Multimodal assessment improves neuroprognosis performance in clinically unresponsive critical-care patients with brain injury.

Accurately predicting functional outcomes for unresponsive patients with acute brain injury is a medical, scientific and ethical challenge. This prospective study assesses how a multimodal approach combining various numbers of behavioral, neuroimaging and electrophysiological markers affects the performance of outcome predictions. We analyzed data from 349 patients admitted to a tertiary neurointensive care unit between 2009 and 2021, categorizing prognoses as good, uncertain or poor, and compared these predictions with observed outcomes using the Glasgow Outcome Scale-Extended (GOS-E, levels ranging from 1 to 8, with higher levels indicating better outcomes). After excluding cases with life-sustaining therapy withdrawal to mitigate the self-fulfilling prophecy bias, our findings reveal that a good prognosis, compared with a poor or uncertain one, is associated with better one-year functional outcomes (common odds ratio (95% CI) for higher GOS-E: OR = 14.57 (5.70-40.32), P < 0.001; and 2.9 (1.56-5.45), P < 0.001, respectively). Moreover, increasing the number of assessment modalities decreased uncertainty (OR = 0.35 (0.21-0.59), P < 0.001) and improved prognostic accuracy (OR = 2.72 (1.18-6.47), P = 0.011). Our results underscore the value of multimodal assessment in refining neuroprognostic precision, thereby offering a robust foundation for clinical decision-making processes for acutely brain-injured patients. ClinicalTrials.gov registration: NCT04534777 .

Should adjuvant radiotherapy be administered in addition to front-line aggressive surgery (FAS) in patients with primary retroperitoneal sarcoma?

BACKGROUND: As most patients with retroperitoneal sarcomas (RPS) die of local recurrence, front-line aggressive surgery (FAS) has been developed, and it seems to achieve better local control. The aim of this study was to evaluate conformal postoperative radiotherapy (PORT) in patients who had enlarged surgery. PATIENTS AND METHODS: Between 1994 and 2008, 110 patients with primary RPS mainly operated by FAS were analysed. Sixty-two patients underwent surgery and no PORT (group S), and 48 received surgery and PORT (group S + R). The median age was 52. Most patients had 3D conformal PORT (81%) with a median dose of 50 Gy. RESULTS: Comparing results at 5 years in the S and the S + R group, the cumulative rate of local failure was, respectively, 36% and 22% (NS); relapse-free survival was 47% and 60% (P = 0.02), and overall survival was, respectively, 77% and 71% (NS). CONCLUSION: Even if patients with adjuvant PORT were at higher risk of recurrence, there was a trend for radiotherapy (RT) to decrease the local relapse rate and improve recurrence-free survival. This study confirms that adjuvant conformal RT should be evaluated in a randomized trial, the control arm being FAS. Adjuvant RT in the preoperative setting is being evaluated in an EORTC trial.

[Prophylactic cranial irradiation in patients with extensive disease caused by small-cell lung cancer responsive to chemotherapy: fewer symptomatic brain metastases and improved survival]. / Profylactische schedelbestraling bij patiënten met uitgebreid kleincellig longcarcinoom dat reageert op chemotherapie: minder symptomatische hersenmetastasen en betere overleving.

OBJECTIVE: To determine the effect of prophylactic cranial irradiation (PCI) in patients with extensive-disease small-cell lung cancer (ED-SCLC) who responded to chemotherapy. DESIGN: Randomised, controlled clinical trial; phase III study (EORTC nr 08993-22993; www.clinicaltrials.gov, nr NCT00016211). METHOD: Patients aged 18-75 years with a functional status according to WHO < or = 2, and with ED-SCLC and any response to chemotherapy, were randomized to observation (standard care) or PCI. The primary endpoint was time to symptomatic brain metastases. If any pre-defined, key symptom suggesting brain metastases presented, a CT or MRI scan of the brain was performed. The size of the study (143 patients per arm) was determined to detect a hazard ratio (HR) of 0.44 at 80% power with 2-sided alpha = 0.05. RESULTS: The study accrued 286 patients. PCI decreased the risk of developing symptomatic brain metastases (HR = 0.27 (95% CI: 0.16-0.44; p < 0.001)). The cumulative incidence of developing brain metastases within 1 year was 40% in the control group (95% CI: 32-49) and 15% in the PCI group (95% CI: 8-21). PCI prolonged disease-free (HR = 0.76; 95% CI: 0.59-0.96, p = 0.02) and overall survival (HR = 0.68; 95% CI; 0.52-0.88, p = 0.003). The 1-year survival rate was 27% (95% CI: 19-36) for the PCI group versus 13% (95% CI: 8-20) for controls. Acute and late treatment toxicity was acceptable. These side effects did not significantly impact on quality of life. CONCLUSIONS: PCI significantly reduced the incidence of symptomatic brain metastases and prolonged both disease-free and overall survival and should be part of standard care in SCLC patients who respond to chemotherapy.

