Palliative Treatment Modality Research Articles

Pancreatic Cancer: Current Concepts, Trends, and Future Directions.

Pancreatic ductal adenocarcinoma (PC) ranks among the deadliest cancers, with a less than 15% 5-year survival rate. Epidemiological studies project that it will become the second leading cause of cancer-associated mortalities in the following decades. The hallmarks of pancreatic cancer lead to tumor aggressiveness and therapeutic resistance. For this reason, the field has been focusing on multiple dimensions to generate better therapeutic approaches, including new adjuvant, neoadjuvant, and palliative concepts to extend the survival of PC patients. Over the last 2 decades, clinical trials have significantly improved disease prognosis and patient survival. To achieve better outcomes and to deeply understand the therapeutic approaches, molecular tumor boards have become crucial for deeper exploitation of tumor genetics and tumor biology, providing better stratification markers for therapeutic regimens. Using recently developed targeted therapies, such as KRAS inhibitors, the field has gathered momentum and been tooled up with the help of new sequencing technologies. Therefore, researchers and clinicians have geared up for the battle against PC. This review will systematically discuss recent developments in adjuvant, neoadjuvant, and palliative treatment modalities. Moreover, the paradigm-shifting importance of genetic profiling on pancreatic cancer. will be explained through a showcase to frame future directions.

Setting up a new radiation therapy centre in Malawi: Opportunities and challenges

Radiotherapy (RT) is one of the three pillars of cancer treatment (with surgery and systemic therapies) and has proven to be a cost–effective modality for curative and palliative treatment. In low and middle-income countries, access to RT treatment is limited posing many challenges to patients and caregivers. Many patients living in low and middle-income countries (LMICs) such as Malawi spend enormous sums of money to be treated abroad, through Government schemes, or, more commonly, go without treatment. This paper reviews the progress of the Malawi Government in establishing the first dedicated cancer treatment center with RT facilities at Kamuzu Central Hospital in Lilongwe. Malawi is expected to have a fully functional dedicated RT centre towards the end of 2024 equipped with one cobalt machine, two linear accelerators (LINAC), and a high dose rate (HDR) Brachytherapy unit. More cancer patients will have access to RT services locally, resulting in the Government saving on the foreign currency required to treat patients out of the country. While there has been great progress towards establishment of services in Malawi, careful and strategic planning is needed for the sustainability of required resources to avoid long-term disruption of treatments.

Pattern of Testicular Atrophy in Bilateral Orchidectomy Specimens from Patients with Advanced Prostate Cancer

Introduction: One of the palliative treatment modalities for advanced prostate cancer (Pca) is bilateral Orchidectomy. Histopathological analysis of submitted Orchidectomy specimens may display normal to various grades of testicular atrophy. Advancing age may be related to testicular atrophy as well as pre-treatment with luteinizing hormone releasing hormone agonist [LHRH(a)], drugs and chronic illnesses. We retrospectively examined results of Orchidectomy specimens submitted for histopathological analysis. Materials and Methods: Bilateral orchidectomy specimen results of twenty seven (27) patients diagnosed with Pca were retrospectively studied. Their clinical information and ancillary laboratory results were retrieved. Of the 27 patients, two (7.4%) patients had no prior treatments for Pca, while twenty patients (74.1%) and five patients (18.5%) had prior exposure to anti-androgens and LHRH(a) respectively. In the histo-analysis, the specimens were graded from normal to various degrees of atrophy. Data collated were analyzed using Statistical package for social sciences (SPSS) version 20.0 software. Results: The mean age of all patients was 68.52±7.266 years, ranging from 51-87 years. Mean PSA was 59.811+38.84ng/ml, while mean Gleason score was 8.30+8.69. On the whole, 3 patients (11.1%) had normal testes, 16 patients (59.3%) and 8 patients (29.6%) respectively had mild and moderate grades of testicular atrophy. Age correlated positively with the grades of atrophy. Conclusion: Degree of testicular atrophy is widely noted to correlate with age and depends less on pre-treatment in the setting of advanced prostate cancer.

