Adult intracranial ependymoma-relevance of DNA methylation profiling for diagnosis, prognosis, and treatment.

BACKGROUND: A methylation-based classification of ependymoma has recently found broad application. However, the diagnostic advantage and implications for treatment decisions remain unclear. Here, we retrospectively evaluate the impact of surgery and radiotherapy on outcome after molecular reclassification of adult intracranial ependymomas. METHODS: Tumors diagnosed as intracranial ependymomas from 170 adult patients collected from 8 diagnostic institutions were subjected to DNA methylation profiling. Molecular classes, patient characteristics, and treatment were correlated with progression-free survival (PFS). RESULTS: The classifier indicated an ependymal tumor in 73.5%, a different tumor entity in 10.6%, and non-classifiable tumors in 15.9% of cases, respectively. The most prevalent molecular classes were posterior fossa ependymoma group B (EPN-PFB, 32.9%), posterior fossa subependymoma (PF-SE, 25.9%), and supratentorial ZFTA fusion-positive ependymoma (EPN-ZFTA, 11.2%). With a median follow-up of 60.0 months, the 5- and 10-year-PFS rates were 64.5% and 41.8% for EPN-PFB, 67.4% and 45.2% for PF-SE, and 60.3% and 60.3% for EPN-ZFTA. In EPN-PFB, but not in other molecular classes, gross total resection (GTR) (P = .009) and postoperative radiotherapy (P = .007) were significantly associated with improved PFS in multivariable analysis. Histological tumor grading (WHO 2 vs. 3) was not a predictor of the prognosis within molecularly defined ependymoma classes. CONCLUSIONS: DNA methylation profiling improves diagnostic accuracy and risk stratification in adult intracranial ependymoma. The molecular class of PF-SE is unexpectedly prevalent among adult tumors with ependymoma histology and relapsed as frequently as EPN-PFB, despite the supposed benign nature. GTR and radiotherapy may represent key factors in determining the outcome of EPN-PFB patients.

A predictive model of lymph node metastasis for thymic epithelial tumours.

OBJECTIVES: Thymic epithelial tumours (TETs) are relatively rare indolent malignancies in the mediastinum. Lymph node metastasis (LNM) is an important prognostic indicator for TETs; however, the pattern of LNM involved in TETs has yet to be elucidated. METHODS: Patients diagnosed with histologically confirmed thymoma (A-B3), thymic carcinomas and thymic neuroendocrine tumours, between 1988 and 2016 were identified from the Surveillance, Epidemiology, and End Results database. Univariable and multivariable logistic regression analyses were applied to identify the predictors for LNM. The predictive nomogram was built from the independent risk factors and measured using the concordance statistic. RESULTS: The overall proportion of TETs with LNM was 18.5% (200/1048). The rate of LNM in thymoma, thymic carcinomas and thymic neuroendocrine tumours was 6.8% (42/622), 30.2% (100/331) and 61.1% (58/95), respectively. According to the logistic regression analysis, histology type and T stage were independent factors correlated with LNM. A predictive nomogram model was developed with a concordance statistic of 0.807 (95% confidence interval: 0.773-0.841), which was significantly better than the T stage (P < 0.001) while had limited benefit to the histology type (P = 0.047). The calibration curve for the nomogram comparing the predicted and actual probabilities after bias correction showed good agreement. CONCLUSIONS: Nodal involvement was not uncommon in TETs. Main factors related to LNM in TETs were histology type and T stage. The probability of LNM could be well calculated using the predictive model.

Intragastric Single-Port Surgery: An Innovative and Multipurpose Technique for the Therapy of Upper Digestive Tract Lesions.

