumour at the University Department of Oral and Maxillofacial Surgery between 2002 and 2023. Demographic, clinical, and therapeutic data as well as tumour follow-up results were collected. Tumour volume and molecular genetic mutations were retrospectively determined. The median patient age was 49.5 years at initial surgery. The left orbit was affected in 65% of cases. The most common clinical symptom was proptosis (80%). This was reported with a mean lateral difference of 3.9 mm (range: 1 - 10 mm). The tumours were localised predominantly in the intra- and extraconal space, craniolateral quadrant and middle third. The median tumour volume was 7.66 cm³ (range 2.15 - 12.57 cm³). In all patients, the diagnosis was made by pathological examination. All tumours investigated showed a NAB2-STAT6 mutation. The most frequently detected mutation was the fusion NAB2 exon 4 - STAT6 exon 2. All patients were initially managed with frontolateral orbitotomy. Incomplete resection (R1-status) occurred in 35% (n = 7). The recurrence rate was 25% (n = 5), with a median disease-free interval of 45.5 months (range 23 - 130). 80% (n = 4) of recurrences were initially R1-resected. Orbital solitary fibrous tumours are rare tumours and are clinically manifested by signs of displacement of orbital structures. Diagnosis is made by histology and immunohistochemistry and can be proven with the molecular genetic detection of the NAB2-STAT6 mutation. The therapy of choice is complete surgical resection. R1-resection is more likely in the intraconal location as well as in location in the posterior third of the orbit - due to difficult surgical accessibility. The greatest risk factor for the development of recurrence is incomplete surgical excision. Late recurrences are possible, which is why a long-term connection to a specialised clinic is necessary.

RADT-35. STEREOTACTIC RADIOSURGERY FOR RESIDUAL, RECURRENT, AND METASTATIC HEMANGIOPERICYTOMAS: A SINGLE INSTITUTION EXPERIENCE

Abstract INTRODUCTION Hemangiopericytomas are infrequent vascular tumors originating from Zimmermann pericytes. The conventional treatment approach involves gross total resection (GTR), followed by adjuvant radiotherapy. Nevertheless, due to their tendency to infiltrate dural sinuses, high degree of vascularity, and anatomic inaccessibility, radical resection may be challenging with substantial risk of recurrence. To address this challenge, stereotactic radiosurgery (SRS) has been proposed as a promising adjuvant therapy. Objectives Our study aims to evaluate the effectiveness and safety of SRS as a potential treatment modality in patients with residual, recurrent, and metastatic hemangiopericytomas. METHODS From 1998 to 2023, 27 patients with 101 tumors underwent CyberKnife SRS at Stanford University Medical Center. The median age was 51 years at the time of treatment. The median follow-up period from SRS was 103 months (range: 6-250). All patients underwent upfront surgical resection. The median tumor volume was 1.5 cc. The median single-fraction equivalent dose (SFED) was 19 Gy. The SRS was administered at the 76% of the median isodose line (range: 64-89). RESULTS Of the 101 treated tumors, 24 (23.8%) progressed with a median time to recurrence of 30 months. At 10 years, the rates of local tumor control (LTC), overall survival (OS), and progression-free survival (PFS) were 74.3%, 80.8%, and 67%, respectively. In patients with residual lesions, the LTC rates were significantly greater when compared to those with residual or metastatic tumors. There was no significant difference between patients with residual, recurrent, and metastatic hemangiopericytomas in OS and PFS. Notably, no cases of radiation-induced adverse events were detected. CONCLUSION Our study provides the largest single-institutional retrospective series with hemangiopericytomas treated with SRS. SRS leads to excellent LTC, PFS, and OS at 10 years with negligible risk for adverse events. Therefore, it is an effective and safe management modality for patients with residual, recurrent, and metastatic hemangiopericytomas.

Transient responses and significant toxicities of anti-CD30 CAR T cells for CD30+ lymphomas: results of a phase 1 trial