Clinical efficacy and prognostic factors of CT-guided radioactive iodine-125 seed implantation for the treatment of superficial soft tissue metastasis: a 12-year retrospective analysis

BackgroundSuperficial soft tissue metastasis (S-STM) of malignant tumors is uncommon and often brings great pain to patients. However, current treatment options are limited. The purpose of this study was to explore the clinical efficacy and prognostic factors of CT-guided radioactive iodine-125 (125I) seed implantation (RISI) for the treatment of S-STM.MethodsWe retrospectively evaluated 132 patients with S-STM who received RISI between June 2010 and July 2022. Local tumor progression-free survival (ltPFS), tumor response, pain control and complication were analyzed. The independent factors affecting ltPFS were screened out using a layered Cox proportional hazards model.ResultsThe median follow-up time was 8.3 months (interquartile range [IQR], 4.5–15.3 months). The objective response rate (ORR) was 81.8%. The median ltPFS was 9.1 (95% CI: 6.6, 11.6) months. The Cox proportional hazard regression model revealed that the independent factors influencing ltPFS included KPS score, primary tumor, metastases, boundary, density and postoperative D90 (All P < 0.05). After RISI, the rate of pain relief was 92.3%. 66 (84.6%) patients reported pain marked relief, and 6 (7.7%) experienced pain moderate relief. No severe adverse events associated with RISI were observed during follow-up.ConclusionsCT-guided RISI was associated with high local control and pain relief without severe adverse events and should be considered as a reliable palliative treatment modality for S-STM.Trial registrationTrial registration Retrospectively registered.

The Landsteiner lung cancer research platform (LALUCA) : Objectives, methodology and implementation of areal-world clinical lung cancer registry.

Lung cancer is amajor health burden in Austria; however, limited real-world data exist on the diagnostic and treatment reality of lung cancer patients in Austria. The collection of high-quality data in aclinical setting is needed to gain insights into the real-world diagnostic and therapeutic management of lung cancer patients. The Karl Landsteiner Institute for Lung Research and Pulmonary Oncology implemented the Landsteiner lung cancer research platform (LALUCA), recruiting unselected lung cancer patients from two high volume centers in Vienna. This article describes the objectives, design, methodology of the registry and the process of implementation. Amultidisciplinary team of lung cancer specialists created acustom designed variable catalogue for the LALUCA platform consisting of 17categories with 180 variables. Detailed information on clinical characteristics, diagnostic interventions, molecular pathology as well as curative and palliative treatment modalities are collected. During an implementation phase in 2020, the platform was optimized using the data of 50patients. Since then atotal of 1200 patients have been enrolled. Recruitment for the registry is ongoing with arecruitment rate of approximately 400 patients per year. The LALUCA registry is aweb-based platform for the collection of real-world clinical data of lung cancer patients. Combining alarge number of patients with afocus on gathering comprehensive data on diagnosis and treatment, the LALUCA registry provides atool for investigation, evaluation, and improvement of the clinical management, survival and quality of care of Austrian lung cancer patients.

Radiotherapy in metastatic bladder cancer

PurposeTo review available and emerging evidence of radiotherapy for symptom management and disease control in metastatic bladder cancer.MethodsA literature search and subsequent cross-referencing were carried out for articles in the PubMed and Scopus databases using terms ‘radiotherapy’ OR ‘palliative radiation therapy’ with ‘metastatic bladder cancer’ OR ‘advanced bladder cancer’ between 1990 and 2023, excluding articles with no English translation.ResultsPalliative radiotherapy is an effective and accessible treatment for the alleviation of haematuria and pain due to the primary and metastatic disease. With growing recognition of oligometastatic disease state at diagnosis, response, or progression, radiotherapy can consolidate response by ablating residual or resistant lesions. Experience with other primary cancers supports positive impact of radiotherapy on disease control, quality of life, and survival in oligometastatic stage, without significant adverse effects. Alongside immune checkpoint inhibitors, fibroblast growth receptor inhibitors, and antibody–drug conjugates, the immunomodulatory potential of radiotherapy is being explored in combination with these systemic therapies for metastatic bladder cancer.ConclusionRadiotherapy is an effective, safe, and accessible treatment modality for palliation as well as disease control in various clinical settings of metastatic bladder cancer. Its role in oligometastatic stage in combination with systemic therapy is expected to expand with emerging evidence.

Comparison of palliative treatment modalities among patients with colon cancer: A review of NCDB Database.

