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Background and Objectives: Guidelines recommend deferral of elective surgery after COVID-19. Delays in cancer surgeries may affect outcomes. We examined perioperative outcomes of elective cancer surgery in COVID-19 survivors. The primary objective was 30-day all-cause postoperative mortality. The secondary objectives were 30-day morbidity, and its association with COVID-19 severity, and duration between COVID-19 and surgery. Methods: We collected data on age, gender, comorbidities, COVID-19 severity, preoperative investigations, surgery performed, and intra and postoperative outcomes in COVID-19 survivors who underwent elective cancer surgery at a tertiary-referral cancer center. Results: Three hundred and forty-eight COVID-19 survivors presented for elective cancer surgery. Of these, 332/348 (95%) patients had mild COVID-19 and 311 (89%) patients underwent surgery. Among patients with repeat investigations, computerized tomography scan of the thorax showed the maximum new abnormalities (30/157, 19%). The 30-day all-cause mortality was 0.03% (1/311) and 30-day morbidity was 17% (54/311). On multivariable analysis, moderate versus mild COVID-19 (odds ratio [OR]: 1.95;95% confidence interval [CI]: 0.52–7.30;p = 0.32) and surgery within 7 weeks of COVID-19 (OR: 0.61;95% CI: 0.33–1.11;p = 0.10) were not associated with postoperative morbidity. Conclusions: In patients who recover from mild to moderate COVID-19, elective cancer surgery can proceed safely even within 7 weeks. Additional preoperative tests may not be indicated in these patients. © 2022 Wiley Periodicals LLC.
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During first outburst of COVID-19, several strategies had been applied for surgical oncology patients to minimize COVID-19 transmission. COVID-19 infection seemed to compromise survival and major complication rates of surgical oncology patients. However, survival, tumor progression and recurrence rates of surgical oncology patients were associated to the consequences of COVID-19 pandemic on their management. In addition, the severity of COVID-19 infections has been downgraded. Therefore, management of surgical oncology patients should be reconsidered. © 2022 Wiley Periodicals LLC.
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Introduction: Identifying the patients at higher risk for poor outcomes after radiotherapy (RT) during coronavirus disease 19 (COVID-19) era is an unmet clinical need. Methods: The Ovid MEDLINE, Ovid Embase, Clarivate Analytics Web of Science, PubMed and Wiley-Blackwell Cochrane Library databases were searched. Eligible studies were required to address the outcomes of cancer patients who underwent RT during the COVID-19 era. The primary outcome was early mortality, while secondary outcomes included length of hospital stay, hospital admission, intensive care unit (ICU) admission and use of mechanical ventilation. Pooled event rates were calculated, and meta-regression and 'leave-one-out' sensitivity analyses were performed. Results: Twelve eligible studies were included out of 928. The prevalence of early mortality after COVID-19 infection was 21.0%. The prevalence of hospital admission, ICU admission and mechanical ventilation was 78.1, 15.4 and 20.0%, respectively. Meta-regression showed that older age was significantly and positively associated with early mortality (β = 0.0765± 0.0349, p = 0.0284), while breast cancer was negatively associated with early mortality (β=-1.2754±0.6373, p = 0.0454). Conclusions: Older age adversely impacts the early mortality rate in cancer patients during COVID-19 era. The risks of interruption/delay of cancer treatment should be weighed against the risk of increased morbidity and mortality from the infection. A global registry is needed to establish international oncologic guidelines during the COVID-19 era. © 2021 The Author(s).
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Background: Colorectal cancer remains the fourth most common malignancy in Korea, and has been ranked as the third leading cause of cancer deaths in 2020. This study aims to describe the epidemiologic status of colorectal cancer in Korea, and provide basic data for effective primary and secondary prevention methods by summarizing risk factors and screening tools. Current Concepts: Although colorectal cancer incidence and mortality have decreased in recent years in Korea, it still poses a significant public health burden. From the early 1990s until the mid-2000s, the 5-year relative survival of patients with colorectal cancer in Korea continuously increased. This can be attributed to the successful introduction of the government-led screening program;development of improved surgical techniques, anticancer drugs, and adjuvant treatment;and advances medical resources and infrastructure along with economic growth. However, since the late 2000s, the improvement in survival has stagnated. The coronavirus disease 2019 outbreak has reduced hospital visits and screenings, which is assumed to cause delays in diagnosis, leading to a worse prognosis in the patients. To overcome these obstacles, it is essential to explore modifiable environmental risk factors and appropriate screening test methods in Korea. Discussion and Conclusion: Primary prevention through risk factor modification and secondary prevention using suitable screening programs can reduce the incidence and mortality rates of colorectal cancer.
