Long-Term PSA Control with Repeated Stereotactic Body Radiotherapy in a Patient with Oligometastatic Castration-Resistant Prostate Cancer

Prostate cancer (PCa) is one of the most common malignancies and main causes of cancer death in Western countries. In the presence of metastatic disease, systemic treatment remains the main clinical option. However, since the introduction of highly sensitive imaging techniques, a new clinical 'entity' of metastatic patients with a limited number of lesions has been defined: oligometastatic patients. In this patient group, the use of stereotactic body radiotherapy (SBRT) or other local therapies against all active sites of disease revealed by 18F-choline positron emission tomography/computed tomography (PET/CT) could achieve sufficient prostate-specific antigen (PSA) control. However, a clear benefit of this procedure in terms of significant endpoints is yet to be demonstrated. This case report describes our experience with treating a castration-resistant PCa patient with 18F-choline PET/CT-guided SBRT. Because of the occurrence of 5 metachronous lesions over 4 years, the pattern of recurrence was defined by the local multidisciplinary team as oligometastatic disease, and the patient was treated with 5 courses of SBRT which yielded good PSA control. He started systemic therapy with abiraterone acetate almost 5 years after the diagnosis of recurrent PCa.

[(18)F]Choline PET/CT and stereotactic body radiotherapy on treatment decision making of oligometastatic prostate cancer patients: preliminary results

BACKGROUND

A new entity of patients with recurrent prostate cancer limited to a small number of active metastatic lesions is having growing interest: the oligometastatic patients. Patients with oligometastatic disease could eventually be managed by treating all the active lesions with local therapy, i.e. either surgery or ablative stereotactic body radiotherapy. This study aims to assess the impact of [(18)F]Choline ([(18)F]FMCH) PET/CT and the use stereotactic body radiotherapy (SBRT) in patients (pts) with oligometastatic prostate cancer (PCa).

METHODS

Twenty-nine pts with oligometastatic PCa (≤3 synchronous active lesions detected with [(18)F]FMCHPET/CT) were treated with repeated salvage SBRT until disease progression (development of > three active synchronous metastases). Primary endpoint was systemic therapy-free survival measured from the baseline [(18)F]FMCHPET/CT.

RESULTS

A total of 45 lesions were treated with SBRT. After a median follow-up of 11.5 months (range 3-40 months), 20 pts were still in the study and did not receive any systemic therapy. Nine pts started systemic therapy, and the median time of the primary endpoint was 39.7 months (CI 12.20-62.14 months). No grade 3 or 4 toxicity was recorded.

CONCLUSIONS

Repeated salvage [(18)F]FMCHPET/CT-guided SBRT is well tolerated and could defer the beginning of systemic therapy in selected patients with oligometastatic PCa.

The Effectiveness of Bevacizumab in Radionecrosis After Radiosurgery of a Single Brain Metastasis

Radionecrosis (RN) of brain tissue is a serious late complication of brain irradiation and historically has been treated with corticos-teroid therapy and alternatively surgical decompression. Recently, bevacizumab has been suggested for treatment of cerebral radiation necrosis. We present a case of a 73-years-old women affected by a primary non-small cell lung cancer with a single brain metastasis treated with radiosurgery. Two years after radiosurgery the patient referred neurological symptoms and a brain magnetic resonance confirmed the presence of RN. The patient refused surgical decompression so underwent at the treatment with bevacizumab 7.5 mg/kg/2 weeks for a total of 4 cycles. After two months of treatment the patient reported strumental and clinical improvement. Ten months after bevacizumab discontinuation the patient experienced a recurrence of RN with evident clinical manifestation and confirmed by radiological imaging. A new treatment with bevacizumab was not performed due to the systemic progression disease and the worsening of clinical status. Despite limited to only one clinical case, our study suggests the efficacy of bevacizumab to treat RN. Future studies are needed to confirm its mechanism and to properly define the optimal scheduling, dosage and duration of therapy.

