Lattice radiotherapy for palliation in a case of metastatic adrenocortical carcinoma

Significant advances in systemic therapy have improved survival for patients with advanced-stage non-small cell lung cancer (NSCLC). However, the present treatment strategies and dose-fractionation for high-dose palliative radiotherapy (RT) are based on trials from the 1990s, when RT planning was simple with less precise delivery. Contemporary lung RT uses 4D-CT, volumetric modulated arc radiotherapy, aided by online verification using cone beam CT, which enables greater accuracy and better target volume coverage, while reducing doses to normal organs at risk. The Shortened High-dose Palliative Radiotherapy for Lung Cancer study aims to evaluate the safety and feasibility of reducing the number of RT fractions and RT duration, using contemporary planning, verification and delivery techniques. This single-arm, multicentre, phase-II study will test the shortened hypofractionated accelerated palliative RT regimen of 30 Gy in 6 alternate-day fractions, with strict normal tissue dose constraints. We aim to recruit 37 patients across 4 sites within the West Midlands. Quality assurance for the RT is supported by the Radiotherapy Trials Quality Assurance Group (RTTQA). Patients with locally advanced or metastatic NSCLC, who are candidates for high-dose palliative RT, before or after first-line systemic therapy, are eligible for recruitment. The primary objective of this study is to assess the safety of the proposed dose-fractionation. Secondary objectives include evaluating toxicity profiles, patient-reported outcome measures, time to progression, feasibility and the National Health Service cost-saving. This study is conducted in accordance with the International Council for Harmonisation Good Clinical Practice (ICH GCP) guidelines and all applicable regulatory frameworks, including, but not limited to, the UK policy framework for health and social care research, as well as the Health Research Authority and Health and Care Research Wales regulations. Approval for the study was granted on 18 April 2024 (IRAS project ID: 332998; REC reference: 24/WM/0032). The chief investigator is responsible for obtaining informed consent from participants. Any individual delegated this responsibility is thoroughly authorised, trained and competent to conduct the informed consent process. On completion of the trial, the results will be shared with participants in a plain language summary and will be submitted for publication in a peer-reviewed journal. If successful, this study will inform a phase III randomised controlled trial to assess efficacy. For updates on the study, visit the study web page (https://research.mededcoventry.org/About-Us/Meet-The-Team/TMU/Ship-Rt). NCT06483308.

Palliative radiation therapy (pRT) is a standard treatment option for bone metastases from malignancies and is recommended in current guidelines. Patients should have an equal opportunity to receive pRT regardless of their residential address or the location of the treatment facility; however, the frequency of use of pRT varied across regions and healthcare systems in studies in North America. This study aimed to examine the disparity in Japan. We conducted a historical cohort study using a regional population-based cohort that included medical insurance data to examine practice disparities in pRT for patients diagnosed with bone metastases who received bone-modifying agents (BMA). The analyses focused on the secondary medical areas (SMA) where the patients lived and facilities where they were treated. Overall, 6289 patients were included in our study, and 39.6% received pRT. The regional disparity in the proportion of pRT delivery was not large, despite some areas having no facilities with RT devices. However, differences among facilities where BMA was initiated were substantial. The BMA facilities with RT devices had a higher proportion of pRT than those without RT devices. In addition, the difference was wide among the facilities with RT devices. Patients treated with BMA in designated cancer hospitals were likely to receive pRT than those of other hospitals. This population-based study using medical claims data demonstrated practice disparities in pRT for bone metastases, particularly at the facility level. To improve this disparity, facility-level strategies seem to be more effective than SMA-level approaches.

Risk of dysfunctional larynx after radiotherapy for early-stage glottic laryngeal cancer: A systematic review and meta-analysis.

