Staging of Prostate Cancer: Role of Multiparametric Magnetic Resonance Imaging in Different Risk Classes.

Using multiparametric magnetic resonance imaging, it is now possible to diagnose prostate cancer and categorize its risk. As it can accurately determine the extracapsu- lar extension of the tumor, invasion of seminal vesicles, involvement of lymph nodes, and the potential presence of bone metastases, multiparametric magnetic resonance imaging plays a crucial role not only in the diagnosis but also in the local staging of prostate cancer. The patients with a history of negative biopsy/increasing prostate- specific antigen and the existence of further data supporting its use in biopsy-naive patients and active surveillance are the most blatant indications for multiparametric magnetic resonance imaging in guidelines. The traditional clinical examination, pros- tate-specific antigen tests, and systematic biopsy are all enhanced by multiparametric magnetic resonance imaging, which will miss certain cancers due to insufficient size or changes in tissue density. The use of multiparametric magnetic resonance imaging is expected to rise, and further advances in the method will be crucial for the secure adoption of targeted therapeutic ideas. Here, we give a succinct overview of multipa- rametric magnetic resonance imaging's application to the identification and risk clas- sification of prostate cancer.

Radiological lung sequelae, functional status and symptoms in older patients 3 and 6 months after hospitalization for COVID-19 pneumonia.

The aim of our study was to assess the lung sequelae and clinical consequences 3 and 6 months after hospitalization for COVID-19 pneumonia in older patients. An observational study was conducted on 55 patients aged 65 years and older. Activities of daily living (ADL) and clinical frailty scale (CFS) were assessed at baseline and after 3 months. Both quantitative assessment at chest high-resolution computed tomography (CT) and semi-quantitative severity score (CTSS) were performed at baseline and after 3 and 6 months. Mean age: 82.3 ± 7.1 years. Male prevalence: 56.4%. After 6 months, ground-glass opacities (GGO) were still detectable in 22% of subjects, while consolidations were no longer appreciable. During follow-up, CTSS reached an overall median score of zero after 6 months. Fibrotic-like changes were found in 40% of subjects with an overall median score of 0 (0-5) points, being more prevalent in males. Patients reporting worsening ADL and CFS were 10.9% and 45.5%, respectively. They were associated with the burden of comorbidities, especially history of heart failure and chronic obstructive pulmonary disease at baseline. Amnesic disorders, exertional dyspnea, and fatigue were the most relevant symptoms reported. No association emerged between persistent or new-onset symptoms and evidence of fibrotic-like changes. The typical chest CT abnormalities of the COVID-19 pneumonia acute phase resolved in most of our older patients. Mild fibrotic-like changes persisted in less than half of the patients, especially males, without significantly affecting the functional status and frailty condition, which instead were more likely associated with pre-existing comorbidities.

Which men with non-malignant pathology at magnetic resonance imaging-targeted prostate biopsy and persistent PI-RADS 3-5 lesions should repeat biopsy?

PURPOSE: To assess predictors of clinically significant (cs) prostate cancer (PCa) in men who had a non-malignant Multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy and persistent Prostate Imaging-Reporting Data System (PI-RADS) 3 to 5 lesions in subsequent mpMRI. MATERIALS AND METHODS: We retrospectively analyzed MRI-targeted biopsy database in three centers. INCLUSION CRITERIA: persistence of at least one PI-RADS ≥3 lesion found negative for cancer in a previous MRI-targeted plus systemic biopsy (baseline biopsy). EXCLUSION CRITERIA: downgrading to PI-RADS 1-2. A logistic regression analysis was performed to estimate the predictors of csPCa. RESULTS: Fifty-seven patients were included. Median interval between biopsies was 12.9(2.43) months. Median age was 68.0(12) years. Median PSA was 7.0(5.45) ng/ml. At follow-up, 24.6%, 54.4%, and 21% of patients had a PI-RADS score 3, 4, and 5 index lesion (IL), respectively. At re-biopsy, 28/57(49.1%) men were found to harbor PCa. Among these, 22(78.6%) had csPCa. csPCa was found outside the IL in only 2 patients. Eleven, 13, and 5 patients with PI-RADS 3, 4, and 5, respectively, had no cancer. Three patients with a PI-RADS 3 lesion had cancer (2 with Gleason score 3+3, 1 with Gleason score 3+4). 14/43 men with a PI-RADS 4/5 lesion harbored Gleason score ≥3+4 PCa. Logistic regression analysis found that PSA (HR 1.281, 95% CI: 1.013-1.619, P = 0.039) and IL size (HR 1.146, 95% CI: 1.018-1.268, P = 0.041) were the predictors of csPCa at re-biopsy. CONCLUSIONS: Patients with non-malignant pathology from PI-RADS ≥3 lesions targeted biopsy should be follow-up with mpMRI, and those with persistent PI-RADS 4 to 5 lesions should repeat MRI-targeted and systematic biopsy.