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INTRODUCTION: The COVID-19 pandemic caused interruptions in the delivery of medical care across a wide range of conditions including cancer. Trends in surgical treatment for cancer during the pandemic have not been well described. We sought to characterize associations between the pandemic and access to surgical treatment for breast, colorectal, and lung cancer in Illinois. METHODS: We performed a retrospective cohort study evaluating inpatient admissions at Illinois hospitals providing surgical care for lung cancer (n = 1913 cases, n = 64 hospitals), breast cancer (n = 910 cases, n = 108 hospitals), and colorectal cancer (n = 5339 cases, n = 144 hospitals). Using discharge data from the Illinois Health and Hospital Association's Comparative Health Care and Hospital Data Reporting Services database, average monthly surgical case volumes were compared from 2019 to 2020. We also compared rates of cancer surgery for each cancer type, by patient characteristics, and hospital type across the three time periods using Pearson chi-squared and ANOVA testing as appropriate. Three discrete time periods were considered: prepandemic (7-12/2019), primary pandemic (4-6/2020), and pandemic recovery (7-12/2020). Hospital characteristics evaluated included hospital type (academic, community, safety net), COVID-19 burden, and baseline cancer surgery volume. RESULTS: There were 2096 fewer operations performed for breast, colorectal, and lung cancer in 2020 than 2019 in Illinois, with the greatest reductions in cancer surgery volume occurring at the onset of the pandemic in April (colorectal, -48.3%; lung, -13.1%) and May (breast, -45.2%) of 2020. During the pandemic, breast (-14.6%) and colorectal (-13.8%) cancer surgery experienced reductions in volume whereas lung cancer operations were more common (+26.4%) compared to 2019. There were no significant differences noted in gender, race, ethnicity, or insurance status among patients receiving oncologic surgery during the primary pandemic or pandemic recovery periods. Academic hospitals, hospitals with larger numbers of COVID-19 admissions, and those with greater baseline cancer surgery volumes were associated with the greatest reduction in cancer surgery during the primary pandemic period (all cancer types, P < 0.01). During the recovery period, hospitals with greater baseline breast and lung cancer surgery volumes remained at reduced surgery volumes compared to their counterparts (P < 0.01). CONCLUSIONS: The COVID-19 pandemic was associated with significant reductions in breast and colorectal cancer operations in Illinois, while lung cancer operations remained relatively consistent. Overall, there was a net reduction in cancer surgery that was not made up during the recovery period. Academic hospitals, those caring for more COVID-19 patients, and those with greater baseline surgery volumes were most vulnerable to reduced surgery rates during peaks of the pandemic and to delays in addressing the backlog of cases.
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Background: Clinical staging of non-small cell lung cancer (NSCLC) by CT and PET, with or without endobronchial ultrasound-guided transbronchial needle aspiration of lymph nodes (EBUS-TBNA), is essential for prognostication and to direct treatment. Our study investigated the accuracy of clinical staging compared to definitive pathological staging. Method(s): Retrospective audit of clinical and pathological staging of all surgical lung cancer cases 2016-present (484 cases). Result(s): Discordance of clinical and pathological TNM staging (excluding sub-staging) was identified in 93 (25.9%) cases where complete data was available. This included clinical understaging in 61 (17%) and N2 disease in 20 (5.6%) cases. EBUS-TBNA was performed in 14 of the cases with N2 disease, and in five of these cases, involvement of N2 nodes detected post-surgery had been called benign at EBUS-TBNA. Factors contributing to clinical understaging may include delays between clinical staging studies and surgery [CT: median 110 days (IQR 82.5-151), PET: 81 days (59-119), EBUS-TBNA 62 days (43-95)], with significantly longer delays evident during the COVID-19 pandemic. Conclusion(s): Improved technical quality of lung cancer clinical staging studies and hospital management workflows will potentially increase concordance between clinical and pathological staging of operable NSCLC, improving outcomes for early stage disease. My contribution to this work has focused on the 2022 cases, analysis of which has elucidated the impact of COVID-19 on the lung cancer staging process in comparison to pre-COVID results. Copyright © 2021
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The proceedings contain 112 papers. The topics discussed include: pediatric sedation for magnetic resonance imaging. the use of intranasal dexmedetomidine to enable a nurse-led, no intravenous access pediatric sedation for radiological procedures at a district general hospital;outcomes in octogenarians undergoing head and neck cancer surgery in a tertiary referral center;the environmental sustainability of propofol use and wastage in total intravenous anesthesia practice;are our patients opioid aware? an audit of take-home analgesia at Charing Cross Hospital, London;evaluating the clinical use of nitrous oxide in our pediatric theatre;implementing a dedicated COVID-19 post intensive care unit follow-up clinic to improve the follow-up of patients in a district general hospital;move to NRfit: the impact of the introduction of new epidural needles on post-dural puncture headache rate;and creating an emergency induction checklist for doctors providing last-minute cover across multiple hospital sites.
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This study was designed to examine the modifications and accommodations African-American and White prostate cancer survivors experience at their workplaces during and following radiation therapy or a prostatectomy. Approximately 1 in 8 men will be diagnosed with prostate cancer. Although the average age at time of prostate cancer diagnosis is 66, the substantial number of younger men diagnosed results in large number of men facing treatment during their working years. African-American men are disproportionately affected by prostate cancer;understanding their experiences is therefore particularly vital. Forty-five prostate cancer survivors who had undergone radiation therapy or a prostatectomy within the past 6-36 months, had worked within one month prior to treatment initiation, and had expected to be working six months in six months participated in semi-structured, in-depth interviews about their experiences at work prior to, during, and after treatment. The audio-recorded interviews were transcribed and systematically analyzed. Twenty of the participants were African-American men and 25 were White men, and their mean age was 61. Most men were able to receive accommodations to address their needs in addition to time off for treatment and recovery if needed. These accommodations included temporarily changing their jobs duties so that they could focus on tasks that eliminated or reduced the most physically demanding aspects of their jobs such lifting heavy objects, performing tasks that could be conducted while seated, and reducing work-related travel. Working from home, reducing their work hours, and taking breaks during the work day also benefited some survivors. Although rare, a man who experienced difficulty meeting the physical demands of his job lacked accommodations and was afraid to request any due to his concern that he would lose his job. Men who lacked access to conveniently placed bathrooms used creative strategies. The move to have employees working at home and eliminating or reducing work-related travel due to the COVID-19 enabled some workers to forgo some accommodations they would have otherwise required. Variation in experience by race will be addressed. The needs of and workplace accommodations provided to prostate cancer survivors undergoing and recovering from prostate cancer treatment vary widely. Increased attention to their needs and strategies to address them could enable prostate cancer survivors to be better prepared for work-related challenges.
