Image-guided moderately hypofractionated radiotherapy for localized prostate cancer: a multicentric retrospective study (IPOPROMISE)

BACKGROUND

Moderate hypofractionated radiotherapy is a treatment option for the cure of localized prostate cancer (PCa) patients based on the results of randomized prospective trials, but there is a clinical concern about the relatively short length of follow-up, and real-world results on outcome and toxicity based on cutting-edge techniques are lacking. The objective of this study is to present the long-term results of a large multicentric series.

MATERIALS AND METHODS

We retrospectively evaluated 1325 PCa patients treated with daily volumetric image-guided hypofractionated radiotherapy between 2007 and 2020 in 16 Centers. For survival endpoints, we used Kaplan-Meier survival curves and fitted univariate and multivariable Cox's proportional hazards regression models to study the association between the clinical variables and each survival type.

RESULTS

At the end of the follow-up, 11 patients died from PCa. The 15-year values of cancer-specific survival (CSS) and biochemical relapse-free survival (b-RFS) were 98.5% (95%CI 97.3-99.6%) and 85.5% (95%CI 81.9-89.4%), respectively. The multivariate analysis showed that baseline PSA, Gleason score, and the use of androgen deprivation therapy were significant variables for all the outcomes. Acute gastrointestinal (GI) and genitourinary (GU) toxicities of grade ≥ 2 were 7.0% and 16.98%, respectively. The 15-year late grade ≥ 2 GI and GU toxicities were 5% (95%CI 4-6%) and 6% (95%CI 4-8%), respectively.

CONCLUSION

Real-world long-term results of this multicentric study on cutting-edge techniques for the cure of localized PCa demonstrated an excellent biochemical-free survival rate of 85.5% at 15 years, and very low rates of ≥ G3 late GU and GI toxicity (1.6% and 0.9% respectively), strengthening the results of the available published trials.

Urethra-Sparing Prostate Cancer Stereotactic Body Radiation Therapy: Sexual Function and Radiation Dose to the Penile Bulb, the Crura, and the Internal Pudendal Arteries From a Randomized Phase 2 Trial

PURPOSE

Erectile dysfunction (ED) is a common side effect after prostate cancer stereotactic body radiation therapy (SBRT). We aimed to assess the correlation between the dose to the penile bulb (PB), internal pudendal arteries (IPA), and crura with the development of ED after ultrahypofractionation as part of a phase 2 clinical trial of urethra-sparing prostate SBRT.

METHODS AND MATERIALS

Among the 170 patients with localized prostate cancer from 9 centers included in the trial, 90 men with Common Terminology Criteria for Adverse Events version 4.03 grade 0 to 1 ED (ED-) at baseline treated with 36.25 Gy in 5 fractions were selected for the present analysis. Doses delivered to the PB, crura, and IPA were analyzed and correlated with grade 2 to 3 ED (ED+) development. The effect on quality of life, assessed by the European Organisation for Research and Treatment of Cancer (EORTC QLQ-PR25) questionnaire, was reported.

RESULTS

After a median follow-up of 6.5 years, 43% (n = 39) of the patients developed ED+, and 57% (n = 51) remained ED-. The dose delivered to the crura was significantly higher in ED+ patients than in ED- patients (7.7 vs 3.6 Gy [P = .014] for the Dmean and 18.5 vs 7.2 Gy [P = .015] for the D2%, respectively). No statistically significant difference between ED+ and ED- patients was observed for the dose delivered to the PB and IPA. The median ED+-free survival was worse in patients receiving a crura Dmean ≥ 4.7 versus < 4.7 Gy (51.5% vs 71.7%, P = .005) and a crura D2% > 12 versus ≤ 12 Gy (54.9% vs 68.9%, P = .015). No ED+-free survival differences were observed for doses delivered to the PB and IPA. Decline in EORTC QLQ-PR25 sexual functioning was significantly more pronounced in patients with higher doses to the crura.

CONCLUSIONS

By keeping a Dmean and D2% to crura below 4.7 and 12 Gy, respectively, the risk of developing ED+ after prostate SBRT may be significantly reduced.

SBRT in 3 Fractions for T1 Glottic Cancer

PURPOSE/OBJECTIVE(S)

The purpose of this study was to report the results of a mature phase II study.

MATERIALS/METHODS

This was a prospective study at a single institution that were enrolling patients with T1 glottic cancer. The true vocal cords (TVCs) were divided into thirds and the third(s) containing disease prescribed 36 Gy in 3 fractions. The portions of the TVCs next to the involved one were planned to receive 30 Gy in 3 fxs. The remaining parts of the TVCs as well the rest of the larynx was tentatively spared. SBRT was delivered by a LINAC-based approach using multiple arcs (VMAT). Toxicity was scored by CTCAE and late events were considered those occurring 3 months after SBRT. Voice quality was investigated by the voice handicap index (VHI) at regular intervals. A generalized linear mixed model was used to analyze longitudinal functional data and the actuarial approach was used to report late toxicity prevalence rates. The planned sample size, 75 patients, was calculated to reject the hypothesis of a 2-yr local control (LC) of 85% against the alternative hypothesis of 95%. The median follow-up time is 40 months (IQR: 31.5-47.3 months).