AbstractNew treatments are needed for relapsed and refractory CD30-expressing lymphomas. We developed a novel anti-CD30 chimeric antigen receptor (CAR), designated 5F11-28Z. Safety and feasibility of 5F11-28Z–transduced T cells (5F11-Ts) were evaluated in a phase 1 dose escalation clinical trial. Patients with CD30-expressing lymphomas received 300 mg/m2 or 500 mg/m2 of cyclophosphamide and 30 mg/m2 of fludarabine on days −5 to −3, followed by infusion of 5F11-Ts on day 0. Twenty-one patients received 5F11-T infusions. Twenty patients had classical Hodgkin lymphoma, and 1 had anaplastic large-cell lymphoma. Patients were heavily pretreated, with a median of 7 prior lines of therapy and substantial tumor burden, with a median metabolic tumor volume of 66.1 mL (range, 6.4-486.7 mL). The overall response rate was 43%; 1 patient achieved a complete remission. Median event-free survival was 13 weeks. Eleven patients had cytokine release syndrome (CRS; 52%). One patient had grade 3 CRS, and there was no grade 4/5 CRS. Neurologic toxicity was minimal. Nine patients (43%) had new-onset rashes. Two patients (9.5%) received extended courses of corticosteroids for prolonged severe rashes. Five patients (24%) had grade 3/4 cytopenias, with recovery time of ≥30 days, and 2 of these patients (9.5%) had prolonged cytopenias with courses complicated by life-threatening sepsis. The trial was halted early because of toxicity. Median peak blood CAR+ cells per μL was 26 (range, 1-513 cells per μL), but no infiltration of CAR+ cells was detected in lymph node biopsies. 5F11-Ts had low efficacy and substantial toxicities, which limit further development of 5F11-Ts. This trial was registered at www.clinicaltrials.gov as #NCT03049449.

SURG-02. SURGICAL OUTCOME OF SUPRATENTORIAL MENINGIOMA PATIENTS AGED ≥80 YEARS – RETROSPECTIVE INTERNATIONAL MULTICENTER STUDY

Abstract BACKGROUND Demographic changes will lead to an increase in old patients, a population with significant risk of postoperative morbidity and mortality, requiring neurosurgery for meningiomas, Objective: To evaluate outcome of supratentorial meningioma patients aged ≥80 years. This multicenter study aims to report neurofunctional status after resection, to identify factors associated with outcome, and to validate a previously proposed decision support tool. METHODS Neurofunctional status was assessed by the Karnofsky Performance Scale (KPS). Patients were categorized in poor (KPS ≤40), intermediate (KPS 50-70), and good (KPS ≥80) preoperative subgroups. Volumetric analyses of tumor and peritumoral brain edema (PTBE) were performed; volumes were scored as small (&amp;lt; 10 cm3), medium (10-50 cm3), and large ( &amp;gt;50 cm3). RESULTS The study population consisted of 262 patients. Median age at surgery was 83.0 years. Median preoperative KPS was 70; 117 (44.7%) patients were allotted to the good, 113 (43.1%) to the intermediate, and 32 (12.2%) to the poor subgroup. Median tumor and PTBE volumes were 30.2 cm3 and 27.3 cm3; large PTBE volume correlated with poor preoperative KPS status (P = .008). The 90-day and 1-year mortality rates were 9.0% and 13.2%. Within the first postoperative year, 101 (38.5%) patients improved, 87 (33.2%) were unchanged, and 74 (28.2%) were functionally worse (including deaths). Each year-increase of age associated with 44% (23–70%) increased risk of 90-day and 1-year mortality. In total, 111 (42.4%) patients suffered from surgery-associated complications. Maximum tumor diameter ≥5cm (odds ratio 1.87 (1.12–3.13)) and large tumor volume (odds ratio 2.35 (1.01–5.50)) associated with an increased risk of complications. Among patients with poor preoperative status and large PTBE, most (58.3%) benefited from surgery. CONCLUSION Patients with poor preoperative status and large PTBE most often showed postoperative improvements. The decision support tool may be of help in identifying cases that most likely benefit from surgery.

NCOG-12. SURVIVAL OF THE ELDERLY: OUTCOMES OF VERY OLD GLIOBLASTOMA PATIENTS – RESULTS FROM AN AUSTRIAN MULTICENTER STUDY