Non-melanoma skin cancer treated with high-dose-rate brachytherapy and Valencia applicator in elderly patients: a retrospective case series

PURPOSE

The incidence of non-melanoma skin cancer (NMSC) has been increasing over the past 30 years. Basal cell carcinoma and squamous cell carcinoma are the two most common subtypes of NMSC. The aim of this study was to estimate tumour control, toxicity, and aesthetic events in elderly patients treated with high-dose-rate (HDR) brachytherapy (BT) using Valencia applicator.

MATERIAL AND METHODS

From January 2012 to May 2015, 57 lesions in 39 elderly eligible patients were enrolled. All the lesions had a diameter ≤ 25 mm (median: 12.5 mm) and a depth ≤ 4 mm. The appropriate Valencia applicator, 2 or 3 cm in diameter was used. The prescribed dose was 40 Gy in 8 fractions (5 Gy/fraction) in 48 lesions (group A), and 50 Gy in 10 fractions (5 Gy/fraction) in 9 lesions (group B), delivered 2/3 times a week. The biological effective dose (BED) was 60 Gy and 75 Gy, respectively.

RESULTS

After median follow-up of 12 months, 96.25% lesions showed a complete response and only two cases presented partial remission. Radiation Therapy Oncology Group - European Organization for Research and Treatment of Cancer (RTOG/EORTC) G 1-2 acute toxicities were observed in 63.2% of the lesions: 56.3% in group A and 77.7% in group B. Late G1-G2 toxicities was observed in 19.3% of the lesions: 18.8% in group A and 22.2% in group B, respectively. No G3 or higher acute or late toxicities occurred. In 86% of the lesions, an excellent cosmetic result was observed (87.5% in group A and 77.8% in group B). Six lesions had a good cosmetic outcome and only 2.3% presented a fair cosmetic impact.

CONCLUSIONS

The treatment of NMSC with HDR-BT using Valencia surface applicator is effective with excellent and good cosmetics results in elderly patients. The hypofractionated course appears effective and no statistical differences were observed between the two groups analysed.

Investigating molecular alterations to profile short- and long-term recurrence-free survival in patients with primary glioblastoma

Glioblastoma (GB) is the most aggressive type of primary brain tumor. Despite the progress in recent years regarding the diagnosis and treatment of GB, the recurrence rate remains high, due to the infiltrative and dispersive nature of the tumor, which typically results in poor patient prognosis. In the present study, 19 formalin-fixed, paraffin-embedded GB samples were selected from patients with GB tumors. The samples were classified into a short or long recurrence-free survival (RFS) group, based on the time of first recurrence of the disease in the patients. The 19 samples were molecularly characterized for mutations in the isocitrate dehydrogenase 1 (IDH1) gene, amplification of the epidermal growth factor receptor (EGFR) gene, presence of the EGFR variant III, and methylation of the promoter region of the O⁶-methylguanine-DNA methyltransferase (MGMT) gene. Then, the expression of 84 genes involved in cell-cell and cell-matrix interactions, and that of 84 microRNAs (miRNAs) associated with brain cancer, was profiled. In addition, a copy number variation analysis of 23 genes reported to undergo frequent genomic alterations in human glioma was also performed. Differences in the expression levels of a number of genes were detected across the short and long RFS groups. Among these genes, 5 in particular were selected, and a 5-genes combination approach was developed, which was able to differentiate between patients with short and long RFS outcome. The high levels of sensitivity and precision displayed by this 5-genes combination approach, which were confirmed with a cross-validation method, provide a strong foundation for further validation of the involvement of the aforementioned genes in GB in a larger patient population. In conclusion, the present study has demonstrated how the expression pattern of miRNAs and mRNAs in patients with GB defines a particular molecular hallmark that may increase or reduce the aggressive behavior of GB tumors, thus influencing the survival rates of patients with GB, their response to therapy and their tendency to suffer a relapse.

New approaches for imaging and therapy of solid cancer

Radionuclide therapy is a systemic treatment that aims to deliver cytotoxic radiation to cancer cells. Due to their properties, antibodies have been considered as suitable agent for the delivery of therapeutic radioisotopes, radioimmunotherapy (RIT). This article gives an overview of new approaches for imaging and therapy of solid cancer with particular attention to strategies to enhance treatment success. Examples of increased antibody uptake by targeting stromal constituent of tumor microenvironment such as fibronectin (FN) an important tumor-associated angiogenesis targeting agent, with specifically designed antibody format will be provided. Strategies oriented to identify patients most likely to benefit from RIT including identification of radiosensitivity profiles, in vivo target identification by teragnostic approach and better prediction of dosimetric estimates would be presents. Combination regimens such as with chemo-radiotherapy and immunotherapy would be also discussed as an approach to enhance RIT success.