A magnetic resonance imaging-based nomogram for predicting clinically significant prostate cancer at radical prostatectomy.

PURPOSE: To develop a nomogram incorporating clinical and multiparametric magnetic resonance imaging (mpMRI) parameters for the detection of clinically significant prostate cancer (csCaP) at radical prostatectomy (RP). MATERIALS AND METHODS: We retrospectively analyzed all consecutive patients who underwent robotic RP between 2016 and 2020. All patients underwent a 1.5-T mp-MRI according to the PI-RADS-v2 scoring system. RP specimens were examined with the whole-mount technique. csCaP definition: any tumor with a volume larger than 0.5 cm3 or with a Gleason score ≥7. Univariable logistic regression models explored the association between clinical and imaging data and the risk of csCaP. Significant variables (P < 0.05) were selected into multivariable regression models to identify independent predictors. A nomogram was designed to select the significant relevant predictors. The nomogram was internally validated in terms of discrimination and calibration. Receiver operating characteristics of the area under the curve was used to assess the discrimination ability of the nomogram. To assess the predictive performance of mpMRI, the accuracy of the mpMRI-based nomogram was compared with that excluding either PI-RADS score or mpMRI IL size. RESULTS: The analysis involved 393 patients. The median age was 65(9) years. The median prostate specific antigen was 5.81(3.76) ng/ml. 363 had csCaP. PI-RADS v2 score of 4-5, prostate specific antigen density of 0.15 or more, and mpMRI index lesion (IL) size were significantly associated with csCaP in the multivariable regression analyses. Based on these variables, a diagnostic model was developed. The full model yielded an area under the curve of 0.77 (95%CI:0.75-0.80) which was significantly better than those excluding mpMRI findings (P = 0.02) Decision curve analysis showed a slight but significant net benefit associated with the use of the mp-MRI based nomograms compared with those excluding either PI-RADS score (Delta net benefit 0.0278) or mpMRI maximum IL size (Delta net benefit 0.0111). CONCLUSIONS: The nomogram constructed in this study can assist urologists in assessing an individual's risk of csCaP at RP.

Chest X-ray Score and Frailty as Predictors of In-Hospital Mortality in Older Adults with COVID-19.

BACKGROUND: The purpose of this study was to evaluate the prognostic impact of chest X-ray (CXR) score, frailty, and clinical and laboratory data on in-hospital mortality of hospitalized older patients with COVID-19. METHODS: This retrospective study included 122 patients 65 years or older with positive reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and with availability to CXRs on admission. The primary outcome of the study was in-hospital mortality. Statistical analysis was conducted using Cox regression. The predictive ability of the CXR score was compared with the Clinical Frailty Scale (CFS) and fever data using Area Under the Curve (AUC) and net reclassification improvement (NRI) statistics. RESULTS: Of 122 patients, 67 died during hospital stay (54.9%). The CXR score (HR: 1.16, 95% CI, 1.04-1.28), CFS (HR: 1.27; 95% CI, 1.09-1.47), and presence of fever (HR: 1.75; 95% CI, 1.03-2.97) were significant predictors of in-hospital mortality. The addition of both the CFS and presence of fever to the CXR score significantly improved the prediction of in-hospital mortality (NRI, 0.460; 95% CI, 0.102 to 0.888; AUC difference: 0.117; 95% CI, 0.041 to 0.192, p = 0.003). CONCLUSIONS: CXR score, CFS, and presence of fever were the main predictors of in-hospital mortality in our cohort of hospitalized older patients with COVID-19. Adding frailty and presence of fever to the CXR score statistically improved predictive accuracy compared to single risk factors.

