Impact of low skeletal muscle mass in oropharyngeal cancer patients treated with radical chemo-radiotherapy: A mono-institutional experience

AIMS

Low skeletal muscle mass index (SMI) has recently emerged as an independent prognostic factor in oncological patients and it is linked with poor survival and higher treatment toxicity. The present study aims to determine the possible impact of low SMI on survival and acute toxicity in oropharyngeal patients.

METHODS

Seventy-six patients with locally advanced oropharyngeal squamous cell carcinoma (stage III-IVC) were treated in our institution with Helical TomoTherapy® (HT - Accuray, Maddison, WI, USA) between 2005 and 2021. All patients received concomitant platinum-based chemotherapy (CT) (at least 200 mg/m2). The SMI was determined using the calculation of cross-sectional area at C3. Twenty patients (26%) presented pre-treatment low SMI, according to Chargi definitions.

RESULTS

All patients concluded the treatment. Thirteen patients with low SMI (65%) and 22 patients with normal SMI (39%) presented acute toxicity greater than or equal to grade 3, but this difference was not statistically significant (p-value = 0.25). Overall survival was analyzed in 65 patients, excluding those who finished CT-RT less than six months before the analysis. Overall survival was significantly lower in low SMI versus normal SMI patients (p-value = 0.035). Same difference was observed in N0-N2a patients, suggesting an important role of SMI also in lower nodal burden and putatively better prognosis.

CONCLUSIONS

Although the results are limited to a small population, our case series has the advantage to be very homogeneous in patients and treatment characteristics. In our setting, SMI demonstrated a crucial impact on overall survival. Further investigation with larger samples is necessary to confirm our results to improve patient outcomes.

Prevalence of Serum Antibody Titers against Core Vaccine Antigens in Italian Cats

Feline core vaccines strongly recommended for all cats are against Feline panleukopenia virus (FPV), Felid herpesvirus type 1 (FeHV-1), and Feline calicivirus (FCV), but cats can be classified as low- and high-risk based on their lifestyle. The aim of this study was to determine the actual seroprotection against FPV, FeHV-1, and FCV in a large cohort of Italian cats by using the VacciCheck test. A total of 740 cats (567 owned and 173 stray cats; 435 vaccinated and 305 unvaccinated) were analyzed for Protective Antibody Titers (PATs). Differences related to origin, sex, age, breed, FIV/FeLV status, health status, and time elapsed since last vaccination were evaluated. Less than half of the entire cohort (36.4%) had PATs for all three diseases simultaneously, increasing to 48.6% if weak positive values were also considered and 50.3% when considering only the 435 vaccinated cats. Particularly, antibodies were detected against FCV, FPV, and FeHV-1 at protective titers (PATs) in 78.6%, 68.1, and 49.1% of the cats, respectively. In general, owned, neutered, and adult FIV- and/or FeLV-negative cats were the most protected categories, even if not always for the three viruses. Most cats maintained high PATs for 3 years or longer after vaccination against FPV and FCV but not FeHV-1. Long-lasting protective immunity persisted for many years after the last vaccination (more than 18 years in the oldest cats). Nevertheless, since not all cats were protected after so many years and for all pathogens, checking protection via antibody titration could be the best choice to prevent immunity breakdowns. The discussion also focuses on the reliability of antibody titration for the two URTD (upper respiratory tract disease) viruses which, unlike for FPV, is not widely accepted as a valid index of protection.

Acute kidney injury and acute kidney disease in high-dose cisplatin-treated head and neck cancer

Background

In locally advanced head and neck squamous cell carcinoma (LA-SCCHN) at least 200mg/m² (standard dose 300 mg/m²) of cisplatin concomitant with radiotherapy represents the standard of care, both in postoperative and conservative settings. Nevertheless, high dose administration every 3 weeks is often replaced with low dose weekly cisplatin to avoid toxicities like kidney injury, though often failing to reach the therapeutic dose. Our aim was to investigate the incidence of renal impairment in the real-life setting, integrating high dose cisplatin with adequate supportive therapy, and to explore both Acute Kidney Injury (AKI) and Acute Kidney Disease (AKD), a recently described clinical renal syndrome that encompasses functional alterations of the kidney lasting fewer than 3 months.

Methods

One hundred and nine consecutive patients affected by LA-SCCHN and treated with at least a cumulative dosage of 200 mg/m² of cisplatin concomitant with radiotherapy were enrolled in this prospective observational study.

Results

AKI was reported in 12.8% of patients, 50% of whom were stage 1 (KDIGO criteria), while 25.7% of the cohort developed AKD. Patients with baseline estimated Glomerular Filtration Rate (eGFR) < 90 ml/min showed a higher incidence of AKD (36.2% vs 17.7%). Hypertension, baseline eGFR, and therapy with Renin-angiotensin-aldosterone system inhibitors proved to be significant factors associated with both AKI and AKD.

Conclusion

AKI and AKD are not rare complications of high-dose cisplatin, but an appropriate prevention strategy and accurate monitoring of patients during treatment could lead to a reduction of the burden of these conditions.

Emergency Department Visits among Cancer Patients during SARS-CoV-2 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a global impact. Patients with cancer, their caregivers, and physicians need to balance the challenges associated with COVID-19 while ensuring cancer care. Nevertheless, emotional distress and hospital departmental reorganization could have led to a decrease in ED admissions even among oncological patients. Methods: We compared the 72 days of the pandemic in 2020 with the same calendar days in 2019 and 2021, defining a 20% decrease in ED visits as clinically significant. We studied the cause for visit, its severity, outcome (admission vs. discharge vs. death vs. hospice/palliative care), the tumor site, and method of arrival to the ED for the 3 time periods. Results: A significant decrease in ED oncological visits was found in 2020 compared to 2019, before returning to similar numbers in 2021. Fear, anxiety, and worry, in addition to hospital departmental reorganization, surely had an important role in the delay of ED visits, which resulted in irreparable consequences.

The observational clinical registry (cohort design) of the European Reference Network on Rare Adult Solid Cancers: The protocol for the rare head and neck cancers

INTRODUCTION

Care for head and neck cancers is complex in particular for the rare ones. Knowledge is limited and histological heterogeneity adds complexity to the rarity. There is a wide consensus that to support clinical research on rare cancer, clinical registries should be developed within networks specializing in rare cancers. In the EU, a unique opportunity is provided by the European Reference Networks (ERN). The ERN EURACAN is dedicated to rare adults solid cancers, here we present the protocol of the EURACAN registry on rare head and neck cancers (ClinicalTrials.gov Identifier: NCT05483374).