Background: Endoscopic treatment can represent a technical challenge for several special situations, such as resecting gastric tumors with larger size or in unfavorable sites and performing endoscopic retrograde cholangiopancreatography (ERCP) after Roux-en-Y gastric bypass (RYGB). This study aims to describe an innovative and multipurpose technique, intragastric single-port surgery (IGS), which can be applied for abovementioned special situations and for assessing its safety, feasibility, and efficacy. Methods: IGS technique was performed through a 2-3 cm skin incision, where the stomach wall is exteriorized and fixed to the skin. The single-port device is inserted and intragastric access is gained for laparoscopic or endoscopic instruments. Three purposes of IGS were performed: (1). gastric intraluminal lesions resection; (2). to perform ERCP after RYGB; and (3). revision of pancreaticogastric anastomosis after pylorus-preserving pancreaticoduodenectomy. Results: IGS was performed successfully in 20 patients. Ten patients underwent gastric intraluminal lesion resection, mostly for gastric gastrointestinal stromal tumors (n = 7, 70%); all pathological specimens were with negative margin, mean operation time was 102.3 ± 43.5 minutes, and mean postoperative hospital stay was 4.6 ± 1.5 days. Nine patients underwent ERCP after RYGB, cleaning of the bile duct was successful in all patients (100%), and mean operation time and mean postoperative hospital stay were 140.6 ± 46.3 minutes and 4.4 ± 2.6 days, respectively. One patient underwent pancreaticogastric anastomosis revision. There were no mortalities in our series. Conclusions: IGS is a safe, feasible, and effective technique for gastric intraluminal lesion resection and for performing ERCP after RYGB, while it has the potential for other future applications.

Palliative treatment with high-dose-rate endobronchial interventional radiotherapy (Brachytherapy) for lung cancer patients.

PURPOSE: to report on the use of high-dose-rate (HDR) endobronchial interventional radiotherapy (brachytherapy, EBIRT) for palliation of symptoms in patients with lung cancer. PATIENTS AND METHODS: retrospective review of lung cancer patients treated with HDR-EBIRT at our institution (1995-2017). Treatment results and treatment related toxicity were recorded. Clinical response was subjectively evaluated within 3 months after treatment. Overall survival (OS) was analyzed. RESULTS: 347 patients were identified. The median age was 69 years and the median follow-up time was 13.4 months. Most patients received external beam radiation therapy during the primary treatment. Within 3 months, 87.7% of the patients had complete or major response of their presenting symptoms. OS was 55.2% at 1 year, 18.3% at 2 years. Patients who had complete or major response had a longer median survival than other patients (13 versus 7 months, p = 0.03). Chronic bronchitis was found in 26.8%, while 7.8% of the patients died due to uncontrollable hemoptysis. CONCLUSION: HDR-EBIRT is a safe and effective treatment option for the palliative treatment of lung cancer patients. HDR-EBIRT is most suitable as a re-irradiation technique. Further clinical studies are needed to validate its role.

Significance of tumor mutation burden and immune infiltration in thymic epithelial tumors.

BACKGROUND: Thymic epithelial tumors (TETs) are relatively rare malignant thoracic tumors. Tumor mutation burden (TMB) and immune infiltration play important roles in tumorigenesis. METHODS: Research data was obtained using the Cancer Genome Atlas (TCGA) database to evaluate the landscape of tumor mutations, related factors, and relationship of prognosis. The CIBERSORT algorithm was used to evaluate immune cell infiltration in TETs and its relationship with TMB. Immune-related differentially expressed genes (irDEGs) were identified. Hub irDEGs independently related to prognosis were analyzed using univariate and multivariate Cox proportional hazard models. A survival signature was constructed from hub irDEGs. RESULTS: A total of 122 patients were included in this study. GTF2I was the most common gene mutation. Higher TMB was significantly associated with the later stage, more advanced pathological type, and older age. The overall survival (OS) of patients in the low-TMB group was significantly better. There was no significant correlation between TMB levels and PD-L1 expression. Enrichment analysis showed that DEGs were mainly involved in the P13K-Akt signaling pathway. There were significant differences in macrophage and other types of immune cell infiltration between the high- and low-TMB groups. CCR5, FASLG, and CD79A independently relating to prognosis were screened from 391 irDEGs. The low-risk group had a significantly better prognosis than the high-risk group based on the signature, which has a good predictive effect on OS. CONCLUSIONS: In this study, TETs patients with high TMB had a significantly poor prognosis and an immune-related gene signature was found to effectively evaluate the long-term prognosis.