RESULTS

Accrual was discontinued after 33 patients due to concerns on late toxicity rates on both the mucosa and the cartilages. Median age was 66 yrs (IQR: 60-71 yrs). T stage was as follows: T1a: 23 pts (69.7%); T1b: 10 pts (30.3%). Only two patients never smoked, while of the remaining ones, 13 (41.9%) kept smoking after SBRT despite appropriate counseling. At last, follow up, all patients are alive and without evidence of disease but one patient who died 21.3 months after SBRT for intercurrent causes. The observed local control rate of 100% allows to reject the null hypothesis because, according to the binomial distribution, the probability of not observing at least one recurrence out of the accrued 33 patients is <0.5% if a 2-yr LR ≤85% would be true. All but 5 patients developed transient confluent mucositis of the treated volume with a prevalence peak at 19 days after SBRT. Six patients (18.2%) developed soft tissue necrosis (N = 4) or cartilage necrosis (N = 2) after a median time of 14.9 months from SBRT (range: 9.1-24.5 months). The actuarial prevalence of any necrosis is 3.0%, 1.3% and 0.8% at 12, 24 and 36 months after SBRT, respectively, with a peak at 6.1% between 9.9 and 11.9 months. All 4 soft tissue events healed with conservative therapy after a median time of 2.5 months (range: 1-12.2 months). One patient with chondronecrosis refused total laryngectomy and is alive with persistent toxicity 22.9 months after its onset; the other patient underwent endoscopic removal of the necrotic arytenoid and he is alive without evidence of disease or further complications more than 2 years afterwards. Patient reported outcomes (VHI) will be presented as well.

CONCLUSION

SBRT to 36/30 Gy in 3 fractions is highly effective in controlling T1 true vocal cord carcinoma, but necrosis, though mostly transient, is a concern. Based on the present results, a reduction in total doses is justified and a novel phase II study is ongoing.

DCE-MRI-Based Atlas for Prostate Bed Recurrence after Radical Prostatectomy: Consistency of CTV Delineation with the Available Contouring Guidelines

PURPOSE/OBJECTIVE(S)

To create a magnetic resonance image (MRI)-based atlas of prostate bed recurrence for prostate cancer patients undergoing salvage radiotherapy (sRT) after radical prostatectomy and to evaluate the consistency of contouring guidelines for the prostatic fossa clinical target volume (PF-CTV) delineation.

MATERIALS/METHODS

Patients with biochemical recurrence and prostate bed lesions at MRI before sRT were included. A reference patient was identified and the lesion(s) of each patient was mapped by a deformable co-registration among T2 weighted (T2w) images. The structure sets were combined to create a 3D recurrence incidence map, overlapped on T2w reference set, then transferred to the planning CT. The volume and the location of the lesions were extracted. On the reference CT, 5 PF-CTV contouring strategies were implemented: Radiation Therapy Oncology Group (RTOG); European Organization for Research and Treatment of Cancer (EORTC); Francophone Group of Urological Radiotherapy (GFRU); Faculty of Radiation Oncology Genito-urinary Group (FROGG) and Princess Margaret Hospital (PMH). Coverage was assessed after identifying the centroid of each lesion: if the centroid was included in the PF-CTV, the coverage was considered complete (fully covered-FC), otherwise uncovered (UC). The coverage was evaluated for each contouring strategy and compared with the chi-squared test; the strength of the correlation was assessed with the phi coefficient.

RESULTS

A total of 112 patients with 124 recurrences were identified. The lesions were located at the vesicourethral anastomosis (VUA), around the bladder neck (BN) and beyond the bladder (RV) in 63, 36 and 25 cases. Regardless the contouring strategy, 89.1% of the lesions were FC. Coverage was higher (p<0.001) for BN (95.6%) over RV (83.2%) and VUA (73.7%) lesions. FC/UC rates were 66.1%/33.9%, 83.9%/16.1%, 89.5%/10.5%, 83.1%/16.9%, 87.1%/12.9% for EORTC, FROGG, GFRU, RTOG and PMH, respectively. At pair-wise comparison, the EORTC definition had lower coverage (p<0.001) and was poorly correlated to the other strategies (phi values ranging 0.385-0.540, p <0.001). Conversely, the correlations between the other definitions were >0.700, the highest between PMH-FROG (0.812, p<0.001). After selecting VUA lesions only (N = 63), the probability of FC was 60.3%, 74.6%, 82.5%, 71.4% and 79.4% for EORTC, FROGG, GFRU, RTOG and PMH, respectively. The EORTC definition performed poorly than GFRU (p = 0.006) and PMH (p = 0.020). When considering lesions above the VUA (N = 61), the performance improved (FC: 72.1%, 93.4%, 96.7%, 95.1% and 95.1% for EORTC, FROGG, GFRU, RTOG and PMH, respectively) but the EORTC was significantly less covering and its correlation with the others was ≤ 0.1.

CONCLUSION

According to the criterium of coverage our data do not support the use of the EORTC definition. Here we provide an MRI-based atlas of prostatic bed recurrence that can optimize sRT contours.

Stereotactic Ablative Radiation Therapy in 3 Fractions Induces a Favorable Systemic Immune Cell Profiling in Prostate Cancer Patients

The impact of radiotherapy (RT) on immune cell status in prostate cancer (PCa) is only partially determined. The aim of this study was to assess the effect of different RT strategies on peripheral B, T, and Natural killer (NK) lymphocytes at precise longitudinal time-points in PCa. 18 patients treated with stereotactic body radiation therapy (SBRT) (40 Gy/3FRX), definitive moderate-hypofractionation (62 Gy/20FRX), or post-operative conventional-fractionation RT (66-69 Gy/30FRX) were prospectively evaluated for the immune cell profile in terms of immune cell composition, differentiation stage, cytokine production and inhibitory receptor (IR) expression. The immune-monitoring of the 18 patients revealed that RT affects the balance of systemic immune cells, with the main differences observed between SBRT and conventionally fractionated RT. SBRT favorably impacts immune response in term of increased B cells, central-memory and effector-memory CD8⁺ T cells, along with decreased Treg cells after treatment. On the contrary, conventional fractionated RT had a long-term negative effect on the systemic immune profile, including a decrease of total lymphocyte counts accompanied by an increase of neutrophils-to-lymphocytes ratio. Total B and T cells decreased and Treg-to-CD8⁺ ratio increased. Functionality of T lymphocytes were not affected by any of the 3-fractionation schedules. Interestingly, SBRT significantly up-regulates the expression of V-domain immunoglobulin suppressor of T-cell activation (VISTA) in CD8⁺ T cells in the absence of other IRs. Our results indicate the relevance of systematic immunomonitoring during RT to identify novel immune-related target to design trials of combined radio-immunotherapy as a promising strategy in the clinical management of PCa.

