Preoperative Radiotherapy In Patients Research Articles

Preoperative Radiotherapy in Patients With Primary Retroperitoneal Sarcoma: EORTC-62092 Trial (STRASS) Versus Off-trial (STREXIT) Results.

The aim of the present study was to compare the effect of radiotherapy (RT) on abdominal recurrence-free survival (ARFS) in patients with primary retroperitoneal sarcoma treated in the EORTC-STBSG-62092 (STRASS) phase 3 randomized controlled trial (STRASS cohort) and off-trial (STREXIT cohort) and to pool STRASS and STREXIT data to test the hypothesis that RT improves ARFS in patients with liposarcoma. The STRASS trial did not show any difference in ARFS between patients treated with preoperative radiotherapy+surgery (RT+S) versus surgery alone (S). All consecutive adult patients not enrolled in STRASS and underwent curative-intent surgery for a primary retroperitoneal sarcoma with or without preoperative RT between 2012 and 2017 (STRASS recruiting period) among ten STRASS-recruiting centres formed the STREXIT cohort. The effect of RT in STREXIT was explored with a propensity score (PS)-matching analysis. Primary endpoint was ARFS defined as macroscopically incomplete resection or abdominal recurrence or death of any cause, whichever occurred first. STRASS included 266 patients, STREXIT included 831 patients (727 after excluding patients who received preoperative chemotherapy, 202 after 1:1 PS-matching). The effect of RT on ARFS in STRASS and 1:1 PS-matched STREXIT cohorts, overall and in patients with liposarcoma, was similar. In the pooled cohort analysis, RT administration was associated with better ARFS in patients with liposarcoma [N=321, hazard ratio (HR), 0.61; 95% confidence interval (CI), 0.42-0.89]. In particular, patients with well-differentiated liposarcoma and G1-2 dedifferentiated liposarcoma (G1-2 DDLPS, n=266) treated with RT+S had better ARFS (HR, 0.63; 95% CI, 0.40-0.97) while patients with G3 DDLPS and leiomyosarcoma had not. At the current follow-up, there was no association between RT and overall survival or distant metastases-free survival. In this study, preoperative RT was associated with better ARFS in patients with primary well-differentiated liposarcoma and G1-2 DDLPS.

Personalised care for high-risk rectal cancer: does one size fit all?

Since 2020, the National Institute for Health and Care Excellence (NICE) guidelines have been used in the UK, recommending neoadjuvant radiotherapy for all patients with rectal cancer, except for those with radiologically staged T1–2, N0 tumours. Assessment of the 2020 NICE criteria for preoperative radiotherapy in patients with rectal cancer treated by surgery alone in comparison with proven MRI prognostic factors: a retrospective cohort studyCompared to previous guidelines, implementation of the 2020 NICE guidelines will result in significantly more patients receiving preoperative radiotherapy. High-quality MRI selects patients with good outcomes (particularly low local recurrence) without radiotherapy, with little margin for improvement. Overuse of radiotherapy could occur with this unselective approach. The high-risk group, with the most chance of benefiting from preoperative radiotherapy, is not well selected on the basis of NICE 2020 criteria and is better identified with proven MRI prognostic factors (extramural venous invasion, tumour deposits, and circumferential resection margin). Full-Text PDF Open Access

Assessment of the 2020 NICE criteria for preoperative radiotherapy in patients with rectal cancer treated by surgery alone in comparison with proven MRI prognostic factors: a retrospective cohort study.