Oncological and functional outcome after partial prostate HIFU ablation with Focal-One®: a prospective single-center study.

BACKGROUND: We aimed to evaluate oncological and functional outcomes of index lesion HIFU ablation with Focal-One®. MATERIALS AND METHODS: We prospectively assessed treatment-naïve men with localized prostate cancer between 2017 and 2019. Inclusion criteria were stage cT ≤ 2, ≥5 years of life expectancy, grade group ≤3. Multiparametric magnetic resonance was performed before ablation. Patients with a prostate volume of ≥80 ml underwent debulking. Treatment failure was defined as a histologically confirmed tumor that required salvage treatment or androgen deprivation therapy. RESULTS: One hundred and eighty nine patients were enrolled. Data are presented as median and Interquartile Range (IQR). Median age was 70(11) years. Median baseline PSA was 5.8(3) ng/ml. Fourteen (7.4%) patients had prostate debulking before ablation. 104 (55%) patients underwent targeted ablation, 45 (23.8%) extended targeted ablation, 31 (16.4%) hemiablation, and 9 (4.8%) extended hemiablation. Median targeted ablated volume was 14(9) ml. Ninety-three complications occurred in 63/189 (33.3%) patients within 90 days. There were 77/93 (82.8%) minor (Clavien grade 1-2) and 16/93 (17.2%) major complications (Clavien grade 3a). Thirty-nine patients suffered from genito-urinary infections (Clavien grade 2). Fifteen patients required transurethral resection of the prostate/urethrotomy for recurrent urinary retention (Clavien grade 3a). One patient developed a recto-urethral fistula (Clavien grade 3a) and two long-lasting urinary incontinence. Median PSA nadir was 2.2(2.9) ng/ml. At a median follow-up of 29(15) months, 21/177 (11.9%) patients were treatment failures, 26 on monitoring, and 26 had a further ablation. Multivariable logistic regression found that failure patients had higher PSA (7.8 vs 5.7 ng/ml,p0.001) and double PSA nadir (4.8 vs 2.0 ng/ml, p < 0.001). Higher PSA nadir correlated with a 74% higher probability of failure (OR 1.74 95% CI 1.40-2.16). Cancer in the anterior stroma increased the odds of failure of three folds (OR 3.36 95% CI 1.18-9.53). Two mixed effect models (one for IPSS and one for IEEF-15) were estimated and they showed that time reaches the statistical significance coefficient only for the IEEF-15, meaning that subsequent evaluations of the indicators were significantly lower at each time point. CONCLUSIONS: Index lesion HIFU ablation demonstrated satisfactory early oncological outcome but anteriorly located tumors had inadequate ablation. Urinary function was well preserved. Sexual function slightly decreased during follow-up.

Combination of Multiparametric Magnetic Resonance Imaging With Elastic-fusion Biopsy Has a High Sensitivity in Detecting Clinically Significant Prostate Cancer in Daily Practice.