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EGID is a recently described condition with an unknown etiology and pathogenesis. There are three case reports of duodenal stricture associated with EGID: one in an adult requiring pancreaticoduodenectomy due to the suspicion of malignancy and 2 cases in a child and a young adult, who responded to oral steroids. We report the case of a 10-year-old who presented to A&E with a 9-month history of epigastric abdominal pain and 1 episode of haematemesis, on a background of asthma. He was treated for Helicobacter pylori, based on a positive stool antigen. Abdominal pain and vomiting persisted, therefore an oesophago-gastro-duodenoscopy (OGD) was performed. This identified widespread white plaques throughout the oesophagus, erythema and nodularity of the gastric antrum and white nodules in the first part of the duodenum. Histology revealed changes of EGID and eosinophilic oesophagitis (EOE) and patient was commenced on Montelukast, oral viscous Budesonide (OVB), Cetirizine and continued proton pump inhibitor (PPI). After the allergy workup identified house dust mites, cat sensitisation and fish allergy, a 6-food elimination diet was initiated. During the next 2 years, symptoms subsided, and endoscopy changes improved, with only mild signs of active EOE while on OVB, PPI and diary/egg/fish free diet. However, the patient relapsed due to poor compliance to treatment. He became more unwell during the Covid pandemic with recurrent vomiting and static weight. A trial of dupilumab was considered, however his reassessment OGD had to be delayed due to restricted access to theatre. He was treated empirically with a reducing course of oral prednisolone, with temporary response. The endoscopic assessment performed subsequently showed erythema, erosions and white plaques in the distal oesophagus and gastric antrum with narrowing between the first and the second part of the duodenum (D2), that could not be entered. Histology identified mild upper oesophagitis (4 eosinophils (eos)/HPF), active middle and lower oesophagitis (20 eos/HPF and 12 eos/HPF, respectively), chronic gastritis (80 eos/HPF) and nonspecific reactive changes of the proximal duodenum. A barium meal confirmed a duodenal stricture. At this stage, we recommended a sloppy diet and a second weaning course of oral prednisolone, along with Montelukast. He was subsequently commenced on azathioprine for maintenance of remission. A repeat barium study and small bowel MRI performed post course of steroids and on azathioprine revealed stable appearances of the proximal duodenal stricture, excluding the presence of further strictures. While the patient has responded to the course of oral steroids and azathioprine, a repeat upper GI endoscopy is currently planned to dilate the duodenal stricture. The challenges posed by this case were the rarity of the condition, limited treatment options and access to endoscopy during the Covid pandemic and the fact that unlike previous case reports a sustained remission could not be obtained on steroids, and a maintenance immunosuppressive medication was required. We can conclude that this subgroup of patients should be monitored closely for signs of bowel obstruction and will require more intense treatment, including immunomodulators, endoscopic dilatation and or surgery.
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Background: Poor prognosis of lung cancer is linked to its late diagnosis, typically in the advanced stage 4 in 50-70% of incidental cases. Lung Cancer Screening Programs provide low-dose lung CT screening to current and former smokers who are at high risk for developing this disease. Greece is an EU country, returning strong from a long period of economic recession, ranked 2nd place in overall age-standardized tobacco smoking prevalence in the EU. In December 2020, at the Metropolitan Hospital of Athens, we started the 1st Screening Program in the country. We present our initial results and pitfalls met. Method(s): A weekly outpatient clinic offers consultation to possible candidates. LDCT (<=3.0mGy), Siemens VIA, Artificial Intelligence multi-computer-aided diagnosis (multi-CAD) system and LungRADS (v.1.1) are used for the validation of any abnormal findings with semi-auto measurement of volume and volume doubling time. Patients get connected when necessary with the smoking cessation and Pulmonology clinic. USPSTF guidelines are used, (plus updated version). Abnormal CT findings are discussed by an MDT board with radiologists, pulmonologists/interventional pulmonologists, oncologists and thoracic surgeons. A collaboration with Fairlife Lung Cancer Care the first non-profit organization in Greece is done, in order to offer the program to population with low income too. An advertisement campaign was organized to inform family doctors and the people about screening programs, together with an anti-tobacco campaign. Result(s): 106 people were screened, 74 males & 32 females (mean age 62yo), 27/106 had an abnormal finding (25%). 2 were diagnosed with a resectable lung cancer tumor (primary adenocarcinoma) of early-stage (1.8%). 2 with extended SCLC (lung lesion & mediastinal adenopathy). 1 with multiple nodules (pancreatic cancer not known until then). 3 patients with mediastinal and hilar lymphadenopathy (2 diagnosed with lymphoma, 1 with sarcoidosis). 19 patients were diagnosed with pulmonary nodules (RADS 2-3, 17%) - CT follow up algorithm. Conclusion(s): We are presenting our initial results, from the first lung cancer screening program in Greece. Greece represents a country many smokers, who also started smoking at a young age, with a both public and private health sector, returning from a long period of economic recession. COVID-19 pandemia has cause practical difficulties along the way. LDCT with AI software, with an MDT board and availability of modern diagnostic and therapeutic alternatives should be considered as essential. A collaboration spirit with other hospitals around the country is being built, in order to share current experience and expertise. Copyright © 2022