Akt1 rs2498801 is related to survival in head and neck squamous cell cancer treated with radiotherapy

BACKGROUND

Radiotherapy (RT) with or without chemotherapy (CT) plays an important role as exclusive treatment in patients with head and neck squamous cell cancer (HNSCC). Unfortunately, in some cases, benefit for patients is not recorded and only treatment-related complications are registered.

MATERIALS AND METHODS

Data relating to Akt1 single nucleotide polymorphism (SNP) and response to treatment of 46 patients treated with exclusive RT or RT-CT for HNSCC were evaluated.

RESULTS

For heterozygous patients median overall survival was 28.5 months, while for the wild-type group median overall survival was 10.9 (p=0.019). Three-year survival was 85% for mutated Akt1 homozygosis and 40% for patients with a heterozygous status (p=0.019, hazard ratio (HR)=7.960).

CONCLUSION

SNP of rs2498804 can recognize patients resistant to RT-CT. Further studies are needed to confirm our data and to investigate the role of Akt SNPs in HNSCC patients.

Radio-chemotherapy with temozolomide in elderly patients with glioblastoma. A mono-institutional experience

AIM

The aim of the present study was to evaluate the toxicity and clinical outcome of radio-chemotherapy with temozolomide in patients with glioblastoma aged more than 65 years.

MATERIALS AND METHODS

The analysis was performed in 20 male and 20 female patients with a mean age at diagnosis of 71.2 (range=65-81) years, with Karnofsky performance status greater than 70 without important comorbidities.

RESULTS

Toxicities related to temozolomide and concomitant radiochemotherapy were similar to those reported for younger patients. The median time to progression and median overall survival of the entire cohort, from the date of diagnosis, were 10.6 (range=6.7-14.4) months and 19.3 (range=17.8-20.7) months, respectively. No significant results for overall survival analysis were found for age at diagnosis and cardiovascular risk factors, as covariates, with hazard ratios of 1.00 (95% confidence interval=0.92-1.10) and 0.9 (95% confidence interval=0.43-1.88), respectively.

CONCLUSION

Considering the relative good toxicity profile and the efficacy of treatment, our experience supports the use of radiochemotherapy with temozolomide in older patients with glioblastoma.

Bevacizumab and fotemustine for recurrent glioblastoma: a phase II study of AINO (Italian Association of Neuro-Oncology)

The optimal combination of bevacizumab with cytotoxic or cytostatic drugs in recurrent glioblastoma is unknown. We performed a phase 2 trial of combined bevacizumab and fotemustine for patients with glioblastoma at first relapse after radiotherapy and temozolomide. The primary endpoint was 6-month progression-free survival (PFS), while secondary endpoints were overall survival (OS), response rate based on RANO criteria and toxicity. Fifty-four patients with recurrent GBM were enrolled. The authors observed a 6-month PFS rate of 42.6% (95% CI 29.3-55.2) and a median PFS of 5.2 months (95% CI 3.8-6.6). The median OS was 9.1 months (95% CI 7.3-10.3). Twenty-eight patients (52%) had a radiographic response, and a significant neurological improvement with steroid reduction was observed in 25/42 symptomatic patients (60%). MGMT promoter methylation was significantly associated with improved PFS in univariate analysis. Most unifocal tumors at baseline had a focal enhancing progression (76%), while the diffuse non-enhancing progression accounted for 9.5%. Response or survival were not associated with any pattern of progression. Survival after failure of treatment was short. Twelve out of 54 patients (22%) discontinued fotemustine for grade 3/4 myelotoxicity, while 4/54 (7.4%) discontinued bevacizumab. This study failed to demonstrate a superiority of the combination of bevacizumab and fotemustine over either bevacizumab or fotemustine alone as historical controls. Future studies should explore alternative regimens of combination of the two drugs.