Selection of patients for preoperative treatment in rectal cancer is controversial. The new 2020 National Institute for Health and Care Excellence (NICE) guidelines, consistent with the National Comprehensive Cancer Network guidelines, recommend preoperative radiotherapy for all patients except for those with radiologically staged T1-T2, N0 tumours. We aimed to assess outcomes in non-irradiated patients with rectal cancer and to stratify results on the basis of NICE criteria, compared with known MRI prognostic factors now omitted by NICE. For this retrospective cohort study, we identified patients undergoing primary resectional surgery for rectal cancer, without preoperative radiotherapy, at Basingstoke Hospital (Basingstoke, UK) between Jan 1, 2011, and Dec 31, 2016, and at St Marks Hospital (London, UK) between Jan 1, 2007, and Dec 31, 2017. Patients with MRI-detected extramural venous invasion, MRI-detected tumour deposits, and MRI-detected circumferential resection margin involvement were categorised as MRI high-risk for recurrence (local or distant), and their outcomes (disease-free survival, overall survival, and recurrence) were compared with patients defined as high-risk according to NICE criteria (MRI-detected T3+ or MRI-detected N+ status). Kaplan-Meier and Cox proportional hazards analyses were used to compare the groups. 378 patients were evaluated, with a median of 66 months (IQR 44-95) of follow up. 22 (6%) of 378 patients had local recurrence and 68 (18%) of 378 patients had distant recurrence. 248 (66%) of 378 were classified as high-risk according to NICE criteria, compared with 121 (32%) of 378 according to MRI criteria. On Kaplan-Meier analysis, NICE high-risk patients had poorer 5-year disease-free survival compared with NICE low-risk patients (76% [95% CI 70-81] vs 87% [80-92]; hazard ratio [HR] 1·91 [95% CI 1·20-3·03]; p=0·0051) but not 5-year overall survival (80% [74-84] vs 88% [81-92]; 1·55 [0·94-2·53]; p=0·077). MRI criteria separated patients into high-risk versus low-risk groups that predicted 5-year disease-free survival (66% [95% CI 57-74] vs 88% [83-91]; HR 3·01 [95% CI 2·02-4·47]; p<0·0001) and 5-year overall survival (71% [62-78] vs 89% [84-92]; 2·59 [1·62-3·88]; p<0·0001). On multivariable analysis, NICE risk assessment was not associated with either disease-free survival or overall survival, whereas MRI criteria predicted disease-free survival (HR 2·74 [95% CI 1·80-4·17]; p<0·0001) and overall survival (HR 2·44 [95% CI 1·51-3·95]; p=0·00027). 139 NICE high-risk patients who were defined as low-risk based on MRI criteria had similar disease-free survival as 118 NICE low-risk patients; therefore, 37% (139 of 378) of patients in this study cohort would have been overtreated with NICE 2020 guidelines. Of the 130 patients defined as low-risk by NICE guidelines, 12 were defined as high-risk on MRI risk stratification and would have potentially been missed for treatment. Compared to previous guidelines, implementation of the 2020 NICE guidelines will result in significantly more patients receiving preoperative radiotherapy. High-quality MRI selects patients with good outcomes (particularly low local recurrence) without radiotherapy, with little margin for improvement. Overuse of radiotherapy could occur with this unselective approach. The high-risk group, with the most chance of benefiting from preoperative radiotherapy, is not well selected on the basis of NICE 2020 criteria and is better identified with proven MRI prognostic factors (extramural venous invasion, tumour deposits, and circumferential resection margin). None.

The lncRNA gene copy number variation as a low-invasive marker of rectal tumor cell sensitivity to radiotherapy.

e15536 Background: Radiotherapy (RT) is a key component of rectal cancer (RC) treatment, however, cases of non-response to preoperative RT in patients are very common, which is associated with radioresistance of tumor cells, mediated by their molecular characteristics, including the expression level of long non-coding RNA (lncRNA). lncRNAs are longer than 200 bp, show specific expression to various incentives, regulate transcription by acting as molecular traps, and can serve as biomarkers. The number of genes encoding lncRNA is 2 times greater than the number of protein coding genes. However, the rapid degradation of lncRNA molecules in the extracellular environment makes this indicator unsuitable for low invasive diagnostics. The problem can be solved by switching to a more stable marker - gene copy number variation (CNV) of lncRNA, which can be determined in extracellular DNA (cfDNA) of blood plasma. Therefore, the aim of this study was to identify the relationship between CNV of lncRNA genes in cfDNA of blood plasma and the RT effectiveness for rectal tumors. Methods: We used cfDNA from blood plasma obtained before RT from 200 RC patients and from the blood plasma of 50 apparently healthy donors (without cancer, AHD). RT was carried out on Novalis TX linear accelerator (TFD = 54 Gy). Blood samples were separated into plasma and cell fraction by centrifugation. Isolation of cfDNA from plasma was carried out by the phenol-chloroform extraction method. Determination of lncRNA genes CNV ( XIST, HELLPAR, NEAT1, AC008124.1, AC016717.2, AC093297.2, AC097634.1, BX890604.1, CASC9, IQCH-AS1, LINC00662, LINC00707, LINC01089, LINC01468, LINC0154, MALAT0154, MUC20-OT1, PVT1, VASH1-AS1) was performed by Real-Time qPCR. Differences were assessed using the Mann-Whitney test (Bonferroni correction was used). Results: An analysis of RT results in 200 patients allowed dividing them into 2 groups: complete tumor regression (group 1, n = 120) and minor or no tumor regression (group 2, n = 80). In cfDNA of patients in group 1, a decrease (p &lt; 0.05) in the CNV of lncRNA XIST, HELLPAR, NEAT1, AC008124.1 and AC016717.2 genes was found by 2.5, 3.3, 2.0, 2.0, and 5.0 times, respectively, relative to the AHD. In cfDNA of patients in group 2, an increase (p &lt; 0.05) in the CNV of lncRNA XIST, HELLPAR, NEAT1, AC008124.1, LINC01089, LINC01547 and VASH1-AS1 genes by 1.9, 2.9, 3.5, 3.7, 2.6, 4.7 and 1.9 times was found respectively relative to the AHD. Differences (p &lt; 0.05) by 4.8, 9.7, 7.0, 7.4, 5.0, 3.1, 4.8 and 2.2 times were observed between 2 groups of patients in terms of CNV of XIST, HELLPAR, NEAT1, AC008124.1, AC016717.2, LINC01089, LINC01547 and VASH1-AS1 genes, respectively. Conclusions: Increased CNV of XIST, HELLPAR, NEAT1, AC008124.1, LINC01089, LINC01547 and VASH1-AS1 genes in blood plasma cfDNA is associated with low RT efficiency.