BACKGROUND: The index lesion (IL) is the largest cancer focus, usually harbors the highest grade, and might drive the history of prostate cancer (PCA). Multiparametric magnetic resonance imaging (mp-MRI) has a high negative predictive value in ruling out clinically significant (cs)PCA. We aimed evaluating the efficiency of mp-MRI and targeted biopsy in detecting csPCA and the concordance between the MRI index lesion (MRI-IL) and the presence of csPCA inside it. MATERIALS AND METHODS: We retrospectively evaluated 158 men who underwent prostate biopsy after a positive pre-biopsy mp-MRI scan. All mp-MRI lesions were biopsied using a transrectal ultrasound elastic-fusion approach (2-4 targeted plus 10-12 random systematic biopsies). csPCA was defined as grading group ≥ 2 or > 3 cores with cancer or ≥ 50% of core involved by tumor. RESULTS: mp-MRI detected 158 ILs and 46 non-ILs. One hundred were Prostate Imaging-Reporting and Data System version 2 (PI-RADS v2) score 3, 84 score 4, and 20 score 5. csPCA was found in 63.9% of the MRI-ILs. Eighty percent of detected cancer using mp-MRI and targeted biopsy was clinically significant. Eighty-seven percent of the transitional zone lesions were clinically non-significant or negative for cancer. The probability of detecting csPCA increases with increasing size of MRI-IL, and every extra millimeter raises the odds of detecting csPCA of 12.2%. All PI-RADS v2 score lesions showed a strong association with csPCA. The risk of matching between MRI-IL and csPCA inside it increases by 36.2% as the total percentage of cancer in all cores increases. CONCLUSIONS: mp-MRI showed high sensitivity in detecting csPCA in the peripheral zone, with concordance between MRI-IL and csPCA.

Phase 2 placebo-controlled, single-blind trial to evaluate the impact of oral ibandronate on bone mineral density in osteopenic breast cancer patients receiving adjuvant aromatase inhibitors: 5-year results of the single-centre BONADIUV trial.

AIM: We present the final results of the BONADIUV trial, a single-blind, randomised, placebo-controlled phase 2 study to evaluate the impact of ibandronate treatment on bone mineral density (BMD) in osteopenic women taking aromatase inhibitors (AI). PATIENTS AND METHODS: Between 2011 and 2014, 171 osteopenic patients were randomised in a 1:1 ratio to receive either placebo or oral monthly ibandronate (150 mg). Treatment duration was 2 years, with 6-month evaluation. Primary end-point was the 2-year lumbar spine (LS) and total hip (TH) T-score mean differences as measure of BMD variation. Secondary analyses of survival outcomes have been performed at a 5-year median follow-up. CLINICALTRIALS. GOV IDENTIFIER: NCT02616744. RESULTS: Median age of study population was 60.2 years (range 44-75). At the database cut-off time, the median follow-up was 63.3 months (range 2.7-87.3). No difference in terms of T-score was shown at baseline between arms both for TH (P = 0.61) and LS (P = 0.96). At 2-year follow up, the mean change was statistically significant in favour of ibandronate arm both at TH (P = 0.0002) and LS (P < 0.0001). No significant difference in terms of adverse events was observed between arms. At a median follow-up of 63.3 months (range 2.7-87.3), the overall survival (OS) rate was 97.5% in the placebo group and 93.0% in the ibandronate arm (P = 0.19). The invasive disease-free survival (iDFS) rates did not differ between groups (P = 0.42). CONCLUSIONS: Ibandronate compared to placebo improved BMD change in osteopenic women treated with adjuvant AI. Five-year survival analyses showed no difference between arms in terms of OS and iDFS rates.

Clustering of ABCB1 and CYP2C19 Genetic Variants Predicts Risk of Major Bleeding and Thrombotic Events in Elderly Patients with Acute Coronary Syndrome Receiving Dual Antiplatelet Therapy with Aspirin and Clopidogrel.