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BACKGROUND: Colorectal cancer is the third most diagnosed cancer globally and the second leading cause of cancer death. We examined colon and rectal cancer treatment patterns in Australia. METHODS: From cancer registry records, we identified 1,236 and 542 people with incident colon and rectal cancer, respectively, diagnosed during 2006-2013 in the 45 and Up Study cohort (267,357 participants). Cancer treatment and deaths were determined via linkage to routinely collected data, including hospital and medical services records. For colon cancer, we examined treatment categories of "surgery only", "surgery plus chemotherapy", "other treatment" (i.e. other combinations of surgery/chemotherapy/radiotherapy), "no record of cancer-related treatment, died"; and, for rectal cancer, "surgery only", "surgery plus chemotherapy and/or radiotherapy", "other treatment", and "no record of cancer-related treatment, died". We analysed survival, time to first treatment, and characteristics associated with treatment receipt using competing risks regression. RESULTS: 86.4% and 86.5% of people with colon and rectal cancer, respectively, had a record of receiving any treatment ≤2 years post-diagnosis. Of those treated, 93.2% and 90.8% started treatment ≤2 months post-diagnosis, respectively. Characteristics significantly associated with treatment receipt were similar for colon and rectal cancer, with strongest associations for spread of disease and age at diagnosis (p<0.003). For colon cancer, the rate of "no record of cancer-related treatment, died" was higher for people with distant spread of disease (versus localised, subdistribution hazard ratio (SHR)=13.6, 95% confidence interval (CI):5.5-33.9), age ≥75 years (versus age 45-74, SHR=3.6, 95%CI:1.8-7.1), and visiting an emergency department ≤1 month pre-diagnosis (SHR=2.9, 95%CI:1.6-5.2). For rectal cancer, the rate of "surgery plus chemotherapy and/or radiotherapy" was higher for people with regional spread of disease (versus localised, SHR=5.2, 95%CI:3.6-7.7) and lower for people with poorer physical functioning (SHR=0.5, 95%CI:0.3-0.8) or no private health insurance (SHR=0.7, 95%CI:0.5-0.9). CONCLUSION: Before the COVID-19 pandemic, most people with colon or rectal cancer received treatment ≤2 months post-diagnosis, however, treatment patterns varied by spread of disease and age. This work can be used to inform future healthcare requirements, to estimate the impact of cancer control interventions to improve prevention and early diagnosis, and serve as a benchmark to assess treatment delays/disruptions during the pandemic. Future work should examine associations with clinical factors (e.g. performance status at diagnosis) and interdependencies between characteristics such as age, comorbidities, and emergency department visits.
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COVID-19 , Colonic Neoplasms , Rectal Neoplasms , Humans , Aged , Middle Aged , Australia/epidemiology , Pandemics , Rectal Neoplasms/epidemiology , Rectal Neoplasms/therapy , Life StyleABSTRACT
Category: Outcomes of treatment (including chemotherapy, chemo-RT and RT) Purpose: Stereotactic ablative body radiotherapy (SABR) and lung resection are both effective treatments for early lung cancer. The UK National Lung Cancer Audit has shown low mortality after thoracic surgery but a high 90-day all-cause hospital readmission rate of 41%. The aim of this study was to evaluate hospital admissions after SABR for primary lung cancer. Methods and materials: Hospital records of patients treated with SABR for primary lung cancer between October 2012 and October 2021 at Royal Free Hospital were retrospectively reviewed. Result(s): 152 patients were identified. The median age was 78 years (range 40-95). Biopsy confirmation rate was 78%. Most patients had T1 tumours (87%). Treatment was with 5# (65%), 3# (19%) and 8# (16%). Ultracentral lesions were not treated. Multiple lesions were treated in ten patients. The median follow-up was 21 months. Oncological outcomes were excellent with a 95% local control rate, 11% distant recurrence, one-year overall survival 92% and two-year overall survival 80%. There was one death within 30 days of treatment due to decompensated cirrhosis in a patient with chronic liver disease. 15 patients (10%) were admitted to hospital within 90 days of SABR treatment. Causes of hospital admission were: * Chest sepsis - 6 (including 1 COVID) * Heart failure - 2 (known cardiac disease) * Decompensated cirrhosis - 1 * Line infection - 1 * Oesophageal reflux - 1 * Miscellaneous surgical - 4 Conclusion(s): SABR is a highly effective and well-tolerated treatment for early lung cancer. The 90-day all-cause hospital admission rate in this cohort was 10%. These hospital admissions were not a direct consequence of SABR, and the majority were due to respiratory and cardiac co-morbidity. This highlights the need for smoking cessation and medical optimisation of co-morbidities in this patient group. Copyright © 2022
