Trends in combined radio-chemotherapy for locally advanced rectal cancer: a survey among radiation oncology centers of Sicily region on behalf of AIRO.

AIM: To conduct a survey among Sicilian centers of radiation oncology belonging to Associazione Italiana di Radioterapia ed Oncologia Clinica (AIRO), to record the different methods of integration of radio-chemotherapy both in neoadjuvant and adjuvant settings, to evaluate surgical procedures in relation to the sphincter preservation and to report the different toxicity profiles of the treatment strategies. METHODS: A questionnaire was sent at the end of 2017 to all the radiation oncology centers of Sicily region in order to collect the data from individual centers and the treatment characteristics retrospectively over the previous 5 years, from 2012 to 2016. The required data were collected from 13 centers out of 17 which, in relation to the single catchment areas, correspond to approximately 85% of the Sicilian population. The requested data concerned the type of integrated treatment (neoadjuvant vs adjuvant vs radical), combination with chemotherapy (induction, concomitant, adjuvant), type of surgical intervention (sphincter-saving vs abdomino-perineal resection), disease stage, schedule and radiotherapy technique adopted, as well as toxicity detected over the treatment period. RESULTS: A total of 784 pts (M/F: 509/275) were treated between 2012 and 2016, with a median age of 67 years (range 25-92). The majority of patients was treated in the neoadjuvant phase (62% of the total) compared to the adjuvant phase (31%) and to those treated radically (7%). Twenty-five percent of patients did not receive combination chemotherapy mainly for cardiovascular problems. Chemotherapy used concomitantly to radiotherapy was single-agent capecitabine (73% of patients) or 5-fluorouracil (27%). The use of chemotherapy alone before concomitant treatment is more common for patients treated in the adjuvant phase (64% of this subgroup), while 14% of patients treated in the neoadjuvant phase received induction chemotherapy before the concomitant phase; in both cases of chemotherapy alone, the majority of patients (91%) received oxaliplatin-based protocols (FOLFOX/XELOX/CAPOX). Few patients (3%) received chemotherapy alone after the concomitant phase. Information on the surgical treatment received is available for 88% of the sample. Of these, 93% received a surgical treatment. The overall rate of sphincter-saving surgery (anterior resection) was 72%, but the contribution of neoadjuvant treatment allowed to reach a rate of 83% in this subgroup (against 65% found in the subgroup of patients treated in adjuvant phase). Traditional radiotherapy schedule (45-50 Gy in 25-28 fractions) was used in 90% of patients, of which an intensified treatment in neoadjuvant phase (45 Gy + boost of 9-10 Gy) was used in 11% of patients. A short-course regimen (25 Gy in 5 fraction) in neoadjuvant setting was opted rarely (7%). Three-dimensional conformal technique was preferred over intensity-modulated ones (73% vs 27%). Toxicity was mainly of grade I-II CTCAE (skin 23%, gastrointestinal 39%, genitourinary 14%) compared to grade III (gastrointestinal 4%, genitourinary and hematological < 1%). Interestingly, the toxicity rates were significantly higher in the adjuvant group compared to the neoadjuvant (GI: 58% vs 31%, GU: 21% vs 10%). CONCLUSION: The present survey shows that in the Sicily region integrated therapies for rectal cancer have allowed a neoadjuvant approach in the majority of patients, thus resulting in a greater use of sphincter conservative surgery. The toxicity has also been reported to be significantly less in this treatment setting.

Nodal Ratio as a Prognostic Factor in Patients with Four or More Positive Axillary Nodes Treated with Breast-conserving Therapy and Regional Nodal Irradiation.

AIM: This study aimed to investigate the prognostic value of the axillary lymph node ratio (i.e. positive axillary nodes to nodes removed) in patients with breast cancer treated with conservative surgery and regional radiotherapy. PATIENTS AND METHODS: We retrieved the records of 195 patients with breast cancer with pathological stage pT1-2 pN2-3, treated from January 2005 to December 2013 at our Radiation Oncology Centers; their clinical data were retrospectively evaluated. All patients underwent lumpectomy or quadrantectomy with axillary lymph node dissection, adjuvant chemo-with/without hormonal therapy and irradiation to the whole breast and ipsilateral axillary apex, infraclavicular and supraclvicular nodes, excluding internal mammary nodes. The primary end-point was to evaluate the nodal ratio as a prognostic factor; moreover, the following prognostic factors were evaluated: age, biological status and molecular profile. RESULTS: The median follow-up was 58 months (range=32-117.6 months). Two- and 5-year overall and recurrence-free survival rates were 96% and 88%, and 92% and 85%, respectively. On univariate analysis, factors influencing overall survival were nodal ratio >0.65 (p=0.033) and age (p=0.023); time to recurrence was detrimentally impacted only by Ki67 positivity ≥50% (p=0.049). At multivariate analysis, no significant associations were found. CONCLUSION: Adding irradiation to regional nodes after conservative surgery in patients with breast cancer with more than three positive axillary nodes does not alter the prognostic value of the nodal ratio, and we confirm this to be an important factor for predicting overall survival.

Breast cancer bone metastases: an epidemiologic study in selected radiation departments.