OBJECTIVE: The clinical efficacy of clopidogrel in secondary prevention of vascular events is hampered by marked inter-patient variability in drug response, which partially depends on genetic make-up. The aim of this pilot prospective study was to evaluate 12-month cardiovascular outcomes in elderly patients with acute coronary syndrome (ACS) receiving dual antiplatelet therapy (aspirin and clopidogrel) according to the clustering of CYP2C19 and ABCB1 genetic variants. METHODS: Participants were 100 consecutive ACS patients who were genotyped for CYP2C19 (G681A and C-806T) and ABCB1 (C3435T) polymorphisms, which affect clopidogrel metabolism and bioavailability, using PCR-restriction fragment length polymorphism. They were then grouped as poor, extensive and ultra-rapid metabolisers based on the combination of CYP2C19 loss-of-function (CYP2C19*2) and gain-of-function (CYP2C19*17) alleles and ABCB1 alleles. The predictive value of each phenotype for acute vascular events was estimated based on 12-month cardiovascular outcomes. RESULTS: The poor metabolisers were at an increased risk of thrombotic events (OR 1.26; 95% CI 1.099-1.45; χ2 = 5.676; p = 0.027), whereas the ultra-rapid metabolisers had a 1.31-fold increased risk of bleeding events compared with the poor and extensive metabolisers (OR 1.31; 95% CI 1.033-1.67; χ2 = 5.676; p = 0.048). Logistic regression model, including age, sex, BMI and smoking habit, confirmed the differential risk of major events in low and ultra-rapid metabolisers. CONCLUSIONS: Our findings suggest that ACS patients classified as 'poor or ultra-rapid' metabolisers based on CYP2C19 and ABCB1 genotypes should receive alternative antiplatelet therapies to clopidogrel.

Endovascular treatment of diabetic peripheral arterial disease in older and oldest old patients: a retrospective study.

BACKGROUND: Peripheral arterial disease (PAD) is frequent among older diabetic patients, but the evidence about endovascular revascularization is very limited. METHOD: We retrospectively analyzed data collected from 120 diabetic patients consecutively admitted to a Diabetic Foot Clinic, including 64 patients aged 65-79 years and 56 patients aged 80 or more. RESULTS: Percutaneous transluminal angioplasty (PTA) was followed by technical success in 82.5% of older patients and 62.5% of oldest old ones (p = 0.05). No significant difference was observed in regards to complete re-epithelization (76.6 vs 76.8%, p = 0.820), recurrent stenosis (26.6 vs 19.6%, p = 0.371), intra- or post-procedure complications (21.9 vs 10.7%, p = 0.102), and amputations (12.5 vs 5.4%, p = 0.176). DISCUSSION: Our findings suggest that older and oldest old patients with diabetic foot and critical ischemia could be effectively and safely treated with PTA.

Long Term Low Molecular Weight Heparin Anticoagulant Therapy Modulates Thrombin Generation and D-dimer in Patients with Cancer and Venous Thromboembolism.

We enrolled 62 consecutive patients with advanced stage cancers and venous thromboembolism (VTE), prospectively followed until 1 year. All patients received 6 month low-molecular-weight heparin (LMWH) therapy. We evaluated thrombin generation (TG) and D-dimer levels at different time points, to determine whether they were sensitive to LMWH and explore a possible association with VTE recurrence, bleeding, and overall survival. During LMWH, levels of TG and D-dimer significantly dropped. No VTE recurrences occurred, one patient had cancer-related intestinal hemorrhage. LMWH treatment was effective in controlling patient hypercoagulation. No VTE recurrences were detected. High D-dimer concentration was an independent predictor of poor survival.

Cutaneous toxicity from epidermal growth factor receptor inhibitors: would a subcutaneous desensitization be helpful? Case report.