220 Background: Among colon cancer patients some patients present with significant symptom burden needing upfront palliation-directed therapies, aimed to improve the quality of life of patients with severe illnesses. These include palliation-directed surgery, chemotherapy, radiation, pain management, or a combination of these. The extent to which these palliation-directed therapies are utilized in colon cancer remains under-explored. This study's purpose was to understand the trends in utilization and factors associated with palliation-directed treatment modalities among patients with colon cancer. Methods: From the National Cancer Database, we identified patients with colon cancer who received first-line palliation-directed therapies from 2004 to 2016 without an intent to give definitive therapy. We evaluated the use of these treatments over time and compared frequencies of categorical variables using Chi square tests. A multivariate logistic regression was also used to evaluate patient characteristics associated with the use of these treatments. Results: We identified a total of 21,516 patients receiving palliation-directed therapy among patients with colon cancer – 19,506 received single palliation-directed therapy, 908 received a combination of palliation-directed treatments without pain management and 1102 received a combination of palliation-directed treatments with pain management. Of the 21,516 patients who received single palliation-directed treatments, 50.6% and 49.4% were male and female, respectively. The mean age was 67 years. Most patients had no existing comorbidities (68.7%), lived in metropolitan areas (81.6%), had grade 2 (59.4%) and AJCC Clinical stage 4 colon cancer (32.6%). Overall, most patients received chemotherapy (50.7%) as a palliative treatment, followed by surgery (25.2%), pain management (14.4%) and radiation (9.7%). The utilization of chemotherapy (39.6% in 2004 to 63.1% in 2016) and pain management (9.7% in 2004 to 12.7% in 2016) increased over time while the utilization of surgery (37.1% in 2004 to 16.9% in 2016), and radiation (13.6% in 2004 to 7.3% in 2016) decreased over time. The type of facility, readmission rates, and proportion of individuals who were whites, elder (age&gt;50), resided in metropolitan areas and had insurance were significantly different between groups. Male patients, patients without existing comorbidities, and patients with grade 2 tumors had higher odds of receiving surgery, radiation, or chemotherapy as palliative therapy compared to pain management. Conclusions: Utilization of first-line palliation-directed chemotherapy has increased significantly from 2004 to 2016 whereas surgery and radiation therapy use has decreased in that period. Notably, patient characteristics such as gender, absence of existing comorbidities and grade 2 tumors influence the choice of therapy.

The course and prognostic value of tumor stiffness detected by ultrasound elastography for transarterial chemoembolization of hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is recommended as the first-line treatment in intermediate-stage patients with hepatocellular carcinoma (HCC) or as a palliative treatment modality in advanced patients. However, tumor control usually requires multiple TACE interventions due to the presence of residual and recurrent lesions. Elastography can provide information about tumor stiffness (TS) to predict tumor residual or recurrence. In this study, we aimed to analyze the effects of TACE on HCC stiffness using ultrasound elastography (US-E). We investigated whether quantifying TS using US-E could predict the recurrence of HCC. This retrospective cohort study included 116 patients undergoing TACE to treat HCC. US-E was performed to measure the tumor's elastic modulus within 3 days before TACE, in the 2 days after the intervention, and at the 1-month follow-up. The known prognostic factors of HCC were also analyzed. The average TS before TACE was 40.1±14.36 kPa, and the average TS 1 month after TACE was 19.3±9.80 kPa. The mean progression-free survival (PFS) was 39.129 months, and the 1-, 3-, and 5-year PFS rates were 81.0%, 56.9%, and 37.9%, respectively. The mean overall survival (OS) was 48.552 months, and the 1-, 3-, and 5-year OS rates of patients with malignant hepatic tumors were 95.7%, 75.0%, and 49.1%, respectively. Tumor number, tumor location, TS before TACE, and TS 1 month after TACE were significant predictive factors for OS (P=0.02, P=0.03, P<0.001, and P<0.001, respectively). Rank correlation analysis and linear regression revealed that a higher TS before or 1 month after TACE was negatively associated with PFS. The reduction ratio in TS before and 1 month after therapy was positively associated with PFS. The optimal cutoff TS value was set at 46 and 24.5 kPa before and 1 month after TACE according to the optimal Youden index. Kaplan-Meier survival analyses demonstrated that the 2 groups had significant differences in OS and PFS and that a higher TS was positively correlated with OS and PFS. Our results verify that US-E provides additional information to characterize the tumoral stiffness of HCC. These findings indicate that US-E is a valuable tool for evaluating the tumor response after TACE therapy in patients. TS can also be an independent prognostic factor. Patients with a high TS had a higher risk of recurrence and a worse survival time.