STUDY DESIGN

Registry-based cohort study including only people with rare head and neck cancers.

OBJECTIVES

to help describe the natural history of rare head and neck cancers;to evaluate factors that influence prognosis;to assess treatment effectiveness;to measure indicators of quality of care.

METHODS

Settings and participants It is an hospital based registry established in hospitals with expertise in head and neck cancers. Only adult patients with epithelial tumours of nasopharynx; nasal cavity and paranasal sinuses; salivary gland cancer in large and small salivary glands; and middle ear will be included in the registry. This registry won't select a sample of patients. Each patient in the facility who meets the above mentioned inclusion criteria will be followed prospectively and longitudinally with follow-up at cancer progression and / or cancer relapse or patient death. It is a secondary use of data which will be collected from the clinical records. The data collected for the registry will not entail further examinations or admissions to the facility and/or additional appointments to those normally provided for the patient follow-up. Variables Data will be collected on patient characteristics (eg. patient demographics, lifestyle, medical history, health status); exposure data (eg. disease, procedures, treatments of interest) and outcomes (e.g. survival, progression, progression-free survival, etc.). In addition, data on potential confounders (e.g. comorbidity; functional status etc.) will be also collected. Statistical methods The data analyses will include descriptive statistics showing patterns of patients' and cancers' variables and indicators describing the quality of care. Multivariable Cox's proportional hazards model and Hazard ratios (HR) for all-cause or cause specific mortality will be used to determine independent predictors of overall survival, recurrence etc. Variables to include in the multivariable regression model will be selected based on the results of univariable analysis. The role of confounding or effect modifiers will be evaluated using stratified analysis or sensitivity analysis. To assess treatment effectiveness, multivariable models with propensity score adjustment and progression-free survival will be performed. Adequate statistical (eg. marginal structural model) methods will be used if time-varying treatments/confounders and confounding by indication (selective prescribing) will be present.

RESULTS

The registry initiated recruiting in May 2022. The estimated completion date is December 2030 upon agreement on the achievement of all the registry objectives. As of October 2022, the registry is recruiting. There will be a risk of limited representativeness due to the hospital-based nature of the registry and to the fact that hospital contributing to the registry are expert centres for these rare cancers. Clinical Follow-up could also be an issue but active search of the life status of the patients will be guaranteed.

MO192: Renal Outcomes in High Dose Cisplatin in Locally Advanced Squamous Cell Cancer of the Head and Neck: A Monocentric Experience

BACKGROUND AND AIMS

Head and neck cancer (HNC) represents the sixth most common neoplasm worldwide, accounting for 400 000 deaths globally every year. Among HNC, the squamous cell carcinoma (SCCHN) is the most aggressive histology, being responsible for more than 90% of cases. The overall 5-year survival rate goes from 33% to 68% according to risk factors and primary site.

In clinical practice, at least two cycles of three-weekly high-dose cisplatin (100 mg/m2) concomitant to radiotherapy represents the standard of care given LA-SCCHN with a curative intent, both in postoperative and conservative settings.

However, concurrent high-dose cisplatin is associated with significant acute and late toxicities. Acute kidney injury (AKI) is a common and serious side effect of high-dose cisplatin-based concurrent chemoradiation (CRT). AKI is a predictor of immediate and long-term adverse outcomes. The aim of this study was to investigate the nephrotoxicity of chemotherapy in real life of LA-SCCHN patients during and after treatment with high-dose cisplatin-based CRT, with a particular focus on AKI onset.

METHOD

Ninety-three consecutive patients affected by LA-SCCHN and treated with high-dose cisplatin-based CRT were enrolled in a prospective observational monocentric study. All patients received adequate supportive care such as SF 750 mL + 16 mEq MgSO4 IV 200 mL/h before and after cisplatin administration (a total of 1500 mL at day 0 and again at day 1), with 375 mL mannitol 10% if diuresis after hydration was less than 100–200 mL/h and dexamethasone 12 mg IV as chemo premedication at day 0 and 8 mg PO at days 1 to 3 as antiemetic prophylaxis followed by 6 days of steroid progressive decalage. Demographic data, medical history, and clinical, laboratory and histological data at presentation were reported from the medical records. Serum creatinine was recorded at baseline and after each cycle of treatmentat day 1 and day 10, respectively. eGFR was calculated using CKD-EPI 2012 formula. Bayesian linear regression was used to evaluate the impact of the clinical and pathological features on eGFR decay through cycles and AKI incidence.

RESULTS

The cohort was composed of 93 patients with a median age of 59 years, M/F ratio 2.4, median BMI 24.9 (IQR: 22.3, 27.4), median eGFR 92.2 mL/min. A total of 58% of patients presented basal eGFR &gt; 90 mL/min, while 42% &lt;90 mL/min (only 4 patients with eGFR &lt; 60 mL/min). Approximately 34.4% patients presented hypertension, and the 8.6% were diabetics.

AKI onset was 22.6% in the overall cohort: among those 21 patients who developed AKI, no one showed stage II-III AKI according to the KDIGO classification. Using a definition of AKI based only on an increase in serum creatinine &gt; 1.5 higher than 1.5 times the baseline value, AKI incidence was 14% with a significative difference (P = .04) between patients with baseline eGFR &gt; 90 mL/min and patients with eGFR &lt; 90. Statistical analysis preformed using a logistic regression model showed a correlation between arterial hypertension and AKI incidence, while other comorbidities (such as diabetes) and concurrent medications were not associated with an increased in AKI incidence.

CONCLUSION

AKI was a common complication of high-dose cisplatin treatment in our LA-SCCHN patients’ cohort (22.6%): interestingly, the totality of AKI cases was represented by stage I AKI. The main risk factor for AKI development was a diagnosis of arterial hypertensions (Figure 1), while no correlation with concomitant medications and diabetes was found. The overall AKI incidence in our cohort was lower than reported in previous Studies, likely due to the use of a preventive protocol based on hydration and mannitol use; among those patients who developed AKI, no modification in cisplatin treatment scheme were needed, particularly all the patients reached a cumulative cisplatin dose ≥200 mg/m2.