The Prognostic Value of DCE-MRI Findings before Salvage Radiotherapy after Radical Prostatectomy

BACKGROUND

To investigate the predictive role of dynamic contrast-enhanced-magnetic resonance imaging (DCE-MRI) findings before salvage radiotherapy after radical prostatectomy (RP).

METHODS

This retrospective study selected patients with biochemical failure (BF) after RP restaged with DCE-MRI. Patients underwent sRT in 30 fractions delivering 66-69 Gy and 73.5 Gy to the prostatic fossa and to the local failure as per DCE-MRI, respectively. Pelvic nodes were treated to 54 Gy in selected patients. The endpoint was BF after sRT.

RESULTS

In total, 236 patients were analyzed and 146 (61.9%) had presumed local failure at DCE-MRI: 54.8%, 23.8% and 21.4% were found at the vesico-urethral anastomosis (VUA), the bladder neck and the retro-vesical space, respectively. The presence of a local failure at DCE-MRI halved the risk of BF; VUA-only location and lesion volume were independently correlated with survival without evidence of biochemical failure (bNED) at multivariable analysis. For patients with VUA-only disease up to 0.4 cc, the 4-year-bNED was 94.6% (95%CI: 80.2-98.6%) as opposed to 80.9% (95%CI: 71.6-87.4%) and 73.7% (95%CI: 63.1-81.8%) for other lesions and no macrodisease, respectively.

CONCLUSIONS

DCE-MRI at restaging for BF after RP provides predictive and therapeutic information. Patients with small lesions at the VUA have an excellent prognosis after sRT.

A systematic review and meta-analysis on non-metastatic castration resistant prostate cancer: The radiation oncologist's perspective

Prostate cancer is the second most common cause of cancer-related mortality in men. In patients undergoing a failure after radical treatment, one of the therapeutic option is androgen deprivation: despite initial response rates, a progression to a state of castration resistance is observed in most of the patients. In the present article, we conducted a systematic review and meta-analysis of all clinical trials assessing treatment for nmCRPC with next-generation androgen receptor inhibitors. We performed a review and meta-analysis of phase III randomized controlled trials comparing new agents (apalutamide, enzalutamide, darolutamide) with placebo as control arm, in the setting of nmCRPC. Patients treated with next-generation ARIs had a 26% reduction in the risk of death compared with placebo; compared with other ARIs, darolutamide had the lowest rate of grade 3 and 4 AEs and the lowest therapy discontinuation rate due to any grade AEs. This meta-analysis shows that treatment with new ARIs is safe and significantly reduces the risk of death and of metastasis onset in nmCRPC patients. Under way studies on new biomarkers such as genomic classifiers will probably allow the stratification in more specific subsets of disease. New imaging modalities such as PSMA-PET have shown greater sensibility and specificity than conventional imaging in metastases detection. All patients were randomized in a 2:1 fashion, with a total of 2,694 who underwent next-generation ARIs (806 apalutamide, 955 darolutamide, 933 enzalutamide) and 1,423 in the placebo arm.

Scenario building model to support the resilience planning of winemaking regions: The case of the Douro territory (Portugal)

Today resilience paradigm is shared by both academic and political debates, and it is gradually being implemented into plans, programmes, and project's initiatives. In this context, wine regions, particularly those designated as UNESCO sites, show their robustness and vulnerabilities as Socio-Ecological Systems. The climate change impact is increasing the exposure of their aesthetic, cultural, economic, natural values to potential losses and therefore an effective response is required To build resilient strategies, Decision Makers are increasingly considering multidimensional models in planning and assessment processes. This paper continues a research work that develops an integrated evaluation framework constituted by Multicriteria Decision Analysis to calculate a Territorial Resilience Index, a dynamical model to predict future ecological scenarios and scenario building to define a resilient strategy for the Douro territory (Portugal). This paper focuses on scenario building which uses specific tools such as Social Network Analysis to identify and investigate the relationships between real actors and stakeholders, Wilson matrix to assess the degree of uncertainty and relevance of the strategies identified by a panel of specialists, and consistency matrix to evaluate the strategies consistency in achieving the Sustainable Development Goals and UNESCO requirements. The obtained protocol of guidelines and recommendations can support Decision Makers in the design of sustainable and resilient transformation, thereby assisting in the preservation of the UNESCO site.

A choice experiment for testing the energy-efficiency mortgage as a tool for promoting sustainable finance

The challenges currently facing the EU in the energy sector include increasing import dependence, limited diversification, high and volatile energy prices, decarbonization, and slow progress in energy efficiency. EU energy policy has provided a wide range of measures to achieve an integrated energy market and sustainability of the building sector. Various incentives and financial instruments have been promoted and financed by governments to help consumers in energy retrofit processes. These include direct investments and fiscal, financial, and market instruments. Public measures have been widely studied but private initiatives have not. In this study, the energy-efficiency mortgage (EEM) is investigated as a credit scheme to attract young people to a real estate market for sustainable buildings, characterized by high sale prices. A choice experiment (CE) was modelled to investigate the preferences of potential young buyers of a new home. The results of this exploratory survey showed an appreciation of the purchase of new A-rated properties according to the Energy Performance Certificate, compared to those that need to be retrofitted or not retrofitted. Consumers like the option of a home energy efficiency renovation being fully managed by a third party (i.e., following the one-stop shop model). The key appeal of energy efficiency for consumers ranges from its ability to support better energy management, to better property value management. The EEM seems to be a promising tool to stimulate investments in energy efficiency and to promote the accessibility and affordability of housing in the sustainable housing market. The results of this study can help private financial institutions to propose appropriate credit plans, which limit the risk of default by the borrower. They can also help public incentive policymakers to propose complementary instruments to EEM.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12053-022-10035-y.