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Category: Outcomes of treatment (including chemotherapy, chemo-RT and RT) Purpose: Hypofractionated (5#) radiotherapy for non-metastatic pancreatic cancer was introduced during the COVID-19 pandemic as an alternative to conventional treatment pathways. This study was performed to evaluate clinical outcomes and acute toxicity of 5# radiotherapy. Methods and materials: We retrospectively identified pancreatic cancer patients treated with 5# radiotherapy at Addenbrookes Hospital from March 2020 to September 2021. Patient characteristics, response on follow-up computed tomography (CT) scans, dosimetry and toxicity data were analysed using Excel and SPSS. Result(s): 40 patients were treated with 5# radiotherapy, 60% (n=24) had locally advanced pancreatic cancer, 30% (n=12) operable disease, 7.5% (n=3) postoperative recurrences and 2.5% (n=1) borderline resectable disease. 45% of patients (n=19) had induction chemotherapy. Radiotherapy was delivered as 35 Gy (67.5%, n= 27) and 30 Gy (32.5%, n=13) in 5# in 1.5 weeks using volumetric-modulated arc therapy (VMAT) technique. Median overall survival (mOS) for all patients was 14.2 months (95% CI 10.3-15.6 months). For induction chemotherapy + radiotherapy versus radiotherapy alone, mOS was 14.2 months (95% CI 8.2-17.7 months) versus 13.9 months (95% CI 10.3-15.7 months), p=0.97. Median progression-free survival (mPFS) for all patients was 10.2 months (95% CI 8.0-11.9 months). For induction chemotherapy + radiotherapy versus radiotherapy alone, mPFS was 10.5 months (95% CI 9.5-12.4 months) versus 10.1 months (95% CI 5.5-10.4 months), p=0.99. There were no grade 3 acute toxicities. When compared to 28# radiotherapy, the 5# regimen reduced patient hospital visits by 82%. Conclusion(s): The observed mOS is comparable with mOS of conventional 28# radiotherapy (14.2 versus 15.2 months (SCALOP trial)), 5# radiotherapy for non-metastatic pancreatic cancer is a safe alternative treatment pathway. Copyright © 2022
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Background: It is important we identify cases of premalignant polyps and stratify patients according to future colorectal cancer (CRC) risk to prevent CRC development. In 2020, the British Society of Gastroenterology (BSG) published guidelines to tailor post-polypectomy and post-CRC resection surveillance. The objective of our audit was to determine whether our department was adhering to these guidelines. Method(s): We performed a retrospective audit of patients who had a colonoscopy at a DGH from February to June 2021. We reviewed case notes for indication, findings, and compliance to BSG's guidelines. Result(s): A total of 578 cases were reviewed. The median age was 61 years old. Most of the referrals were via the 2-week-wait pathway. 285 had normal findings on colonoscopy, 28 had CRC, 22 had polyps meeting high risk findings, and 12 had large non-pedunculated colorectal polyps. Our unit was 93.6% (547/578) compliant with the guidelines. 6.4% (31/578) were not compliant. Of those, 18 were scheduled for a surveillance colonoscopy when the polyps did not meet the criteria, 6 colonoscopies were not booked within the appropriate timeframe, 2 did not have their 6-month site check, and 1 had a surveillance colonoscopy despite a normal index colonoscopy. Conclusion(s): Our unit is highly compliant with BSG's guidelines. COVID-19 may have influenced the timing of colonoscopies, which could have impacted our compliance. Furthermore, there is little data on how our DGH compares to national data. We have placed the updated guidelines throughout the department to enhance awareness across the wider team. Copyright © 2022
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Purpose: Locally advanced cervical cancer was defined by an international consensus panel as a high priority malignancy during the COVID-19 pandemic, recommending prompt initiation of definitive treatment and completion of treatment (PMID 32563593). The objective of this study was to study the clinical outcomes of patients (pts) with cervical cancer treated with definitive chemoradiation (CRT) and brachytherapy (BT) at our institution in 2019 (pre-COVID) and in 2020 (peri-COVID). Material(s) and Method(s): This was a retrospective cohort study of pts with FIGO Stage IB2-IVA cervical cancer at our institutions from 1/1/2019 to 12/31/2020. Pts received CRT followed by intracavitary brachytherapy (IC) with two operative insertions one week apart, or interstitial (IS) BT with one operative insertion. BT treatment was planned using image-guided CT or MR delineation. Pre-COVID was defined by initiation of CRT in 1/2019-12/2019, and peri-COVID was defined by initiation in 1/2020-10/2020. Process changes peri-COVID included limited on-site staff (e.g., minimal OR staff, no trainees, remote physics team), universal implementation of COVID-19 testing prior to surgery, and CT instead of MR-delineation based treatment. Outcomes of interest were time to treatment initiation and completion and differences in treatment planning modality or dosimetry. Fisher's exact and Mann Whitney U tests were used with significance p<0.05. Result(s): Thirty-one pts were included, with 18 patients undergoing treatment pre-COVID