Abstract INTRODUCTION Glioblastoma (GBM) outcomes in very old patients remain understudied. Limited data exist on outcomes and treatment options for this specific population, necessitating further research. Materials and METHODS We retrospectively analyzed all elderly GBM patients ( &amp;gt;65 years), who underwent treatment at two Austrian academic centers from 2007 to 2021. We conducted a comparative analysis between patients aged 65-79 years (old cohort) and a cohort of patients aged over 80 years (very old cohort). RESULTS 387 patients were included, 43 of them over 80 years of age at the time of surgery. Median preoperative Karnofsky Performance Score (KPS) amounted to 80, median preoperative tumor volume was 26.44cm3. Among elderly patients 283 (75%) underwent resection and 61 (25%) only biopsy. 66.5% of the elderly cohort underwent adjuvant treatment following the EORTC protocol. 88 patients (25.6%) experienced preoperative seizures. Among the very old cohort 29 patients (67%) underwent resection and 14 (33%) biopsy only. 42.5% received adjuvant treatment, 5 patients (11.6%) presented with preoperative epilepsy. Mean PFS was 8.9 months in old patients and 8.4 months in very old patients. Kaplan Meier Analysis revealed a mean OS of 12.8 vs 10.7 months respectively. Elderly patients showed significantly better preoperative KPS (p=0.033) as well as higher preoperative tumor volumes (p=0.039). Old patients showed significantly higher incidences of both preoperative (p=0.043) and postoperative (p=0.032) epilepsy. Furthermore, old patients underwent significantly more often resection (p=0.020) and adjuvant therapy (p=0.009) compared to very old patients. However, survival analysis showed no statistic differences regarding PFS and OS between the two groups (p &amp;gt;0.05). CONCLUSION Despite preexisting unfavorable prognostic features, we could not find any significant differences between old and very old GBM patients. Hence, the treatment of glioblastoma in very old patients should adopt a more inclusive approach considering the patient's overall health status and comorbidities.

RADT-46. STEREOTACTIC RADIOSURGERY FOR CYSTIC AND SOLID INTRACRANIAL HEMANGIOBLASTOMAS: A SINGLE-INSTITUTION RETROSPECTIVE SERIES

Abstract INTRODUCTION Intracranial hemangioblastoma is a rare neoplasm that poses significant challenges in clinical management. Hemangioblastomas are characterized by unique radiological features into cystic or solid tumors. Out study aims to evaluate the role of SRS in the management of cystic and solid hemangioblastomas in a single institution setting. METHODS We conducted a retrospective analysis of clinical and radiological outcomes of patients with intracranial hemangioblastomas treated with CyberKnife SRS at our institute between 1998 and 2023. The follow-up data were available for 93 intracranial hemangioblastomas in 23 patients. Ten (43.5%) patients presented with 23 (25.6%) cystic hemangioblastomas, while 13 (56.5%) patients had 70 (75.3%) solid hemangioblastomas at the time of SRS treatment. The median age was 36 years and the median tumor volume accounted for 0.43 cc. The SRS was administered with the median single-fraction equivalent dose (SFED) of 20 Gy at the 77% of the median isodose line. RESULTS At a one-year follow-up, 11 initially solid hemangioblastomas developed cystic formation, resulting in a total of 34 (36.6%) cystic hemangioblastomas and 59 (63.4%) solid hemangioblastomas across 13 and 10 patients, respectively. Among these, 84.6% exhibited peritumoral edema prior to the onset of cystic formation. For 37 solid hemangioblastomas accompanied by peritumoral edema, SRS was administered before cystic transformation, remaining solid throughout the latest follow-up. Over a median follow-up period of 59 months (range: 3-260), 6 (17.6%) cystic and 13 (22%) solid hemangioblastomas progressed. The 5-year local tumor control (LTC) rate for intracranial hemangioblastomas was 84.7%, with 97% and 76.9% in cystic and solid lesions, respectively. CONCLUSION Our study illustrates the largest single-institutional long-term retrospective analysis of intracranial hemangioblastomas treated with SRS to date. Early SRS treatment at the time of edema may prevent cystic hemangioblastoma development and provides durable treatment outcomes for patients with both cystic and solid hemangioblastomas in long-term.

