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.

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.

Prospective Assessment of the Association Between Circulating Tumor Cells and Control of Brain Disease After Focal Radiation Therapy of Breast Cancer Brain Metastases.

PURPOSE: Predicting the risk of early distant brain failure (DBF) is in demand for management decisions in patients who are candidates for local treatment of brain metastases. This study aimed to analyze the association between circulating tumor cells (CTCs) and brain disease control after stereotactic radiation therapy/radiosurgery (SRT) for breast cancer brain metastasis (BCBM). METHODS AND MATERIALS: We prospectively assessed CTCs before (CTC1) and 4 to 5 weeks after (CTC2) SRT and their relationship with the number of new lesions (NL) suggestive of BCBM before SRT. CTC were quantified and analyzed by immunocytochemistry to evaluate the expression of the proteins COX2, EGFR, ST6GALNAC5, NOTCH1, and HER2. Distant brain failure-free survival (DBFFS), the primary endpoint, diffuse DBFFS (D-DBFFS), and overall survival were estimated. Analysis for DBF within 6 months, with death as competing risk, was performed. RESULTS: Patients were included between 2016 and 2018. CTCs were detected in all 39 patients before and in 34 of 35 patients after SRT. After median follow-up of 16.6 months, median DBFFS, D-DBFFS, and overall survival were 15.3, 14.1, and 19.5 months, respectively. DBF at 6 months was 40% with CTC1 ≤0.5 and 8.82% with CTC1 >0.5 CTC/mL (P = .007), and D-DBF at 6 months was 40% with CTC1 ≤0.5 and 0 with CTC1 >0.5 CTC/mL (P = .005) and 25% with NL/CTC1 >6.8 and 2.65% with NL/CTC1 ≤6.8 (P = .063). On multivariate analysis, DBFFS was inferior with CTC1 ≤0.5 (hazard ratio, 8.27; 95% confidence interval, 2.12-32.3; P = .002), and D-DBFFS was inferior with CTC1 ≤0.5 (hazard ratio, 10.22; 95% confidence interval, 1.99-52.41; P = .005). Protein expression was not associated with outcomes. CONCLUSIONS: These data suggest that CTC1 and NL/CTC1 may have a role as a biomarker of early diffuse DBF and as a subsequent guide between focal or whole-brain radiation therapy in patients with BCBM.

Trombose venosa cerebral em paciente com câncer colorretal sob quimioterapia com 5-Fluorouracil infusional (esquema de Gramont) associado a bevacizumabe / Cerebral vein thrombosis in colorectal cancer patient under chemotherapy with 5-FU de Gramont regimen plus bevacizumab

Introdução: A trombose venosa cerebral constitui entidade clínica rara, respondendo por menos de 1% dos casos de AVC. Está associada a trombofilias hereditárias, infecções parameníngeas, traumatismos, além de vasculites, câncer e a própria quimioterapia. Relato do caso: Paciente de 59 anos com adenocarcinoma colônico sob quimioterapia com 5-Fluorouracil infusional (esquema de Gramont) associado a bevacizumabe apresentou quadro de tontura em desequilíbrio, déficit de força em membro inferior, cefaleia e convulsões, sendo constatada trombose venosa cerebral. Evoluiu com reversão total dos déficits neurológicos com anticoagulação. Conclusão: Enfatiza-se papel do câncer e da própria quimioterapia na etiopatogenia da trombose venosa cerebral em paciente sem aparente trombofilia hereditária e outros fatores tipicamente implicados na gênese desta rara condição.