Skeletal Muscle Depletion and Major Postoperative Complications in Locally-Advanced Head and Neck Cancer: A Comparison between Ultrasound of Rectus Femoris Muscle and Neck Cross-Sectional Imaging

Simple Summary

Skeletal muscle mass (SMM) depletion is gaining popularity as independent predictor of postoperative complications in many surgical scenarios, even in the field of head and neck oncology. In this study, we demonstrate the value of ultrasound scans of the rectus femoris muscle together with the neck CT/MRI at C3 level in terms of estimation of SMM (through muscle cross sectional area), the identification of sarcopenic patients and as a predictor of major surgical morbidity in a cohort of locally-advanced head and neck cancer patients submitted to surgical treatment. This provides important tools for the on-going re-assessment of patients with regards to any pre-habilitation strategy aimed at reducing postoperative complications.

Abstract

Skeletal muscle mass (SMM) depletion has been validated in many surgical fields as independent predictor of complications through cross-sectional imaging. We evaluated SMM depletion in a stage III-IV head and neck cancer cohort, comparing the accuracy of CT/MRI at C3 level with ultrasound (US) of rectus femoris muscle (RF) in terms of prediction of major complications. Patients submitted to surgery were recruited from 2016 to 2021. SMM was estimated on CT/MRI by calculating the sum of the cross-sectional area (CSA) of the sternocleidomastoid and paravertebral muscles at C3 level and its height-indexed value (cervical skeletal muscle index, CSMI) and on US by computing the CSA of RF. Specific thresholds were defined for both US and CT/MRI according to ROC curve in terms of best prediction of 30-day major complications to detect sarcopenic subjects (40–53%). Sixty-five patients completed the study. At univariate analysis, major complications were associated to lower RF CSA, lower CSA at C3 level and lower CSMI, together with previous radiotherapy, higher ASA score and higher modified frailty index (mFI). At multivariate analysis RF CSA (OR 7.07, p = 0.004), CSA at C3 level (OR 6.74, p = 0.005) and CSMI (OR 4.02, p = 0.025) were confirmed as independent predictors in three different models including radiotherapy, ASA score and mFI. This analysis proved the value of SMM depletion as predictor of major complications in a head and neck cancer cohort, either defined on cross-sectional imaging at C3 or on US of RF.

Angiogenesis inhibition in lung cancer: emerging novel strategies

PURPOSE OF REVIEW

In the current review, we will explore the molecular bases that have determined the design of clinical trials exploring the efficacy of antivascular agents in combination with chemotherapy, immune check point inhibitors and epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) in patients with advanced nonsmall cell lung cancer.

RECENT FINDINGS

Recent clinical trials have demonstrated the synergistic effect of antivascular agents with immune checkpoint inhibitors and EGFR-TKIs, despite no molecular marker has been identified yet to select patients.

SUMMARY

Lung cancer remains one of the first causes of cancer-related death. However, thanks to the development of stratified molecular medicine and the introduction of immune checkpoint inhibitors, patients' survival has significantly improved. Due to the critical role of pro-angiogenic factors in cancer progression, antivascular agents targeting the vascular endothelial growth factor (VEGF) and its receptor (VEGFR) have been developed. Their efficacy has been explored in combination with chemotherapy, and immune checkpoint inhibitors, with promising but not definitive conclusions about their impact on prolonging patients' survival.

Prognostic role of pre-treatment magnetic resonance imaging (MRI)-based radiomic analysis in effectively cured head and neck squamous cell carcinoma (HNSCC) patients

OBJECTIVES

To identify and validate baseline magnetic resonance imaging (b-MRI) radiomic features (RFs) as predictors of disease outcomes in effectively cured head and neck squamous cell carcinoma (HNSCC) patients.

MATERIALS AND METHODS

Training set (TS) and validation set (VS) were retrieved from preexisting datasets (HETeCo and BD2Decide trials, respectively). Only patients with both pre- and post-contrast enhancement T1 and T2-weighted b-MRI and at least 2 years of follow-up (FUP) were selected. The combination of the best extracted RFs was used to classify low risk (LR) vs. high risk (HR) of disease recurrence. Sensitivity, specificity, and area under the curve (AUC) of the radiomic model were computed on both TS and VS. Overall survival (OS) and 5-year disease-free survival (DFS) Kaplan-Meier (KM) curves were compared for LR vs. HR. The radiomic-based risk class was used in a multivariate Cox model, including well-established clinical prognostic factors (TNM, sub-site, human papillomavirus [HPV]).

RESULTS

In total, 57 patients of TS and 137 of VS were included. Three RFs were selected for the signature. Sensitivity of recurrence risk classifier was 0.82 and 0.77, specificity 0.78 and 0.81, AUC 0.83 and 0.78 for TS and VS, respectively. VS KM curves for LR vs. HR groups significantly differed both for 5-year DFS (p<.0001) and OS (p=.0004). A combined model of RFs plus TNM improved prognostic performance as compared to TNM alone, both for VS 5-year DFS (C-index: 0.76 vs. 0.60) and OS (C-index: 0.74 vs. 0.64).

CONCLUSIONS

Radiomics of b-MRI can help to predict recurrence and survival outcomes in HNSCC.

What to Do and What Not to Do in the Management of Cancer Pain: A Physician Survey and Expert Recommendations

Background

Despite the prevalence of pain among patients with cancer and the availability of pertinent guidelines, the clinical management of oncological pain is decisively insufficient. To address this issue, we evaluated current trends in clinical practice and subsequently generated a list of ten corrective actions—five things to do and five things not to do—for the diagnosis, management, and monitoring of cancer pain.

Methods

The survey included 18 questions about clinical practice surrounding background pain and breakthrough cancer pain (BTcP). Survey questions were developed by a scientific board of 10 physician experts and communicated via email to an expanded panel of physicians in Italy. Responses were tabulated descriptively for analysis.

Results

Of 51 invited physicians, 32 (63%) provided complete survey responses. The responses revealed several incongruencies with current guideline recommendations: physicians did not always diagnose or monitor pain using diagnostically validated or disease-specific instruments; frequently based clinical decision-making on time availability or convenience; and pharmacological therapy was often inappropriate (eg, prescribing NSAIDs or corticosteroids for BTcP). The list of corrective actions generated by the scientific board favored a guideline-oriented approach that systematically characterizes oncological pain and implements treatment based on pain characteristics (eg, fast-acting transmucosal opioids for BTcP) and evidence-based recommendations.