Proud about PRADA: radiotherapy before deep inferior epigastric perforator flap reconstruction

In The Lancet Oncology, Paul Thiruchelvam and colleagues 1 Thiruchelvam PTR Leff DR Godden AR et al. Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer requiring mastectomy (PRADA): a multicentre, prospective, feasibility study. Lancet Oncol. 2022; (published online April 7.)https://doi.org/10.1016/S1470-2045(22)00145-0 Summary Full Text Full Text PDF PubMed Google Scholar report the findings of a prospective study (PRADA) that evaluated the safety and feasibility of skin-sparing mastectomy with axillary surgery and immediate autologous-based deep inferior epigastric perforator (DIEP) flap reconstruction after preoperative radiotherapy for patients with breast cancer. Over a period of almost 2 years, 33 patients were enrolled at two centres in the UK. The primary endpoint was the rate of open breast wounds greater than 1 cm requiring dressing or packing at 4 weeks after surgery. Secondary outcomes included the presence of an open breast wound at 8 and 12 weeks after surgery, DIEP flap failure rate, and patient-reported satisfaction with the breast reconstruction. 1 Thiruchelvam PTR Leff DR Godden AR et al. Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer requiring mastectomy (PRADA): a multicentre, prospective, feasibility study. Lancet Oncol. 2022; (published online April 7.)https://doi.org/10.1016/S1470-2045(22)00145-0 Summary Full Text Full Text PDF PubMed Google Scholar Primary radiotherapy and deep inferior epigastric perforator flap reconstruction for patients with breast cancer (PRADA): a multicentre, prospective, non-randomised, feasibility studyPreoperative radiotherapy followed by skin-sparing mastectomy and immediate DIEP flap reconstruction is feasible and technically safe, with rates of breast open wounds similar to those reported with post-mastectomy radiotherapy. A randomised trial comparing preoperative radiotherapy with post-mastectomy radiotherapy is required to precisely determine and compare surgical, oncological, and breast reconstruction outcomes, including quality of life. Full-Text PDF Open Access

Changes in treatment intent and target definition for preoperative radiotherapy after 18F-Fluorodeoxyglucose positron emission tomography in rectal cancer: A Meta-analysis

PurposeTo evaluate the impact of 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) on changes in treatment plan and target definition for preoperative radiotherapy in patients with rectal cancer. MethodsEmbase, PubMed, and Cochrane Library were searched up to November 2020 for all studies investigating the role of preoperative FDG PET in patients who underwent neoadjuvant radiotherapy before curative-intent surgery. The proportion of patients whose treatment plan (curative vs. palliative intent) or target definition was changed after FDG PET was analyzed. A random-effects model was used for pooled analysis. The change in target definition was compared between conventional radiological imaging-based target volume [gross tumor volume (GTV) or planning target volume (PTV)] and PET-based target volume (GTV or PTV) using the standardized mean difference (SMD) and 95% confidence interval (CI). ResultsA total of 336 patients from twelve studies were included. In eight studies, PET changed either the treatment intent or target definition in 24.8% of patients (95% CI 15.1% to 37.9%, I2 = 69%). In ten studies, the PET-based GTV was lower than the conventional imaging-based target volume (SMD −7.0, 95% CI −1.39 to −0.01). However, there was no significant difference between conventional imaging-based and PET-based PTV (SMD −0.07, 95% CI −0.75 to 0.62). In six studies evaluating the initial staging based on PET, the initial staging (nodal or metastasis status) was changed in 53 of 229 patients (23.1%). Newly detected or additional distant metastases were identified in 22 patients (9.6%) after FDG PET. ConclusionThe use of FDG PET influences radiotherapy planning in a fourth of patients with rectal cancer. FDG PET can provide additive information for accurate tumor delineation, although PET-based PTV did not significantly change. These findings suggest that FDG PET may be beneficial to patients with rectal cancer before establishing a radiotherapy plan.