CTNI-45. UPFRONT CHEMOTHERAPY AND SUBSEQUENT RESECTION UTILIZING NEOADJUVANT STRATEGY FOR OLIGODENDROGLIOMAS

Abstract Although both of functional preservation and higher extent of resection are required in glioma surgery, maximal resection with the risk of functional sequela is uniformly performed regardless of tumor pathology and treatment sensitivity in the current practice. Oligodendrogliomas are known to be associated with relatively favorable prognosis, however, many patients still eventually succumb to death due to tumors. Improvement in the long-term survival rate and functional preservation would be the next step to be achieved. In our hospital, patients with 1p/19q-codeleted glioma have been treated by upfront chemotherapy, if deemed in need of adjuvant treatment after initial resection, since 2006. If the initial resection was incomplete, the second surgery was intended following tumor volume decrease by chemotherapy (second-look resection, SLR). Intentional staged resection was performed in several cases for whom presence of 1p/19q codeletion was strongly suggested based on preoperative imaging characteristics. Utility of this strategy was evaluated. Forty-one patients with 1p/19q-codeleted glioma have been treated with the strategy. Of these, 30 were grade 2, and 11 were grade 3 tumors. In 9 of the 41 cases, radiotherapy was prescribed immediately after chemotherapy or SLR. Median tumor volume decrease rate by chemotherapy in the cases with initial incomplete resection was -35%. SLR following tumor volume decrease was performed in 22 cases. Median progression-free survival and overall survival after the initiation of chemotherapy were 81 months and 175 months for each in both of the total 41 cases and 32 cases for whom radiotherapy was deferred. Most of the recurrence occurred in the residual FLAIR high intensity. Upfront chemotherapy and subsequent resection strategy utilizing chemotherapeutic response provides more precise resection as well as reduction of resection volume as compared with one-time maximal safe resection. Radiotherapy may be indicated for the cases with residual FLAIR abnormality after chemotherapy or SLR.

Subependymomas of the fourth ventricle: To operate or not to operate?

BackgroundThere is a paucity of literature regarding the clinical characteristics and management of subependymomas of the fourth ventricle due to their rarity. Here, we describe the operative and non-operative management and outcomes of patients with such tumors. MethodsThis retrospective single-institution case series was gathered after Institutional Review Board (IRB) approval. Patients diagnosed with a subependymoma of the fourth ventricle between 1993 and 2021 were identified. Clinical, radiology and pathology reports along with magnetic resonance imaging (MRI) images were reviewed. ResultsPatients identified (n = 20), showed a male predominance (n = 14). They underwent surgery (n = 9) with resection and histopathological confirmation of subependymoma or were followed with imaging surveillance (n = 11). The median age at diagnosis was 51.5 years. Median tumor volume for the operative cohort was 8.64 cm3 and median length of follow-up was 65.8 months. Median tumor volume for the non-operative cohort was 0.96 cm3 and median length of follow-up was 78 months. No tumor recurrence post-resection was noted in the operative group, and no tumor growth from baseline was noted in the non-operative group. Most patients (89 %) in the operative group had symptoms at diagnosis, all of which improved post-resection. No patients were symptomatic in the non-operative group. ConclusionsSurgical resection is safe and is associated with alleviation of presenting symptoms in patients with large tumors. Observation and routine surveillance are warranted for smaller, asymptomatic tumors.

High PDL1/PDL2 gene expression correlates with worse outcome in primary mediastinal large B-cell lymphoma

AbstractPrimary mediastinal B-cell lymphoma (PMBL) is an uncommon entity of aggressive B-cell lymphoma with an unusually good prognosis, except for 10-15% of chemotherapy-refractory cases. To identify earlier these higher risk patients, we performed molecular characterization of a retrospective multicenter cohort of patients treated with firstline immunochemotherapy. The traits of the patients with gene-expression profiling data (n = 120) were as follows: median age of 34 years (range, 18-67 years); female sex, 58.3%; elevated lactate dehydrogenase, 82.5%; Eastern Cooperative Oncology Group performance status score of 0 to 1, 85.7%; Ann Arbor stage I/II, 55%; International Prognostic Index score of 1 to 2, 64.4%; and median metabolic tumor volume, 290.4 cm3 (range, 15.7-1147.5 cm3). Among all 137 markers tested for correlation with survival data, only programmed death-ligand (PDL) 1 and PDL2 expression showed a prognostic impact. Overall, both PDL1 and PDL2 genes were highly expressed in 37 patients (30.8%; PDL1high/PDL2high). The baseline clinical characteristics of patients with PDL1high/PDL2high were similar to those of other patients. In univariate analysis, PDL1high/PDL2high status was associated with poor progression-free survival (PFS) (hazard ratio [HR], 4.292) and overall survival (OS; HR, 8.24). In multivariate analysis, PDL1high/PDL2high status was an independent prognostic factor of adverse outcomes (PFS: HR, 5.22; OS: HR, 10.368). We validated these results in an independent cohort of 40 patients and confirmed the significant association between PDL1high/PDL2high status and inferior PFS (HR, 6.11). High PDL1/PDL2 gene expression defines a population with strong immune privilege and poorer outcomes from standard chemotherapy who might benefit from firstline checkpoint inhibitor therapy.

MRI Tumor Regression Grade Combined with T2-Weighted Volumetry May Predict Histopathological Response in Locally Advanced Rectal Cancer following Neoadjuvant Chemoradiotherapy-A New Scoring System Proposal.

