Multimodal Treatment Approach Research Articles

Cerebral Intricacies: Deciphering the Mystique of Primary Central Nervous System Angiosarcoma

AbstractAngiosarcoma of the central nervous system (CNS) is an exceptionally rare and aggressive vascular malignancy presenting significant diagnostic and therapeutic challenges. We report the case of a 22-year-old female with CNS angiosarcoma, highlighting diagnostic intricacies, therapeutic approaches, and management outcomes. Initial symptoms included headache and dizziness, with magnetic resonance imaging revealing a space-occupying lesion in the right parietal lobe, initially misinterpreted as cavernoma. Subsequent surgical resection confirmed angiosarcoma histologically, supported by immunohistochemical analysis showing endothelial markers. Treatment comprised local irradiation postoperatively, resulting in no recurrence or metastasis. Histopathological examination revealed an infiltrative growth pattern with atypical endothelial cells forming irregular vascular spaces. Challenges in diagnosis arise due to overlapping features with other intracranial lesions. Multimodal treatment approaches involving surgery, radiation, and chemotherapy were employed, although their efficacy remains uncertain. Prognosis remains poor, underscoring the imperative for collaborative efforts to enhance understanding and management of this rare malignancy. Our case contributes valuable insights to the limited literature on CNS angiosarcoma, emphasizing the need for comprehensive case studies to refine diagnostic and therapeutic strategies.

Thermal Ablation and Intralesional Cisplatin Injection as Adjunct to Systemic Chemotherapy in Managing Malignant Central Airway Obstruction: A Case Report

Endobronchialultrasound (EBUS)-guidedintralesional chemotherapy and thermal ablation using cryotherapy and electrocautery can be used for the management of malignant central airway obstruction (CAO). This is a case of a 62-year-old male presenting with cough, hoarseness, and shortness of breath. He was diagnosed with squamous cell carcinoma stage IVA (T4N2M1a), causing malignant CAO that progressed to impending respiratory failure (ECOG PS 4). Chest CT scan findings included a left main bronchus mass measuring 3.7 x 5.8 x 5.9 cm causing complete atelectasis, a right pleural-based mass, and osteolytic destruction of the 3rd lateral ribs. Bronchoscopy showed a fungating, friable mass in the carina extending to the orifice of the right and left mainstem bronchus with 70% and 100% occlusion, respectively. A multimodality treatment approach was taken with tumor debulking by thermal ablation with cryotherapy and electrocautery, EBUS-guided intralesional cisplatin, and systemic chemotherapy. Subsequently, there was an interval decrease in the size of the tumor in multiple areas, with left lung re-expansion. The clinical symptoms of the patient significantly improved and ECOG status increased to 1. No adverse effects were noted post procedure. Intralesional cisplatin can be an effective and safe adjunct treatment in malignant CAO, alongside thermal ablation and systemic chemotherapy.

Glutathione Induced In Situ Activation of Dual-Locked Cuproptosis Nanoamplifier with Glycolysis Metabolism Inhibition to Boost Cancer Immunotherapy.

Interference with glycolysis metabolism not only promotes the efficient sensitization of cuproptosis, but also amplifies cytotoxic T cell functions and proliferations, thus contributing to relieve immunosuppressive tumor microenvironment. However, the synergistic mechanism and the design of multicomponent nanoformulations involving these three pathways have not yet been explored. a copper-coordinated nanoassembly (designated as Cu-GM) is reported here that integrates a lactate dehydrogenase inhibitor, galloflavin (GF), with an immune checkpoint inhibitor, myricetin (MY), to boost cancer cuproptosis-immunotherapy. These results suggest that Cu-GM can be activated by the endogenous overexpressed glutathione to release Cu+, leading to the abnormal aggregation of lipoylated proteins and iron-sulfur cluster proteins loss, which triggers proteotoxic stress and cell cuproptosis. Meanwhile, the released GF not only inhibits the glycolysis to amplify cuproptosis efficacy but also achieves effective lactate depletion, thus alleviating immunosuppressive effects of lactate. Notably, the killed tumor cells can induce immunogenic cell death to evoke the anti-tumor immunity, which further augmented by the MY-mediated immune checkpoint blockade. Taken together, the first anticancer synergy of glycolysis metabolism, cuproptosis, and immunotherapy is presented, showcasing remarkable in vivo antitumor effects and encouraging further exploration of a rational multimodal treatment approach.