Comparison of preoperative and postoperative radiation therapy for extremity soft-tissue sarcoma: a randomized clinical trial

Background: The optimal sequencing of radiotherapy and surgery for the treatment of soft-tissue sarcoma (STS) is an ongoing source of controversy. In this study, the authors compared preoperative and postoperative radiotherapy in patients with extremity STS. Methods: Eighty patients with localized extremity STS were randomly assigned to either preoperative or postoperative radiotherapy group. Baseline characteristics of the patients were not significantly different between the two study groups. Primary outcome measures were pain, acute complications (wound dehiscence and infection), and late complications (limb edema, subcutaneous fibrosis, and joint stiffness). The severity of late complications was evaluated using the radiation therapy oncology group criteria. Secondary outcome measures were oncologic outcomes, including local recurrence and distant metastasis. Results: The mean pain level was not significantly different between the two groups (P=0.1). Infection was not seen in any of the patients. The rate of wound dehiscence and infection was not significantly different between the two groups (P=0.32 for both). Of the late complications, the rate of limb edema and subcutaneous fibrosis was similar in the two groups (P=0.16 and P=0.35, respectively). In contrast, the rate of joint stiffness was significantly more in the postoperative radiotherapy group (P&lt;0.001). The severity of all three late complications also was more in the postoperative radiotherapy group at 6 and 12 mo. There were no significant differences between the two groups regarding local recurrence and distant metastasis (P=0.99 and P=0.77, respectively). Conclusions: The authors suggest preoperative radiotherapy in patients with localized extremity STS because of its lower rate of and less severe complications, particularly joint stiffness. Level of Evidence: Level I.

Preoperative Short-Course Radiotherapy and Surgery versus Surgery Alone for Patients with Rectal Cancer: A Propensity Score-Matched Analysis at 18-Year Follow-Up.

A significant problem for long-term rectal cancer survivors may be the late toxicity of radiotherapy. It creates the possible risk of developing second primary malignancy and a theoretical decrease in overall survival. This study aimed to assess the influence of short-course preoperative radiotherapy in patients with locally advanced rectal cancer on overall survival, local recurrence rate, and second malignancy at 18-year follow-up. The rectal cancer trial was conducted in a single tertiary center between February 1992 and June 2006. A total of 389 patients with locally advanced rectal cancer (cT2-cT4, cN0/+, cM0) were included in the study. Preoperative radiotherapy was conducted in 148 patients and 241 patients underwent surgery alone. The propensity-matched group consisted of 105 patients operated on after radiotherapy and 105 controls. The number of local recurrences was 7 (6.7%) in the preoperative radiotherapy group and 22 (21%) in the surgery alone group (p = 0.016). The 18-year survival analysis showed no survival benefit in the preoperative radiotherapy group (38% versus 48%, p = 0.107) but improved recurrence-free survival (81% versus 58%, p = 0.001). The preoperative short-course radiotherapy significantly decreases the risk of local recurrence in locally advanced rectal cancer and may improve recurrence-free survival without an increased risk of second primary malignancy.

Preoperative stereotactic ablative body radiotherapy with postoperative conventional irradiation of soft tissue sarcomas: Protocol overview with a preliminary safety report

Preoperative radiotherapy in patients with soft tissue sarcomas is characterized by important advantages: high precision of dose delivery, reduction of tumor volume and implantation potential, induction of immunologic response. Postoperative irradiation is associated with a reduced risk of complication, and a comprehensive radiotherapy planning in accordance with the pathologic report. Combination of pre- and postoperative irradiation gives the opportunity to use the best of both methods. ObjectiveTo analyze feasibility and safety of radiotherapy protocol that combined pre- and postoperative radiotherapy in patients with soft tissues sarcomas of extremities. Materials and methodsFrom 06.2018 to 01.2021, 23 patients with soft tissue sarcomas of extremities were included in the protocol (NCT04330456) and 14 cases with at least 12 months follow-up were eligible for analysis. Preoperative stereotactic ablative body radiotherapy (SBRT) was performed as 5 fraction of 7 Gy with dose reduction (5 fractions of 5 Gy) on the margins of the tumor. Postoperative radiotherapy started 5–8 weeks after the surgery and was performed as standard compartmental irradiation in 25 fractions of 2 Gy. Complications were determined according to CTCAE and wound complication scales. ResultsPreoperative SBRT and subsequent radical resection with tumor free surgical margins were performed in all 14 cases. Primary wound closure was mentioned in all patients. Postoperative radiotherapy started 51.8 days (range 33–99 days) days after the surgery. With a relatively short follow-up of 21.5 (13–30) months, we recorded 2 cases (14%) of severe complications (Canadian sarcoma group criteria), and there were no local recurrences. ConclusionOur preliminary results demonstrate that the combination of preoperative SBRT and postoperative conventional radiotherapy is feasible and does not increase the risk of postoperative complications.