Modern studies focus on the discovery of innovative methods to improve the value of post-treatment magnetic resonance imaging (MRI) in the prediction of pathological responses to preoperative neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC). The aim of this study was to assess the potential benefits of combining magnetic resonance tumor regression grade (mrTRG) with T2-weighted volumetry in the prediction of pathological responses to nCRT in LARC. This was a cohort study conducted on patients with histopathologically confirmed LARC in a period from 2020 to 2022. After histopathological verification, all patients underwent initial MRI studies, while the follow-up MRI was performed after nCRT. Tumor characteristics, MRI estimated tumor regression grade (mrTRG) and tumor volumetry were evaluated both initially and at follow-up. All patients were classified into responders and non-responders according to pathological tumor regression grade (pTRG) and mrTRG. A total of 71 patients, mostly male (66.2%) were included in the study. The median tumor volume reduction rate was significantly higher in nCRT-responders compared to non-responders (79.9% vs. 63.3%) (p = 0.003). Based on ROC analysis, optimal cut-off value for tumor volume reduction rate was determined with an area under the curve (AUC) value of 0.724 (p = 0.003). Using the tumor volume reduction rate ≥75% with the addition of response to nCRT according to mrTRG, a new scoring system for prediction of pTRG to preoperative nCRT in LARC was developed. Diagnostic performance of prediction score was tested and the sensitivity, PPV, specificity, and NPV were 81.8%, 56.3%, 71.4%, and 89.7%, respectively. The combination of mrTRG and T2-weighted volumetry increases the MRI-based prediction of pTRG to preoperative nCRT in LARC. The proposed scoring system could aid in distinguishing responders to nCRT, as these patients could benefit from organ-preserving treatment and a "watch and wait" strategy.

Stereotactic Radiosurgery for Cranial and Spinal Hemangioblastomas: A Single-Institution Retrospective Series.

Stereotactic radiosurgery (SRS) has been an attractive treatment modality for both cranial and spinal hemangioblastomas, especially for multiple lesions commonly associated with von Hippel-Lindau (VHL) disease. This study aims to provide the largest long-term analysis of treatment efficacy and adverse effects of SRS for cranial and spinal hemangioblastomas at a single institution. We evaluated the clinical and radiological outcomes of patients with hemangioblastomas treated with CyberKnife SRS at our institute from 1998 to 2022. The follow-up data were available for 135 hemangioblastomas in 35 patients. Twenty-eight patients had 123 hemangioblastomas associated with VHL, and 7 had 12 sporadic hemangioblastomas. The median age was 36 years, and the median tumor volume accounted for 0.4 cc. The SRS was administered with the median single-fraction equivalent dose of 18 Gy to the 77% median isodose line. At a median follow-up of 57 months (range: 3-260), only 20 (16.2%) of the VHL-associated and 1 (8.3%) sporadic hemangioblastomas progressed. The 5-year local tumor control rate was 91.3% for all hemangioblastomas, 91.7% among the sporadic lesions, and 92.9% in patients with VHL. SRS improved tumor-associated symptoms of 98 (74.8%) of 131 symptomatic hemangioblastomas, including headache, neck pain, dizziness, visual disturbances, dysesthesia, ataxia, motor impairment, seizures, and dysphagia. Two patients developed radiation necrosis (5.7%), and 1 of them required surgical resection. SRS is a safe and effective treatment option for patients with hemangioblastomas in critical locations, such as the brainstem, cervicomedullary junction, and spinal cord, and in patients with multiple hemangioblastomas associated with VHL disease.

The role of [68Ga]Ga-FAPI-04 PET/CT in renal cell carcinoma: a preliminary study.