and 13 peri-COVID. The median age at diagnosis pre-COVID was 57.7 (range 23-77) and for peri-COVID, 45.5 (range 28-62, p=0.06). There were no differences in non-English speaking pts (44% vs 59%, p=0.71) or uninsured pts (11% vs 33%, p=0.184) between the two cohorts. Median time to initiation of treatment from biopsy diagnosis was 52 days (range 13-209) in 2019 and for peri-COVID, 55.5 (range 20-173, p=0.71). During COVID, four pts had delayed initiation to treatment >100 days: two related to fertility, and one due to fear of COVID-19. For this pt, tumor size progressed from 2.3 cm to 4.2 cm maximal dimension. One pt treated in 2020 tested positive following treatment and did not require hospital admission. All pts except one completed CRT with RT: 25 pts pelvic RT (45 Gy), 3 pelvic and para-aortic RT (45 Gy with 57.5 Gy concomitant boost to nodes), 8 pts pelvic RT (45Gy) with sequential parametrial boost (50.4-59.4 Gy) using IMRT with no dose differences between pre and peri-COVID (Table 1). No pts required treatment breaks and the median overall treatment time was 50 days (range 31-85) in 2019 vs 50 days (range 43-63) in 2020 (p=0.710). Conclusion(s): Despite the significant burden of the COVID-19 pandemic on our health care system, all cervical cancer pts receiving CRT met standard of care including CRT and BT within the recommended time frame with no significant differences in dosimetric treatment parameters pre- and peri-COVID. Delays in treatment initiation of treatment initiation were seen in 30% of pts in the peri-COVID period, suggesting that patients may have had increased barriers to access care. More follow-up is needed to determine how the Covid pandemic impacted cervical cancer outcome measures. Copyright © 2022
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Purpose: Brachytherapy remains a critical component of locoregional therapy for many women with gynecologic cancers. Other groups have demonstrated racial disparities in the utilization of brachytherapy. Specifically, black women with locally advanced cervical cancer are less likely to receive brachytherapy compared to non-black women. We hypothesized that similar disparities may exist for the utilization of vaginal brachytherapy (VBT) for women who meet PORTEC-2 criteria for high-intermediate risk (HIR) endometrial cancer. Material(s) and Method(s): Using the Surveillance, Epidemiology, and End Results (SEER) database, we identified patients who were diagnosed with endometrial cancer between 2011 to 2018, who met PORTEC-2 criteria for HIR disease (age 60 or greater with 1) FIGO stage IC (1988) and grade 1-2 disease or 2) FIGO stage IB (1988) and grade 3 disease). We limited our analysis to the year following the initial PORTEC-2 publication (2010) and beyond in order to allow for adoption into routine clinical practice. The impact of race and ethnicity on utilization of VBT versus external beam radiation therapy (EBRT) was analyzed on univariate and multivariate analyses (binary logistic regression, with significance assumed if p<=0.05), as was the impact of marital status, United States (U.S.) Census Bureau region, and whether or not a lymph node dissection was performed. Result(s): A total of 2,182 patients were included in the analysis with a median age of 68 (range 60-97). The majority of patients were White (77.3%), married (50.8%), resided in the Western U.S. (45.1%), diagnosed with adenocarcinoma (97.2%), underwent lymph node dissection (84.7%), and received VBT (75.5%). On UVA, patients who were Hispanic (HR 1.58, CI 95% 1.15-2.16, p=0.005) and Asian or Pacific Islanders (HR 1.47, CI 95% 1.01-2.15, p=0.046) were less likely to receive VBT compared to White patients. There was a non-significant trend for Black patients (HR 1.43, 95% CI 0.98-2.08, p=0.066). Patients in the Southern (HR 1.69, CI 95% 1.24-2.31, p=0.001), Western (HR 1.7, CI 95% 1.31-2.20, p<0.001), and Pacific (HR 2.89, CI 95% 1.09-7.64, p=0.032) U.S. Census regions were less likely to receive VBT compared to the Northeast. Those who were divorced were more likely to receive VBT (HR 0.65, 95% CI 0.43-0.98, p=0.038). Finally, those patients who underwent lymph node dissection were more likely to receive VBT on UVA (HR 0.28, CI 95% 0.22-0.36, p<0.001). On MVA, patients who were Hispanic (HR 1.43, CI 95% 1.01-2.03, p=0.046), lived in the Southern (HR 1.82, CI 95% 1.30-2.55, p=0.001), Western (HR 1.61, CI 95% 1.21-2.14, p=0.001), or Pacific regions (HR 3.04, CI 95% 1.05-8.78, p=0.04) were less likely to receive VBT. Although it did not meet statistical significance, there was a trend for decreased utilization of VBT for Asian or Pacific Islanders (HR 1.45, CI 95% 0.94-2.25, p=0.094) and Black patients (HR 1.42, CI 95% 0.94-2.15, p=0.099), potentially a reflection of small patient numbers. Lastly, patients who underwent lymph node dissection were more likely to receive VBT on MVA (HR 0.27, CI 95% 0.21-0.35, p<0.001). Conclusion(s): Brachytherapy remains a critical component of locoregional therapy for many women with endometrial cancer. VBT provides a significant improvement in local control in the pelvis with an improved toxicity profile compared to EBRT. Efforts should be made to make VBT available to those women in which it is clinically indicated, with apparent disparities based on the patient's race, ethnicity, and/or their geographic location within the U.S. in the setting of HIR disease. These disparities may have been further exacerbated during the ongoing COVID-19 pandemic, which has been shown in other settings to widen many pre-existing healthcare disparities. Copyright © 2022