Preoperative stereotactic ablative body radiotherapy with postoperative conventional irradiation of soft tissue sarcomas: Protocol overview with a preliminary safety report.

e23546 Background: Preoperative radiotherapy in patients with soft tissue sarcomas is characterized by important advantages: high precision of dose delivery, reduction of tumour volume and implantation potential, induction of immunologic response. Postoperative irradiation is associated with a reduced risk of complication, and a comprehensive radiotherapy planning in accordance with the pathologic report. Combination of pre- and postoperative irradiation gives the opportunity to use the best of both methods. Methods: from 06.2018 to 01.2021 24 patients with soft tissue sarcomas of extremities were included in the protocol (NCT04330456) and 14 cases with at least 12 months follow-up were eligible for analysis. Preoperative stereotactic ablative body radiotherapy (SBRT) was performed as 5 fraction of 7 Gy with dose reduction (5 fractions of 5 Gy) on the margins of the tumor. Postoperative radiotherapy started 5-8 weeks after the surgery and was performed as standard compartmental irradiation in 25 fractions of 2Gy. Complications were determined according to CTCAE and wound complication scales. Results: Preoperative SBRT and subsequent radical resection with tumor free surgical margins were performed in all 14 cases. Primary wound closure was mentioned in all patients. Postoperative radiotherapy started 51.8 days (range 33-99 days) days after the surgery. With a relatively short follow-up of 21.5 (13-30) months, we recorded 2 cases (14%) of severe complications (Canadian sarcoma group criteria), and there were no local recurrences. Conclusions: Our preliminary results demonstrate that the combination of preoperative SBRT and postoperative conventional radiotherapy is feasible and does not increase the risk of postoperative complications. Clinical trial information: NCT04330456.

Occurrence of seeding metastases in resectable perihilar cholangiocarcinoma and the role of low-dose radiotherapy to prevent this.

BACKGROUNDPreoperative biliary drainage in patients with presumed resectable perihilar cholangiocarcinoma (PHC) is hypothesized to promote the occurrence of seeding metastases. Seeding metastases can occur at the surgical scars or at the site of postoperative drains, and in case of percutaneous biliary drainage, at the catheter port-site. To prevent seeding metastases after resection, we routinely treated PHC patients with preoperative radiotherapy (RT) for over 25 years until January 2018.AIMTo investigate the incidence of seeding metastases following resection of PHC.METHODSAll patients who underwent resection for pathology proven PHC between January 2000 and March 2019 were included in this retrospective study. Between 2000-January 2018, patients received preoperative RT (3 × 3.5 Gray). RT was omitted in patients treated after January 2018.RESULTSA total of 171 patients underwent resection for PHC between January 2000 and March 2019. Of 171 patients undergoing resection, 111 patients (65%) were treated with preoperative RT. Intraoperative bile cytology showed no difference in the presence of viable tumor cells in bile of patients undergoing preoperative RT or not. Overall, two patients (1.2%) with seeding metastases were identified, both in the laparotomy scar and both after preoperative RT (one patient with endoscopic and the other with percutaneous and endoscopic biliary drainage).CONCLUSIONThe incidence of seeding metastases in patients with resected PHC in our series was low (1.2%). This low incidence and the inability of providing evidence that preoperative low-dose RT prevents seeding metastases, has led us to discontinue preoperative RT in patients with resectable PHC in our center.