Neuroprotective Potential of Dendritic Cells and Sirtuins in Multiple Sclerosis

Myeloid cells, including parenchymal microglia, perivascular and meningeal macrophages, and dendritic cells (DCs), are present in the central nervous system (CNS) and establish an intricate relationship with other cells, playing a crucial role both in health and in neurological diseases. In this context, DCs are critical to orchestrating the immune response linking the innate and adaptive immune systems. Under steady-state conditions, DCs patrol the CNS, sampling their local environment and acting as sentinels. During neuroinflammation, the resulting activation of DCs is a critical step that drives the inflammatory response or the resolution of inflammation with the participation of different cell types of the immune system (macrophages, mast cells, T and B lymphocytes), resident cells of the CNS and soluble factors. Although the importance of DCs is clearly recognized, their exact function in CNS disease is still debated. In this review, we will discuss modern concepts of DC biology in steady-state and during autoimmune neuroinflammation. Here, we will also address some key aspects involving DCs in CNS patrolling, highlighting the neuroprotective nature of DCs and emphasizing their therapeutic potential for the treatment of neurological conditions. Recently, inhibition of the NAD⁺-dependent deac(et)ylase sirtuin 6 was demonstrated to delay the onset of experimental autoimmune encephalomyelitis, by dampening DC trafficking towards inflamed LNs. Thus, a special focus will be dedicated to sirtuins’ role in DCs functions.

The Italian Association of Radiotherapy and Oncology Recommendation for Breast Tumor Recurrence: Grades of Recommendation, Assessment, Development and Evaluation Criteria

Salvage mastectomy is currently considered the standard of care for ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) and postoperative radiotherapy (RT). Alternative treatment options for these patients, such as a second BCS followed by repeated RT, have been suggested. The panel of the Italian Association of Radiotherapy and Clinical Oncology developed clinical recommendations for second BCS followed by re-irradiation over mastectomy alone for women with IBTR using the Grades of Recommendation, Assessment, Development, and Evaluation methodology and the evidence to decision framework. The following outcomes were identified by the panel: locoregional control, metastasis-free survival, overall survival, and cancer-specific survival; acute and late toxicity, specific late toxicity, second locoregional tumor, and death related to treatment. An Embase and PubMed literature search was performed by two independent authors. Five retrospective observational studies were eligible for inclusion in the present analysis. According to the reports in the literature and our analysis, the advantages of second quadrantectomy and re-irradiation (re-QUART) outweigh its side effects, with overall good rates of survival and adequate toxicity without increasing costs. Given the very low level of evidence, the panel stated that a second BCS plus re-irradiation can be considered as an alternative to salvage mastectomy for selected patients with IBTR.

A decision support system for territorial resilience assessment and planning: An application to the Douro Valley (Portugal)

This paper aims to assess the territorial resilience of a socio-ecological system through an innovative integrated evaluation framework to aid the decision-making process in the planning of transformation scenarios. This framework employs a set of resilience indicators through a Multicriteria Decision Analysis (MCDA) coupled with a Lotka-Volterra mathematical model of cooperative type. The set of indicators aims to calculate a composite index of Territorial Resilience (TRI), whereas the mathematical model is an extension of an existing model, aimed to predict possible long-time scenarios. The proposed operational framework for rural and vineyard landscapes aims to bridge the existing gap between territorial resilience theory and practice, with an innovative Decision Support System able to assist Decision Makers and territory planners in the planning and management of resilient territorial systems. This integrated evaluation framework is applied to a famous wine region in Portugal, the Douro Valley, where Port-wine grows. Such framework, especially in a context of adaptive governance, proves to be a suitable support in the field of landscape and urban planning to evaluate the dynamics of socio-ecological systems and to envision long-term policies and actions.

Radiotherapy treatment volumes for oligorecurrent nodal prostate cancer: a systematic review

BACKGROUND

Radiotherapy is an emerging treatment strategy for nodal oligorecurrent prostate cancer (PCa) patients. However, large heterogeneities exist in the RT regimens used, with series reporting the use of elective nodal radiotherapy (ENRT) strategies and others the delivery of focal treatments to the relapsing nodes with Stereotactic Body Radiotherapy (SBRT). In this systematic review of the literature we compared the oncological outcomes and toxicity of the different RT regimens for nodal oligorecurrent PCa patients, with the aim of defining the optimal RT target volume in this setting.

METHODS

We performed a systemic search on the Pubmed database to identify articles reporting on the use of ENRT or SBRT for oligometastatic PCa with nodal recurrence.

RESULTS

Twenty-two articles were analyzed, including four prospective phase II trials (3 with SBRT and 1 with ENRT). Focal SBRT, delivered with an involved node, involved site, and involved field modality, was the most commonly used strategy with 2-year progression-free survival (PFS) rates ranging from 16 to 58% and a very low toxicity profile. Improved PFS rates were observed with ENRT strategies (52-80% at 3 years) compared to focal SBRT, despite a slightly higher toxicity rate. One ongoing randomized phase II trial is comparing both modalities in patients with nodal oligorecurrent PCa.

CONCLUSIONS

With a large variability in patterns of practice, the optimal RT strategy remains to be determined in the setting of nodal oligorecurrent PCa. Ongoing randomized trials and advances in translational research will help to shed light on the best management for these patients. .

Detection rate, pattern of relapse and influence on therapeutic decision of PSMA PET/CT in patients affected by biochemical recurrence after radical prostatectomy, a retrospective case series

AIMS

⁶⁸Ga-Prostate-specific membrane antigen (PSMA) PET/CT is widely used in patients with biochemical recurrence (BCR) after radical prostatectomy. We collected data about patients staged with PSMA PET/CT after BCR (PSA < 1 ng/ml) in four different institutes. Impact of baseline features (Gleason score, risk classification, PSA at recurrence, PSA doubling time and time to recurrence) was explored to understand predictive factors of (PSMA) PET/CT positivity. Impact of restaging on following treatment approaches was reported.