PURPOSE: Cetuximab and panitumumab are monoclonal antibody inhibitors that bind the epidermal growth factor receptor (EGFR) currently used in the treatment of metastatic colorectal cancer. The main adverse event related to EGFR inhibitors (EGFR-Is) is cutaneous toxicity, which can cause dosage reduction and interruption of treatment. State-of-the-art management of skin toxicity associated with EGFR-Is therapy involves the topical administration of corticosteroids and oral antibiotics, but is not completely effective in the management of toxicity. Subcutaneous desensitization with increasing concentrations of monoclonal antibodies can induce a tolerance to drug administration and reduce cutaneous adverse effects. To our knowledge, this is the first case in which a reduction or a disappearance of skin toxicity caused by EGFR-Is through subcutaneous desensitization has been achieved. CASE REPORT: We present cases of 2 Caucasian patients with adenocarcinoma of the colon treated with EGFR-Is who developed severe cutaneous toxicity. A 73-year-old man presented grade 4 skin toxicity of the face and grade 3 skin toxicity of the trunk during treatment with cetuximab. A 68-year-old woman developed G2 rash on the face after the first administration of cetuximab. These patients underwent subcutaneous desensitization with increasing concentrations of EGFR-Is. After this procedure, patients restarted therapy at the optimal dosage with reduction or disappearance of skin toxicity. CONCLUSIONS: These cases suggest that by giving rising doses of antibody it is possible to obtain desensitization able to prevent severe cutaneous adverse events in patients treated with EGFR-Is.

Inferior Vena Cava Duplication: Incidental Case in a Young Woman.

A case of a double inferior vena cava (IVC) with retroaortic left renal vein, azygos continuation of the IVC, and presence of the hepatic portion of the IVC drained into the right renal vein is reported and the embryologic, clinical, and radiological significance is discussed. The diagnosis is suggested by multidetector computed tomography (MDCT), which reveals the aberrant vascular structures. Awareness of different congenital anomalies of IVC is necessary for radiologists to avoid diagnostic pitfalls and they should be remembered because they can influence several surgical interventions and endovascular procedures.

Isolated limb infusion chemotherapy with or without hemofiltration for recurrent limb melanoma.

AIM: To better define the efficacy and the safety of intra-arterial infusion performed with or without hemofiltration for recurrent limb melanoma. METHODS: Patients with the following characteristics were included in the study: recurrent limb melanoma not indicated for surgical resection, measurable disease in the extremity, > 18 years, performances status (Eastern Cooperative Oncology Group ) was 0-1 and life expectancy of at least 6 mo. Twenty nine consecutive patients were enrolled in the study. Patients underwent fluoroscopic placement of angiographic arterial and venous catheters to infuse the drug in the artery [isolated limb infusion (ILI)], and to stop the out flow (venous). Melphalan was rapidly infused into the isolated limb via the arterial catheter after the inflation of venous balloon catheter. Then the circulation of the limb was completely blocked with a pneumatic cuff at the root of the limb. Haemofiltration (HF) was available only in the main center, and was performed with an extracorporeal perfusion system, in order to reduce high systemic toxic peaks of drug. RESULTS: Thirty seven ILI were done in 29 cases (31 ILI-HF and 6 ILI) between 2001 and 2014 at Ancona and Pesaro Hospitals, Italy. Clinical outcomes were monitored 30 d after treatment. Eleven patients (38%) received infusion of melphalan alone, 7 (24%) melphalan associated to mitomicin C and 7 (24%) melphalan associated to cisplatin, the remaining 4 were treated with cisplatin, melphalan and epirubicin or cisplatin and mitomicin C. The overall response rate was 66%, in particular, 3 patients (10%) were complete responders and 16 (56%) were partial responders; whereas 7 patients (24%) had stable disease, and 3 (10%) showed progressive disease. Limb toxicity was assessed adopting Wieberdink scale, with evidence of 90% of low grade (I and II) toxicity. CONCLUSION: ILI-HF and ILI are effective and safe treatments for recurrent non-resectable limb melanoma. They present evidence of favorable clinical benefit and is effective in delaying progression.

Radiotherapy timing in the treatment of limited-stage small cell lung cancer: the impact of thoracic and brain irradiation on survival.