Spinal Metastases and the Evolving Role of Molecular Targeted Therapy, Chemotherapy, and Immunotherapy.

Metastatic involvement of the spine is a common complication of systemic cancer progression. Surgery and external beam radiotherapy are palliative treatment modalities aiming to preserve neurological function, control pain and maintain functional status. More recently, with development of image guidance and stereotactic delivery of high doses of conformal radiation, local tumor control has improved; however recurrent or radiation refractory disease remains a significant clinical problem with limited treatment options. This manuscript represents a narrative overview of novel targeted molecular therapies, chemotherapies, and immunotherapy treatments for patients with breast, lung, melanoma, renal cell, prostate, and thyroid cancers, which resulted in improved responses compared to standard chemotherapy. We present clinical examples of excellent responses in spinal metastatic disease which have not been specifically documented in the literature, as most clinical trials evaluate treatment response based on visceral disease. This review is useful for the spine surgeons treating patients with metastatic disease as knowledge of these responses could help with timing and planning of surgical interventions, as well as promote multidisciplinary discussions, allowing development of an individualized treatment strategy to patients presenting with widespread multifocal progressive disease, where surgery could lead to suboptimal results.

Comprehensive Management of Molar-Incisor-Hypomineralization by Preventive, Palliative, and Restorative Treatment Modalities in a Pediatric Patient: A Case Report and Literature Review

Molar–incisor–hypomineralization (MIH) is a developmental defect of enamel dental tissue caused by the disturbances in the maturation stage of amelogenesis. It usually affects the permanent first molars and incisors. In children, MIH condition clinically appears as the demarcated discolored hypomineralized defects of affected teeth, post-eruptive breakdown (PEB) of affected enamel, dentine exposure, hypersensitivity, increased susceptibility to dental caries and behavioral management challenges owing to dental anxiety/fear and dental esthetic concerns. This case report describes the comprehensive dental management of MIH in an 8-year-old male pediatric patient by conservative and noninvasive treatment approach with preventive, palliative, and restorative treatment modalities under nonpharmacological behavior management techniques.

Spinal metastases of bronchopulmonary cancers: interest of balloon kyphoplasty in the control of mechanical rachialgia

IntroductionSpinal metastases are a classic complication of lung cancer. New palliative treatment modalities have emerged. Among them are minimally invasive approaches such as balloon kyphoplasty. With the aim of evaluating the efficiency of balloon kyphoplasty in the control of spinal pain during these lesions, we report a series of 24 patients.Methods and materialsOver a period of 6 years, we retrospectively studied 24 files of patients suffering from vertebral compression of metastatic pulmonary origin and treated by balloon kyphoplasty from January 2009 to December 2014 in the neurosurgery department of the North Hospital of Marseille (France).ResultsThe mean age was 66.2 years (39–80 years) with a sex ratio of 5. Dorsal location was predominantly 17 cases. Balloon kyphoplasty involved one level in 14 patients. The general condition (Karnofski) was bad in 16 patients. Survival prediction was less than 6 months in 22 patients. The indication was mainly pain with a mean visual analog scale of 7.7. The evolution was marked by the regression of the painful symptomatology in all patients with a mean visual analog scale of 2.2 postoperatively. Postoperative complications were noted in two cases (pulmonary embolism, compression of the left iliac vein).ConclusionOur short series shows the efficacy and low morbidity of balloon kyphoplasty in the control of spinal pain secondary to vertebral metastases of bronchopulmonary cancers.

Trans-arterial therapy for Fibrolamellar carcinoma: A case report and literature review.

IntroductionFibrolamellar carcinoma (FLC) is a rare pathologically distinct primary liver cancer. Surgical resection is the only treatment associated with prolonged survival. Trans-arterial embolization (TAE), which is a recognised treatment for hepatocellular carcinoma has been used to treat FLC. We present a case and performed a literature review of patients with FLC treated with TAE.Case presentationWe present a 19-year old female with a large potentially resectable FLC which was initially treated with trans-arterial chemo-embolization (TACE) with drug eluting beads. The TACE was followed by surgical resection. Histology confirmed tumour necrosis related to the previous TACE.Discussion & literature reviewWe identified seven case reports and one case series of TAE for FLC. TAE was either used as a neo-adjuvant therapy to facilitate subsequent tumour resection or as a palliative treatment modality. We propose an algorithm for the treatment of FLC that includes TAE.ConclusionThe rarity of FLC and the paucity of data precludes establishing clear evidence-based standards of care. We propose an algorithm for the treatment of FLC. The establishment of an international registry may facilitate the collection of better quality evidence.