Management and outcome of high-grade multicentric gliomas: a contemporary single-institution series and review of the literature

BACKGROUND

Multicentric malignant gliomas are well-separated tumours in different lobes or hemispheres, without anatomical continuity between lesions. The purpose of this study was to explore the clinical features, the pathology and the outcome according to the management strategies in a consecutive series of patients treated at a single institution. In addition, an analysis of the existing literature is presented.

METHODS

For the institutional analysis, a retrospective review of all patients who underwent treatment for multicentric gliomas in the last 7 years was performed. For the analysis of the literature, a MEDLINE search with no date limitations was accomplished for surgical treatment of multicentric malignant gliomas.

RESULTS

Two hundred and thirty-nine patients with glioma were treated in our department. Eighteen patients (7.5 %) with a mean age of 64 years (age range, 37-78 years) presented multicentric malignant gliomas. Thirteen patients (72 %) underwent surgical resection of at least one lesion that was followed by adjuvant treatment in all but one case. Five patients (28 %) underwent stereotactic biopsy and thereafter received chemotherapy. A survival advantage was associated with resection of at least one lesion followed by adjuvant treatment (median overall survival 12 months) compared with 4 months for stereotactic biopsy followed by chemotherapy. Similar results were obtained from the review of the literature.

CONCLUSIONS

Resection of at least one lesion seems to play a significant role in the management of selected patients with multicentric malignant gliomas. Multi-institutional studies on larger series are warranted to define how aggressively the patients with malignant multicentric gliomas should be treated.

Phase II study of neoadjuvant chemotherapy with modified FOLFOXIRI in borderline resectable or unresectable stage III pancreatic cancer

4062

Background: FOLFIRINOX has shown high activity in metastatic pancreatic cancer (PC) patients and could be an interesting regimen also for patients with inoperable locally advanced disease. Our group had developed a similar schedule in metastatic colorectal cancer named FOLFOXIRI with good tolerance and activity. Therefore, we have decided to perform a phase II trial to prospectively evaluate the activity of modified FOLFOXIRI in borderline resectable or unresectable PC. Methods: Modified FOLFOXIRI consisted of a lower dose of irinotecan (150 mg/sqm) and of infusional 5-fluorouracil (2800 mg/sqm as a 48-hour continuous infusion on days 1 to 3) with no bolus 5-fluorouracil. Folinic acid and oxaliplatin (85 mg/sqm) remained unchanged. The study enrolled patients with diagnosis of pancreatic adenocarcinoma, stage III borderline resectable or unresectable disease (cT4,cN0-1,cM0), ECOG PS 0-1, age 18-75. The primary end-point of the study was the percent of patients who undergo radical surgical resection after chemotherapy. Results: Thirty-two patients have been enrolled; M/F=12/20; PS 0/1=16/16. Median age was 60 years (range 44-75). Median number of FOLFOXIRI cycles was 6 (range 2-14). Grade 3-4 toxicities was experienced by 20 patients during chemotherapy. Twelve partial responses (37%) and 14 stable diseases (45%) have been observed; 2 patients had progressive diseases (6%). The remaining 4 patients (12%) have not been yet evaluated because are still in the first months of treatment. A local treatment was received after chemotherapy by 18 patients until now: 13 (41%) received radical surgical resection and 5 received concomitant chemo-radiotherapy. Three explorative laparotomy showed occult metastases. In other 7 cases surgery is planned while 2 patients refused surgery. Median progression-free survival is 14.0 months and median overall survival is 24.2 months with a two-year survival rate of 54%. Conclusions: Chemotherapy with FOLFOXIRI seems active in locally advanced PC and may allow to obtain a downstaging of disease leading to achieve a curative surgical resection in some cases. Longer follow up is needed to better evaluate long-term outcome of this strategy.

Clinical outcome of tailored adjuvant postoperative chemoradiotherapy in IB FIGO stage cervical cancer

AIM

The aim of the present report is to review a mono-institutional experience of postoperative radiotherapy in selected patients with cervical cancer.