Conclusion

Oncologists require better education and training about the diagnosis, treatment, and monitoring of oncological pain. Physicians should be aware of current guideline recommendations as well as available pharmacological tools for BTcP.

Intratumoral Cellular Heterogeneity: Implications for Drug Resistance in Patients with Non-Small Cell Lung Cancer

Simple Summary

The number of druggable tumor-specific molecular alterations in the treatment of non-small cell lung cancer (NSCLC) has grown significantly in the past decade. Emerging technologies such as liquid biopsy and single-cell methods allow for studying targetable drivers and develop personalized treatments. However, although new therapies confer prolonged disease control and high tumor response rates, most patients eventually progress on targeted treatments. Intratumoral heterogeneity is a frequent event in NSCLC, driving the tumor cells to develop adaptive or new resistance mechanisms within the drug environment. This review summarizes the current and upcoming research on the biological role of tumor heterogeneity, highlighting the link between early and acquired drug resistance and tumoral heterogeneity in targetable driver mutated NSCLC.

Abstract

Tailored therapies based on the identification of molecular targets currently represent a well-established therapeutic scenario in the treatment of non-small cell lung cancer (NSCLC) patients. However, while aiming to improve patients’ response to therapy, development of resistance is frequently observed in daily clinical practice. Intratumoral heterogeneity is a frequent event in NSCLC, responsible for several critical issues in patients’ diagnosis and treatment. Advances in single-cell sequencing technologies have allowed in-depth profiling of tumors and attributed intratumoral heterogeneity to genetic, epigenetic, and protein modification driven diversities within cancer cell populations. This review highlights current research on the biological role of tumor heterogeneity and its impact on the development of acquired resistance in NSCLC patients.

Low skeletal muscle mass as predictor of postoperative complications and decreased overall survival in locally advanced head and neck squamous cell carcinoma: the role of ultrasound of rectus femoris muscle

PURPOSE

Skeletal muscle mass (SMM) depletion and sarcopenia as predictors of postoperative complications and poorer overall survival (OS) have been validated in many surgical fields through cross-sectional imaging (CT, MRI), with potential limitations. We evaluated it in a stage III-IV head and neck squamous cell carcinoma (HNSCC) surgical cohort through ultrasound (US) of rectus femoris muscle (RF), a quick, cheap, repeatable alternative.

METHODS

Patients submitted to surgical treatment with curative purpose were recruited and prospectively evaluated through clinical, biometric, biochemical, surgical, pathological and functional prognosticators and with preoperative US of RF with regards to 30-day complications and OS.

RESULTS

Forty-seven patients completed the study. RF cross-sectional area (RF-CSA) was used to identify patients with low SMM (CSA ≤ 0.97 cm²: 18/47, 38.3%). RF-CSA was lower in complicated cases (0.95 ± 0.48 vs 1.41 ± 0.49 cm²; p = 0.003), remaining the only independent predictor of postoperative complications at multivariate analysis, with a model including ASA score and modified Frailty index (OR 9.84; p = 0.004). SMM depletion significantly impaired OS (13.6 ± 2.9 vs 26.3 ± 2.1 months; p = 0.017), being its only independent prognosticator at multivariate Cox regression analysis (OR 4.42; p = 0.033).

CONCLUSION

RF-CSA, evaluated with US, seems a reliable method for identification of patients with low SMM in a stage III-IV HNSCC cohort, defining a subset at high-risk of 30-day complications and poorer OS.

Prognostic role of pre-treatment magnetic resonance imaging (MRI) radiomic analysis in patients with squamous cell carcinoma of the head and neck (SCCHN)

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Background: Emerging data suggest that radiomics can be used to predict outcomes in SCCHN. At present, only few data are available for pre-treatment MRI. Methods: Study population was retrieved from an ongoing multicenter, randomized, prospective trial (NCT02262221, HETeCo) evaluating health and economic outcomes of two different follow-up (FUP) strategies (intensive vs non-intensive) in effectively cured stage III-IV (VIII TNM ed.) SCCHN. We selected only patients with both pre- and post-contrast enhancement T1 and T2-weighted baseline MRI (b-MRI) and at least 2 years (2y) of FUP. A radiomic model was developed to identify high risk (HR) and low risk (LR) of disease recurrence. Radiomic features (RF) were extracted from the primary tumor in the b-MRI. The best RF combination was selected by Least Absolute Shrinkage and Selection Operator (LASSO). Ten-fold cross-validation was used to compute sensitivity, specificity and area under the curve (AUC) of the classifier. Kaplan-Meier (KM) curves were estimated for HR and LR, for both overall survival (OS) and disease-free survival (DFS) and log rank test was performed. Three years (3y)-DFS and OS were also estimated for the two groups. The radiomic risk class was used as a new variable in a multivariate Cox model including well established prognostic factors in SCCHN (TNM stage, subsite and HPV). Results: Out of 155 enrolled HETeCO patients, 98 baseline imaging were retrieved of which 57 b-MRI. Of these, 51 met the eligibility criteria (25 in intensive and 26 in non-intensive arm). Baseline patients’ characteristics were: median age 66 yr (38-86); sex (M 42; F 9); median smoking history: 30 packs/y (1-100); 25 oral cavity (49%), 18 oropharynx (35%, 14 HPV+), 6 larynx (12%), 2 hypopharynx (4%). At a median FUP of 42 months (25-64), 45 (88%) patients are still alive. The recurrence rate was 20% (10/51, of which 2 distant). In total, 1608 RF were extracted. The sensitivity, specificity and AUC of the classifier were 90%, 76%, and 80%, respectively. The radiomic risk class was found to be an independent prognostic factor for both DFS and OS (p=0.01 and p=0.046, respectively). KM curves for DFS and OS were significantly different between HR and LR groups (p=0.002 and p=0.04, respectively). In HR vs LR, 3-y DFS and OS were: 78% [61-100%] vs 97% [90-100%], and 88% [75-100%] vs 96% [88-100%], respectively. Conclusions: Radiomics of pre-treatment MRI can predict outcomes in SCCHN. External validation of this preliminary radiomics-based model is currently ongoing.

Prognostic factors in recurrent or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

In clinical trials of recurrent and metastatic head and neck carcinoma, Argiris et al have identified prognostic factors for overall survival (OS) and progression-free survival (PFS), weight loss, Eastern Cooperative Oncology Group performance status (ECOG-PS), tumor primary site, tumor differentiation, prior radiotherapy, deriving a two-group prognostic classification. This study evaluates Argiris's classification in "field-practice" patients.