AIMS AND BACKGROUND: Small cell lung cancer is an aggressive histologic subtype of lung cancer in which the role of chemotherapy and radiotherapy has been well established in limited-stage disease. We retrospectively reviewed a series of limited-stage small cell lung cancers treated with chemotherapy and thoracic and brain radiotherapy. METHODS AND STUDY DESIGN: A total of 124 patients affected by limited-stage small cell lung cancer has been treated over 10 years in our Institute. Fifty-three patients (42.8%) had concomitant radio-chemotherapy treatment and 71 patients (57.2%) a sequential treatment. Eighty-eight patients (70.9%) underwent an association of a platinum-derived drug (cisplatinum or carboplatinum) and etoposide. Prophylactic cranial irradiation was planned in all patients with histologically proven complete response to primary radio-chemotherapy. RESULTS: With a mean follow-up of 2.2 years, complete response was obtained in 50.8% of cases. We found a significant difference between different radio-chemotherapy association approaches (P = 0.007): percentages of overall survival were respectively 10.0%, 12.9% and 5.6% in early, late concomitant and sequential radio-chemotherapy timing. Cranial prophylaxis did not seem to influence overall survival (P = 0.21) or disease-free survival for local relapse (P = 0.34). CONCLUSIONS: Concomitant radio-chemotherapy is the best approach according to our experience. Our results show a benefit of prophylactic cranial irradiation in distant metastasis-free survival.

Postmastectomy radiotherapy for locally advanced breast cancer receiving neoadjuvant chemotherapy.

Neoadjuvant chemotherapy (NAC) is widely used in locally advanced breast cancer (BC) treatment. The role of postmastectomy radiotherapy (PMRT) after NAC is strongly debated. The aim of our analysis was to identify major prognostic factors in a single-center series, with emphasis on PMRT. From 1997 to 2011, 170 patients were treated with NAC and mastectomy at our center; 98 cases (57.6%) underwent PMRT and 72 cases (42.4%) did not receive radiation. At a median follow-up period of 7.7 years (range 2-16) for the whole cohort, median time to locoregional recurrence (LRR) was 3.3 years (range 0.7-12.4). The 5-year and 10-year actuarial LRR rate were 14.5% and 15.9%, respectively. At the multivariate analysis the factors that significantly correlated with survival outcome were ≥ 4 positive nodes (HR 5.0, 1.51-16.52; P = 0.035), extracapsular extension (HR 2.18, 1.37-3.46; P = 0.009), and estrogen receptor positive disease (HR 0.57, 0.36-0.90; P = 0.003). Concerning LRR according to use of radiation, PMRT reduced LRR for patient with clinical T3 staged disease (P = 0.015). Our experience confirmed the impact of pathological nodal involvement on survival outcome. PMRT was found to improve local control in patients presenting with clinical T3 tumors, regardless of the response to chemotherapy.

Cutaneous and cardiac toxicity of concurrent trastuzumab and adjuvant breast radiotherapy: a single institution series.

Pilot studies have shown that patients with human epidermal growth factor receptor 2-positive disease have greater risk of relapse and death. The sooner trastuzumab is administered, the greater seems to be the benefit. A delay in the initiation of adjuvant radiotherapy (RT) may result in an increased rate of local recurrence. Since limited published data exist, the aim of our analyses was to evaluate the skin and heart toxicity of concomitant treatment. Between 2003 and 2012, 95 women were treated at our Institute by concomitant therapy for clinical stage I-III invasive breast cancer. Cardiac toxicity was evaluated according to the left ventricular ejection fraction (LVEF) decrease, with a prospective monitoring program. All acute and late toxicities were assessed according to the CTCAE-v3 criteria. At a median follow-up of 4.3 years (range 1.3-10.4), 5 patients developed locoregional relapse and 7 patients developed distant metastases; disease-free survival was 90% and overall survival 97.9%. Overall, skin toxicity ≥ Grade 2 was recorded in 13 patients (13.7%). No dysphagia and esophagitis ≥ Grade 2 were recorded. Cosmetic outcome was excellent in 41 patients (43.2%), good in 39 patients (41.1%), and fair in 10 patients (10.5%). All patients concluded the programmed RT. Among the 58 patients (61.1%) that recorded a LVEF dysfunction, the median decrease from baseline to the end of trastuzumab was 10%, while the median decrease from baseline to the last follow-up was 7% (p = 0.01). In our experience, concomitant trastuzumab and radiation treatment was overall well tolerated.