Prevalence of anxiety in women undergoing mammography

Objective:The aim of this study was to evaluate the frequency and possible causes of anxiety in women undergoing mammography and verify the impact of prior information as a tool to reduce anxiety. Material and Methods: The sample consisted of female patients who underwent mammography at an oncology reference center in Brazil. Total sample was divided into two groups and only one group received an explanatory folder with information regarding the mammography and its follow-up. All patients received a questionnaire containing demographic and clinical data, questions about the mammographic exam and the State-Trait Anxiety Inventory (STAI). Results: Two hundred and seventy-four patients were included, aged between 21 and 89 years. Exam purpose was screening in 48.3%. Self-perception of anxiety was reported in 52.2% and most frequent causes of anxiety referred by patients were worry over results (35.3%) and fear of having pain or discomfort during the procedure (26.6%). The levels of anxiety according to the STAI were moderate or high on 52.6% on the state component, and 82.1% on the trait component. There was no statistically significant difference on anxiety levels according to any of the demographic or clinical variables, or between patients who received and did not receive the educational folder prior to the exam. Conclusion: Anxiety is a common feature of women undergoing mammography, mainly caused by fear of the results and lack of knowledge of the exam. According to the results of this and other studies, there was no impact on reducing levels of anxiety with information measures immediately before the exam.

Biópsia transtorácica de nódulos e massas pulmonares dirigida por tomografia computadorizada / Computed tomography-guided transthoracic needle biopsy of pulmonary nodules

Biópsia percutânea dirigida por tomografia computadorizada tem sido amplamente utilizada como um procedimento efetivo e seguro para obtenção de diagnóstico histológico em muitas situações clínicas e em diversos órgãos. No pulmão, a biópsia percutânea tornou-se uma das principais escolhas para investigação de nódulos e massas. Sua versatilidade permite o acesso de lesões nas diversas localizações do pulmão, podendo ser utilizada para lesões periféricas e profundas mesmo de pequenas dimensões. Discutiremos as indicações, os aspectos técnicos do procedimento e os índices esperados de sucesso e complicação das biópsias percutâneas de nódulos e massas pulmonares.

Computed tomography-guided needle biopsy has been widely utilized as an effective and safe diagnostic procedure in many clinical settings. In the lungs, transthoracic needle biopsy has become one of the primary choices to investigate nodules and mass lesions. The procedure versatility allows access to either peripheral or central lesions at almost any site, even in cases of small nodules. In this article, indications, technical aspects of the procedure, expected success and complication rates of computed tomography-guided transthoracic needle biopsy of pulmonary nodules and masses are discussed.

Computed tomography guided needle biopsy: experience from 1,300 procedures.

CONTEXT AND OBJECTIVE: Computed tomography (CT) guided biopsy is widely accepted as effective and safe for diagnosis in many settings. Accuracy depends on target organ and needle type. Cutting needles present advantages over fine needles. This study presents experience from CT guided biopsies performed at an oncology center. DESIGN AND SETTING: Retrospective study at Hospital do Câncer A. C. Camargo, São Paulo. METHODS: 1,300 consecutive CT guided biopsies performed between July 1994 and February 2000 were analyzed. Nodules or masses were suspected as primary malignancy in 845 cases (65%) or metastatic lesion in 455 (35%). 628 lesions were thoracic, 281 abdominal, 208 retroperitoneal, 134 musculoskeletal and 49 head/neck. All biopsies were performed by one radiologist or under his supervision: 765 (59%) with 22-gauge fine-needle/aspiration technique and 535 (41%) with automated 16 or 18-gauge cutting-needle biopsy. RESULTS: Adequate samples were obtained in 70-92% of fine-needle and 93-100% of cutting-needle biopsies. The specific diagnosis rates were 54-67% for fine-needle and 82-100% for cutting-needle biopsies, according to biopsy site. For any site, sample adequacy and specific diagnosis rate were always better for cutting-needle biopsy. Among 530 lung biopsies, there were 84 pneumothorax (16%) and two hemothorax (0.3%) cases, with thoracic drainage in 24 (4.9%). Among abdominal and retroperitoneal biopsies, there were two cases of major bleeding and one of peritonitis. CONCLUSION: Both types of needle showed satisfactory results, but cutting-needle biopsy should be used when specific diagnosis is desired without greater incidence of complications.