Gender differences in stage at diagnosis and preoperative radiotherapy in patients with rectal cancer

BackgroundFew studies have examined gender differences in the clinical management of rectal cancer. We examine differences in stage at diagnosis and preoperative radiotherapy in rectal cancer patients.MethodsA prospective cohort study was conducted in 22 hospitals in Spain including 770 patients undergoing surgery for rectal cancer. Study outcomes were disseminated disease at diagnosis and receiving preoperative radiotherapy. Age, comorbidity, referral from a screening program, diagnostic delay, distance from the anal verge, and tumor depth were considered as factors that might explain gender differences in these outcomes.ResultsWomen were more likely to be diagnosed with disseminated disease among those referred from screening (odds ratio, confidence interval 95% (OR, CI = 7.2, 0.9–55.8) and among those with a diagnostic delay greater than 3 months (OR, CI = 5.1, 1.2–21.6). Women were less likely to receive preoperative radiotherapy if they were younger than 65 years of age (OR, CI = 0.6, 0.3–1.0) and if their tumors were cT3 or cT4 (OR, CI = 0.5, 0.4–0.7).ConclusionsThe gender-specific sensitivity of rectal cancer screening tests, gender differences in referrals and clinical reasons for not prescribing preoperative radiotherapy in women should be further examined. If these gender differences are not clinically justifiable, their elimination might enhance survival.

Morphological substantiation of radiomodification of preoperative radiotherapy in patients with advanced endometrial cancer

Relevance. Endometrial cancer ranks first among oncogynecological diseases, however, 5-year survival can be achieved only in 67,7 % of patients, while 22,4 % of patients die during this period from the con­tinuation of the tumor process. Therefore, improving the complex therapy of patients with EC is very important.&#x0D; Purpose of the study. to investigate therapeutic pathomorphosis in pa­tients with advanced endometrial cancer with neoadjuvantchemoradiation therapy.&#x0D; Materials and methods. In order to study radiation pathomorphosis, 26 patients with ER T1-3N0-1M0-1 were examined. Group I consisted of 11 patients with a preoperative course of external radiation therapy SOD 30 Gywithout radiomodification, II – 15 patients with a preoperative course of external radiation therapy SOD 30 Gywith radiomodification.&#x0D; Results and its discussion. When conducting a comparative assessment of radiation pathomorphism in patients of the study groups, it was found that when using the preoperative course of TFD on Gy 30 with radiomodi­fication, a significant decrease in the mitotic index occurs. There is also a tendency to an increase in the degree of tumor regression, the number of pathological mitoses and stromal reactions during the preoperative course of TFD on 30 Gywith radiomodification.&#x0D; Conclusions. It was found that radiation therapy with EС with radiomodi­fication gives a more positive effect and regression of more than 50,0 % of the tumor volume, a decrease in its biological potential. The volume of the damaged tumor was 58,0 %, and the volume of the residual tumor was 42,0 %, that is, most of the tumor mass underwent regression.

RESULTS OF COMBINED TREATMENT PATIENTS WITH SOFT TISSUE SARCOMAS USING STEREOTACTIC ABLATIVE BODY RADIOTHERAPY

Preoperative radiotherapy in patients with soft tissue sarcomas characterized by important advantages: high precision of dose delivery, reduction of tumour volume and implantation potential, induction of immunologic response. Postoperative radiotherapy associated with decreased complication rate, delivery of treatment to microscopic disease according to pathologic report. Combination of pre- and postoperative irradiation gives the opportunity to use best of both methods. The aim: analyses of feasibility and safety of radiotherapy protocol that combined pre- and postoperative radiotherapy in patients with soft tissues sarcomas of extremities. Materials and methods: from 06.2018 to 01.2020 ten patients with soft tissue sarcomas of extremities were included in the protocol. Preoperative stereotactic ablative body radiotherapy (SABR) was performed as 5 fraction of 7 Gy on the main tumor volume with dose reduction to 5Gy in 5 fraction on the margins of the field. Postoperative radiotherapy started 5-8 weeks after surgery and was performed as standard compartmental irradiation in 25 fractions of 2Gy. Complications were determined according to CTCAE and wound complication scales. Results: from 06.2018 to 01.2020 10 patients with soft tissue sarcomas of extremities were included in the study. Pre-opeartive SABR and subsequent radical resection with tumor free surgical margins were performed in all 10 cases. Primary wound closure was mentioned in all patients. With relatively short follow-up of 9.1 (3-20) months we didn’t mentioned any case of grade II or more toxicity and no local recurrences. Conclusion: Our preliminary results demonstrate that combination of preoperative SABR and postoperative conventional radiotherapy is feasible and associated with low probability of grade II (and higher) toxicity.