METHODS

The main analysis included 327 cases; a secondary analysis excluded 31 patients with oropharyngeal carcinoma (OPC) p16-positive and/or human papilloma virus (HPV)-positive. OS and PFS curves were estimated with the Kaplan-Meier method; multivariable Cox analyses were also performed.

RESULTS

In the full series, OS was significantly different in patients with 0-2 and ≥3 adverse features (median, 14 vs 10 months; P = .03). PFS was statistically different in the two groups (median, 7 vs 5 months; P = .02). At a multivariable analysis investigating additional prognostic features, site of relapse and disease-free interval were significant predictors of OS and PFS.

CONCLUSION

The Argiris's model was confirmed in a "field-practice" population. Moreover, we found additional putative prognostic factors.

Predictors of Patient-Reported Dysphagia Following IMRT Plus Chemotherapy in Oropharyngeal Cancer

The aim of this cross-sectional study is to evaluate the factors associated with patient-reported dysphagia in patients affected by locally advanced oropharyngeal cancer (OPC) treated with definitive intensity-modulated radiation therapy (IMRT) and concurrent chemotherapy (CHT), with or without induction CHT. We evaluated 148 OPC patients treated with IMRT and concurrent CHT, without evidence of disease and who had completed their treatment since at least 6 months. At their planned follow-up visit, patients underwent clinical evaluation and completed the M.D. Anderson dysphagia inventory (MDADI) questionnaire. The association between questionnaire composite score (MDADI-CS) and different patients' and tumor's characteristics and treatments (covariates) was investigated by univariable and multivariable analyses, the latter including only covariates significant at univariable analysis. With a median time from treatment end of 30 months [range 6-74 months, interquartile range (IQR) 16-50 months], the median (IQR) MDADI-CS was 72 (63-84). The majority of patients (82.4%) had a MDADI-CS ≥ 60. At multivariable analysis, female gender, human papilloma virus (HPV)-negative status, and moderate and severe clinician-rated xerostomia were significantly associated with lower MDADI-CS. Patient-perceived dysphagia was satisfactory or acceptable in the majority of patients. HPV status and xerostomia were confirmed as important predictive factors for swallowing dysfunction after radiochemotherapy. Data regarding female gender are new and deserve further investigation.

Combination of immunotherapy with chemotherapy and radiotherapy in lung cancer: is this the beginning of the end for cancer?

Immune checkpoint inhibitors have significantly improved overall survival with an acceptable safety profile in a substantial proportion of non-small cell lung cancer (NSCLC) patients. However, not all patients are sensitive to immune checkpoint blockade and, in some cases, programmed death 1 (PD-1) or programmed death ligand 1 (PD-L1) inhibitors accelerate tumor progression. Several combination strategies are under evaluation, including the concomitant or sequential evaluation of chemotherapy or radiotherapy with immunotherapy. The current review provides an overview on the molecular rationale for the investigation of combinatorial approaches with chemotherapy or radiotherapy. Moreover, the results of completed clinical studies will be reported.

Metal nanoinks as chemically stable surface enhanced scattering (SERS) probes for the analysis of blue BIC ballpoint pens

Metal nanoinks constituted by Ag nanoparticles and Au nanorods were employed as probes for the Surface Enhanced Raman Scattering (SERS) analysis of a blue BIC ballpoint pen. The dye components of the pen ink were first separated by thin layer chromatography (TLC) and subsequently analysed by SERS at illumination wavelengths of 514 nm and 785 nm. Compared to normal Raman conditions, enhanced spectra were obtained for all separated spots, allowing easy identification of phthalocyanine Blue 38 and triarylene crystal violet in the ink mixture. A combination of effects such as molecular resonance, electromagnetic and chemical effects were the contributing factors to the generation of spectra enhanced compared to normal Raman conditions. Enhancement factors (EFs) between 5 × 10³ and 3 × 10⁶ were obtained, depending on the combination of SERS probes and laser illumination used. In contrast to previous conflicting reports, the metal nanoinks were chemically stable, allowing the collection of reproducible spectra for days after deposition on TLC plates. In addition and in advance to previously reported SERS probes, no need for additional aggregating agents or correction of electrostatic charge was necessary to induce the generation of enhanced SERS spectra.

Report from European Association for the Study of the Liver: HCC Summit, Geneva, Switzerland, 2-5 February 2017

The European Association for the Study of the Liver Hepatocellular Carcinoma (HCC) international meeting held in Geneva in February 2017 focused on the state of the art of HCC management, from diagnosis to treatment and the potential development of clinical research in this field. This report reviews some of the most interesting topics discussed at the meeting such as the role of hepatitis C viral infection treatment with direct-acting antivirals in enhancing HCC risk, current prognostic systems, early diagnosis techniques, curative therapies for early HCC and the systemic treatments for advanced disease with a look into future perspectives.

Oncological supportive-care unit (OSU): An effective toxicity management model

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Background: Oncological patients (pts) frequently experience treatment-related toxicities worsening outcome. According to literature data, 23% - 50% emergency department (ED) and/or hospital admissions in this setting could be avoidable and hesitate in higher management costs and worse quality of life (QoL). Cancer treatment adherence rate is 27% - 87%, mostly related to chemotherapy and post-surgical side effects. Since May 2014 we established an OSU to improve clinical outcome and treatment adherence, to reduce ED access/hospital admissions and toxicities management costs. Methods: All OSU data have been recorded in a database which includes daily management costs into an Italian regional regimen called MAC (Complex Ambulatory Macro-activities). ED accesses were recorded by our “First aid ED operative system”. Hospitalizations costs were evaluated according to regional DRG (Diagnosis Related Group) value and Hospital Discharge Register (HDR). All pts admitted to OSU should answer to two validated questionnaires regarding QoL and anxiety: FACT-G (General FunctionalAssessment Cancer Therapy) and HADS (Hospital Anxiety and depression Scale). We compared toxicities management costs 20 months before and 20 months during OSU. Results: From May 2014 to December 2015, 302/719 pts were admitted to OSU for a supportive care therapy. We obtained the reduction of the costs of the ED access/hospital admission to 52%, while the gain in management was 59% (see table). PS ECOG improved in 9 (18%) pts while it was unchanged in 41 (82%) pts. Adherence to oncologic treatment was satisfactory (95%) and the average values of total FACT and HADS in the follow-up phase improved compared to baseline in 63% and 43% of pts respectively. Conclusions: The interim analysis suggests that OSU improves clinical outcome in terms of QoL and treatment adherence. Moreover, our OSU model demonstrated the possibility to reduce toxicity-related ED accesses/hospital admissions and management costs. [Table: see text]