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Aim/Introduction: Since its introduction in March 2020, the COVID-19 epidemic restrictions altered cancer care including melanoma. Shortly thereafter, we adjusted the clinical management of melanoma patients according to epidemicspecific recommendations provided by the multidisciplinary team for melanoma from the National Referral Melanoma Centre (NRMC), designed according to the National Comprehensive Cancer Network (NCCN). Our study aims to determine whether histopathologic features and sentinel lymph node biopsy (SLNB) in melanoma patients have been changed a year after the introduction of COVID-19 epidemic guidelines. Material(s) and Method(s): We retrospectively reviewed data of melanoma patients of stages IA to IIC (AJCC Staging System 8thedition) who underwent SLNB at our NRMC. We compared melanoma patients who had undergone SLNB during the 6-month (March-Aug) pre-COVID-19 period in 2019 with patients operated on during the corresponding period in the COVID-19 era in 2021. Selected patients underwent FDG PETCT before SLNB. After peritumoral injection of 99mTc-nanocolloid, dynamic and static planar imaging and in certain cases followed by SPECT/CT was performed. Result(s): Seventy-eight melanoma patients had undergone SLNB during the specified period in 2021 (Covid-19 group), and 61 patients during the same period in 2019 (pre-COVID-19 group). Among COVID-19 group, the most frequent melanoma location was trunk (57.7% vs. 44.3%), followed by arms (15.4% vs. 14.8%), legs (15.4% vs. 18.0%) and head and neck (11.5% vs. 23%), although the groups did not differ significantly (p=0.256). The pre-COVID-19 and COVID-19 group did not differ with regard to mean age (59.00 vs. 60.68 years, p = 0.525), gender (47.5% vs. 51.3% men, p=0.733), mean tumor thickness (2.63 vs.2.69 mm, p = 0.903), mean mitotic count (5.53 vs. 4.63/mm2 = 0.368) or presence of ulceration (31% vs. 32%, p=1.00). The mean time from primary melanoma excision to SLNB performance was slightly longer in COVID-19 group (54.67 vs.49.98 days, p=0.303). Patients in COVID-19 group more frequently underwent PET-CT before SLNB (17.9 % vs. 14.8%, p=0.653) and less frequently performed SPECT-CT (21.8% vs.29.5%, p=0.329), however without significant difference. The number of patients having tumor-positive SLNs (17.1% vs. 25.4%, p=0.287) and those with residual melanoma (5.1% vs. 4.9%, p=1.000) did not differ between the COVID-19 and pre-COVID-19 group, respectively. Conclusion(s): Besides slight differences in location of primary melanoma, interval to SLNB performance, and SPECT-CT use, we demonstrated that SLNB management and histopathologic features in our melanoma patients followed the pre-pandemic period a year after starting COVID-19 epidemic restrictions.
ABSTRACT
Aim/Introduction: Sentinel lymph node (SLN) biopsy is widely accepted for lymph node staging in breast cancer, intermediaterisk melanoma and low-grade cervical cancer. The reproducibility of lymphatic drainage is a fundamental premise behind this procedure, but it has not been sufficiently studied yet. The aim is to evaluate the reproducibility of the lymphoscintigraphy for SLN detection in breast cancer, melanoma and cervical cancer using SPECT/CT images. Material(s) and Method(s): Retrospective study from February/2009 to October/2021 that included 64 consecutive patients (36-81 y.o., 62+/-11 years, 60 female) who underwent SLN study on two consecutive occasions due to suspension of the surgical procedure for different reasons (insufficient fasting, respiratory infection, hypertension, coordination problems, COVID-19). Fifty-six had breast cancer, 6 had melanoma and 2 cervical cancer. The interval between the two studies was 1-112 days. Patients with previous breast surgery or excisional biopsy were excluded. The radiopharmaceutical used was 99mTc-nanocolloid by subdermal periareolar injection in breast cancer, in 4 points surrounding the surgical scar in melanoma and in 4 points in the cervix in cervical cancer. Planar images followed by SPECT/CT of the region were acquired. Result(s): In the 56 patients with breast cancer, 115 SLNs were detected in the first procedure (85 level I, 20 level II and level III and 2 in the internal mammary chain) and 120 SLNs in the second procedure (87 level I, 24 level II, 8 level III and 1 internal mammary chain). One patient did not show SLN uptake in the first study and 2 level I SLNs were observed in the second. Ninety-eight percent concordance was observed in the topography of the SLNs of the level I. In the 6 patients with melanoma (2 of the upper limbs, 2 of the lower limbs, one from the back and one from the head) 21 SLNs were detected. The topography of the SLN was concordant in all cases. In the 2 patients with cervical cancer, 6 nodes were detected (4 bilateral external iliac and 2 obturator nodes). One patient had bilateral SLNs in the first study and unilateral in the second. Conclusion(s): The technique showed high reproducibility in breast cancer and melanoma. Concordance was maintained even in patients who showed several SLNs, suggesting that the main determining factor is the individual variability of the lymphatic drainage, beyond possible differences in the technical conditions of the procedure. More data are needed for cervical cancer.