Maintaining an Adult Hematology/Oncology Service at a Tertiary Care Center during the SARS-CoV-2 Pandemic: An Eight-Week-Experience with a Newly Implemented Procedural Plan.

Treatment of cancer patients has become challenging when large parts of hospital services need to be shut down as a consequence of a local COVID-19 outbreak that requires rapid containment measures, in conjunction with the shifting of priorities to vital services. Reports providing conceptual frameworks and first experiences on how to maintain a clinical hematology/oncology service during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic are scarce. Here, we report our first 8 weeks of experience after implementing a procedural plan at a hematology/oncology unit with its associated cancer center at a large academic teaching hospital in Germany. By strictly separating team workflows and implementing vigorous testing for SARS-CoV-2 infections for all patients and staff members irrespective of clinical symptoms, we were successful in maintaining a comprehensive hematology/oncology service to allow for the continuation of treatment for our patients. Notably, this was achieved without introducing or further transmitting SARS-CoV-2 infections within the unit and the entire center. Although challenging, our approach appears safe and feasible and may help others to set up or optimize their procedures for cancer treatment or for other exceedingly vulnerable patient cohorts.

Dynamic nomogram for long-term survival in patients with non-small cell lung cancer after pneumonectomy.

BACKGROUND: The study aims to identify prognostic factors of overall survival (OS) in patients who had pneumonectomy, in order to develop a practical dynamic nomogram model. METHODS: A total of 2,255 patients with non-small cell lung cancer (NSCLC) who underwent pneumonectomy were identified from 2010-2015 in the Surveillance, Epidemiology, and End Results (SEER) database. The cohort was divided into a training (2011-2015) and a validation [2010] cohort. A nomogram and a risk classification system were constructed from the independent survival factors in multivariable analysis. The predictive accuracy of the nomogram was measured through internal and external validation. RESULTS: Independent prognostic factors associated with OS were gender, age, pathology, tumor size, N stage, chemotherapy, and radiotherapy. The C-index of the nomogram for OS was 0.675 (95% CI: 0.655-0.694). Similarly, the AUC of the model was 0.733, 0.709, and 0.701 for the 1-, 3-, and 5-year OS, respectively. The calibration curves for survival demonstrated good agreement. Significant statistical differences were found in the OS of patients within different risk groups. An online calculation tool was established for clinical use. CONCLUSIONS: This novel nomogram was able to provide a reliable prognosis for survival in patients with NSCLC undergoing pneumonectomy.

Endoscopic Sleeve Gastroplasty (ESG) for High-Risk Patients, High Body Mass Index (> 50 kg/m2) Patients, and Contraindication to Abdominal Surgery.

BACKGROUND: For high-risk classified patients, patients with superobesity and in cases of contraindication to abdominal surgery, traditional bariatric surgery might lead to potential morbidity and mortality. Endoscopic sleeve gastroplasty (ESG) is a novel and effective bariatric therapy for morbidly obese patients. Our research group initially evaluated the safety, feasibility, and efficacy of ESG for high-risk, high body mass index (BMI) patients, and patients contraindicated to abdominal surgeries. METHODS: Eligible patients characterized as high-risk for bariatric surgery due to high-BMI, severe comorbidities, or impenetrable abdomen were prospectively documented. ESG was performed by using Overstich® (Apollo Endosurgery, Austin, TX, USA). Primary outcomes included technical success, post-procedure adverse events and mortality, and the change of weight and BMI. RESULTS: ESG was successfully performed for all patients (N = 24, mean age was 55.6 (± 9.2) years old, 75% male). Baseline weight and BMI were 157.9 (± 49.1) kg and 49.9 (± 14.4) kg/m2. According to Edmonton Obesity Staging System (EOSS), 8 (33.3%), 14 (58.3%), and 2 (8.3%) patients were respectively classified as EOSS 2, 3, and 4. Mean operation time was 114.7 (± 26.0) min, without intraoperative complication. Weight loss, BMI reduction, %total weight loss (%TWL), and %excess weight loss (%EWL) were 17.5 (± 14.6) kg, 5.6 (± 4.6) kg/m2, 12.2% (± 8.9%), and 29.1% (± 17.9%) at post-ESG 12-month, respectively. One (4.2%) moderate post-procedure adverse event (gastric mucosal bleeding) was observed. CONCLUSIONS: ESG can be used as a safe, feasible, and effective option for the therapy of patients with superobesity, high-risk patients, and patients contraindicated to abdominal surgery. Graphical Abstract.