COMPARATIVE ANALYSIS OF DIFFERENT MANUAL THERAPY TECHNIQUES IN THE MANAGEMENT OF CHRONIC LOW BACK PAIN

Chronic low back pain (CLBP) is a widespread and debilitating condition that affects the quality of life and productivity of individuals globally. Manual therapy techniques, such as spinal manipulation (SMT), mobilization, massage therapy, soft tissue mobilization (STM), manual traction, and joint mobilization of the pelvis and sacroiliac joint, are widely used interventions for managing CLBP. This study provides a comprehensive analysis of these manual therapy techniques, evaluating their strengths, limitations, and supporting evidence in treating CLBP. A literature review reveals key insights into the effectiveness, safety, and clinical utility of these techniques. The findings emphasize the importance of tailoring treatment to individual patient needs and preferences. Spinal manipulation and mobilization have shown benefits in reducing pain and improving function, while massage and soft tissue techniques enhance relaxation and flexibility. Manual traction and joint mobilization provide targeted relief for specific conditions. This abstract underscores the role of manual therapy as part of multimodal treatment approaches, integrating therapeutic interventions to optimize outcomes. Future research should focus on refining manual therapy practices and identifying patient subgroups most likely to benefit. The findings inform clinicians about evidence-based approaches to CLBP, highlighting the need for patient-centered care and interdisciplinary collaboration.

Improved survival of patients with newly diagnosed oligometastatic prostate cancer through intensified multimodal treatment

Background and objectivesThe standard of care for patients with metastatic hormone-sensitive prostate cancer (mHSPC) includes androgen deprivation therapy (ADT), novel antihormonal therapies (NHT) and/or chemotherapy. Patients with newly diagnosed oligometastatic prostate cancer (omPCa) represent a distinct subgroup of mHSPC, for which the optimal treatment, particularly the role of radical prostatectomy (RP) and metastasis-directed therapy (MDT), is currently under debate.Materials and methodsIn this single center, retrospective analysis, 43 patients with newly diagnosed omPCa were included. All patients underwent RP as part of a multimodal, personalized treatment approach. Other treatments included ADT, NHT, MDT (surgery or radiotherapy), adjuvant radiotherapy (prostatic fossa and/or pelvic lymph nodes) or chemotherapy in various combinations. Clinical endpoints were progression free and cancer specific survival (PFS, CSS).ResultsNo patient with omPCa died from prostate cancer during an up to ten years follow-up period after intensified multimodal treatment i.e., RP, ADT, adjuvant radiation therapy and MDT (n=13). In contrast, patients requiring chemotherapy (n=10) showed a significantly worse PFS (p<0.001) and CSS (p<0.001). Patients receiving various combinations (<4 therapeutic modalities; n=20) showed a more favorable outcome than patients receiving chemotherapy, but differences in PFS and CSS were not statistically significant compared to patients receiving an intensified multimodal treatment.ConclusionsAn intensified, multimodal treatment approach including RP can lead to excellent survival outcomes in patients with newly diagnosed omPCa. Patients requiring chemotherapy have most likely a more aggressive disease and therefore a more rapid tumor progression. Future studies to identify markers for risk stratification in patients with omPCa are therefore needed.

Nonoperative management of rectal cancer.

The management of locally advanced rectal cancer has changed drastically in the last few decades due to improved surgical techniques, development of multimodal treatment approaches and the introduction of a watch and wait (WW) strategy. For patients with a complete response to neoadjuvant treatment, WW offers an opportunity to avoid the morbidity associated with total mesorectal excision in favor of organ preservation. Despite growing interest in WW, prospective data on the safety and efficacy of nonoperative management are limited. Challenges remain in optimizing multimodal treatment regimens to maximize tumor regression and in improving the accuracy of patient selection for WW. This review summarizes the history of treatment for rectal cancer and the development of a WW strategy. It also provides an overview of clinical considerations for patients interested in nonoperative management, including restaging strategies, WW selection criteria, surveillance protocols and long-term oncologic outcomes.