PATIENTS AND METHODS

Between 1999 and 2008, fifty-one patients with high-risk stage IB cervical cancer underwent tailored adjuvant postoperative radiotherapy; concurrent chemoradiotherapy was administered to patients presenting a high risk of recurrence. The median follow-up was 58 months.

RESULTS

All patients were in complete remission at first follow-up assessment. Ten patients were subject to recurrences between 7 and 54 months after treatment. The 2-year and 5-year disease-free survival rates were 88.1% and 74.9%, respectively; 2-year and 5-year overall survival rates of the whole group were 91.8% and 82.0%, respectively. Only one case of grade 4 and four cases of grade 3 side effects were reported.

CONCLUSION

Tailored adjuvant postoperative chemoradiotherapy is able to obtain a satisfactory clinical outcome in patients with high-risk early-stage IB cervical cancer.

Brain recurrences in patients with ovarian cancer: report of 12 cases and review of the literature

The aim of the investigation was to assess 12 cases of brain recurrences among ovarian cancer patients who had undergone surgery followed by platinum-based chemotherapy. Brain lesions were the first recurrence in 4 (33%) patients, the second recurrence in 7 (58%), and the fourth recurrence in one patient. The median time from ovarian cancer diagnosis to brain metastasis detection was 33.5 months (range, 13.5-86.5 months), brain metastases were multiple in 6 (50%) cases, and extra-cranial disease was present in 7 (58%) cases. Brain recurrence was symptomatic in 10 patients and the clinical presentation included impaired deambulation, extremity weakness, seizure, headache, nausea/vomiting and visual disturbance. Out of the 6 patients with single brain metastases, one underwent surgery, one had surgical excision followed by whole brain irradiation, 3 patients received stereotactic radiotherapy (followed by chemotherapy for coexistent extra-abdominal recurrence in one), and one had only symptomatic treatment. Out of the 6 patients with multiple brain metastases, four received whole brain irradiation (followed by chemotherapy for concomitant extra-cranial recurrence in one case), one patient had gamma-knife irradiation of three cerebral lesions (followed by chemotherapy for concurrent abdominal recurrence), and one patient had only symptomatic treatment. The median overall survival from diagnosis of brain metastasis was 8.3 months (range, 1-28 months), and it was not related to the number of brain metastases (multiple versus single), presence or absence of extra-cranial disease, or interval between ovarian cancer diagnosis and brain metastasis detection (<33.5 months versus > or =33.5 months). In conclusion, brain metastasis from ovarian cancer can represent a late manifestation of the disease, associated with a very poor prognosis.

Synergistic Antitumor Activity of ZD6474, An Inhibitor of Vascular Endothelial Growth Factor Receptor and Epidermal Growth Factor Receptor Signaling, with Gemcitabine and Ionizing Radiation against Pancreatic Cancer

PURPOSE

Standard treatments have modest effect against pancreatic cancer, and current research focuses on agents targeting molecular pathways involved in tumor growth and angiogenesis. This study investigated the interactions between ZD6474, an inhibitor of tyrosine kinase activities of vascular endothelial growth factor receptor-2 and epidermal growth factor receptor (EGFR), gemcitabine, and ionizing radiation in human pancreatic cancer cells and analyzed the molecular mechanisms underlying this combination.

EXPERIMENTAL DESIGN

ZD6474, ionizing radiation, and gemcitabine, alone or in combination, were given in vitro to MIA PaCa-2, PANC-1, and Capan-1 cells and in vivo to MIA PaCa-2 tumor xenografts. The effects of treatments were studied by the evaluation of cytotoxicity, apoptosis, cell cycle, EGFR and Akt phosphorylation, modulation of gene expression of enzymes related to gemcitabine activity (deoxycytidine kinase and ribonucleotide reductase), as well as vascular endothelial growth factor immunohistochemistry and microvessel count.

