Involved-Field Radiation Therapy for Patients With Unresectable Pancreatic Adenocarcinomas: Failure Pattern Analysis.

Introduction Unresectable pancreatic tumors are frequently diagnosed. Initial treatment is carried out with chemotherapy. Eventually, in selected cases, radiotherapy may be used to improve local control rates and relieve the symptoms. The volume of radiotherapy treatment fields is the subject of controversy in the literature. The use of involved fields with the gross tumor volume encompassing the primary tumor and lymph nodes considered clinically positive is associated with a lower rate of side effects, but can lead to a higher rate of regional loco failures, especially in regional lymph nodes. The purpose of this article is to analyze the failure pattern of chemotherapy and involved-field radiation therapy (IFRT) for treating patients with unresectable pancreatic adenocarcinomas. Methods Clinical records of thirty consecutive patients treated from March 2016 to June 2020 for unresectable pancreatic adenocarcinoma were analyzed. The patients were treated with initial systemic chemotherapy (median: 6 cycles) with regimens based on gemcitabine or oxaliplatin-irinotecan (folfirinox/folfox) followed by radiotherapy (total dose of 50-54 Gy/with fractionation of 2 Gy/day). The patients were treated with IFRT. Local failure (LF) was defined as an increase in radiographic abnormality within the planning target volume (PTV). Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF). Results The median age of the patients was 68 years (range: 44-80 years); 20 patients (66.7%) were men, and 11 (36.6%) and 19 (63.4%) patients presented with tumors of stage II and III, respectively. Most patients (63.3%) had tumors in the pancreatic head. The median survival was 17.2 months. Tumor recurrences were classified as LF, DF, LF and DF in 7 (23.3%), 17 (56.7%), and 5 (16.7%) patients, respectively. Only one patient (3.3%) had both LF and ENF. No severe side effects related to radiotherapy were reported. Conclusion The use of IFRT did not cause a significant amount of ENF, besides presenting low morbidity, which is of special importance for patients with locally advanced tumors or low performance status. The predominant failure pattern was distant metastases.

Intraoperative radiotherapy for brain metastases: first-stage results of a single-arm, open-label, phase 2 trial.

OBJECTIVE: Focal stereotactic radiosurgery to the surgical cavity lowers local recurrence after resection of brain metastases (BM). To evaluate local control (LC) and brain disease control (BDC) after intraoperative radiotherapy (IORT) for resected BM. METHODS: Adult patients with completely resected single supratentorial BM were recruited and underwent IORT to the cavity with a prescribed dose of 18 Gy to 1 mm-depth. Primary endpoints were actuarial LC and BDC. Local failure (LF) and distant brain failure (DBF), with death as a competing risk, were estimated. Secondary endpoints were overall survival (OS) and incidence of radiation necrosis (RN). Simon's two-stage design was used and estimated an accrual of 10 patients for the first-stage analysis and a LC higher than 63% to proceed to second stage. We report the final analysis of the first stage. RESULTS: Between June 2019 to November 2020, 10 patients were accrued. Median clinical and imaging FU was 11.2 and 9.7 months, respectively. Median LC was not reached and median BDC was 5 months. The 6-month and 12-month LC was 87.5%. The 6-month and 12-month BDC was 39% and 13%, respectively. Incidence of LF at 6 and 12 months was 10% and of DBF at 6 and 12 months was 50% and 70%, respectively. Median OS was not reached. The 6-month and 12-month OS was 80%. One patient had asymptomatic RN. CONCLUSION: IORT for completely resected BM is associated with a potential high local control and low risk of RN, reaching the pre-specified criteria to proceed to second stage and warranting further studies.

Postmastectomy Radiation Therapy Bolus Associated Complications in Patients Who Underwent 2-stage Breast Reconstruction.