ABSTRACTNUT carcinoma is a rare and highly aggressive malignancy, particularly when arising in the thorax. Radiotherapy is commonly used for symptom palliation; however, radiotherapeutic response patterns in thoracic NUT carcinoma remain poorly characterised. We report a 22‐year‐old woman with thoracic NUT carcinoma who demonstrated markedly heterogeneous responses to palliative radiotherapy across metastatic sites. A thoracic lesion causing superior vena cava (SVC) syndrome showed sustained radiographic improvement after irradiation, whereas a pelvic bone metastasis progressed shortly after single‐fraction radiotherapy despite transient symptom relief. Although differences in delivered radiation dose likely contributed to these outcomes, this case illustrates practical considerations in palliative radiotherapy for thoracic NUT carcinoma, including effective symptom control for SVC syndrome and the limited durability of single‐fraction radiotherapy for bone metastases. This case highlights practical considerations in palliative radiotherapy for thoracic NUT carcinoma and provides an educational perspective for respiratory physicians involved in multidisciplinary cancer care.

Stereotactic ablative body radiotherapy for PSMA-PET/CT staged, oligometastatic prostate cancer - A multi-centre study.

Identification of a novel RET::FOXJ3 fusion in lung adenocarcinoma associated with lack of response to pralsetinib.

A woman in her 30s without prior medical history presented with 4 months of progressive back pain that evolved to paraplegia, followed by dyspnoea and haemoptysis. Imaging revealed numerous, well-circumscribed pulmonary nodules consistent with cannonball metastases, a loculated right pleural effusion, bilateral renal masses, pancreatic nodules and osteolytic L5 collapse with cord compression. The lung lesion biopsy demonstrated a poorly differentiated neoplasm, which on immunohistochemistry was most consistent with metastatic sarcomatoid carcinoma of renal origin. She required intubation, pleural drainage and high-dose dexamethasone, achieving partial neurological recovery, and subsequently received palliative spinal radiotherapy. Sarcomatoid renal cell carcinoma is a rare, aggressive variant with rapid progression and poor prognosis. Immune checkpoint inhibitors, alone or combined with vascular endothelial growth factor-targeted agents, are current standard therapy, but access may be restricted in resource-limited settings. Although the cannonball pattern can suggest renal or other hypervascular primaries, a comprehensive imaging and histological evaluation remains essential for diagnosis.

Grid Spatially Fractionated Radiation Therapy for Bulky Tumors: A Large Single Institution Experience.

Outcome of palliative radiotherapy on liver in hepatocellular carcinoma

PurposeSinonasal mucosal melanoma (SNMM) accounts for approximately 4-8% of sinonasal malignancies. SNMM frequently originates in the nasal cavity, causing nonspecific nasal symptoms that inevitably delay diagnosis. Left untreated, the tumor may extend into the orbit.Case DescriptionHerein, the authors describe two patients presenting with compressive optic neuropathy and were found to have advanced SNMM involving the orbit. Both patients presented with vision loss, decreased color vision, proptosis, conjunctival chemosis, and restricted extraocular movements. One patient was found to have a relative afferent pupillary defect. Neither patient was a surgical candidate, and both received palliative radiotherapy and immunotherapy.ConclusionsThese cases and literature review demonstrate the potential for the disease to initially manifest with orbital extension and ocular symptoms. Ophthalmologists can play a crucial role in the early detection of SNMM, which may improve outcomes, given the challenges of SNMM treatment.