Modern possibilities of minimally invasive biliary drainage techniques for patients with malignant jaundice

Malignant biliary obstruction is a complex condition requiring a multimodal approach for both diagnosis and treatment. Most patients diagnosed with this disease are not candidates for radical surgery, as they come to us at advanced stages of the disease. Therefore, they need quality palliative care. Aim. Based on the data from scientific articles and literature, to highlight the possibilities of minimally invasive biliary drainage techniques in patients with malignant jaundice. The article analyzes the available sources of scientific literature and articles from the electronic resources PubMed, Google Scholar, UpToDate from 2019 to 2024. Minimally invasive methods of biliary drainage have demonstrated significant advantages over open surgeries, including a reduced risk of surgical complications, shorter rehabilitation period, and the ability to perform the procedure under local anesthesia. However, despite technological progress and accumulated clinical experience, a number of unresolved issues remain, in particular, related to choosing the optimal drainage method for a particular patient, and assessing the effectiveness and safety of a specific technique. Conclusions. The most controversial issue is the choice between endoscopic and percutaneous drainage methods. Some studies have shown that endoscopic drainage might be more effective in patients with tumors located in the distal bile ducts, while percutaneous drainage might be more appropriate in case of proximal obstructions. Therefore, the situation calls for additional studies to evaluate long-term results of different drainage techniques and the effectiveness of plastic, covered and uncovered metal stents in different clinical situations.

A challenging Case of Recurrent Leiomyosarcoma of the sacral-coccygeal region with Multimodal Treatment Approach

A challenging Case of Recurrent Leiomyosarcoma of the sacral-coccygeal region with Multimodal Treatment Approach

Novel Therapies in the Perioperative Management of Localized Gastric Cancer: Current Perspectives and Future Directions

The management of localized gastric cancer has evolved considerably with the advent of novel perioperative treatment strategies with chemotherapy, significantly impacting patient outcomes. Traditionally, surgery has been the cornerstone of treatment, but recurrence rates remained high, necessitating the exploration of additional therapies to enhance long-term survival. The interplay between chemotherapy and radiotherapy is being meticulously studied to define the optimal sequencing and combination that maximizes tumor control while minimizing toxicity. Furthermore, the integration of targeted therapies and immunotherapy into the perioperative setting is gaining momentum with agents targeting HER2, VEGF, and PD-1/PD-L1, pathways have shown promise in advanced gastric cancer and are now being tested in the neoadjuvant and adjuvant settings. Preliminary results from trials investigating these agents, such as pembrolizumab and trastuzumab-deruxtecan, suggest potential survival benefits and warrant further exploration in combination with chemotherapy in the perioperative context. Additionally, the heterogeneity of gastric cancer across different populations and geographic regions necessitates tailored approaches that consider genetic and molecular characteristics of tumors, as well as patient comorbidities. This Comment provides a comprehensive overview of the latest therapeutic advancements in the perioperative setting for localized gastric cancer, emphasizing the critical role of multimodal treatment approaches.

Neoadjuvant therapy in rectal cancer—one year follow-up results of standard versus total neoadjuvant strategies

BackgroundLocally advanced rectal cancer (LARC) poses a significantly challenge in clinical management, requiring a multimodal treatment approach. Among innovative strategies, Total Neoadjuvant Therapy (TNT) has emerged, delivering all planned chemotherapy before surgery.ObjectiveOur aim was to evaluate the real-world application and efficacy of TNT and to compare it with the non-TNT standard strategy.MethodsThis retrospective study compared locally advanced rectal adenocarcinoma patients treated with Total Neoadjuvant Therapy (TNT) in 2022 with those who underwent traditional chemoradiotherapy (CRT) in 2020–2021. The primary endpoints were the pathologic complete response rate and the sustained clinical complete response rate in patients under W&W.ResultsAmong 107 patients (54.2% male, mean age 62.48 years), non-TNT (67 patients) and TNT (40 patients) mean follow-ups were 26.7 and 8.2 months, respectively. No differences in gender(p = 0.163), staging (p = 0.707), or location (p = 0.727) were noted. TNT patients received more short-course radiotherapy (42.5% vs1.5%, p < 0.001). Clinical responses favored TNT (p = 0.030) with no significant differences in pathological responses, recurrence rates, or survival. TNT exhibited higher chemotherapy completion (p = 0.007) and lower adverse events (p < 0.001). Post-surgery events showed no significant differences (p = 0.470). Single center with retrospective design and carries limitations that may restrict the generalizability of the findings and the relatively short follow-up duration are our main limitations.ConclusionOur data add to the body of literature favoring the TNT treatment strategy for locally advanced rectal cancer, aiming to achieve comparable complete response rates with less adverse events.