Interventional bronchoscopy-an overview

Die Bronchoskopie stellt neben der Lungenfunktion und der radiologischen Bildgebung das wichtigste Diagnostikum bei Patienten mit Atemwegs- und Lungenerkrankungen dar. Aufgrund des kombinierten Einsatzes flexibler und starrer Bronchoskope kommt sie heutzutage aber auch zunehmend als endoskopisches Therapieverfahren bei pulmonalen Erkrankungen in Frage. Bei thorakalen Tumoren kann die interventionelle Bronchoskopie sowohl in palliativer als auch kurativer Intention zum Einsatz kommen. Neben der bronchoskopischen Tumorbehandlung rückten in den letzten Jahren zunehmend die Techniken der endoskopischen Lungenvolumenreduktion in den Fokus. Darüber hinaus bieten sich Therapiemöglichkeiten für Asthma und chronische Bronchitis sowie bei Atemwegsstenosen und -fisteln.

Chemoembolization for Symptomatic Metastatic Epidural Spinal Cord Compression Refractory to Re-radiotherapy.

To evaluate the efficacy of chemoembolization for inoperable metastatic epidural spinal cord compression (MESCC) refractory to re-radiotherapy. Nineteen consecutive patients with recurrent MESCC after re-radiotherapy who had undergone chemoembolization were retrospectively analyzed. Outcome measures were pain relief rate, neurological improvement rate, objective response rate, and adverse events. MESCC degree classification was assessed using Bilsky grades. Pain assessment was performed using Numerical Rating Scale, and neurological function was evaluated using the Frankel classification. The median follow-up period was 7 (range 2-44) months. All participants had MESCC grade 2 or higher and had severe pain. Fifteen patients (79%) had neurological deficits, and ten had Frankel classification C and five had D. Symptoms were relieved in almost all patients the day following chemoembolization. Pain relief was achieved in 18 of 19 (95%) patients; the median decrease in Numerical Rating Scale score was 8 (range 0-10; p < 0.001). Neurological improvement was achieved in 11 of 15 patients (73%); the median increase in Frankel classification was 1 (range 0-2; p = 0.006). Ten of 19 (53%) patients showed a reduction in MESCC; the median decrease in Bilsky grade was 1 (range 0-2; p = 0.005). There was no correlation between the change in Bilsky grade and pain relief (p = 0.421). However, the decrease in Bilsky grade significantly improved neurological symptoms (p = 0.01). No serious adverse events occurred. Chemoembolization may be a useful palliative treatment modality for MESCC refractory to re-radiotherapy. Level 3b, Follow up Study.

Outcomes of Patients With Spinal Metastases From Prostate Cancer Treated With Conventionally-Fractionated External Beam Radiation Therapy.

Retrospective cohort study. To evaluate the outcomes of conventionally-fractionated external beam radiation therapy (cEBRT) in the treatment of prostate cancer spinal metastases (PCSM). Patients who received palliative cEBRT for PCSM in our institution between 2008 and 2018 were included. Our outcomes were local progression-free survival (LPFS), overall survival (OS), pain response and toxicities graded using CTCAE version 4.03. Univariable and multivariable Cox proportional hazard regressions were performed to identify predictors for LPFS and OS. A total of 100 patients with 132 sites of PCSM were identified, with a median follow-up of 54 months. Fourteen-percent of patients underwent surgical intervention before receiving cEBRT. Eighteen spinal segments (13.6%) had local progression, with a median time to local progression of 8 months. The median LPFS and OS were 7.8 and 9.0 months, respectively. The complete and partial pain response rates were 57% and 39% respectively. The incidence of grade ≥3 acute toxicities was 11%. Better ECOG performance status (0 to 1), castration-sensitive disease, spinal surgery and use of novel antiandrogen agent were identified as significant predictors for improved OS on multivariable analysis. In our prostate cancer cohort, cEBRT is an effective treatment modality for local palliation of spinal metastases. More aggressive treatment approach should be considered for patients with excellent performance status and castration-sensitive disease in light of their expected longer survival. Further studies are warranted to identify the predictors for radiotherapy response in this population.