Background:There is a lack of studies concerning the end of life (EOL) of patients with head and neck cancer (HNC).Objectives:To investigate whether the timing of palliative care decision (PCD), that is, decision to terminate life-prolonging anticancer treatments, is associated with reduced secondary health care utilization and medical procedures at the EOL among patients with head and neck cancer.Design and methods:A total of 108 patients with HNC treated at the Helsinki University Hospital Comprehensive Cancer Center were reviewed retrospectively. Three study groups were formed according to the timing of PCD: (1) the early PCD group (PCD >30 days prior to death), (2) the late PCD group (⩽30 days prior to death), and (3) the no PCD group.Results:PCD was made for 78 patients (72%), of which 57 (73%) were considered as early PCD and 21 (27%) as late. The median interval between PCD and death was 71 days (IQR 108). During the last month of life, a significantly smaller proportion of patients with an early PCD was hospitalized (19% vs 67%, OR = 0.12, CI [0.04-0.37], P < .001 and 19% vs 47%, OR = 0.27, CI [0.10-0.72], P = .007) and readmitted (5% vs 29%, OR = 0.14, CI [0.03-0.62], P = .004 and 5% vs 20%, OR = 0.22, CI [0.05-0.96], P = .032) in secondary health care compared with the patients with late or no PCD. Early PCD also associated with less ED visits (28% vs 52%, OR = 0.36, CI [0.126-0.997], P = .045) compared with the late PCD in the last month of life. Compared with the late PCD group, early PCD group was more likely to receive palliative radiotherapy (42% vs 14%, OR 4.36, 95% CI [1.15-16.51], P = .022).Conclusion:Early PCD associated with reduced utilization of secondary health care and emergency services at the EOL. The disease trajectories for patients with HNC should warrant more attention to the earlier timing of PCD.

Abstract Curative management for oesophagogastric adenocarcinoma traditionally involves four cycles of neo-adjuvant chemotherapy, FLOT (fluorouracil, leucovorin, oxaliplatin and docetaxel) followed by surgery and four cycles of adjuvant FLOT. Chemotherapy aims to reduce tumour bulk and prevent recurrence. Chemotherapy agents, especially fluorouracil, are known to cause cardiotoxicity which subsequently can impact cardiac function. We discuss three cases of cardiac dysfunction during neoadjuvant chemotherapy for patients diagnosed with oesophagogastric cancer. The first patient (56M) presented with chest pain following their first cycle of FLOT for oesophageal cancer, presumed squamous cell carcinoma. Echocardiogram showed severely impaired left ventricular (LV) function (ejection fraction of 35%). Chemotherapy was stopped. He was listed for surgery after a cardiac MRI showed a full recovery in his LV function however the tumour was too advanced and not resectable. The second patient (64F) had completed her neoadjuvant FLOT for oesophageal adenocarcinoma. Pre-operative echocardiogram showed a mildly dilated left ventricle with severe systolic dysfunction (estimated ejection fraction 25-30%) and deemed not fit for surgery. She received palliative radiotherapy during which her LV function improved and went on to have an oesophagectomy. The third patient (65M), diagnosed with a gastric adenocarcinoma, suffered an NSTEMI following their third-cycle of FLOT. A cardiac MRI revealed hypertrophic cardiomyopathy. He underwent a gastrectomy although did not have any adjuvant chemotherapy due to the cardiac risk. He subsequently had a recurrence within one-year of surgery. Our cases demonstrate the importance of cardiac monitoring during chemotherapy for these patients and highlights the significant impact when chemotherapy is disrupted.

BackgroundThe role of external beam radiation therapy (RT) in non-surgical gastric cancer (GC) remains controversial due to conflicting trial results and a lack of large-scale real-world evidence. This study utilizes the population-based Surveillance, Epidemiology, and End Results (SEER) database to examine the association between RT and overall survival (OS) in non-surgical GC patients, while acknowledging inherent confounding factors.MethodsWe identified 29,923 non-surgical GC patients [2004–2021] from the SEER database, categorizing them into RT (n=6,629) and non-RT (n=23,294) groups. Baseline demographic and clinicopathological characteristics were collected. Survival was followed until death or censoring. Kaplan-Meier analysis, multivariable Cox regression (adjusting for age, sex, year of diagnosis, marital status, race, tumor site, grade, stage, and chemotherapy), propensity score matching (PSM), and subgroup analyses were employed.ResultsThis investigation included 29,923 patients with non-surgical GC. Of these, 6,629 (22.2%) received radiotherapy (RT), while 23,294 (77.8%) did not. Baseline characteristics differed significantly between groups (P<0.001), with the RT group having a higher proportion of patients with regional stage disease (30.9% vs. 10.5%) and receiving chemotherapy (82.4% vs. 57.3%). The results showed that the median OS was 10.5 months in both groups (P<0.001), with 3-year survival rates of 12.4% in the RT group versus 17.8% in the non-RT group. Multivariate analysis demonstrated an association between RT and OS [hazard ratio (HR), 1.11, 95% confidence interval (CI): 1.07–1.15, P<0.001], which remained significant after PSM analysis (HR, 1.10, 95% CI: 1.06–1.15). In the subgroup of metastatic patients, the association between RT and OS was attenuated (HR, 1.05, 95% CI: 0.98–1.12).ConclusionsIn this SEER-based analysis, RT was associated with reduced OS in patients with non-surgical gastric cancer. The SEER database’s lack of treatment intent and symptom data precludes causal interpretation. RT remains clinically relevant for symptom control, and individualized decision-making is paramount. Prospective studies distinguishing curative versus palliative RT are warranted.