Targeted transcriptomic analysis of well-differentiated and dedifferentiated liposarcoma reveals multiple dysregulated pathways including glucose metabolism, TGF-β, and HIF-1 signaling.

Liposarcoma is the most prevalent sarcoma in adults representing 20% of all sarcomas with well-differentiated/dedifferentiated among the most common subtypes represented. Despite multimodality treatment approaches, there has not been any appreciable change in survival benefit in the past 10 years. The future of targeted therapy for WD/DDLPS is promising with the intention to spare multi-visceral removal due to radical surgical resection. Therefore, there is a need to expand upon the molecular landscape of WDLPS and DDLPS which can help identify potential therapeutic targets for the treatment of this disease. Targeted transcriptome analysis using the NanoString tumor signaling 360 panel revealed a dysregulation in glucose metabolism and HIF1 signaling pathways in both WDLPS and DDLPS when compared to normal fat controls. WDLPS, however, demonstrated upregulation of HIF-1A and TGF-β when compared to DDLPS by targeted transcriptome analysis and orthogonal validation by RT-qPCR suggesting activation of EMT pathway in WDLPS when compared to DDLPS. Our findings implicate a putative role for dysregulation in glucose metabolism, TGF-β and HIF1 signaling in the pathogenesis of both WD/DDLPS suggesting a possible proinflammatory tumor environment within WDLPS and subsequent activation of the TGF-β signaling pathway.

Synthesis of pseudo-PET/CT fusion images in radiotherapy based on a new transformer model.

PET/CT and planning CT are commonly used medical images in radiotherapy for esophageal and nasopharyngeal cancer. However, repeated scans will expose patients to additional radiation doses and also introduce registration errors. This multimodal treatment approach is expected to be further improved. A new Transformer model is proposed to obtain pseudo-PET/CT fusion images for esophageal and nasopharyngeal cancer radiotherapy. The data of 129 cases of esophageal cancer and 141 cases of nasopharyngeal cancer were retrospectively selected for training, validation, and testing. PET and CT images are used as input. Based on the Transformer model with a "focus-disperse" attention mechanism and multi-consistency loss constraints, the feature information in two images is effectively captured. This ultimately results in the synthesis of pseudo-PET/CT fusion images with enhanced tumor region imaging. During the testing phase, the accuracy of pseudo-PET/CT fusion images was verified in anatomy and dosimetry, and two prospective cases were selected for further dose verification. In terms of anatomical verification, the PET/CT fusion image obtained using the wavelet fusion algorithm was used as the ground truth image after correction by clinicians. The evaluation metrics, including peak signal-to-noise ratio, structural similarity index, mean absolute error, and normalized root mean square error, between the pseudo-fused images obtained based on the proposed model and ground truth, are represented by means (standard deviation). They are 37.82 (1.57), 95.23 (2.60), 29.70 (2.49), and 9.48 (0.32), respectively. These numerical values outperform those of the state-of-the-art deep learning comparative models. In terms of dosimetry validation, based on a 3%/2mm gamma analysis, the average passing rates of global and tumor regions between the pseudo-fused images (with a PET/CT weight ratio of 2:8) and the planning CT images are 97.2% and 95.5%, respectively. These numerical outcomes are superior to those of pseudo-PET/CT fusion images with other weight ratios. This pseudo-PET/CT fusion images obtained based on the proposed model hold promise as a new modality in the radiotherapy for esophageal and nasopharyngeal cancer.

Evaluating the Efficacy of Capacitive Resistive Monopolar Radiofrequency Combined With Proprioceptive Neuromuscular Facilitation in Managing Chronic Low Back Pain: A Randomised Controlled Trial.