Survival and Prognostic Nomogram for Primary Gastrointestinal Melanoma (PGIM): A Population-based Study.

BACKGROUND/AIM: Primary gastrointestinal mucosal melanoma (PGIM) is an aggressive and rare disease, commonly with poor prognosis. We aimed to determine the clinical risk and prognosis of this rare entity. PATIENTS AND METHODS: Patients (n=962) with PGIM documented in the Surveillance, Epidemiology, and End Results database between 1975-2016 were included. Prognostic factors on overall survival (OS) and cancer-specific survival (CSS) were identified. A nomogram was constructed to predict the OS of PGIM patients. RESULTS: Primary site, summary stage, and therapeutic method were all independent predictors of OS and CSS, and age was the only factor significantly associated with OS. Independent prognostic factors of OS were selected to develop a predictive nomogram. The Harrell's C-index of the nomogram was 0.712, the area under the curve (AUC) was 0.746, 0.758, 0.810 for the 1-, 3-, and 5-year OS, respectively, and calibration plots were in good agreement. CONCLUSION: Several prognostic factors of PGIM were demonstrated and a practical nomogram model was created in this study.

Quantitative volumetric assessment of baseline enhancing tumor volume as an imaging biomarker predicts overall survival in patients with glioblastoma.

BACKGROUND: Glioblastoma multiforme (GBM) is the commonest malignant primary brain tumor and still has one of the worst prognoses among cancers in general. There is a need for non-invasive methods to predict individual prognosis in patients with GBM. PURPOSE: To evaluate quantitative volumetric tissue assessment of enhancing tumor volume on cranial magnetic resonance imaging (MRI) as an imaging biomarker for predicting overall survival (OS) in patients with GBM. MATERIAL AND METHODS: MRI scans of 49 patients with histopathologically confirmed GBM were analyzed retrospectively. Baseline contrast-enhanced (CE) MRI sequences were transferred to a segmentation-based three-dimensional quantification tool, and the enhancing tumor component was analyzed. Based on a cut-off percentage of the enhancing tumor volume (PoETV) of >84.78%, samples were dichotomized, and the OS and intracranial progression-free survival (PFS) were evaluated. Univariable and multivariable analyses, including variables such as sex, Karnofsky Performance Status score, O6-methylguanine-DNA-methyltransferase status, age, and resection status, were performed using the Cox regression model. RESULTS: The median OS and PFS were 16.9 and 7 months in the entire cohort, respectively. Patients with a CE tumor volume of >84.78% showed a significantly shortened OS (12.9 months) compared to those with a CE tumor volume of ≤84.78% (17.7 months) (hazard ratio [HR] 2.72; 95% confidence interval [CI] 1.22-6.03; P = 0.01). Multivariable analysis confirmed that PoETV had a significant prognostic role (HR 2.47; 95% CI 1.08-5.65; P = 0.03). CONCLUSION: We observed a correlation between PoETV and OS. This imaging biomarker may help predict the OS of patients with GBM.

Effect of Lymph Node Dissection on the Prognosis of Thymic Carcinomas and Thymic Neuroendocrine Tumors.