RESULTS

92 patients were included. PSMA PET/CT detection rate was 56.5% and low-volume disease (≤ 3 non-visceral lesions) was detected in 52.2% of patients. After positive scan, 13.5% of patients still lies on observation, ADT alone was administered in 30.8% of cases, Stereotactic body RT (SBRT) alone was delivered to 44.2% of patients and 11.5% of patients underwent concomitant SBRT and ADT. Seven patients underwent conventional salvage prostate bed RT. Chi-squared test showed a higher rate of positive PSMA PET/CT for patients with Gleason score > 7 (p = 0.004) and TTR < 29.5 months (p = 0.003).

CONCLUSIONS

PSMA PET/CT showed a high detection rate. This influenced clinical management in a significant percentage of patients, allowing treatment tailoring on the basis of imaging.

Electromagnetic Transponder Localization and Real-Time Tracking for Prostate Cancer Radiation Therapy: Clinical Impact of Metallic Hip Prostheses

PURPOSE

Our purpose was to assess the ability of electromagnetic transponders (EMTs) to localize and track movements in patients with prostate cancer (PCa) with metallic hip prostheses (MHPs) treated with curative radiation therapy (RT).

METHODS AND MATERIALS

Data sets of 8 PCa patients with MHPs (3 bilateral and 5 unilateral) treated between 2016 and 2018 with RT and EMT tracking were retrospectively assessed. The distances between the 3 EMTs (apex to left, left to right, right to apex) and the isocenter were calculated both on planning computed tomography (CT) and cone beam CT (CBCT) at the first treatment fraction and compared with data reported by Calypso. EMT position and treatment interruptions triggered by Calypso were analyzed for all evaluable treatment fractions (n = 120). Localization accuracy was quantified by recording the geometric residual value (expected limit ≤0.2 cm) at the RT setup.

RESULTS

The Calypso system was able to localize and track prostate position without any detectable interference from MHP. For every treatment fraction, the agreement between the CBCT images and Calypso guidance was optimal, with EMTs always within the defined tolerance (ie, CT-Calypso or CBCT-Calypso measured differences in inter-EMT distances within 0.3 cm). EMT to isocenter distances measured by Calypso reproduced CT data and were confirmed on CBCT scans. During RT, the EMT centroid exceeded the threshold 24 times (20% of all fractions): 5 times in the left-right, 15 times in the anteroposterior, and 4 times in the superoinferior directions. The largest motions recorded were in the anteroposterior axis: 0.6 cm anteriorly and 0.5 cm posteriorly in patients with unilateral and bilateral MHP, respectively.

CONCLUSIONS

Our study represents the first clinical experience assessing the localization and tracking accuracy of Calypso EMTs during curative RT of patients with PCa with unilateral or bilateral MHP.

Radiotherapy for papillary tumor of the pineal region: A systematic review of the literature

Papillary tumor of the pineal region (PTPR) is a rare neuroepithelial brain tumor, characterized by a high risk of local recurrence (greater than 70 % at 6 years). The aim of our study was to review the available literature on radiotherapy for PTPR in order to evaluate timings, schedules, outcomes and toxicities of this treatment modality. In our review, 72.4 % (84) of the patients diagnosed with PTPR received radiation therapy. There is heterogeneity in the dose prescription, ranging from 45 Gy (25 × 1.8 Gy) to 60 Gy (30 × 2 Gy) for 3D Conformal Radiation Therapy and from 12 Gy to 36 Gy for Stereotactic Radiosurgery. Being considered as a grade II or III tumor, PTPR should receive higher total radiation dose in the adjuvant setting. Our analysis showed a very limited treatment-related toxicity with an expected 10-y OS of 72.5 %. At 5-years from the diagnosis, about 60 % of the patients experienced a local recurrence, whereas at 10 years the rate is higher than 80 %. In the literature, conflicting data about radiotherapy for PTPR are reported, in particular regarding disease progression. Although radiotherapy represents a fundamental treatment in the management of PTPR, prospective studies are required to better define its impact on overall survival and progression-free survival.

Nonsurgical Salvage Local Therapies for Radiorecurrent Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT

Different nonsurgical therapeutic strategies can be adopted for intraprostatic relapse of prostate cancer after primary radiotherapy, including re-irradiation (with brachytherapy [BT] or external beam radiotherapy [EBRT]), high-intensity focused ultrasound (HIFU), and cryotherapy. The main issues to consider when choosing nonsurgical salvage local therapies are local tumor control and significant genitourinary toxicity.

OBJECTIVE

To conduct a systematic review and meta-analysis of the role of nonsurgical salvage modalities in patients with radiorecurrent prostate cancer and associated clinical outcomes and toxicity profiles.

EVIDENCE ACQUISITION

We performed a critical review of the Medline, Scopus, and ClinicalKey databases from January 1, 2000 through February 1, 2018 according to the Preferred Reporting Items and Meta-Analyses statement. To assess the overall quality of the literature reviewed, we used a modified Delphi tool for case-series studies.

EVIDENCE SYNTHESIS

A total of 64 case-series studies were included, corresponding to a cohort of 5585 patients. The modified Delphi checklist evidenced high methodological quality overall (mean quality score of 80.6%). Biochemical control rates were lowest for patients treated with HIFU (58%, 95% confidence interval [CI] 47-68%) and highest for patients treated with BT (69%, 95% CI 62-76%) and EBRT (69%, 95% CI 53-83%). The lowest prevalence of incontinence was for patients treated with BT (3%, 95% CI 0-6%; I²=63.4%) and the highest was among patients treated with HIFU (28%, 95% CI 19-38%; I²=89.7%).

CONCLUSIONS

Nonsurgical therapeutic options, especially BT, showed good outcomes in terms of biochemical control and tolerability in the local recurrence setting.