We aimed to investigate the role of [68Ga]Ga-FAPI-04 PET/CT and uptake patterns of primary and metastatic lesions in patients with renal cell carcinoma (RCC). Twenty patients with a suspicious lesion considered primary renal malignancy or a history of RCC were included in our study. Two patients were excluded from further analyses due to other confirmed malignancies. Six patients were newly diagnosed, while the indication of 12 patients was restaging. All patients underwent [68Ga]Ga-FAPI-04 and [18F]F-FDG PET/CT. SUVmax and tumor-to-background ratio (TBR) of primary (n = 7) and local recurrent lesions (n = 6) and lymph node (n = 26), lung (n = 32), bone (n = 5), and other metastases (n = 14) were compared between the two tracers. We detected 90 lesions in 18 patients with varying FAPI and FDG uptake values on both PET/CT. The median TBR of FAPI-PET/CT of all lesions was higher than TBR of FDG-PET/CT with statistically significance (5.6 vs. 2.1, p < 0.001). In primary and recurrent lesions, the median SUVmax, TBR, and tumor volume on FAPI-PET/CT were higher than FDG-PET/CT. The median SUVmax of lung lesions on FAPI-PET/CT was statistical significantly higher than FDG-SUVmax (3.8 vs. 1.8, p = 0.02). The median of FAPI-SUVmax on primary lesions was lower in the early stage based on TNM compared to the advanced stage. FAPI-SUVmax in 49% of all lesions were SUVmax ≥ 6, and 13% were SUVmax ≥ 10. In patient-based analyses, seven patients (39%) had at least one lesion with FAPI-SUVmax ≥ 10; 12 patients (67%) had at least one lesion with FAPI-SUVmax ≥ 6. This study showed the potential utility of [68Ga]Ga-FAPI-04 PET/CT showing promising results in RCC. We have presumed that FAPI-PET/CT may be performed for complementary imaging modality providing prognosis and possibility of theranostic application in selected patients.

Photodynamic interstitial stereotactic therapy for recurrent malignant glioma

Objectives Stereotactic photodynamic therapy (sPDT) using 5-aminolaevulinic acid (5-ALA) as a cytotoxic photosensitizer may be a potentially prospective treatment option for malignant gliomas. Material and Methods We analyzed data from 10 patients with recurrent malignant gliomas of the brain who were treated with sPDT at the Department of Neurosurgery of the Military-Medical Academy S. M. Kirov, from 2020 to November 2021. Three patients were treated with sPDT again after 3, 7, and 15 months due to relapse. Results The median age of the patients was 55.5 years, range was 30–60 years, there were six men and four women. At the time of sPDT, 7 (70%) patients with recurrent tumors were diagnosed with glioblastomas (WHO grade IV), and 3 (30%) with anaplastic astrocytomas (WHO grade III). Tumors were without IDH mutation in 7 (70%) patients; MGMT gene expression status was evaluated in tumors in 9 (90%) patients. A 1p/19q co-deletion was not detected in any of the patients. The median tumor volume was 5.85 cm3 (min. 3.2 cm3, max. 22.5 cm3). We have found that the median recurrence-free period after sPDT in patients with anaplastic astrocytomas and glioblastomas was 435 and 195 days, respectively. Conclusion This result allows to consider sPDT as one of the perspective methods of treatment of patients with recurrent gliomas of high malignancy in cases when repeated open surgical intervention has high risks of new neurological deficit.

Marginless 5-Fraction Robotic Radiosurgery for Unfavorable Nonfunctioning Pituitary Macroadenoma: 5-year Outcomes from a Single Institution Protocol

Nonfunctioning macroadenoma is a commonly diagnosed pituitary tumor. Resection is the favored treatment, with radiosurgery often utilized for residual or progressing disease. Long-term outcomes are established for single-session radiosurgery, but mature outcomes are lacking for multisession radiosurgery. We report our institution's 5-year efficacy and safety results for unfavorable nonfunctioning pituitary macroadenoma patients treated with marginless 5-fraction robotic radiosurgery. Between 2010-2020, patients who completed marginless 5-fraction radiosurgery for the treatment of unfavorable nonfunctioning pituitary macroadenomas were included. A tumor was considered unfavorable if the gross tumor volume (GTV) was larger than 5 cc or if it closely approached a critical structure (optic apparatus, brainstem or pituitary gland). Local control was calculated using the Kaplan-Meier Method. Twenty predominately female patients (60%), age from 21-77 (median: 53 years) were included in this study. All underwent primary resection. Indications for radiosurgery included unresectable recurrence (85%) and residual disease progression (70%). Median tumor volume was 3.4 cm3 (range: 0.3-20.8 cm3) and 40% of the tumors were suprasellar. A mean dose of 28.8 Gy (range: 25 Gy-30 Gy), was delivered to a median isodose line of 80% (range: 75%-89%). The median optic chiasm maximum point dose was 21.8 Gy (range: 12.0-25.9 Gy). Toxicity was minimal with 12 patients (40%) developing acute short-lived headaches and 1 patient (5%) developing a brief ipsilateral 6th nerve palsy. There was no radiation induced optic or pituitary dysfunction identified in this cohort. At a median follow up of 5 years local control was 95%. There was 1 in-field failure pathologically confirmed following surgery for pituitary tumor hemorrhage and 2 radiographically confirmed out-of-field failures in patients with large tumors (>20 cc). The treatment of unfavorable nonfunctioning pituitary macroadenoma with marginless 5-fraction robotic radiosurgery provides excellent local control to date, with minimal toxicity. However, tumors with GTV's greater than 20 cc may require conventionally fractionated treatment with a margin to optimize local control.