Impact of age on the use of adjuvant treatments in patients undergoing surgery for colorectal cancer: patients with stage III colon or stage II/III rectal cancer

BackgroundMany older patients don’t receive appropriate oncological treatment. Our aim was to analyse whether there are age differences in the use of adjuvant chemotherapy and preoperative radiotherapy in patients with colorectal cancer.MethodsA prospective cohort study was conducted in 22 hospitals including 1157 patients with stage III colon or stage II/III rectal cancer who underwent surgery. Primary outcomes were the use of adjuvant chemotherapy for stage III colon cancer and preoperative radiotherapy for stage II/III rectal cancer. Generalised estimating equations were used to adjust for education, living arrangements, area deprivation, comorbidity and clinical tumour characteristics.ResultsIn colon cancer 92% of patients aged under 65 years, 77% of those aged 65 to 80 years and 27% of those aged over 80 years received adjuvant chemotherapy (χ2trends < 0.001). In rectal cancer preoperative radiotherapy was used in 68% of patients aged under 65 years, 60% of those aged 65 to 80 years, and 42% of those aged over 80 years (χ2trends < 0.001). Adjusting by comorbidity level, tumour characteristics and socioeconomic level, the odds ratio of use of chemotherapy compared with those under age 65, was 0.3 (0.1–0.6) and 0.04 (0.02–0.09) for those aged 65 to 80 and those aged over 80, respectively; similarly, the odds ratio of use of preoperative radiotherapy was 0.9 (0.6–1.4) and 0.5 (0.3–0.8) compared with those under 65 years of age.ConclusionsThe probability of older patients with colorectal cancer receiving adjuvant chemotherapy and preoperative radiotherapy is lower than that of younger patients; many of them are not receiving the treatments recommended by clinical practice guidelines. Differences in comorbidity, tumour characteristics, curative resection, and socioeconomic factors do not explain this lower probability of treatment. Research is needed to identify the role of physical and cognitive functional status, doctors’ attitudes, and preferences of patients and their relatives, in the use of adjuvant therapies.

Role of the status of the mesorectal fascia in the selection of patients with rectal cancer for preoperative radiation therapy: a retrospective cohort study

Patients with rectal cancer in whom the mesorectal fascia is threatened by tumour are more likely than all patients with stage II/III disease to benefit from preoperative radiotherapy (RT). The objective of this study was to assess whether the status of the mesorectal fascia versus a stage II/III designation can best inform the use of preoperative RT in patients undergoing major rectal cancer resection. We reviewed the charts of consecutive patients with primary rectal cancer treated by a single surgeon at McMaster University, Hamilton, Ontario, between March 2006 and December 2012. The status of the mesorectal fascia was assessed by digital rectal examination, pelvic computed tomography and, when needed, pelvic magnetic resonance imaging (MRI). Patients whose mesorectal fascia was threatened or involved by tumour received preoperative RT. The study outcomes were rates of positive circumferential radial margin (CRM) and local tumour recurrence. A total of 153 patients were included, of whom 76 (49.7%) received preoperative RT because of concerns of a compromised mesorectal fascia. The median length of follow-up was 4.5 years. The number of CRM-positive cases in the RT and no-RT groups was 16 (22%) and 1 (1%), respectively (p < 0.01), and the number of cases of local tumour recurrence was 5 (7%) and 2 (3%), respectively (p = 0.2). Rates were similar when only patients with stage II/III tumours were included. Overall, 26 patients (17.0%) received MRI. The status of the mesorectal fascia, not tumour stage, may best identify patients for preoperative RT.

Preoperative radiotherapy for patients with rectal cancer: a risk factor for non-reversal of ileostomy caused by stenosis or stiffness proximal to colorectal anastomosis.

The influence of radiotherapy on permanent stoma and the bowel proximal to anastomosis was not well investigated. The current study aimed to analyze the effect of preoperative radiotherapy on colorectal anastomosis and incidence of non-reversal ileostomy. A total of 184 eligible patients with rectal cancer undergoing loop ileostomy were included. Patients were well selected by excluding some confounding factors and divided into two groups according to whether they received preoperative radiotherapy.Patients with preoperative radiotherapy had higher incidence of non-reversal stoma (12.8%, P = 0.004) and stenosis or stiffness around anastomosis (21.1%, P < 0.01) including 13 patients with stenosis or stiffness proximal to anastomosis. Stenosis proximal to anastomosis was different from anastomotic stricture caused by surgery and could be described by imaging findings. Preoperative radiotherapy prolonged the interval to closure (P = 0.008) and was defined as a significant risk factor for permanent stoma (HR, 0.627; 95% CI, 0.405–0.973; P = 0.04) by multivariate Cox regression analysis. In conclusion, Preoperative radiotherapy increased incidence of non-reversal ileostomy and stenosis or stiffness proximal to anastomosis in rectal cancer patients with radical resection and diverting ileostomy.