PATIENT SUMMARY

The current analysis demonstrated that nonsurgical salvage local therapies offer a chance of a curative local approach in radiorecurrent prostate cancer. However, high-quality data from prospective trials are needed to validate long-term outcomes from nonsurgical strategies for the treatment of intraprostatic recurrence after previous radiotherapy.

Oligometastatic cancer in elderly patients: the "blitzkrieg" radiotherapy approach : SBRT in oligometastatic elderly patients

AIMS

To retrospectively evaluate the outcome of stereotactic body radiation therapy (SBRT) in the treatment of elderly patients affected by isolated body metastasis from different primitive tumors.

METHODS

70 patients with isolated body metastasis were treated. Median age at diagnosis was 75 years (IQR 69-80). The most common SBRT fractionation scheme was 5 × 7 Gy (total dose 35 Gy). The primary endpoints were Local Control (LC) and Toxicity. Secondary endpoints were Overall Survival (OS) and Disease-Specific Survival (DSS). Response to radiotherapy was assessed according to RECIST criteria v1.1. Toxicity was registered according to Common Terminology Criteria for Adverse Events (CTCAE) v 4.0. We performed survival analysis with the Kaplan-Meier method. The correlation between time actuarial incidence and clinical parameters was studied.

RESULTS

Median follow-up was 26.5 months. 44 patients (62.8%) were alive at the time of analysis, while 22 (31.4%) died because of the disease. Local control at 2 and 3 years was 87%. The 2-year OS and DSS were 84 and 71%, respectively, while the 3-year values were 57 and 62%. PFS at 2 and 3 years was 41 and 25%, respectively. On univariate analysis, KPS ≥ 90 is statistically correlated with improved OS and DSS (p < 0.05). Acute toxicity of grade ≥ 2 occurred in 4 (5.7%) patients, while late toxicity ≥ 2 was recorded in 6 (8.6%) patients.

CONCLUSIONS

Ablative Radiotherapy represents a safe, effective, and minimally invasive treatment modality for elderly oligometastatic patients who are judged unfit for systemic therapy.

Stereotactic body radiation therapy (SBRT) on renal cell carcinoma, an overview of technical aspects, biological rationale and current literature

BACKGROUND

Stereotactic body radiotherapy (SBRT) is characterized by the delivery of high doses of ionizing radiation in few fractions. It is highly effective in achieving local control, and, due to the high biological effective dose administered, it seems to overcome the radioresistance of renal cell carcinoma (RCC). Thus, SBRT could constitute a treatment option for the management of localized RCC in patients who are not surgical candidates. In this paper, we report an overview about data from the current evidence about SBRT in patients affected by localized RCC.

MATERIALS AND METHODS

A non-systematic review was performed, including data from both retrospective and prospective studies focusing on the use of SBRT for localized RCC and its biological rationale. Furthermore, ongoing trials on this issue are reported.

CONCLUSION

Currently, SBRT might be considered a treatment alternative in inoperable patients affected by primary RCC. Currently, dose-escalation to 48 Gy in 3-4 fractions are effective and well tolerated. Emerging role of immune therapies in RCC patients warrant further studies to explore interactions between SBRT and immune response.

Volumetric image-guided conformal radiotherapy for localized prostate cancer: Analysis of dosimetric and clinical factors affecting acute and late toxicity

Aim

To identify factors influencing toxicity in patients affected by localized prostate cancer treated with conformal image-guided radiotherapy.

Background

Image guidance in combination with conformal techniques is the standard of care in localized prostate cancer, but factors affecting toxicity are still under investigation.

Materials and methods

294 patients were analyzed. Median age at diagnosis was 71 year. 76 Gy (38 × 2 Gy) were delivered to the target volume. We used the χ² test to analyse associations between toxicity and dosimetric and clinical parameters. Multivariate analysis was performed using binary logistic regression. Kaplan-Meier method was used for survival analysis.

Results

Median follow-up was 62.9 months. Acute grade ≥2 gastro-intestinal toxicity (GI) was 12.1%. Acute genito-urinary (GU) toxicity of grade ≥2 was 33.9%. Actuarial 4 and 5 years late grade ≥2 GI was 3% and 4%, respectively. Four and 5-year late grade ≥2 GU toxicity was 6% and 10%. At multivariate analysis for acute toxicity rectal V₇₀ was correlated with GI toxicity (p = 0.01, HR 2.73 CI 1.19-6.26), and smoking habit with GU toxicity (p < 0.01, HR 2.50 CI 1.51-4.14). For late toxicity, rectal V₇₀ was correlated with gastro-intestinal toxicity (p = 0.04, HR 4.76 CI 1.07-21.13), and pre-radiotherapy urinary symptoms with genito-urinary toxicity (p = 0.01, HR 2.84 CI 1.29-6.22).

Discussion

Conformal image-guided radiotherapy shows low rates of toxicity. Smoking should be avoided during radiotherapy. Besides the evaluation of high doses received by the organs at risk, individual factors, such as co-morbidities and lifestyle choices, have an impact on normal-tissue complication risk.

A multi-methodological evaluation approach for assessing the impact of neighbourhood quality on public health

Starting from a growing interest for urban neighbourhood health effects, the purpose of this paper is to suggest a multi-methodological approach for providing a comprehensive evaluation of the quality of open spaces under the urban design perspective. Despite the growing body of research and empirical evidence about the relationship among quality of built environment and public health, there is still a lack of studies on urban quality assessment. This paper brings forward a multi-methodological approach for assessing the quality of open spaces by the assignment of a composite score. The study combines Geographic Information Systems (GIS) and Multi-Attribute Value Theory (MAVT) with the aim of proposing urban quality maps. Open spaces, including green and walkable areas, streets and squares are evaluated with respect to the following attributes: accessibility, liveability, vitality, and identity. The urban quality maps provide a robust basis to run different kind of analysis and to support cross-sectorial policies towards the improvement of public health.