We aimed to analyze the effect of lymph node dissection (LND) and accurate lymph node (LN) status on the survival and prognosis of patients with thymic carcinomas (TCs) and thymic neuroendocrine tumors (TNETs) undergoing surgical treatment. The Surveillance, Epidemiology, and End Results database was queried for patients who underwent surgical resection for TCs and TNETs during 1998-2016. LN status were defined as no LND (LND-), pathologically negative with LND (N0), and LN metastasis positive (N+). We investigated outcomes of LN status together with other clinicopathological features for overall survival (OS). Subgroup analyses were performed between LND-, N0, and N+ cohorts using propensity score matching, to analyze the significance of LND in prognosis. A total of 812 patients were enrolled, including 623 with TCs and 189 with TNETs. The proportion of LN metastasis positive in TNETs was 58.8% which was significantly higher than that in TCs (30%) (P < 0.001). In multivariable Cox analysis of OS, patients with LND- had a significantly worse prognosis than those with N0 (P = 0.018); there was no difference between N+ and LND- (P = 0.560). After propensity score matching, patients with N0 still had better survival than those with LND- and N+ in subgroup univariable and multivariable analyses of OS; however, the survival of patients with LND- and N+ was not significantly different in multivariable analysis. It was demonstrated that LND in TCs and TNETs can clarify the status of LN metastasis, to more accurately evaluate patients' long-term prognosis.

Intragastric single-port surgery (IGS) for gastric endophytic gastrointestinal stromal tumor (GIST): A novel surgical treatment.

BACKGROUND: Intragastric surgery with a single incision has been performed for several diseases, such as gastric tumors[1] and pancreatic pseudocyst[2], safety, feasibility and potential benefits of which have been reported in previous relevant studies[3]. METHODS: The video shows a 65-year-old man with upper gastrointestinal hemorrhage, preoperative abdominal CT scan and endoscopy suggested an endophytic tumor located in gastric corpus, suggesting gastrointestinal stromal tumor (GIST). Intragastric single-port surgery (IGS) was indicated. RESULTS: Under general anesthesia, patient was placed in supine position. Surgeons stood on the right side of the patient. After a 2.5cm transverse incision was made on left upper abdominal wall, gastric anterior wall was exteriorized and fixed to the skin incision. Single-port device was inserted inside the stomach after anterior gastric wall was opened. Next, laparoscope was introduced into gastric cavity and identified the location of tumor. Full thickness resection of the tumor was performed by using linear stapler, then stapler line was embedded with continuous sutures. Finally, after specimen and single-port device removal, the stomach incision was closed extracorporeally. The operation time was 112 minutes. Final pathology confirmed GIST (4.5cm) with negative margins and patient discharged after 4 days, without postoperative complications. In 1-year follow-up time, without recurrence or death. CONCLUSION: IGS is safe and effective for gastric endophytic GIST resection, which not only preserves all advantages of conventional laparoscopic operation, but also includes other benefits like obviating the need of abdominal cavity exploration, potential reduction of risk of neoplasm seeding, and offering good postoperative cosmetic result.

kOBCS©: a novel software calculator program of the Objective Breast Cosmesis Scale (OBCS).

PURPOSE: The Objective Breast Cosmesis Scale (OBCS) is an objective method that documents the aesthetic changes in breast cancer patients. This work evaluates the kOBCS© software (http://www.kobcs.info) which simplifies the estimation of the OBCS values. METHODS: Five schematic drawings were photographed and imported into the kOBCS©. Thirty photos of breast cancer patients were imported into kOBCS©; 20 users (experts and non-experts) evaluated the photographs on two different settings. Subjective evaluation was performed using the Harvard breast cosmesis scale. RESULTS: There was a highly significant correlation between the OBCS values based on hand measurements and the values estimated by kOBCS© (r = 0.997, P < 0.001). Agreement among the users using the kOBCS© was strong with high statistical significance (ICC = 0.846, P < 0.001, 95% CI 0.774-0.910, Cronbach's alpha = 0.991). Results of the subjective analyses and mean OBCS values as estimated by kOBCS© correlated significantly (r = 0.961, P < 0.001). CONCLUSIONS: The kOBCS© is a reliable and reproducible easy-to-use software for reporting breast cosmesis following breast-conserving therapy.

Adjuvant radiotherapy improves progression-free survival in intracranial atypical meningioma.