RESULTS

In vitro, ZD6474 dose dependently inhibited cell growth, induced apoptosis, and synergistically enhanced the cytotoxic activity of gemcitabine and ionizing radiation. Moreover, ZD6474 inhibited phosphorylation of EGFR and Akt and triggered cell apoptosis. PCR analysis showed that ZD6474 increased the ratio between gene expression of deoxycytidine kinase and ribonucleotide reductase. In vivo, ZD6474 showed significant antitumor activity alone and in combination with radiotherapy and gemcitabine, and the combination of all three modalities enhanced MIA PaCA-2 tumor growth inhibition compared with gemcitabine alone.

CONCLUSIONS

ZD6474 decreases EGFR and Akt phosphorylation, enhances apoptosis, favorably modulates gene expression in cancer cells, and acts synergistically with gemcitabine and radiotherapy to inhibit tumor growth. These findings support the investigation of this combination in the clinical setting.

Cyclin A and E2F1 overexpression correlate with reduced disease-free survival in node-negative breast cancer patients

BACKGROUND

Available prognostic factors do not accurately identify node-negative breast cancer patients at high risk of disease recurrence and progression.

PATIENTS AND METHODS

Cyclin A and E2F1 expression levels were evaluated in 75 consecutive node-negative breast cancer patients with a median follow-up of 10 years. Both parameters were tested for correlation with all the available clinicopathological parameters and with the clinical evolution of the disease.

RESULTS

Cyclin A was overexprNed in 45.3% of patients and significantly related to large tumor size, high Ki67 and high E2F1 expression levels. No relationship was observed between cyclin A and tumor estrogen receptor (ER) status, grading or patient age. Seventeen patients relapsed within 5 years from diagnosis. Twelve (71%) of them showed cyclin A overexpression in comparison with 22 (38%) out of the 58 who did not relapse (p = 0.02). Disease-free survival (DFS) was significantly shorter in patients with cyclin A-overexpressing tumors compared to non-overexpressing ones (p = 0.01). DFS was also significantly longer in low vs. high Ki67 expression (p = 0.003) and in low vs. high E2F1 expression (p = 0.02). On multivariate analysis, the simultaneous high expression of all three parameters (cyclin A, Ki67 and E2Fl) was a strong independent prognostic factor for shorter DFS (HR 13.4).

CONCLUSION

These findings suggest that assessment of cyclin A and/or E2F1 expression levels, associated with Ki67, might be useful for a better prognostic evaluation of node-negative breast cancer patients and support the need for further studies to evaluate their suitability for use in the routine clinical management of these patients.

Comparison of various diffraction formulas in a study of open resonators

Modes and losses of the planar Fabry-Perot and confocal resonators have been computed using various kernels obtained by different approximations of diffraction theory. For Fabry-Perot resonators no practical influence was found of the shape of the kernel on the results, at least for Fresnel numbers ranging up to 42.25. For the confocal resonator large differences were found even at small Fresnel numbers N greater, similar 1. In particular, a qualitative difference was found between the results obtained by the so-called parabolic approximation and the kernel of Rayleigh-Luneberg diffraction theory. These differences confirm the influence of the amplitude in the approximations.

Resonances and resonant fields in a fabry-perot resonator illuminated by a line source

In the present paper, the field internal to an infinite-strip plane-parallel mirror resonator is evaluated in the case when the structure is illuminated by a cylindrical primary wave. The feeder where the primary wave originates constitutes a perturbation of the resonator and is assumed to scatter a cylindrical wave proportional to the field impinging on it. The quasi-stationary field pattern internal to the structure is evaluated for several values of the efficiency of the scatterer, that is, of the factor relating the wave scat- tered by the feeder to the wave impinging on the feeder. Resonant frequencies and fields are compared with the resonant frequencies and fields of a Fabry-Perot resonator not perturbed by the presence of the feeder. The effect of the persistent primary wave alone is analyzed by considering the case of a feeder with vanishing efficiency.

Quasi-stationary wave patterns inside infinite-strip open resonators

The quasi-stationary wave patterns inside a two-mirror optical resonator are evaluated as the sum of a progressive and a regressive wave by assuming the mirrors to be illuminated by the fundamental mode of the resonator at a resonance frequency. The progressive and the regressive waves are also evaluated in the case of the first-order mode. Calculations are made for an infinite-strip Fabry-Perot resonator, as well as for a cylindrical and a confocal resonator, with Fresnel number N = 1.