AIMS: To quantify radiation treatments for bone metastases from breast cancer in three Sicilian provinces (Messina, Catania, Ragusa) with respect to the general population and the incidence and prevalence of breast cancer in this macro-area in a 8-year period. METHODS: All bone metastasis patients treated using radiotherapy in 8 radiation departments operating in the provinces of Messina, Catania and Ragusa were collected. Among these, metastases from breast carcinoma were analyzed according to year of irradiation. An analysis of breast cancer incidence and prevalence with respect to inhabitants in this macro-area was conducted using literature and census data. RESULTS: From January 2004 to December 2011, irradiation was delivered in 4419 bone metastasis patients. Among these, 1617 had a primary breast cancer with a median treatment per year of 206.5 (range, 164-251); 211 patients were treated in 2004 and 206 in 2011. In 2004, there were 1,048,957 female residents in the three provinces and 1,065,422 in 2011. The reported breast cancer incidence and prevalence in Sicily was respectively 100.79/100,000 and 908.54/100,000 in 2004 and 108.41/100,000 and 1091.29/100,000 in 2010. CONCLUSIONS: There has been an increase in both incidence and prevalence of breast cancer in Sicily. Nevertheless, it seems that there was no increment in skeletal-related events requiring irradiation in such patients in eastern Sicily radiation departments.

Enlarged axillary nodes and position of the arms in axillary irradiation--a computed tomography and magnetic resonance imaging evaluation.

The purpose of this study was to evaluate the axillary node displacement away from chest wall and their anatomical location in relation to the humeral head, according to the position of the arms, when the axilla is the site of enlarged nodes. In 13 patients with enlarged axillary nodes, the anatomical span of the nodes according to two arms positions, akimbo (A) and up over the head (U), was prospectively evaluated using computed tomography (CT) and magnetic resonance imaging (MRI). The nodes were classified into two groups, i.e. the lower and upper groups. The mean distances of the lower node group from the chest wall when the patients were in A, and U positions were 3 cm and 6.4 cm, respectively (p = 0.002). The upper group nodes showed a smaller difference in the distance from the chest wall: in A position, mean 2.1 cm; in U position 2.8 cm (p = 0.03). In U position, there was always a node of the lower group that was displaced in front of the humeral head. This study demonstrates the displacement of enlarged axillary nodes according to the position of the arms. In patients with axillary node involvement, CT planning should be considered when they have their arms held up over their heads.

Muscle-invasive bladder cancer in elderly-unfit patients with concomitant illness: can a curative radiation therapy be delivered?

AIMS AND BACKGROUND: There is no standard treatment for elderly-unfit patients with muscle-invasive bladder cancer. Pelvic irradiation alone is an usual approach in this instance, and some reports have demonstrated that curative radiotherapy is feasible in elderly patients. To our knowledge, no data exist about the feasibility of a curative treatment in elderly patients with concomitant illness and a Charlson Comorbidity Index (an index of comorbidity that includes age) greater than 2. The main purpose of the present study was to establish the feasibility of irradiation in a cohort of elderly patients in poor general condition. METHODS: The records of 45 elderly-unfit patients (median age, 75 years; range, 70-85), with a comorbid Charlson score >2, treated with curative dose, planned continuous-course, external beam radiotherapy for muscle-invasive bladder cancer were reviewed. The patients were treated to a median total dose of 60 Gy (range, 56-64), with an average fractional dose of 190 +/- 10 cGy using megavoltage (6-15 MV). All patients were treated with radiation fields encompassing the bladder and grossly involved lymph nodes with a radiographic margin of at least 1.5 cm. RESULTS: No treatment-related mortality and clinically insignificant acute morbidity was recorded. No patient was hospitalized during or after the irradiation because of gastrointestinal or urogenital side effects. In one patient a week rest from therapy was necessary due a febrile status. Median survival was 21.5 months; overall 3- and 5-year survival was 36% and 19.5%, respectively. CONCLUSIONS: Elderly-unfit patients with comorbidities and >70 years of age can be submitted to radical pelvic irradiation. The results observed in this retrospective analysis have encouraged us to use non-palliative radiotherapy doses in these patients with muscle-invasive bladder cancer.

Older people with non small cell lung cancer in clinical stage IIIA and co-morbid conditions. Is curative irradiation feasible? Final results of a prospective study.

Radiotherapy (RT) is widely used in the management of lung cancer but age-oriented randomized trials are lacking in older-unfit patients. We started a prospective study to evaluate the toxicity and efficacy of definitive RT in very old-unfit patients with non-small cell lung cancer (NSCLC) in clinical stage IIIA, according to AJCC 1988. Forty patients, age > or = 75 years, Karnofsky Performance status (KPS) > or = 60, unfit to receive an aggressive combined treatment, were entered in the study. Each patient had one or more comorbidities, and the Charlson score was greater than two in 7/40. All patients were treated with radiation fields encompassing the primary tumor and grossly involved lymph nodes. A median radiation dose of 60 Gy/2 Gy day/5 days a week, was delivered. The 40 patients have been followed up, including those who died, for a potential median time of 4.6 years. As results, no treatment-related mortality, and clinically insignificant acute morbidity was recorded: in 28/40 cases a mild esophagitis occurred. Two patients showed a clinical radiation pneumonitis (RP). Late normal tissue damage was represented by lung fibrosis (40/40 patients). The treatment was efficacy since each patient obtained some clinical benefit from it. Median survival (MS) was 19 months (range 5-68); the 3 and 5-year actuarial survival was 18 and 12%, respectively. In conclusion, we think that older patients with concomitant illness can be submitted to curative 'involved field' irradiation and the results observed in this trial encourage to use curative RT in older subjects with local-regionally advanced NSCLC and co-morbid condition.