How to Support Strategic Decisions in Territorial Transformation Processes

Territorial transformations can be regarded as a multifaceted concept which includes socio-economic, ecological, technical, political and ethical perspectives. Decision problems in the domain of territorial transformations represent “weak” or unstructured problems since they are characterized by multiple actors, many and often conflicting values and views, a wealth of possible outcomes and high uncertainty. This paper addresses decision problems in the context of urban and territorial planning projects using the Multi Attribute Value Theory (MAVT), a particular kind of Multiple Criteria Decision Analysis method and it provides an application on a real case located in the city of Torino (Italy).

Sustainable healthcare: how to assess and improve healthcare structures' sustainability

BACKGROUND

Sustainability is a broad and debated subject, often difficult to be defined and applied into real projects, especially when dealing with a complex scenario as the one of healthcare. Many research studies and evaluation systems have handled this topic from different perspectives, but many limits and criticalities still have to be overcome to properly cope with actual needs.

METHODS

The Sustainable Healthcare project has been developed through three main phases: a deep study of the state of the art, unraveling pros and cons of available sustainability scoring systems; an accurate analysis of the stakeholders network and their needs; the realization of an objective evaluation framework, through scientific methods, as the ANP.

RESULTS

The newly developed evaluation system takes into consideration all the three pillars of sustainability, analyzing social, environmental and economic sustainability through a set of criteria, specified by measurable indicators. So the system identifies both global sustainability and specific critical areas, pointing out possible strategic solutions to improve sustainability. The evaluation is achieved through technical analyses and qualitative surveys, which eventually allow to quantitatively assess sustainability, through a sound scoring method.

CONCLUSIONS

This study proposes an innovative evaluation method to determine the sustainability of a hospital, already existing or in the design phase, within the European context. The Sustainable Healthcare system overcomes some of the current evaluation systems' limits by establishing a multidisciplinary approach and being an easy-to-use tool. This protocol is intended to be of support in the identification of the main hospital's weaknesses and in setting priorities for implementation of the solutions.

Management of fluid overload in congestive heart failure: learning from a case report

A case of refractory fluid overload due to congestive heart failure and consequent renal insufficiency is reported. The case was approached multidisciplinarily, at the beginning with conservative and pharmacological therapy, subsequently with extracorporeal fluid removal in which a specific attention was payed to the maintenance of circulating blood volume and achievement of dry weight, and finally with chronic peritoneal dialysis as a maintenance therapy. The case seems to summarize the pathway of many patients seen initially in intensive care and cardiology departments and subsequently in nephrological wards.

Abciximab in rescue coronary angioplasty after full-dose tissue-type plasminogen activator

BACKGROUND

Rescue angioplasty is a complex procedure because of frequent reocclusions secondary to a paradoxical pro-thrombotic effect brought about by thrombolytic therapy. Administration of abciximab may improve procedural results but its utilization in this setting is limited by the potential hemorrhagic risk. Very few data on this approach are currently available in the medical literature.

METHODS

After failed full-dose tissue-type plasminogen activator (tPA), 30 patients (23 males, 7 females, mean age 64 +/- 13 years) referred for rescue angioplasty received abciximab (0.25 mg/kg bolus + 0.125 mcg/kg/min x 12 hour infusion) (Abc+ group). The procedural results, hemorrhagic complications and in-hospital outcome observed in these patients were compared to those of 35 patients submitted to rescue angioplasty in the same time period (1997-1999) who did not receive abciximab (Abc- group).

RESULTS

In the Abc+ group, 11 patients (37%) were in Killip class 3-4, 14 (47%) had multivessel disease, and 4 (13%) had previous bypass surgery. In all Abc+ patients, factors suggestive of procedural failure were present (i.e. saphenous vein graft occlusion, intraluminal thrombus, dissection, reocclusion, slow flow). The periprocedural heparin dose was 5,000 IU in Abc+ and 100 IU/kg in Abc-patients (range 5,000-10,000 IU). The procedure was successful in 29 Abc+ (97%) and in 34 Abc- patients (97%). A hemoglobin drop > 5 g occurred in 3 Abc+ (10%) and in 4 Abc- patients (11%) with a similar incidence of blood transfusion in the two groups. In all these cases, significant bleeding occurred at the vascular access site. There were 2 in-hospital deaths in Abc+ and 1 in Abc- patients. CONCLUSIONS. Selected patients undergoing rescue angioplasty may be treated with abciximab without an undue increase in hemorrhagic complications. Larger studies are needed to confirm the feasibility of this approach and to assess its potential benefits.

[Acute changes in the hemodynamic profile and circulating levels of atrial natriuretic peptide induced by dobutamine in severe heart failure]

METHODS

Sixteen patients (15 males, 1 female; mean age 63 years, range 45-78) with severe heart failure (NYHA class III = 5; class IV = 11) secondary to ischemic heart disease (8), dilated cardiomyopathy (5) and valvular heart disease (3), were evaluated for eligibility to intermittent Dobutamine (D) treatment. As a part of this evaluation, they were submitted to an acute dose-ranging test with D, up to 10 micrograms/Kg/min under hemodynamic and electrocardiographic monitoring. By inclusion criteria, all patients had:-cardiac index (CI) < 2.2 L/min/m2;-pulmonary wedge pressure (WP) > 18 mmHg;-left ventricular ejection fraction (EF) < 30%. At each step of the procedure, hemodynamic measurements and blood sampling for atrial natriuretic peptide (ANP) concentration were performed.