Purpose: This study aimed to evaluate the association of bolus and 2-stage breast reconstruction complications, and whether the dosimetric advantage translates into improvements in local control. Methods and Materials: We retrospectively analyzed data from 2008 to 2019 of women who underwent a mastectomy and a planned 2-stage breast reconstruction, followed by adjuvant radiation therapy. We reviewed all data from medical records and radiation plans regarding patient characteristics, diagnoses, surgeries, complications, pathology, staging, systemic therapy, radiation therapy, and outcomes, and compared complication rates according to bolus usage. Results: A total of 288 women, age 25 to 71 years, were included in the study. Of these women, 6 were treated with daily bolus and 19 with alternate days bolus, totaling 25 of 288 patients (8.7%) in the bolus group. A total of 226 patients (78.5%) had the second stage performed. The median follow-up time was 61 months. The rates for 5-year overall survival and locoregional control were both 97%, and the metastasis-free rate was 83%. In the first stage, 6.25% of patients in the entire cohort had an infection and 4.2% had implant loss. Daily bolus significantly increased the risk of expander infection (hazard ratio [HR]: 10.3; 95% confidence interval [CI], 1.7-61.8) and loss (HR: 13.89; 95% CI, 2.24-85.98), but alternate-day bolus showed a nonsignificant increase for expander infection (HR: 1.14; 95% CI, 0.14-9.295) and loss (HR: 1.5; 95% CI, 0.19-12.87). Bolus was not associated with second-stage complications or local-regional failure. Local infection and implant loss were more frequent in the second than in the first stage (5.2% vs 10.2% and 4.2% vs 12.8%, respectively). Conclusions: Skin bolus significantly increased first-stage breast reconstruction complications (infection and reconstruction failure). Despite the small sample size and the need for future studies, these findings need to be taken into consideration when planning treatment and reconstruction, and recommendations should be individualized.

Salvage Post-Operative Stereotatic Ablative Radiotherapy for Re-Current Squamous Cell Carcinoma of Head and Neck.

Background and Objectives: Patients with recurrent squamous cell carcinoma of the head and neck (rHNC) face an aggressive disease. Surgical resection is the gold standard treatment. Immediate adjuvant post-operative stereotactic ablative radiotherapy (PO-SABR) for rHNC is debatable. Materials and Methods: We retrospectively identified patients who were treated with PO-SABR at the AC Camargo Cancer Center, Brazil. Results: Eleven patients were treated between 2018 and 2021. The median time between salvage surgery and PO-SABR was 31 days (range, 25-42) and the median PO-SABR total dose was 40 Gy (range, 30-48 Gy). The 2-and 4-year actuarial DFS were 62.3% and 41.6%, while the 2-and 4-year OS probabilities were 80.0% and 53.3%, respectively. Eight (72.7%) patients were alive and six (54.5%) were without disease at the last follow-up. Two (18.1%) patients had local failure in the PO-SABR field. Three (27.3%) patients had distant metastasis, diagnosed in a median time of 9 months (range, 4-13) after completion of PO-SABR. On univariate analysis, predictive factors related to worse OS were: interval between previous radiotherapy and PO-SABR ≤ 24 months (p = 0.033) and location of the salvage target in the oral cavity (p = 0.013). The total dose of PO-SABR given in more than three fractions was marginally statistically significant, favoring the OS (p = 0.051). Conclusions: Our results encourage the use of a more aggressive approach in selected patients with rHNC by combining salvage surgery with immediate PO-SABRT, but this association needs to be further explored.

Heterogeneity of HER2 Expression in Circulating Tumor Cells of Patients with Breast Cancer Brain Metastases and Impact on Brain Disease Control.

HER2 expression switching in circulating tumor cells (CTC) in breast cancer is dynamic and may have prognostic and predictive clinical implications. In this study, we evaluated the association between the expression of HER2 in the CTC of patients with breast cancer brain metastases (BCBM) and brain disease control. An exploratory analysis of a prospective assessment of CTC before (CTC1) and after (CTC2) stereotactic radiotherapy/radiosurgery (SRT) for BCBM in 39 women was performed. Distant brain failure-free survival (DBFFS), the primary endpoint, and overall survival (OS) were estimated. After a median follow-up of 16.6 months, there were 15 patients with distant brain failure and 16 deaths. The median DBFFS and OS were 15.3 and 19.5 months, respectively. The median DBFFS was 10 months in patients without HER2 expressed in CTC and was not reached in patients with HER2 in CTC (p = 0.012). The median OS was 17 months in patients without HER2 in CTC and was not reached in patients with HER2 in CTC (p = 0.104). On the multivariate analysis, DBFFS was superior in patients who were primary immunophenotype (PIP) HER2-positive (HR 0.128, 95% CI 0.025-0.534; p = 0.013). The expression of HER2 in CTC was associated with a longer DBFFS, and the switching of HER2 expression between the PIP and CTC may have an impact on prognosis and treatment selection for BCBM.