ABSTRACT
Aim/Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) is a difficult entity to diagnose due to its association with other etiologies causing pulmonary hypertension (PHT), mainly cardiological disease. Our aim is to analyse the value of pulmonary perfusion SPECT/CT in the presence of suspected CTEPH and to evaluate its impact on the diagnosis and subsequent therapeutic approach. Material(s) and Method(s): Retrospective series of 108 patients with suspected CTEPH who were performed a lung perfusion SPECT/CT in the presence of perfusion defects on planar images between March 2020-April 2022. Variables such as age, sex, scintigraphic result, other radiological findings, correlation with catheterisation and CT angiography, type of PHT (according to Dana Point Consensus Classification of Pulmonary Hypertension, California 2008) and therapy of choice after scintigraphy were analysed. Result(s): Mean age: 69 +/- 12 years (25-90). 54% women. In 55 patients(51%) CTEPH was ruled out by SPECT/CT(-), although other radiological findings were observed (13% chronic parenchymal pathology/post-COVID-19 infection, 7% cardiomegaly, 5% pleural effusion, 4% infiltrates consistent with COVID-19 infection,2% pulmonary nodule suspicious of malignancy). 6 of the 18 patients with catheterisation(33%) had a pulmonary capillary pressure(PCP) suspicious for CTEPH(<=15mmHg), which was ruled out after negative scintigraphy. In the 53(49%) confirmed CTEPH by SPECT/ CT(+), 28 with other radiological findings(36% chronic pulmonary pathology/post-COVID-19,11% pulmonary nodule suspicious of malignancy,11% infiltrates consistent with COVID-19 infection). 10 of 15 patients(67%) with CT angiography(-). 55% of the patients with catheterisation(11/20) presented with a PCP not suspicious of CTEPH(>=15mmHg), and were finally diagnosed with CTEPH after positive SPECT. In patients without CTEPH after SPECT(-), PHT was classified into the following types:37 with PHT type-II/left heart disease(6 candidates for valve replacement),9 type-III/pulmonary disease and/or hypoxaemia, 5 mixed type-II+III, 2 type-I (1 portal hypertension in cirrhotic patient and 1 scleroderma), 2 type-V (1 obstruction of tumour origin and 1 chronic renal failure). of the patients who were confirmed to have CTEPH, 19(36%) had purely embolic PHT(type-IV), with 5 being candidates for endacterectomy/ angioplasty, and the remaining 34(64%) had mixed PHT(24 type-II+IV, 5 type-III+IV, 5 type-II+III+IV), with 35% being candidates for surgery. Conclusion(s): Lung perfusion SPECT/CT imaging is a very useful test for the classification of pulmonary hypertension leading to better therapeutic management of these patients. The greatest efficiency is seen with a negative result as the embolic origin is excluded with excellent reliability, thus avoiding more aggressive and/or difficult-to-manage therapies. In addition, low-dose CT provides additional information of great clinical relevance.
ABSTRACT
Aim/Introduction: Immune checkpoint inhibitors (ICI), like targeting programmed death receptor ligand 1 (PD-L1), have revolutionized anti-cancer treatments, including non-small cell lung cancer (NSCLC) [1, 2]. Assessment of PD-L1 expression on tumor biopsies is current practice, but there is a need for additional biomarkers correlating to the complex mechanism of action of ICI. The presence of tumorinfiltrating CD8+ T-cells (TILs) is a robust biomarker associated with immune therapy success [3]. Tools to track TILs in patients during ICI treatment allow further development of immune-oncology drugs. Material(s) and Method(s): This ongoing single-center prospective study (NCT03853187) includes patients with histologically proven T1b-3N0-1M0 NSCLC eligible for resection. Exclusion criteria are previous anti-cancer therapy and known immune disorders or suppression. Patients receive two courses neo-adjuvant durvalumab (750mg Q2W), after which TIL imaging is performed. Cohort 1 underwent apheresis and magnetic-activated cells sorting to isolate 100 x10e6 autologous CD8+ T-cells for cell labeling with 111In-oxine. Re-injection was followed by 4h post-injection (p.i.) planar imaging, 70h p.i. SPECT imaging, standard-of-care surgery and 78h p.i. uSPECT of the resected lobe. Patients in cohort 2 (ongoing) receive 1.5mg 89Zr-Df-crefmirlimab followed by PET/CT 24h p.i. Result(s): In cohort 1, 8/10 patients underwent apheresis and TIL imaging;one procedure was withdrawn due to COVID-19 restrictions and one due to unsuccessful T-cell isolation. Yield ranged 240-714 x10e6 CD8+ T-cells, purity 84%-97% and cell viability 92%-100%. Labeling efficacy of 100 x10e6 cells for re-injection ranged 42%-64% and injected activity 22,4-36,7 MBq In-111.TIL imaging was completed by 4/5 patients in cohort 2, one subject discontinued neo-adjuvant treatment due to post-obstruction pneumonia.Tumor-to-bloodpool were determined to quantify specific TIL accumulation in the tumor. Our results favor quantification of T-cells on PET over SPECT given its higher sensitivity and spatial resolution. Correlation of imaging findings with density of CD8+ T-cells in the resected tumor is currently ongoing. Conclusion(s): We implemented two methods for tracking CD8+ T-cells in earlystage NSCLC patients after neo-adjuvant durvalumab treatment. Although ex vivo cell labeling perhaps more specifically targets migrating TILs into the tumor, 89Zr-Df-crefmirlimab has the potential to also target residing cells. Quantitative correlation with presence of TILs in the resected tumor will help to determine the role of these imaging tools in the development of immune-oncology drugs.