This randomised controlled trial evaluates the effectiveness of capacitive resistive monopolar radiofrequency (CRMRF) combined with proprioceptive neuromuscular facilitation (PNF) training in managing chronic low back pain (CLBP). Given the multifactorial nature of CLBP, this study explores a multimodal treatment approach integrating CRMRF, known for its thermal effects and ability to alleviate pain through improved cell metabolism and microcirculation, with PNF training, which enhances muscle strength, flexibility, and proprioception. This study was designed as a single-blind, parallel, randomised controlled trial conducted in an outpatient clinical setting. Over the course of four months, 62 participants, suffering from chronic low back pain were randomly assigned to receive either the combined CRMRF and PNF treatment or PNF alone, with primary outcomes measured in terms of pain and functional disability using the Visual Analogue Scale (VAS), Oswestry Disability Index (ODI). For secondary outcome of disability associated with pain, Quebec Pain Disability Scale (QPDS) and Roland-Morris Disability Questionnaire (RMDQ) were used. The study's hypothesis was that the combined treatment would reduce pain and disability more effectively than PNF alone. Results indicated that the experimental group experienced greater improvements in pain and functional disability, surpassing the minimally clinically important difference (MCID) for the VAS, ODI, QPDS and RMDQ, suggesting the clinical relevance of the combined CRMRF and PNF approach. These findings are consistent with previous research highlighting the benefits of CRMRF in various musculoskeletal disorders and suggest that integrating CRMRF with PNF training offers a promising non-invasive treatment option for CLBP sufferers. Overall, our study contributes to the growing evidence base supporting innovative, multimodal treatment strategies for managing CLBP, with the potential to enhance patients' quality of life. ClinicalTrials.gov identifier: NCT05682287.

Clinicopathological Analysis of 14 Cases of Primary Pulmonary Lymphoepithelial Carcinoma

Primary pulmonary lymphoepithelial carcinoma (PPLEC) is a rare form of lung malignancy, accounting for only 0.7% of all lung cancers. It is currently classified as a distinct subtype within squamous cell carcinomas. This study aims to explore the clinicopathological characteristics of PPLEC and its subtypes, with the objective of enhancing understanding and improving diagnostic accuracy for this disease. A retrospective analysis was conducted on the clinical, pathological, imaging, and prognostic data of 14 patients diagnosed with PPLEC at the First Affiliated Hospital of Soochow University between February 2019 and June 2023. A total of 14 cases of PPLEC were identified, including 5 cases of the Regaud type, with ages ranging from 33 to 73 years, comprising 2 males and 3 females; and 9 cases of the Schmincke type, with ages ranging from 36 to 79 years, including 4 males and 5 females. Computed tomography (CT) scans consistently demonstrated soft tissue masses or nodular shadows. Reagud type mainly showed peripheral masses and Schmincke type mainly showed central masses. Pathological examination revealed tumor cells exhibiting syncytial-like growth, accompanied by lymphocytic infiltration and stromal fibrosis, with the Regaud type showing well-defined borders combined with granulomatous inflammation, while the Schmincke type exhibited indistinct tumor margins. Immunohistochemistry showed that CK, CK5/6, P40 and P63 were positive, and the Ki-67 index of Regaud type was lower than that of Schmincke type; notably, all 8 cases tested for programmed death-ligand 1 (PD-L1) were positive. Epstein-Barr virus-encoded RNA (EBER) in situ hybridization was positive in all instances. Among these cases, 6 underwent surgical treatment, and 8 received comprehensive therapy; by the end of the follow-up period, all 14 patients remained alive. PPLEC is a rare form of malignant lung tumor associated with Epstein-Barr virus (EBV) infection. The Regaud and Schmincke subtypes display distinct imaging and pathological characteristics. In the early stages of the disease, surgical intervention is the primary treatment method; however, for advanced stages, a multimodal treatment approach is utilized, resulting in a relatively favorable prognosis. Immunotherapy represents a promising and effective treatment modality for patients with middle to advanced stage disease exhibiting high PD-L1 expression levels.