Determining the Ideal Time for Implementing Adaptive Radiation Therapy in the Treatment of Non-Small Cell Lung Cancer through the Analysis of Cone-Beam Computed Tomography Images

Radiotherapy (RT) has an important role in the management of locally advanced non-small cell lung cancer (LA-NSCLC) but is also challenging due to treatment uncertainties. Adaptive radiation therapy (ART) is a possible solution that is widely used but varied with limited consensus. Cone beam computed tomography (CBCT) is frequently used during the treatment process to confirm the accuracy of the treatment location and the changes in the tumor during treatment can be observed also from CBCT images. We collected the characteristics of patients and analysis the changes of tumor volumes from weekly CBCT images and try to predict the optimal timing for ART in modern RT. LA-NSCLC patients treated with definitive chemo-radiotherapy by volumetric modulated arc therapy (VMAT) or intensity-modulated radiation therapy (IMRT) were enrolled in this study. CBCT images during treatment in the second, fourth, and sixth weeks were collected and the region of interest (ROI) was contoured by the same experienced radiation physician. The image segmentation and processing were done using a programming environment. The change in tumor volume during mid-treatment and at the end of treatment were calculated and the regression analysis was used to evaluate the correlation of tumor volume changes during treatment course. Since 2018 to 2021, total 20 LA-NSCLC patients treated with definitive chemo-radiotherapy (CCRT) were enrolled in this study. There are 17 males and 3 females, respectively with an average age of 67 years. All patients received chemotherapy and a radiation therapy prescriptive dose of 60 Gy in 30 fractions to a planning target volume (PTV). Totally 1,760 image slices were analyzed. The average tumor volume before treatment in patients who underwent ART or without ART was 273.84 cm3 and 132.84 cm3 respectively. The median tumor volume changes were 15.04%, 35.68%, and 55.37% at 2,4, and 6 weeks, respectively. Patients who achieved a tumor volume reduction of more than 40% in the fourth week had a better final tumor reduction outcome than those who did not meet this volume reduction goal. However, no significant difference was found in the change in tumor volume from the fourth to the sixth week. This study suggests that monitoring tumor volume changes during the first half of treatment using CBCT images may be an effective way to predict the final tumor reduction outcome in patients with LA-NSCLC undergoing adaptive radiation therapy (ART) in a modern CCRT treatment setting. Specifically, the study found that a tumor volume reduction of more than 40% in the fourth week may predict a better final tumor reduction outcome. Based on this finding, the study suggests that redesigning the treatment plan based on the change in tumor volume during the first half of treatment may improve the final tumor reduction effect in patients with NSCLC undergoing ART.

Hypofractionated Intensity Modulated Proton Therapy (IMPT) and Systemic Therapy for Unresectable Hepatobiliary Cancers

Proton therapy offers significantly reduced normal liver dose compared to photon therapy for liver tumors, and therefore has the potential for dose escalation and hypofractionation. Employing IMPT, we have initiated a hypofractionated treatment regimen for unresectable liver cancer at a single academic institution. Here we report our initial results on dosimetry and clinical outcomes of hypofractionated IMPT for unresectable hepatocellular carcinoma (HCC) and cholangiocarcomas (CC). We retrospectively reviewed records of consecutive patients treated with IMPT for CC and HCC from 2018 to 2021. Inverse treatment planning with robust optimization, daily image guidance, pencil beam scanning dose delivery were used for all patients. Motion management included 4D-CT and abdominal compression. Toxicity was graded using the Common Terminology Criteria for Adverse Events version 5.0 and survival was calculated using the Kaplan Meier method. We identified 15 patients (3 HCC, 4 intrahepatic CC, 8 hilar CC) treated with IMPT to a median dose of 5805 cGy (range, 4500 - 6000 cGy) in 15 fractions. Two had metastatic and 13 had regional disease. Median tumor volume was 91.5 cc (range, 10.92 - 366.31 cc). Prior therapies included: 12 patients received upfront chemotherapy, (gemcitabine plus cisplatin most common), 4 received prior surgery on the liver, and 5 received prior liver directed treatment. With a median follow up of 10 months, the median overall survival (OS) and 1-year OS was 18.7 months and 76% respectively. One patient underwent resection and 1 patient received liver transplant; 7 (47%) patients had disease progression (3 local, 1 regional lymph node, 4 elsewhere liver, 5 distant metastatic). Five patients with CC developed grade 3 toxicity in the form of cholangitis (4) and hemobilia (1). Of these patients, 4 patients were of the hilar type. Our early results using hypofractionated IMPT for unresectable HCC and CC resulted in encouraging local control rates with an acceptable toxicity profile. Further study is warranted to determine the optimal liver directed therapy for this challenging patient population.