Impact of a breathing-control system on target margins and normal-tissue sparing in the treatment of lung cancer: experience at the radiotherapy unit of Florence University.

PURPOSE: In lung cancer, a high radiation dose to the target area correlates with better local control but is frequently counterbalanced by a higher risk of lung toxicity. Several methods exist to coordinate respiratory motion in lung radiotherapy. We aimed to investigate the impact of a breathing-control system on irradiated volumes and dosimetric parameters in three-dimensional conformal radiotherapy (3D-CRT) and stereotactic radiotherapy (SRT) treatments. MATERIALS AND METHODS: Twelve patients were scheduled for radical radiotherapy: five for SRT and seven for 3D-CRT. For each patient, in addition to the free-breathing computed tomography (CT) scan, four additional sets of CT slices were acquired using the Active Breathing Coordinator device (ABC, Elekta Oncology Systems Ltd., UK). RESULTS: The volumes acquired with the ABC device were significantly smaller than the free-breathing volumes [23 % reduction of planning tumour volume (PTV), p = 0.002]. ABC allowed a reduction of all dosimetric parameters [2.28 % reduction of percentage volume of lung treated to a dose of ≥ 20 Gy (V20), p = 0.004; 10 % reduction of mean lung dose (MLD), p = 0.009]. Significant differences were found both in SRT and in 3D-CRT, in peripheral and apical lesions. CONCLUSION: In our experience, ABC has the potential to reduce lung toxicity in the treatment of lung cancer; alternatively, it can allow the prescribed dose to be increased while maintaining the same risk of lung toxicity.

Clinical outcome of stereotactic body radiotherapy for abdominal lymph node metastases.

Aims and background. To report the clinical outcome of linac-based or robotic, image-guided stereotactic body radiotherapy in patients affected by abdominal lymph node metastases from different primary cancers. Methods and methods. Twenty-six patients with 32 abdominal lymph node metastases were consecutively treated at the University of Florence between April 2011 and May 2012. The mean follow-up was 4.6 months (SD, 3.9; range, 0.3-13). The dose prescription ranged between 24 Gy and 36 Gy delivered in 1-5 fractions. Results. In terms of local control, complete response to stereotactic body radiotherapy was obtained in 18 cases (66.7%), partial response in 7 (25.9%), and stable disease in 2 (7.4%). At the Cox univariate regression analysis, an increased risk of partial response or absence of local response to radiotherapy was found for subjects of the female sex (P = 0.036), age less than 50 years (P = 0.022), primary tumor of the genital tract (P = 0.007), and previous chemotherapy (P = 0.057). An excellent local control rate (90.9%) was obtained in patients affected by abdominal lymph node metastases of prostatic origin. Conclusions. Stereotactic body radiotherapy for abdominal lymph node metastases is a safe and effective treatment in terms of high rates of local control, especially in a subset of patients affected by prostate cancer.

Paclitaxel and bevacizumab in first-line treatment for HER2-negative metastatic breast cancer: single-center experience.

The aim of our analysis was to report the outcome and safety of patients treated with bevacizumab and paclitaxel as first-line treatment for HER2-negative metastatic breast cancer. Between February 2009 and August 2011, 62 consecutive patients received paclitaxel 90 mg/m(2) on days 1, 8, and 15 and bevacizumab (BV) 10 mg/kg intravenously on days 1 and 15, every 28-day cycle. After 6 cycles of combined treatment, patients were given maintenance BV every 3 weeks (15 mg/kg) until progression disease or unacceptable toxicity. At time of analysis, median overall survival was 12.3 months (range 4.6-44.8 months), progression-free survival was 8.1 months (range 2.3-33.2 months), and time to treatment failure was 8.4 months (range 2.3-33.2 months). Our results confirmed the efficacy and the acceptable toxicity profile of bevacizumab plus paclitaxel as first-line regimen for metastatic breast cancer.