Comparison of McMaster and Mini-FLOTAC fecal egg counting techniques in cattle and horses.

The aim of this study was to compare two fecal egg count (FEC) techniques; McMaster (McM) and Mini-FLOTAC (mF), for the detection of cattle and horse gastrointestinal nematode eggs, in different locations. Experiment 1: feces were collected from 16 cattle and FEC was performed individually, using mF with the sensitivity of 5 eggs per gram of feces (EPG) and McM with a sensitivity of 50 EPG at Empresa de Pesquisa Agropecuária de Minas Gerais - EPAMIG and the Laboratory of Parasitic Diseases of the University of Parana - LDP/UFPR. Experiment 2: Fecal samples from 30 horses were analyzed with mF (sensitivity of 5 EPG) and McM (sensitivity of 25 EPG) at the University of Mato Grosso do Sul - UFMS and LPD/UFPR. Experiment 3: feces were collected from 14 foals and FEC was performed using mF (sensitivity of 5 EPG); and McM (sensitivity of 25 EPG) only at the LPD/UFPR. For cattle, the average FEC of mF was 962 at LPD; and 1248 at EPAMIG; for McM it was 1393 at LPD and 1563 at EPAMIG. For horses, the FEC average using the mF was 650 at LPD and 469 at UFMS; and for McM it was 677 at LPD and 554 at UFMS. For foals, the average FEC for mF was 404 and 436 for McM. In all experiments, the standard deviation and the coefficient of variation values were significantly lower for mF. Therefore, it is recommended the use of the Mini-FLOTAC technique, which is a method with less variability and higher accuracy, particularly for animals with low FEC.

Hérnia do ceco e cólon ascendente pelo forame de Winslow / Cecum and ascending colon herniation through foramen of Winslow

As hérnias pelo forame de Winslow fazem parte de uma condição extremamente rara, compreendendo apenas 0,08% de todas as hérnias já descritas. O diagnóstico pré-operatório dessa afecção é infrequente (menos de 10% das vezes) e por isso atinge altas taxas de mortalidade, em torno de 36% a 49% dos casos. Apresentamos o caso de paciente, 92 anos, sexo feminino, com quadro de náuseas, vômitos, dor e distensão abdominal de rápida evolução sem melhora ao tratamento clínico, caracterizando diagnóstico sindrômico de abdome agudo obstrutivo. Exames laboratoriais e de imagem foram pouco elucidativos, sendo indicado uma abordagem cirúrgica por meio de uma laparotomia exploradora. Os achados cirúrgicos definiram o diagnóstico etiológico de encarceramento do ceco e cólon ascendente na retrocavidade através do forame de Winslow. O quadro clínico dessa afecção é muito variável, refletindo sintomas de acordo com o conteúdo herniado e o tempo de evolução. Trata-se de uma patologia de difícil suspeição, sendo que o diagnóstico definitivo é geralmente realizado durante o ato operatório. A lembrança dessa hipótese diagnóstica como diagnóstico diferencial de quadros de abdomes agudos oclusivos deve ser adequadamente pensada para que se possa propor o melhor e mais específico tratamento, a fim de se evitar maiores complicações de um diagnóstico tardio.

Herniations through foramen of Winslow are part of a extremely rare condition, establishing only 0.08% of all descripted hérnias. The pre operative diagnosis is uncommon (less than 10%) and this condition allows mortality rates to reach high levels, beetween 36 to 49% of the cases. The presente case reports a 92 years of age woman, presenting náuseas, vomits, distension and abdominal pain, persisting through hours with no positive response to clinical treatment, this way featuring an abdominal urgency syndrom. Laboratorial e image exams had no great findings; surgical treatment was so proposed. Surgical findings have defined the condition as being a cécum and ascending colon herniation through foramen of Winslow in retrocavity. Clinical findings of this condition are variable, reflecting sympthons of which content is herniated as well as duration of the herniation process. It is a hard suspicion patology, as most of the cases diagnosis are made during the surgery, only. The knowledge about this diagnosis hypothesys may be of great importance while maneging abdominal pain patients, this way porpousing best exams procedures and precocious treatment, avoiding late diagnosis complications.