Clinical Outcomes for Chest Wall Ewing Sarcoma: A Multi-Center Single Institution Experience

We report tumor and treatment characteristics, oncologic outcomes, and treatment-associated toxicities in a cohort of chest wall Ewing sarcoma (cwES) patients treated at a single tertiary care institution. After IRB approval, patients with cwES treated from 1997-2022 were retrospectively reviewed. Patient, tumor, treatment, outcomes, and toxicity data were abstracted. Local control (LC), progression-free survival (PFS), and overall survival (OS) were defined from end of treatment and assessed using the Kaplan-Meier method. Log-rank test and unadjusted Cox models were performed to determine factors associated with outcomes. The cohort includes 45 patients. Median age at diagnosis was 19.8 years (range: 3.5 - 57.8 years). Five patients (11.1%) presented with pleural effusion and eight patients with lung metastases (17.8%). Two (4.4%) patients had metastatic disease outside the thorax. Median tumor volume (TV) was 138.6 mL (range: 3.0-6762.0 mL). All patients received VDC/IE chemotherapy. LC modality was surgery (S) in 21 patients (47%), radiation therapy (RT) in 5 (11%), and S+RT in 19 (42%). Median TV was larger in S+RT patients (319.4 mL, range: 5.3-6761.9 mL) compared to RT (152.3 mL, range: 20.4-366.9 mL) or S (70.4 mL, range: 3.1-1037.8 mL) (p = 0.03). R0 and R1 resections were performed in 36 (90%) and 4 (10%) patients, respectively. Proton beam therapy was used in 15 (63%) patients. Median dose was 50.40 Gy (range: 34.2 - 60 Gy) in 28 fractions to the primary tumor or post operative bed. Median dose for hemithorax (1 patient, 2.2%) and whole lung irradiation (7 patients, 15.6%) was 15.0 Gy (range: 15.0-15.0 Gy) in 10 fractions. Median follow-up was 2.38 years (range: 0 - 21.90 years). Five-year LC, PFS, and OS for all patients was 77.9% (95% CI, 65.3 - 92.9%), 54.2% (95% CI, 39.9 - 73.5%), and 63.5% (95% CI, 49.3 - 81.8%), respectively. In patients with localized disease, 5-year LC, PFS, and OS were 82.4% (95% CI, 67.9-99.8%), 66.4% (95% CI, 49.7-88.8%), and 71.3% (95% CI, 54.2-93.9%), respectively. Two-year LC by modality was 100% for RT (95% CI, 100-100%), 84.2% (95% CI, 69.3- 100%) for S and 73.3% (95% CI, 54 - 99.5%) for S+RT (p = 0.51). On univariate analysis, TV ≥ 200 mL was associated with a significantly worse 5-year OS (49.5%, TV ≥ 200 mL vs. 80.8%, TV < 200 mL; HR 4.44, p = 0.032) and PFS (35.2%, TV ≥ 200 mL vs. 76%, TV < 200 mL; HR 3.55, p = 0.025). TV ≥ 200 mL trended towards worse 5-year LC: 69.2% for TV ≥ 200 mL versus 81.5% for TV <200 mL [HR 2.26(95% CI 0.49 - 10.47), p = 0.287]. Overall, low rates of grade ≥2 toxicity were observed: 4 (8.9%) fatigue, 4 (8.9%) radiation dermatitis, 1 (2.2%) chyle leak, 3 (6.6%) scoliosis, 4 (8.9%) infection, 1 (2.2%) pneumonia, and 1 (2.2%) chest wall deformity. RT is a safe, effective local therapy for small to moderate cwES tumors. Patients with TV ≥ 200 mL had significantly worse survival outcomes and an inferior LC rate. This suggests large cwES tumors may benefit from an aggressive multi-modality approach.