Presentation and outcome of Gastric Cancer at a Tertiary Care Center

Introduction: Gastric cancer is the fifth most common cancer globally and the fourth leading cause of cancer-related deaths. Early-stage disease can be managed with endoscopic therapy or surgery, while advanced gastric cancer requires a multimodal treatment approach, including extensive lymphadenectomy. This study aims to evaluate the clinicodemographic profile and treatment outcomes of gastric cancer patients and to establish an effective therapeutic strategy. Methods: This retrospective descriptive cross-sectional study was conducted in the Department of Surgery at Shree Birendra Hospital. It included patients with gastric malignancies who had complete medical records. Data on patient history, AJCC staging, operative details, and postoperative findings were analyzed. Surgical choices were based on the clinical indication in each case. Clinicopathological characteristics and surgical outcomes were compared across tumor stages. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 24. Results: The study included 90 patients (62 males, 28 females) aged between 23 and 82 years. The most common clinical presentations were abdominal pain (58%), gastric outlet obstruction (18%), lump (5%), anemia (5%), and peritonitis (4%). Adenocarcinoma was the predominant histological type (87.78%). Curative surgery was performed on 73 patients (81.11%), while 17 patients (18.89%) underwent palliative procedures. Morbidity occurred in 16 patients (17.7%), primarily due to chest complications and sepsis, and mortality was recorded in 5 patients (5.5%). Conclusion: This study highlights the predominance of locally advanced gastric cancer in males, with distal gastric cancer and well-differentiated adenocarcinoma being the most common. Chest complications and sepsis were the leading causes of morbidity and mortality. No patients received perioperative chemotherapy, underscoring the need for updated treatment protocols to improve outcomes.

Management of Plaque Psoriasis with Multimodal Treatment of Ayurveda - A Case Report

Psoriasis is the immune system problem that causes skin to revitalize at faster rate. It’s the chronic disease that has psychological and social impact on patient’s life. This condition had been narrated many decennium ago but proper aetiology and its cure remain under researched. In Ayurveda this multifaceted etiology disease needs multimodal treatment. The modern treatment provides only temporary relief with too many serious side effects. The treatment embraced here was in accordance with ayurvedic Samprapti. This case report details the successful management of plaque psoriasis in a 32-year-old female patient using a multimodal treatment approach, which incorporated Panchakarma, a traditional Ayurvedic detoxification therapy. The patient presented with erythematous plaques on forehead, neck region, lateral surface of legs and at arms along with itchy and burning skin. Auspitz sign and Koebner phenomenon was positive. Diagnosis made on the basis of Sign and Symptoms. After a thorough evaluation of the patient's constitution and the nature of the disease, a customized Panchakarma protocol was devised involving Virechana (Purgation) followed by Basti (medicated enema) along with Shamana Chikitsa (Internal Medication). The results revealed a remarkable improvement in the patient's psoriasis lesions, with a significant reduction in PASI scores, reduction in scaling, erythema, and in duration. The patient reported a substantial reduction in itching and discomfort. This case report emphasizes the potential of Panchakarma as an adjunctive therapy for plaque psoriasis, highlighting the holistic and personalized approach of Ayurveda in managing chronic skin conditions. Further research and larger-scale studies are warranted to confirm the effectiveness of Panchakarma in the treatment of psoriasis and to observe its long-term benefits and safety profile.

A comprehensive overview of gastric cancer management from a surgical point of view

Despite advancements in medical care, surgical technologies, and the development of novel treatments over the past decade, the prognosis for patients with gastric cancer (GC) has only modestly improved. This is primarily due to the fact that the majority of patients are diagnosed at advanced stages or present with metastatic disease. Radical resection remains the cornerstone of potentially curative treatment, yet the overall 5-year survival rate remains below 35%. The management of GC varies globally, influenced by factors such as geographical disparities, patient comorbidities and performance status, surgical approaches, and available medical resources. Multidisciplinary collaboration and a multimodal treatment approach are essential for optimizing patient outcomes. Surgeons must stay updated on emerging surgical concepts and make informed decisions regarding patient selection, timing of intervention, and the adoption of appropriate surgical techniques to improve both quality of life and prognosis. This review aims to provide a surgical perspective on the management of GC across all stages, highlighting the importance of a comprehensive treatment approach. Endoscopic resection may be a viable option for early GC in patients with minimal risk of lymph node metastasis, particularly in elderly patients with high surgical risk or severe comorbidities. For advanced GC, neoadjuvant therapy followed by surgery could be a promising strategy to improve patient outcomes. Conversion surgery offers a potential survival benefit for patients who respond to treatment with tumor downstaging. The treatment of peritoneal carcinomatosis remains challenging; however, hyperthermic intraperitoneal chemotherapy combined with complete cytoreductive surgery or pressurized intraperitoneal aerosolized chemotherapy may prolong survival or improve quality of life in highly selected patients.