Computed tomography guided needle biopsy: experience from 1.300 procedures

CONTEXT AND OBJECTIVE: Computed tomography (CT) guided biopsy is widely accepted as effective and safe for diagnosis in many settings. Accuracy depends on target organ and needle type. Cutting needles present advantages over fine needles. This study presents experience from CT guided biopsies performed at an oncology center. DESIGN AND SETTING: Retrospective study at Hospital do Câncer A. C. Camargo, São Paulo. METHODS: 1,300 consecutive CT guided biopsies performed between July 1994 and February 2000 were analyzed. Nodules or masses were suspected as primary malignancy in 845 cases (65 percent) or metastatic lesion in 455 (35 percent). 628 lesions were thoracic, 281 abdominal, 208 retroperitoneal, 134 musculoskeletal and 49 head/neck. All biopsies were performed by one radiologist or under his supervision: 765 (59 percent) with 22-gauge fine-needle/aspiration technique and 535 (41 percent) with automated 16 or 18-gauge cutting-needle biopsy. RESULTS: Adequate samples were obtained in 70-92 percent of fine-needle and 93-100 percent of cutting-needle biopsies. The specific diagnosis rates were 54-67 percent for fine-needle and 82-100 percent for cutting-needle biopsies, according to biopsy site. For any site, sample adequacy and specific diagnosis rate were always better for cutting-needle biopsy. Among 530 lung biopsies, there were 84 pneumothorax (16 percent) and two hemothorax (0.3 percent) cases, with thoracic drainage in 24 (4.9 percent). Among abdominal and retroperitoneal biopsies, there were two cases of major bleeding and one of peritonitis. CONCLUSION: Both types of needle showed satisfactory results, but cutting-needle biopsy should be used when specific diagnosis is desired without greater incidence of complications.

Prevalência de ansiedade e depressão em pacientes na sala de espera do Departamento de Radiologia em de um Centro Oncológico brasileiro de referência / Prevalence of anxiety and depression on patients at the waiting room of the Radiology Department of a Brazilian Oncology Reference Center

Ansiedade e depressão ocorrem em pacientes com câncer e a realização de exames radiológicos pode contribuir para aumentar a ansiedade pelo seu impacto sobre a decisão diagnóstica e terapêutica. Como os transtornos de humor estão negativamente relacionados com a qualidade de vida, o curso da doença e na relação médico-paciente, reconhecer esses pacientes é importante, inclusive para radiologistas, que cada vez mais participam na decisão de conduta médica. O objetivo do estudo é descrever a prevalência de ansiedade e depressão em pacientes na sala de espera do Departamento de Radiologia de um Centro Oncológico Brasileiro de Referência e correlacionar com as variáveis demográficas, clínicas e relacionadas ao exame radiológico. Fontes de ansiedade e preferências de comunicação, também, foram avaliadas. Realizou-se um estudo de corte transversal com 398 pacientes, que responderam a um questionário auto-aplicável, incluindo a Escala de Ansiedade e Depressão Hospitalar (HADS) e o Inventário de Ansiedade Traço-Estado (IDATE). Na população estudada, 18,9% apresentaram ansiedade e 9,6% depressão, pela HADS. Utilizando o IDATE, 6,7% e 7,0% apresentaram alta ansiedade, estado e traço, respectivamente. Entre as variáveis correlacionadas, apresentaram prevalência de ansiedade e/ou depressão, aqueles pacientes: em acompanhamento psiquiátrico; jovens; em investigação ou tratamento do câncer; sem experiência com exame; mulheres; desempregados; menor nível de instrução; e estadiamento III/IV. Conhecer os pacientes, suas expectativas e as variáveis correlacionadas à ansiedade e à depressão é o primeiro passo para estabelecer uma melhor assistência ao doente.

Anxiety and depression occur on patients with cancer and undergoing radiological exams may contribute to increase the anxiety because of the impact of their results on diagnostic and therapeutic decision. As psychological distresses are negatively related with life quality, disease course and physician-patient relationship, recognizing those patients is important, also for radiologists, who increasingly participate in medical procedure decisions. The aim of the present study is to describe the prevalence of anxiety and depression on patients at the waiting room of the Radiology Department of a Brazilian Oncology Reference Center and to correlate it with demographic, clinical, and radiological exam related variables. Anxiety sources and patient's preference about communication of results were also accessed. A cross-section study was accomplished with 398 patients who answered a selfapplicable questionnaire containing the Hospital Anxiety and Depression Scale (HADS) and the State-Trait Anxiety Inventory (STAI). The studied population presented 18.9% of anxiety and 9.6% of depression according to the HADS. Using the STAI, 6.7% presented high state anxiety and 7.0% high trait anxiety. Among the correlated variables, the following patients presented prevalence of anxiety and/or depression: under psychiatric attendance; young ones; under cancer treatment or investigation; without experience with exams; women; unemployed; with lower schooling level; and cancer stage III/IV. Knowing the patients, their expectations and correlated variables with anxiety and depression is the first step to establish a better assistance to the patient.