Low energy amplitude modulated radiofrequency electromagnetic fields in combination with standard treatment or as monotherapy to show improvement in quality of life in patients with advanced hepatocellular carcinoma.

290 Background: Hepatocellular carcinoma (HCC) is a fatal cancer without curative option for most patients. Hence the importance to improve health related quality of life (HRQoL). Amplitude-modulated radiofrequency electromagnetic fields (EMF), as a novel and non-toxic therapy, has potential for improving HRQoL in advanced HCC patients. Methods: An open-label, single center, prospective clinical protocol was performed in advanced HCC patients as an initial and salvage treatment modality. Systemic exposure to EMF was used in combination with a systemic conventional treatment or as a single treatment. A spoon-shaped antenna placed in the oral cavity delivered EMF over 90 minutes with monthly repetitions until death or consent withdrawal. The effect on HRQoL was the primary objective of this study. Patients answered the EORTC-C30 v3.0 questionnaires prior to every EMF exposure. Clinically meaningful change (CMC) and time to deterioration (TTD) for Global Health (QoL), Role Functioning (RF) and Physical Functioning (PF) were used in the analysis. Results: From March 2018 to April 2020, 55 advanced HCC patients were submitted to 373 EMF exposures. 41/55 (75%) patients had repetitive exposures (mean # 4, ranging from 2-16). 87% were male, median age was 67, 84% were BLCL-C, 16% were Child-Pugh B, 29% had extra-hepatic metastasis, 55% had failed previous treatment and 71% had documented radiological progression. 31(56%) patients received EMF in combination with systemic therapy (28 TKI and 3 anti-PDL1). 24 patients received EMF as a single treatment modality. The mean baseline score was 68.1 for QoL and 77.1 for RF and PF. 61%, 76% and 49% of patients experienced positive change in QoL, RF and PS scores immediately prior to the second exposure, respectively. +CMC was reported in 20%, 17% and 32% of patients, respectively for QoL, RF and PS. The median QoL TTD was not reached. The median RF TTD was 7.2 month and the median PF TTD was 11.9 month. The median RF TTD for patients in combination treatment was 11.4 months and in a single treatment was 13.5 month. The median PF TTD for patients in combination treatment was 12.8 months and in single treatment was 14.5 month. Conclusions: Advanced HCC patients showed positive changes in QoL, RF and PF HRQoL scores after single exposure to EMF. The benefit from EMF in HRQoL was durable both in combination with TKI or as a single modality in advanced HCC patients. These results support future development as a novel palliative treatment modality in advanced HCC patients. Clinical trial information: NCT 01686412.

Role of intraluminal brachytherapy as a palliative treatment modality in unresectable cholangiocarcinomas.

Cholangiocarcinoma, a primary malignant tumor of the bile ducts mainly originates from cholangiocytes. The incidence of biliary tract tumours is high in Asian countries, mainly in Thailand, India, Japan and Korea. These tumor relapse frequently and can metastsize to distant organs. Biliary stenting either by percutaneous transhepatic biliary drainage is widely used procedure used to attain symptomatic relief. Radiation therapy can be used to prevent the tumor growth in or surrounding the stent, maintaining its patency. External beam radiation therapy and intraluminal brachytherapy are the two methods by which tumoricidal doses could be delivered. Intraluminal brachytherapy can help in delivering high to the tumor while not exceeding the normal tissue tolerance of surrounding organs. In the present article we try to emphasize on the role of intra luminal brachytheraphy for palliation in advanced unresectable cholangiocarcinomas.

Clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the palliative treatment of retroperitoneal metastatic lymph nodes

BackgroundDue to the unique anatomical location of retroperitoneal metastatic lymph nodes, current treatment options are limited. This study was designed to explore the clinical efficacy and prognostic factors of CT-guided 125I brachytherapy for the treatment of retroperitoneal metastatic lymph nodes.MethodsWe retrospectively evaluated 92 patients received 125I brachytherapy for retroperitoneal metastatic lymph nodes. A layered Cox proportional hazards model was established to filter out the independent factors affecting local tumor progression-free survival (LTPFS).ResultsThe median LTPFS was 8 months. Metastatic lymph node with uniform density (p-0.009), clear boundaries (p-0.011), regular morphology (P < 0.001), and < 3 organs at risk of metastasis (p-0.020) were associated with better LTPFS. Necrotic lymph nodes (p < 0.001), fusion (p-0.003), and invasion of vessels visible on images (p < 0.001) were associated with poor LTPFS. Puncture path through abdominal wall or paravertebral approach were also associated with better LTPFS than a hepatic approach (P < 0.05). A maximum diameter ≤ 3 cm (P-0.031) or 3–5 cm (P-0.018) were also associated with significantly better LTPFS than a maximum diameter ≥ 5 cm. The Cox proportional hazards model suggested that lymph nodes invaded the large vessels visible on images, maximum diameter and puncture path were independent risk factors for LTPFS.ConclusionCT-guided 125I brachytherapy is an optional palliative treatment modality for retroperitoneal metastatic lymph nodes, which can provide high local control without severe complications. Better preoperative planning, intraoperative implementation, better choice of puncture path, and selection of appropriate tumor size are important factors that can improve the clinical efficacy of 125I brachytherapy for retroperitoneal metastatic lymph nodes.

Oral etoposide and cyclophosphamide: A low-cost palliative metronomic chemotherapy in advanced pediatric cancers

Introduction: Oral metronomic chemotherapy (OMC) is a less intensive and cost-effective palliative treatment modality in children with relapsed/refractory cancers in low-middle income countries. We aimed to study the safety and efficacy of OMC with oral etoposide and cyclophosphamide in relapsed/refractory pediatric malignancies treated at our center.Patients and Methods: This was a retrospective study from the case records of patients treated at our center from 2011 to 2018. Patients <18 years old and who received at least one cycle of OMC were included in the study. Cyclophosphamide and etoposide were given at a dose of 25 mg or 50 mg daily. Schedule of the drugs was variable; the most common schedule followed was 2 weeks on, followed by 2 weeks off. Progression-free survival (PFS) and overall survival (OS) were calculated using the Kaplan–Meier method.Results: A total of 49 patients were included in the study. The median age was 8 years (range, 1–18 years) and 23/49 (46%) were males. The most common malignancies were Ewing's sarcoma (n = 13, 26%) and neuroblastoma (n = 11, 22%). The median duration of OMC intake was 50 days (range, 9–570 days). The clinical benefit rate was 22.4% with 10.2% patients having partial response and 12.2% having stable disease. Thirty-two (65.3%) patients had progressive disease on OMC and six (12.2%) were lost to follow-up. The median PFS was 63 days (95% confidence interval [CI], 18–107 days) and median OS was 155 days (95% CI, 19–219 days). Lower age and longer duration of treatment were independent predictors of higher OS.Conclusion: Oral cyclophosphamide and etoposide are a convenient and economical regimen with response rates and survival similar to those historically reported from other OMC regimes.

Pathogenesis, diagnosis and treatment of premalignant and malignant stages of cholangiocarcinoma in primary sclerosing cholangitis.

Patients with primary sclerosing cholangitis (PSC) confer a high risk of cholangiocarcinoma (CCA). The molecular mechanisms of CCA development in PSC are incompletely understood, but pro-oncogenic processes resulting from chronic biliary inflammation are presumably of central importance. Distinguishing benign from malignant biliary strictures in PSC patients is challenging and accurately diagnosing CCA in PSC often requires a multifaceted approach involving imaging, serological testing, biliary brush cytology and fluorescence in situ hybridization (FISH). Lack of early detection tools leads to a late diagnosis in the majority of cases. Surgical resection or liver transplantation represent the only curative intent treatments in PSC-CCA, but is only an option for the small subset of patients where CCA is detected at an early stage. Current palliative treatment modalities result in only a modest increase in survival. Overall, PSC-CCA carries a dismal prognosis with a 5-year survival less than 20%. Advances aiming at improving strategies for early detection, treatment and surveillance of CCA will be essential to provide better future patient care for PSC patients. Herein, we review the pathogenetic mechanisms for PSC-CCA as well as strategies for diagnosing and managing premalignant and malignant stages of CCA in PSC.