Treatment of Nonsocial Environmental Fear in a Service Dog UsingFluoxetineand Behavior Modification.

Training and maintaining a service dog requires extensive time and financial resources. The emotional bond between service dogs and their handlers poses unique challenges when dogs develop behavioral issues. We present a case of an otherwise healthy adult service dog exhibiting acute environmental fears, hindering her job performance. The dog's fear responses escalated in various settings, including school and home environments. Diagnostic evaluation ruled out medical pathology, leading to a diagnosis of nonsocial environmental fear and generalized anxiety. A multimodal treatment approach involving environmental management, antidepressant medication (fluoxetine), and behavior modification was implemented. Desensitization and counterconditioning protocols targeted specific triggers, such as shiny floors and elevators. Eight weeks after treatment initiation, the dog showed improvement, enabling a modified behavior treatment plan to be implemented as she gradually returned to work with reduced fear responses. Follow-up revealed sustained progress with additional dosage adjustment of fluoxetine.

The Critical Role of Stereotactic Body Radiation Therapy in Multimodal Treatment of Lung Metastasis from Bone and Soft Tissue Sarcomas.

Stereotactic body radiotherapy (SBRT) is increasingly used to treat lung metastasis (LM) in patients with soft tissue sarcoma (STS) and bone sarcoma (BS). This retrospective study evaluated the outcomes of patients with BS and STS treated with SBRT for LM between 2010 and 2023. We enrolled 102 patients (51 each with STS and BS), of whom 71 were males and 31 were females (median age, 40 years; range, 11-81 years). At diagnosis, 76 and 26 patients had localized and metastatic disease, respectively, with a median of 4 recurrences (range, 1-12). Before SBRT, 75 patients received chemotherapy and 52 underwent surgery for LM, with 276 nodules treated with SBRT (median dose, 48 Gy; range, 40-52). Local control of irradiated LM was 86% at 1 year and 78% at 2 years. By 31 December 2023 (median follow-up, 4.8 years), 60 patients had died and 42 survived (20 without ongoing disease). From the first LM relapse, the median overall survival (OS) was 4.8 years and the 5-year OS was 49% (95% confidence interval, 39-60%), with no difference between STS and BS; the median OS was 2.9 years and the 5-year OS was 36% after SBRT. Chemotherapy before SBRT was a negative prognostic factor by multivariate analysis. Long-term follow-up shows that SBRT as part of a multimodal treatment approach has reasonable survival rates in patients with LM due to sarcoma. Compared with historical results using only surgery and chemotherapy, SBRT has improved the 5-year OS.

Quelles avancées dans la prise en charge du carcinome anaplasique de la thyroïde en 2024 ?

LATEST DEVELOPMENTS IN ANAPLASTIC THYROID CARCINOMA MANAGEMENT IN 2024: Anaplastic thyroid carcinomas (ATCs) represent a rare and undifferentiated form of thyroid cancer with a poor prognosis, typically marked by a median overall survival of four to ten months. However, recent advances have shown improvements due to the more systematic application of molecular testing, targeted therapies, and immunotherapy, alongside the establishment of rapid specialized care protocols in expert centers. Clinically, ATCs often present as a rapidly enlarging cervical mass originating from the thyroid, causing neck, pain and tenderness, dyspnea and dys-phagia, and associated lymphadenopathy, typically in elderly patients. Diagnostic confirmation requires an urgent biopsy, reviewed by a pathologist within the TUTHYREF-path network, with a mandatory search for BRAFV600E molecular alterations. Following diagnosis, care coordination is expedited within an expert center of the ENDOCAN-TUTHYREF network whenever feasible. Initial surgery is rarely an option due to frequent loco-regional cervical invasion. A multimodal treatment approach is essential: BRAF/MEK inhibitors (dabrafenib/trametinib) in cases of BRAFV600E mutation, or chemotherapy in the absence of a molecular target, combined with radiotherapy and, potentially, surgery if the disease becomes resectable following induction therapy. PD-1/PD-L1 targeted immunotherapy, either alone or in combination with targeted therapies, has shown potential to extend survival in some patients; however, predictive biomarkers and the optimal sequencing of immunotherapy (whether as induction and/or maintenance) require further clarification and may vary depending on the clinical context.