Computed tomography-guided cutting needle biopsy of pulmonary lesions.

PURPOSE: To report the experience of a radiology department in the use of computed tomography - guided cutting needle biopsy of pulmonary nodules, by evaluating diagnostic yield and incidence of complications. METHODS: This is a retrospective analysis of 52 consecutive patients who underwent lung lesion biopsy guided by computed tomography, performed between May 1997 and May 2000. Thirty-five patients were male and 17 were female, with ages ranging from 5 to 85 years (median, 62 years). The size of the lesions ranged from 1.8 to 15 cm (median, 5.4 cm). RESULTS: In a total of 52 biopsies of lung lesions, 51 biopsies (98.1%) supplied appropriate material for histopathological diagnosis, with 9 diagnosed (17.3%) as benign and 42 (80.8%) as malignant lesions. Specific diagnosis was obtained in 44 (84.6%) biopsies: 4 benign (9.1%) and 40 (90.9%) malignant lesions. The sensitivity, specificity, and accuracy of the cutting needle biopsies for determining presence of malignancy were 96.8%, 100%, and 97.2%, respectively. Complications occurred in 9 cases (17.3%), including 6 cases (11.5%) of small pneumothorax, 1 (1.9%) of hemoptysis, 1 (1.9%) of pulmonary hematoma, and 1 (1.9%) of thoracic wall hematoma. All had spontaneous resolution. There were no complications requiring subsequent intervention. CONCLUSION: The high sensitivity and specificity of the method and the low rate of complications have established cutting needle biopsy as an efficient and safe tool for the diagnosis of lung lesions. In our hospital, cutting needle biopsy is considered a reliable procedure for the evaluation of indeterminate pulmonary nodules.

Computed tomography-guided cutting needle biopsy of pulmonary lesions

PURPOSE: To report the experience of a radiology department in the use of computed tomography - guided cutting needle biopsy of pulmonary nodules, by evaluating diagnostic yield and incidence of complications. METHODS: This is a retrospective analysis of 52 consecutive patients who underwent lung lesion biopsy guided by computed tomography, performed between May 1997 and May 2000. Thirty-five patients were male and 17 were female, with ages ranging from 5 to 85 years (median, 62 years). The size of the lesions ranged from 1.8 to 15 cm (median, 5.4 cm). RESULTS: In a total of 52 biopsies of lung lesions, 51 biopsies (98.1 percent) supplied appropriate material for histopathological diagnosis, with 9 diagnosed (17.3 percent) as benign and 42 (80.8 percent) as malignant lesions. Specific diagnosis was obtained in 44 (84.6 percent) biopsies: 4 benign (9.1 percent) and 40 (90.9 percent) malignant lesions. The sensitivity, specificity, and accuracy of the cutting needle biopsies for determining presence of malignancy were 96.8 percent, 100 percent, and 97.2 percent, respectively. Complications occurred in 9 cases (17.3 percent), including 6 cases (11.5 percent) of small pneumothorax, 1 (1.9 percent) of hemoptysis, 1 (1.9 percent) of pulmonary hematoma, and 1 (1.9 percent) of thoracic wall hematoma. All had spontaneous resolution. There were no complications requiring subsequent intervention. CONCLUSION: The high sensitivity and specificity of the method and the low rate of complications have established cutting needle biopsy as an efficient and safe tool for the diagnosis of lung lesions. In our hospital, cutting needle biopsy is considered a reliable procedure for the evaluation of indeterminate pulmonary nodules