[Comparison of intensity-modulated postoperative radiotherapy with conventional postoperative conformal radiotherapy for retroperitoneal sarcoma]. / Etude théorique d'une radiothérapie postopératoire avec modulation d'intensité d'un sarcome rétropéritonéal.

External postoperative radiation therapy for retroperitoneal sarcoma is an example of treatment using large fields for complex shaped volumes of irradiation. Prescribed dose is limited by tolerance of adjacent organs at risk (OAR). From a recent case treated by conventional conformal radiotherapy (3D-CRT), we evaluate the benefit of five theoretical IMRT plans. Criteria used are calculated from DVH related to delineated PTV and OAR. IMRT should permit to enhance the prescribed dose without increasing dose in the OAR (especially residual kidney, spinal cord and small bowel). This theoretical study show the feasibility of a dose escalation from a treatment dose of 45 Gy delivered by 3D-CRT up to a planning dose of 54 Gy calculated by IMRT with: for the PTV: an improvement of the dose homogeneity about 5% (range 2-6%) and moreover the coverage factor (CF) about 13% (range 9-16%); for the OAR: an improvement of the protection factor (PF) about 20% (range 11-24%); and thus an improved conformity index (CI = CF x PF) about 25% (range 15-32%).

[Locally advanced breast cancer in the elderly]. / Cancerul mamar local avansat la femeile vârstnice.

The data concerning the influence of old age and locally advanced stages on breast cancer treatment and outcome are lacking or sparse. The authors reviewed treatment modalities in women over 65 years old with locally advanced breast cancer. The purpose of the study is to determine if differences in treatment modalities, clinical stage and pathological type influence the outcome. For patients with locally advanced disease but without over evidence of metastatic disease, radical surgical procedures should be attempted. Most study results confirm that loco-regional therapy and adjuvant chemohormonotherapy is feasible and safe even for older patients.

[Whole-body bone scintigraphy in the diagnosis and follow-up of the evolution of breast cancer]. / Scintigrafia osoasa corp întreg în diagnosticul si în urmarirea evolutiei cancerului mamar.

UNLABELLED: We have studied 75 patients, diagnosed with breast cancer, (39 on the right, 36 on the left and 4 on the two breasts), the TNM classification being: stage I--13.3%, stage II--36%, stage III--40% and stage IV--10.6%. Each patient has undergone a whole body scan, 2 hours after a 20-25 mCi 99mTc MDP i.v. dose, using a Siemens Diacam gamma camera. Three parameters where assessed: 1) the distribution of multiple metastasis bone sites; 2) an index, the counts/pixel ratio between the metastatic site interest region and a homologous normal bone interest region (IMDP); 3) a graphic representation of the metastasis heterogeneity radiotracer uptake. RESULTS: Bone metastasis have been found in 23 patients (30.6%), 16 cases having multiple sites; the rate between right and left breast cancer, for these metastases, was 13:10, according with the previous mentioned breast frequency. From all the 23 cases, the most involved site was the ribs (18 cases), followed by the spine (in 17 cases), the iliac bone (9 cases), the femur (7 cases), the skull (3 cases). On the spine, the more frequent involved was the dorsal spine (49.23%), than the lumbosacral (26.13%) and last the cervical spine (12.3%). On the dorsal vertebrae, in 91% the metastasis were localized between D8 and D12. The highest values of I-MDP characterize the femoral metastasis. The heterogeneity was high only for the vertebrae multiple sites. In conclusion, our study show pattern characteristics on the distribution and also on the uptake radiotracer bone metastasis quantification in breast cancer, in respect with others neoplasm's bone metastasis.