Role of nutrition in incidence and management of cancer therapy-induced diarrhea (CTID): HEAT (Health Eat and Toxicity) prospective interventional study and preliminary data

e18251

Background: Metastatic colorectal cancer (mCRC) patients (pts) are at high risk of CTID influencing treatment outcome. The primary end-point of our study was the decrease of grade 3-4 (G3-4 from Common Terminology Criteria for Adverse Events 4.0) CTID incidence to 50% in respect to literature data. A predefined nutritional regimen was planned and administrated to each pts. In explorative analyses, we investigated the correlation between Vitamin D deficiency and CTID incidence and between dihydropyrimidine dehydrogenase (DpD) mutations and CTID. Methods: All mCRC pts undergoing chemotherapy (CT) with an expected G3-4 CTID incidence of about 17% were enrolled. During CT the nutritionist administered a predefined, slag free diet according to Italian Society of Human Nutrition indications and within World Cancer Research Found recommendations. Results: Fifty consecutive pts were enrolled within 11 months. Pts characteristics are summarized in the table. A significant decrease (p-value 0.00096; IC 95% 0.059) of G3-4 CTID incidence to 95% was obtained in respect to literature data. No CT modification or admissions/supportive care were needed. Due to strict diet adherence (96%) > 50% pts had no diarrhea and no one had G4 diarrhea. BMI improved in 35% over-weights and in 40% obese, no changes in normal-weights. The correlation analysis showed the decrease of CTID incidence with the increase of vitamin D levels, but did not reveal a relation between DpD mutations and diarrhea. Conclusions: The preliminary results suggest a possible role of the diet on CTID prevention and a correlation with vitamin D levels. [Table: see text]

Temporal course and predictive factors of analgesic opioid requirement for chemoradiation-induced oral mucositis in oropharyngeal cancer

BACKGROUND

Oral mucositis (OM)-related pain affects most patients with head and neck cancer during treatments, but its management is not standardized.

METHODS

We retrospectively collected data about the opioid therapy used for OM-induced pain in all patients with oropharyngeal cancer treated with chemoradiotherapy (CRT) between 2009 and 2013. To compare the different opioids, a conversion into oral morphine equivalent daily dose (OMEDD) was performed. The highest OMEDD (h-OMEDD) and the opioids' weekly increase were associated with patient, tumor, or treatment-related characteristics in order to identify predictive factors of opioid consumption.

RESULTS

Ninety-seven percent of patients received opioids. The h-OMEDD was significantly correlated with a higher OM-grade and a lower smoking history. The weekly opioids' increase was higher in patients with lower smoking history and human papillomavirus (HPV) positivity.

CONCLUSION

Opioid therapy remains the mainstay for OM-related pain management during CRT. The role of previous smoking and HPV on opioid use needs further confirmations. © 2016 Wiley Periodicals, Inc. Head Neck 38: E1521-E1527, 2016.

Health care-associated infections in patients with head and neck cancer treated with chemotherapy and/or radiotherapy

BACKGROUND

The incidence of health care-associated infections in patients with head and neck cancer receiving chemotherapy and/or radiotherapy (RT) is unknown. This retrospective study investigated the most common pathogens and their antibiotic sensitivity/resistance patterns in patients with head and neck cancer.

METHODS

Infection rates in patients with head and neck cancer were analyzed over 2 periods (January 2005 to December 2009 and January 2010 to November 2012).

RESULTS

In the first period, 140 health care-associated infections were observed among 2288 admissions, mostly because of gram-negative pathogens affecting the respiratory tract. In the second period, 212 health care-associated infections were observed. An increase in antibiotic resistance was reported. Health care-associated infections were more frequent with: male sex, age <65 years, important comorbidities, smoking, proton pump inhibitors (PPIs), prophylaxis, and/or central venous catheter (CVC), locally advanced disease, and chemotherapy/RT, especially after the third week of treatment.

CONCLUSION

Health care-associated infections increased over time, with corresponding increases in gram-negative pathogens and resistant strains. Prevention and treatment protocols should be implemented in institutions treating patients with head and neck cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1009-E1013, 2016.

Evaluation of an every-other-day palonosetron schedule to control emesis in multiple-day high-dose chemotherapy

AIM

Efficacy of intermittent palonosetron dosing in patients undergoing multiple-day, high-dose chemotherapy (HDC) was investigated.

PATIENTS & METHODS

Fifty-eight patients received palonosetron (0.25 mg intravenous [iv.]) every other day plus daily dexamethasone (8 mg iv. twice daily) dosing. The primary end point was complete control (CC; no emesis, no rescue anti-emetics, and no more than mild nausea) in the overall acute-period (until 24 h after chemotherapy completion).

RESULTS

Acute-period CC occurred in 81% and 50% of patients receiving palonosetron and ondansetron (historical control cohort), respectively. Palonosetron (odds ratio [OR]: 4.37; p = 0.001) and a longer duration of HDC regimen (OR: 3.47; p = 0.011) independently predicted a better anti-emetic outcome.

CONCLUSION

Palonosetron every other day plus daily dexamethasone is an effective anti-emetic coverage in patients undergoing HDC.

Aprepitant versus metoclopramide, both combined with dexamethasone, for the prevention of cisplatin-induced delayed emesis: a randomized, double-blind study

BACKGROUND

A combination of aprepitant, a 5-HT3 receptor antagonist (r.a.), and dexamethasone is recommended for the prophylaxis of cisplatin-induced nausea and vomiting in the acute phase, and aprepitant + dexamethasone (A + D) in the delayed phase. The aim of this study was to verify if A + D is superior to metoclopramide plus dexamethasone (M + D) in preventing delayed emesis in cancer patients receiving the same prophylaxis for acute emesis.

PATIENTS AND METHODS

A randomized double-blind study comparing A + D versus M + D was completed in previously untreated cancer patients. Before chemotherapy, all patients were treated with intravenous palonosetron 0.25 mg and dexamethasone 12 mg, and oral aprepitant 125 mg. On day 2-4, patients randomly received oral dexamethasone 8 mg plus aprepitant 80 mg once daily (days 2-3) or metoclopramide 20 mg four times daily plus dexamethasone 8 mg bid. Primary endpoint was rate of complete response (no vomiting, no rescue treatment) in day 2-5 after chemotherapy.