Outcomes for upper gastrointestinal (UGI) cancers are poor except for those patients whose cancers are diagnosed at a very early stage. Unique socioeconomic factors may result in worse outcomes in the safety-net setting given that these patients often seek care later in the disease course. This study aims to understand the survival outcomes of patients with UGI cancers in a safety-net health care (SNH) setting. Patients diagnosed with esophageal squamous (ES), esophageal adenocarcinoma (EA), and gastric carcinomas (G) at JPS Health Network in Fort Worth, Texas from January 1, 2018, to December 31, 2022, were identified in the tumor registry database. The electronic health record was queried for clinical characteristics, pathology variables, and management outcomes. Kaplan-Meier curve was used to illustrate the difference in survival time across cancer stages from an index date of diagnosis with censoring at date of last contact. A total of 171 patients were included: the median age was 57 years, but 15 patients were under 40 years. By ethnicity, 40% were Hispanic. The majority were male (71%) and uninsured (65%). G was the most common primary site (n = 92, 54%), followed by EA (n = 58, 34%) and ES (n = 21, 12%). Of the 125 stage 4B patients, 69 (55%) did not receive any treatment, 6 received only palliative radiation, and the remainder received systemic therapy. In patients with stage 4B, the median overall survival for patients with systemic treatment was 7.9 months (95% CI: 6.7-11), compared with 2.1 months (95% CI: 1.5-3.0) without treatment. In an urban safety-net population with a high percentage of Hispanic population, most patients with advanced UGI cancers did not receive systemic therapy. Interventions to improve outcomes must consider the unique socioeconomic needs of this vulnerable population to translate clinical trial results into improved outcomes.

This is a case of a 66-year-old female with a past medical history of stage III clear cell ovarian carcinoma (CCOC), status post chemotherapy and radical hysterectomy, who was incidentally found to have a metastatic retroperitoneal mass ten years later during a workup for persistent and vague thigh pain. Her pain was initially treated conservatively, and she was told to follow up in 3 months after attempting conservative measures such as over-the-counter pain medications and physical therapy. Despite adhering to these recommendations, here pain persisted, and a subsequent MRI revealed an unresectable presacral mass that was consistent with metastatic recurrence of clear cell carcinoma, for which the patient agreed to proceed with recommended palliative radiation therapy.

The proportion of older adults with head and neck cancer is steadily rising. Treatment planning in this population is often challenging due to more frequent comorbidities; reduced physiological reserves; and, at times, differing treatment goals. Additionally, older adults have been significantly underrepresented in pivotal radiotherapy trials, making evidence-based decision-making difficult. This article strives to present current controversies in the radiotherapeutic management of older adults with head and neck cancer. Aselective literature search for studies addressing radiotherapy in elderly head and neck cancer patients was conducted via PubMed and ClinicalTrials.gov. Geriatric screening tools such as the G8 test are associated with treatment adherence and survival but are still rarely implemented in routine clinical practice. The SENIOR cohort study (NCT05337631) demonstrated asurvival benefit for the combination of radiotherapy with concurrent chemotherapy in older patients with good performance status and few comorbidities, but not for the combination with cetuximab. Current studies are investigating hypofractionated radiotherapy regimens and novel agents for patients with contraindications to cisplatin. For patients ineligible for curative treatment, effective palliative radiotherapy concepts with shortened overall treatment duration are available. The management of older adults with head and neck cancer remains challenging and requires further prospective research. Advanced age alone should not be considered acontraindication to curative radiotherapy, including concurrent chemotherapy. For patients not eligible for curative treatment, various palliative radiotherapy regimens are available.