RESULTS

Peak effect, defined as the dose corresponding to the maximum increase in CI, was reached at a mean of 7.8 +/- 0.5 micrograms/Kg/min. CI increased from 1.7 +/- 0.3 to 2.53 +/- 0.7 L/min/m2 (p < 0.001) and ANP decreased from 234 +/- 112 to 173 +/- 118 pg/ml (p < 0.001). Correspondingly, heart rate, stroke volume index and stroke work index increased, while right atrial pressure (RAP), mean pulmonary artery pressure (PAP), WP, systemic and pulmonary vascular resistance all significantly decreased. Mean arterial pressure was not affected. Changes in ANP concentration correlate significantly with changes in WP and in PAP (r = 0.65, p < 0.05 and r = 0.89, p < 0.001, respectively), but not with changes in RAP (r = 0.26, p = 0.34). Patients showing an increase > 40% in CI or a CI > or = 2.5 L/min/m2 at peak effect (responders) had significantly lower baseline PAP with respect to non-responders. Besides PAP, baseline ANP levels, end-systolic pressure/volume ratio and ejection fraction were also independent predictors of response. The test did not induce complex arrhythmias and was well tolerated in all patients.

CONCLUSIONS

Patients with severe heart failure retain the ability to respond to acute administration of D. with a significant improvement in their hemodynamic profile. Response to D. administration is predicted by lower baseline pulmonary pressure and ANP levels and a lesser degree of left ventricular dysfunction. Despite high baseline ANP concentration, a significant decrease is obtained which parallels the decrease in pulmonary artery and pulmonary wedge pressure, but is not related to changes in right atrial pressure. These findings suggest that changes in left ventricular performance induced by D. are the major determinants of the decrease in ANP concentration in this clinical setting.

[Esophageal stimulation in WPW syndrome]

Transoesophageal stimulation of the atria combined with bicycle ergometry provides a satisfactory reproducibility of a number of basic electrophysiological parameters at rest and during a load. Due to the good sensitivity and low specificity this test can be recommended in WPW syndrome as a screening examination in particular in active sportsmen and junior subjects. To assess the risk of sudden death in subjects with this syndrome it is, however, necessary to evaluate the complex of all assembled data, as the shortest R-R interval in induced atrial fibrillation is not sufficiently specific.

[Transcatheter fulguration of the atrioventricular junction in supraventricular hyperkinetic arrhythmia. Immediate and long-term results]

Transcatheter direct-current ablation of the atrio-ventricular junction is a recently developed technique in the treatment of medically refractory supraventricular tachycardia. Twenty patients underwent this procedure between July 1987 and May 1989 and were followed-up for a mean period of 8.3 +/- 6 months (range 1-23). Indication for ablation included atrial flutter in 4 patients, atrial fibrillation in 8, atrial tachycardia in 1, atrio-ventricular nodal re-entrant tachycardia in 4, atrioventricular re-entrant tachycardia (concealed pathway) in 2, permanent junctional reciprocating tachycardia in 1. These arrhythmias were resistant to a mean of 3.3 +/- 1.7 antiarrhythmic drugs. A mean of 1.4 +/- 0.59 (range 1-3) electrical shocks, with a mean energy of 285 +/- 135J (range 200-700), were delivered during 1-2 sessions. In all patients a persistent complete atrio-ventricular block was achieved. Immediate complications included transient hypotension in 2 pts, acute pulmonary edema in 1, premature ventricular complexes in 4, non sustained ventricular tachycardia in 4, sustained ventricular tachycardia in 1. Late complications included thrombophlebitis of the right femoral vein in 2 pts; one of them died suddenly as a result of massive pulmonary embolism 10 days after the procedure. Follow-up evaluation reveals chronic complete atrio-ventricular block in all patients. Symptoms related to pre-existing arrhythmia are absent in all pts and none of them is currently taking antiarrhythmic drugs. Two patients with DDD pacing had pacemaker mediated re-entrant tachycardia and 1 patient with VVIR pacing developed a pacemaker syndrome. This experience confirms that transcatheter fulguration of atrio-ventricular junction is an effective technique. However, possible severe complications related to the procedure suggest this approach be restricted to patients with very symptomatic and drug-refractory supraventricular tachyarrhythmias.

[Superior axial deviation in the young adult. An electro-vectorcardiographic study]

We analyzed the VCGs of 100 young subjects without apparent cardiac disease showing an ECG superior Axis Deviation, i.e. AQRS greater than - 30 degrees, and a rS aspect in V1. Our findings demonstrated that, in these subjects, the superior axis deviation is due to a distal right bundle branch block with posterior displacement of the terminal forces in 78% of the cases. The other cases being left anterior hemiblocks, either isolated (12%) or associated with a block of the anterior subdivision of the right bundle branch (10%). The differential diagnosis, easy on VCG, is sometimes very difficult on ECG. The most reliable ECG criteria to discriminate this kind of right bundle branch block from left anterior hemiblock are: intrinsic deflection in a VL-V6 greater than or equal to 0.015" (sensitivity 100%; specificity 57%), RV6/Ra VL ratio greater than 1 (sensibility 100%; specificity 50%) and the presence of a notched R wave in L2, L3 and a VF (sensitivity 90%; specificity 100%).

[Electro-vectorcardiographic behavior of right bundle branch block in endocardial cushion defects. Its probable relation to the so-called left anterior fascicular hemiblock]

We have investigated the possible ECG signs of incomplete Left Anterior Hemiblock (LAH). As an experimental model we chose the endocardial cushion defect, which is proved to have a ventricular activation correspondent to different degrees of LAH due to the particular disposition of the AV node and the His bundle. The VCG of 50 patients with endocardial cushion defect were divided into 5 groups according to the entity of the left and superior deviation of the maximum left vector. Comparison with the ECG signs shows that: a) minimal degrees of LAH occur with simple counterclockwise rotation of the frontal loop without a significant left axis deviation; b) there is no linear correlation between the importance of the left axis deviation and the signs of left ventricular activation asincronism. We conclude that, with the exception of this particular congenital heart disease, minimal LAH degrees can only be suspected on the basis of a counterclockwise VCG frontal loop, because the ECG diagnosis is possible only when the left axis deviation becomes important.