RESULTS

Due to difficulty in the accrual of patients, 303 of the 480 planned patients were enrolled, 284 were fully evaluable, 147 receiving A + D, 137 M + D. Day 1 results were similar in both arms. On day 2-5, complete response rate was not significantly different (80.3% with A + D versus 82.5% with M + D, P < 0.38, respectively), and all secondary endpoints were also similar (complete protection, total control, no vomiting, no nausea, and score of Functional Living Index-Emesis; P < 0.24). Adverse events incidence was not significantly different between the two treatments.

CONCLUSIONS

In cancer patients submitted to cisplatin-based chemotherapy, receiving the same antiemetic prophylaxis for acute emesis, A + D is not superior to M + D in preventing delayed emesis, and both treatments present similar toxicity.

CLINICALTRIALSGOV NUMBER

NCT00869310.

Fentanyl pectin nasal spray as treatment for incident predictable breakthrough pain (BTP) in oral mucositis induced by chemoradiotherapy in head and neck cancer

BACKGROUND

Painful mucositis is one of the most distressing toxicities of chemoradiotherapy (CRT) for head and neck cancer (HNC), with the characteristics of incidental predictable breakthrough pain (BTP) during swallowing. Fentanyl pectin nasal spray (FPNS) could be a good therapeutic option.

METHODS

Patients were prospectively considered if receiving basal analgesic therapy with opiates for painful mucositis of grade ⩾4 on a numerical rating scale from 0 to 10. They were offered FPNS 100mcg before oral intake. When patients reached the effective dose, they evaluated the basal pain intensity before FPNS use and after 10, 20, 30 and 40min.

RESULTS

Seventeen HNC patients were offered FPNS before oral intake, with 15 patients completing treatment. Mean reduction of incidental BTP intensity after FPNS was 3.1 points (range 1.2-5.8). Mean time elapsed since FPNS use and highest pain reduction was 26min.

CONCLUSIONS

FPNS demonstrated activity against BTP when swallowing in HNC patients. These data should be considered as hypothesis-generating.

Health care-associated infections (HAIs) in head and neck carcinoma (HNC) patients treated with chemotherapy (CT) and/or radiotherapy (RT)

6046

Background: HAIs are dangerous complications of HNC treatment. In lack of data we collected own data in a high volume HNCMOU, comparing them with those observed in other departments. Methods: HAIs recorded retrospectively among 2,288 hospital admissions at our HNCMOU observed from 2005 to 2009 were compared with 427 recent (2010-2012) hospital admissions. In the same period HAIs observed in ENT Surgical, Medical Oncology (MO) and Bone Marrow Transplantation (BMT) dept were recorded. Results: Between 2005 and 2009, 140 HAIs were observed in the HNCMOU: 49% Gram-, 35% Gram+, 16% fungi; 88% of P. Aeruginosa and all Enterobacteriaceae were sensible to meropenem and piperacillin/tazobactam, methicillin-resistant S. aurei (MRSA) were 42% (Table). In the last 3 years infections and resistances rates increased with a similar pattern of bacteria: among 212 HAIs (43% Gram-, 32% Gram+, 24% fungi) the majority (39%) involved respiratory tract, 89% of P. aeruginosa and 92% of Enterobacteriacae were sensible to carbapenem and 89% and 51% were sensible to piperacillin/tazobactam. MRSA were 29%. We compared these data with HAIs occurred from 2005 to 2012 into other dept: most of HAIs in ENT Surgical dept were at surgical site (41%) due to Gram+ (45%), in BMT were sepsis (56%) due to Gram+ (51%) and in MO were urinary tract infections (39%) due to Gram – (70%). Conclusions: Gram- continue to represent the first cause of HAIs in HNC cancer patients treated with CT and/or RT, suggesting a peculiar pattern. This is paralleled by a rise in carbapenem resistance, while MRSA still represent a significant fraction. [Table: see text]

Identification of a gene expression profile associated with progression-free survival (PFS) in relapsed or metastatic (RM) head and neck squamous cell cancer (HNSCC) patients (pts) treated with first-line cetuximab and platinum therapy

6027

Background: First-line chemotherapy with platinum and cetuximab is usually offered to RM-HNSCC pts. In the Extreme trial a median PFS time of 5.6 months was reported. However, a small fraction of pts achieves a prolonged PFS (> than 12 months). Until now, no recognized predictive biological factor has been identified. Methods: A group of 14 pts treated with a first-line platinum and cetuximab with a PFS exceeding 12 months (long PFS) and a group of 26 pts with a PFS less than 5.6 months (short PFS) were selected. Tumor specimens of the recurrence (25 cases) or, if not available, of the primary tumor were collected. In order to identify molecular profiles deregulated between the 2 groups, a gene expression microarray analysis was performed using the Whole-Genome DASL assay and HumanHT-12_v4 BeadArray chips (lllumina). Results: The 2 groups were well balanced in regard to recognized prognostic factors (performance status, weight loss, prior radiotherapy, tumor grade, site of primary tumor, residual disease at primary tumor site). Mean PFS was 21 months in long (range 13-36) and 4 months in short PFS group (range 1-5). By class comparison analysis between the 2 groups, the expression pattern of 136 genes was found differentially expressed (FDR<0.05). In long PFS group, EGFR and genes associated to EGFR pathway including CDCP1 and EPGN were up regulated, as well as its ligand (EREG). Several members of the Kallikrein serine proteases gene family are present among the most upregulated genes in long PFS group, suggesting the involvement of extracellular-matrix remodelling. In addition to cellular morphology, pathways analysis showed an enriched modulation of genes belonging to cell-to-cell signalling, DNA replication/DNA repair and lipid metabolism. Conclusions: Our analysis suggests that a specific molecular signature may be associated with long and short PFS after platinum/cetuximab first line chemotherapy in RM-HNSCC pts. To our knowledge, it is the first study attempting to generate hypotheses in this field and further validation is required.