Clinical efficacy of of endoscopic assisted open pathway combined with radiotherapy in the treatment of advanced maxillary sinus malignant tumor

Objective:The aim of this study is to analyze the clinical effect of endoscopic assisted open pathway combined with radiotherapy in the treatment of patients with advanced maxillary sinus malignant tumor.Method:A retrospective analysis was performed on the survival of 29 patients with advanced maxillary sinus malignant tumor treated by endoscopic assisted open approach combined with radiotherapy.Result:A total of twenty nine patients with cancer lesions were successfully resected, of which 7 cases underwent preoperative radiotherapy plus surgery plus postoperative radiotherapy, 22 cases were treated by surgery plus radiotherapy after operation. The median follow up time was 60 months (23-129 months). The 3 year and 5 year survival rate of the patients was 72% and 61%, respectively (90% and 80% was in Ⅱ stage respectively. 63% and 51% was in Ⅲ+Ⅳ stage respectively).Conclusion:Endoscopic assisted open pathway combined with radiotherapy is an effective method for the treatment of maxillary sinus carcinoma, and it can still be well treated with preoperative radiotherapy in patients with stage Ⅳ without distant metastasis.

A phase I study on the combination of neoadjuvant radiotherapy plus pazopanib in patients with locally advanced soft tissue sarcoma of the extremities

Accumulating evidence suggests significant synergism combining radiotherapy (RT) with angiogenesis targeted therapies. This multicenter prospective phase I clinical trial established the safety profile and recommended dose for further studies of pazopanib concurrent with preoperative RT in patients with extremity soft tissue sarcomas (ESTS) in curative setting.Methods. Patients with deep seated intermediate and high grade sarcomas, ≥ 5 cm, received once daily pazopanib (dose-escalation cohorts 400 mg, 600 mg and 800 mg) for 6 weeks and 50 Gy preoperative RT starting Day 8. Surgery was performed 5–7 weeks later. Toxicity was scored according to CTC criteria 4.0. Dose limiting toxicities (DLT) were divided into two separate sets; DLT-I being toxicities occurring during the 6-week chemoradiotherapy period within the radiation portals until day of surgery (designated as DLT-I) and those occurring perioperatively until Day 21 after surgery (DLT-II).Results. A total of 12 patients were enrolled, 11 were evaluable (3 females and 8 males, median age 58 years, range 24–78 years, median tumor size 9 cm, range 5–15 cm). Ten underwent surgery. No increased toxicity inside the radiation fields was seen, but two of 10 patients (one each in the 400 mg and 600 mg cohorts) showed delayed wound healing after surgery. None of the patients showed significant volume reductions after RT. Evaluation of the resection specimen showed pathological (near) complete responses (≥ 95% necrosis rate) in four of 10 cases. Unexpectedly, grade 3 + hepatotoxicity led to premature pazopanib interruption in three of 11 (27%) of cases.Conclusion. Apart from hepatotoxicity, neoadjuvant pazopanib 800 mg daily in combination with 50 Gy seems tolerable; the regimen appears to demonstrate promising activity in ESTS and is the recommended dose for further studies.

Multidisciplinary team conferences promote treatment according to guidelines in rectal cancer

Background. Multidisciplinary team (MDT) conferences have been introduced into standard cancer care, though evidence that it benefits the patient is weak. We used the national Swedish Rectal Cancer Register to evaluate predictors for case discussion at a MDT conference and its impact on treatment.Material and methods. Of the 6760 patients diagnosed with rectal cancer in Sweden between 2007 and 2010, 78% were evaluated at a MDT. Factors that influenced whether a patient was discussed at a preoperative MDT conference were evaluated in 4883 patients, and the impact of MDT evaluation on the implementation of preoperative radiotherapy was evaluated in 1043 patients with pT3c-pT4 M0 tumours, and in 1991 patients with pN+ M0 tumours.Results. Hospital volume, i.e. the number of rectal cancer surgical procedures performed per year, was the major predictor for MDT evaluation. Patients treated at hospitals with < 29 procedures per year had an odds ratio (OR) for MDT evaluation of 0.15. Age and tumour stage also influenced the chance of MDT evaluation. MDT evaluation significantly predicted the likelihood of being treated with preoperative radiotherapy in patients with pT3c-pT4 M0 tumours (OR 5.06, 95% CI 3.08–8.34), and pN+ M0 (OR 3.55, 95% CI 2.60–4.85), even when corrected for co-morbidity and age.Conclusion. Patients with rectal cancer treated at high-volume hospitals are more likely to be discussed at a MDT conference, and that is an independent predictor of the use of adjuvant radiotherapy. These results indirectly support the introduction into clinical practice of discussing all rectal cancer patients at MDT conferences, not least those being treated at low-volume hospitals.