Dural metastasis is a rare sign of advanced cancers, most often linked to breast, lung, and prostate cancers. With better survival rates in metastatic prostate cancer due to improvements in systemic treatment, unusual patterns like dural involvement are becoming more common. We present an unusual case of widespread dural metastasis from prostate adenocarcinoma that resulted in facial paralysis. A 69-year-old man with metastatic prostate cancer and extensive bone involvement came in with a headache and one-sided facial paralysis. A cranial MRI showed thickening of the dura and contrast enhancement affecting all dural surfaces. The patient received corticosteroids and palliative whole-brain radiotherapy, but he passed away from pneumonia three weeks later. This case emphasizes the need to consider dural metastasis in cancer patients who show unusual neurological symptoms. Early detection with cranial MRI is essential, and radiotherapy is an important option for palliative care. Reporting such rare cases helps improve awareness and guides clinical decisions.

Case summary An 8-year-old spayed female Ragdoll cat presented with a several-month history of coughing and exertional dyspnea. Initial treatment for presumed feline asthma was unsuccessful. Thoracic CT revealed an intraluminal mass at the carina and complete atelectasis of the right middle lung lobe. Endoscopy initially demonstrated the mass, but biopsy was considered unsafe; brush cytology was non-diagnostic. Because of progressive obstructive respiratory failure, urgent palliative radiation therapy was initiated (6 Gy × 6 fractions weekly; total dose 36 Gy). By the fourth fraction, the cat showed marked clinical improvement, and imaging confirmed tumor shrinkage. Prior to the fifth fraction, endoscopic biopsies were repeated, and histopathology established a diagnosis of an epithelial malignant tumor, most consistent with adenocarcinoma. Toceranib phosphate was introduced on an alternate-day schedule as adjuvant therapy. Short-term outcome was favorable, with resolution of clinical signs and improved quality of life, and the cat remains alive and clinically well more than 150 days after the initiation of radiation therapy. Relevance and novel information Primary tracheal tumors are rare in cats, and treatment protocols are not well defined. Surgical excision of masses involving the carina is technically challenging, and radiation therapy for this location has not previously been reported. In this case, a short course of hypofractionated radiation therapy rapidly alleviated airway obstruction, allowing stabilization of ventilation and subsequent histopathological confirmation. This staged diagnostic–therapeutic approach highlights the utility of hypofractionated radiation therapy as an emergency airway-sparing treatment for cats with obstructive tracheal tumors.

Responses to palliative radiotherapy (RT) for metastatic lesions vary among patients, and molecular determinants of radiosensitivity remain unclear. This study investigated genomic features associated with local progression-free survival (LPFS) in metastatic breast cancer patients treated with palliative RT. Forty-four patients who underwent next-generation sequencing of 523 cancer-related genes were retrospectively analyzed. The biologically effective dose (BED) was calculated using an α/β ratio of 3 Gy, and local progression was defined as recurrence or progression within the irradiated field. A total of 60 metastatic lesions, predominantly in bone (68.3%), were evaluated. Higher BED (≥88 Gy) was significantly associated with longer LPFS (p = 0.011). Among 320 detected mutations mapped to 141 Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways, and the PI3K–Akt signaling pathway remained an independent predictor in multivariate analysis (p = 0.03). Subgroup analyses demonstrated that patients with Ras, PI3K–Akt, or FoxO pathway mutations derived greater LPFS benefit from high BED, whereas this advantage was confined to wild-type tumors for the PD-L1/PD-1 checkpoint and choline metabolism pathways. These findings suggest that pathway-specific molecular contexts modulate RT response and may inform individualized radiation dose strategies in metastatic breast cancer.