Sorafenib in recurrent and/or metastatic salivary gland carcinomas (RMSGCs): An investigator-initiated phase II trial (NCT01703455)

6020

Background: Palliative chemotherapy is the standard of care for RMSGCs. However its activity is usually poor especially in adenoid cystic carcinoma (ACC), while in histotypes other than ACC (non ACC) the response, if any, is of short duration. Some preclinical and clinical evidence suggest a rationale for the employment of anti-angiogenetic agents in RMSGCs, such as sorafenib. Methods: Subjects withproven RMSGC not amenable to surgery and/or radiotherapy were enrolled to receive sorafenib at 400 mg BID q28 days until disease progression, unacceptable toxicity or consent withdrawal. Primary endpoint was response rate (RR) (CR+PR) according to RECIST; secondary objectives included RR according to CHOI criteria, disease control rate (DCR) and toxicity. 37 subjects were required to test the null hypothesis that RR will be ≤ 5% versus the alternative that RR ≥ 20% within a two stage Simon design. At least 4 responders were necessary to reject the null hypothesis. Results: 19 ACC and 18 non ACC subjects were accrued from September 2010 to September 2012. 21 patients had received at least one chemotherapy regimen for RMSGC. Overall 6 PRs according to RECIST were recorded corresponding to a RR of 16% (95% CI 6,2-32,0) (11% in ACC and 22% in non ACC). PR according to CHOI was observed in 10 cases (of which only 2 were concordant with RECIST); no response was reported in 15 cases while CHOI response was not evaluable in 12 patients. A dramatic necrotic evolution of the disease, which resulted in cavitation of metastatic lesions in one case, was observed in two patients with mucoepidermoid cancer (MEC). SD was 57% lasting a median of 7 months (range 2-15+ months). At a median follow up of 10 months (range 3-28+ months): 5 patients are still receiving sorafenib; 15 are no longer being treated and 17 have died. AEs were generally consistent with previous sorafenib studies, except for one G5 toxicity due to meningitis (probably related to necrosis of a local relapse) and one G3 aspergillus abscess. Conclusions: Sorafenib is the first anti-angiogenetic agent to demonstrate some activity in RMSGCs, particularly in MEC. Molecular analyses, typifying MEC and ACC are ongoing. Clinical trial information: NCT01703455.

Association between salivary cytokine levels and chemoradiotherapy-induced toxicities in head and neck cancer patients

5555

Background: Mucositis is a common complication of chemoradiotherapy (CTRT) for head and neck cancer (HNC), linked to a balance between pro- and anti-inflammation serum cytokines. No study has yet addressed the role of salivary cytokines in influencing toxicity severity. Methods: Twenty consecutive stage III (15%) and IV (85%) HNC patients (pts) were treated with radiotherapy (64-70 Gy) plus cisplatin (n=15), carboplatin (n=4) or cetuximab (n=1). Primary tumor site was oral cavity (15%), oropharynx (55%), nasopharynx (15%), larynx or hypopharynx (15%). Unstimulated saliva samples were collected according to standardized protocols before CTRT, during (3rd, 5th and 7th weeks) and two weeks after; concomitantly, mucositis grade (WHO classification), weight loss and need for feeding tube were evaluated. The salivary levels of 11 different cytokines (IFNγ, IL1β, IL2, IL4, IL5, IL6, IL8, IL10, IL12p70, TNFα and TNFβ) were analysed both in pts and in healthy donors (HD, n=10) by optimized bead-based multiplex immunoassay. The cytokine change during treatment was calculated as the difference between the mean of individual values and the baseline value. The Wilcoxon rank sum test was used for between-groups comparisons. Results: At baseline, no difference in cytokine levels was observed in pts as compared with HD, except IL8. A significant and progressive increase of IL1β, IL6, IL8, TNFα and IL10 levels was observed during treatment, with high levels persisting two weeks after treatment for all cytokines but IL1β. Significant association was shown between IL6 increase and G3/4 mucositis (p=0.009) or feeding tube need (p=0.04). The same trend was observed for TNFα. Interestingly, IL8 increase appeared to be specifically linked to weight loss (>10%, p=0.003). In contrast, baseline cytokine salivary levels were not predictive of treatment-induced toxicities. Conclusions: The increase of IL6, IL8 and TNFα salivary levels occurring in HNC patients with CTRT seems to be directly associated with mucositis severity, feeding tube prevalence and weight loss. Cytokines may represent a potential new target for preventive and/or therapeutic intervention.

Docetaxel, cisplatin and 5-fluorouracil-based induction chemotherapy followed by intensity-modulated radiotherapy concurrent with cisplatin in locally advanced EBV-related nasopharyngeal cancer

BACKGROUND

This monocentric study evaluates the activity and tolerability of docetaxel (Taxotere), cisplatin and 5-fluorouracil (5-FU) (TPF) induction chemotherapy followed by intensity-modulated radiotherapy (IMRT) concurrent with high-dose cisplatin in Epstein-Barr virus -related locally advanced undifferentiated nasopharyngeal cancer.

PATIENTS AND METHODS

We retrospectively reviewed the records of patients who received induction docetaxel 75 mg/m(2) and cisplatin 75 mg/m(2) on day 1, and 5-FU 750 mg/m(2)/day (96-h continuous infusion). Following induction, patients received full doses of IMRT concurrently with cisplatin 100 mg/m(2) every 21 days for three cycles.

RESULTS

Thirty patients received three TPF cycles (median). Induction was well tolerated; the main toxicity was neutropenia (33%, grade 3-4). During chemoradiotherapy, neutropenia (40%) and mucositis (43%) were the most frequent grade 3-4 adverse events. Mean dose of IMRT was 68.8 Gy. Worst late toxicity was xerostomia. Complete response rate was 93%. At 35 months, two patients had locoregional recurrence, three had distant metastases, and one had both. Three-year progression-free survival and overall survival were 79% [95% confidence interval (CI) 64% to 94%] and 87% (95% CI 74%- to 100%), respectively.

CONCLUSIONS

In this high-stage nonendemic cancer population, TPF followed by high-dose cisplatin IMRT was promising; this treatment approach deserves evaluation in randomized trials.

MALT lymphoma and Kaposi sarcoma in an HIV-negative patient

A 77-year-old caucasian man presented on March 2005 with important epigastric pain without any other significant history of gastritis. Patient refers a history of cutaneous Kaposi's sarcoma (KS) treated since 1974 with surgical excision or oncovorin topical injection. He underwent endoscopic evaluation showing a 1.5-cm ulcerated area at the gastric angulus, associated with edematous and erythematous nodular mucosa (Fig. 1).