BACKGROUND: Meningiomas are the most common primary tumors of the central nervous system. In patients with WHO grade I meningiomas no adjuvant therapy is recommended after resection. In case of anaplastic meningiomas (WHO grade III), adjuvant fractionated radiotherapy is generally recommended, regardless of the extent of surgical resection. For atypical meningiomas (WHO grade II) optimal postoperative management has not been clearly defined yet. METHODS: We conducted a retrospective analysis of patients treated for intracranial atypical meningioma at Charité Universitätsmedizin Berlin from March 1999 to October 2018. Considering the individual circumstances (risk of recurrence, anatomical location, etc.), patients were either advised to follow a wait-and-see approach or to undergo adjuvant radiotherapy. Primary endpoint was progression-free survival (PFS). RESULTS: This analysis included 99 patients with atypical meningioma (WHO grade II). Nineteen patients received adjuvant RT after primary tumor resection (intervention group). The remaining 80 patients did not receive any further adjuvant therapy after surgical resection (control group). Median follow-up was 37 months. Median PFS after primary resection was significantly longer in the intervention group than in the control group (64 m vs. 37 m, p = 0.009, HR = 0.204, 95% CI = 0.062-0.668). The influence of adjuvant RT was confirmed in multivariable analysis (p = 0.041, HR = 0.192, 95% CI = 0.039-0.932). CONCLUSIONS: Our study adds to the evidence that RT can improve PFS in patients with atypical meningioma.

Patient-Reported Outcomes-Secondary Analysis of the SCORE-2 Trial Comparing 4 Gy × 5 to 3 Gy × 10 for Metastatic Epidural Spinal Cord Compression.

PURPOSE: To compare 4 Gy × 5 (1 week) to 3 Gy × 10 (2 weeks) in relieving pain and distress in patients with metastatic epidural spinal cord compression (MESCC). METHODS AND MATERIALS: The randomized SCORE-2 trial compared 4 Gy × 5 (n = 101) to 3 Gy × 10 (n = 102) for MESCC. In this additional analysis, these regimens were compared for their effect in relieving pain and distress. Distress was evaluated with the distress-thermometer (0 = no distress, 10 = extreme distress) and pain on a linear scale (0 = no pain, 10 = worst pain). Relief of distress was defined as decrease of ≥2 points; complete and partial pain relief were defined as achieving a score of 0 points and a decrease ≥2 points, respectively, without increase of analgesic use. This prospective secondary analysis of the SCORE-2 trial aimed to show that 4 Gy × 5 was not inferior to 3 Gy × 10 regarding distress and pain relief. Analyses were performed using the unconditional test of noninferiority for binomial differences based on restricted maximum likelihood estimates (noninferiority margin: -20%). Evaluations were performed before, directly after, and 1, 3, and 6 months after radiation therapy. (ClinicalTrials.gov: NCT02189473). RESULTS: At baseline, median distress scores were 8 (2-10) points in the 4 Gy × 5 group and 8 (2-10) points in the 3 Gy × 10 group. At 1 month, distress relief rates were 58.1% (43/74) and 62.7% (47/75) (difference: -4.6%; 95% confidence interval, -20.0% to +11.1%; P = .025). At baseline, median pain scores were 7 (2-10) and 7 (2-10) points, respectively. At 1 month, complete pain relief rates were 23.5% (16/68) versus 20.0% (14/70) (difference, +3.5%; 95% confidence interval, -10.4% to +17.5%; P < .001), and overall pain relief rates were 52.9% (36/68) versus 57.1% (40/70) (difference, -4.2%; 95% confidence interval, -20.5% to +12.3%; P = .029). Distress and pain relief rates after 4 Gy × 5 were largely comparable to 3 Gy × 10 at all time points. Associated 95% confidence intervals did not point toward any relevant differences. CONCLUSIONS: In patients with MESCC and poor to intermediate survival prognoses, 4 Gy × 5 appeared noninferior to 3 Gy × 10 regarding pain and distress relief.

Salvage treatment with sole high-dose-rate endobronchial interventional radiotherapy (brachytherapy) for isolated endobronchial tumor recurrence in non-small-cell lung cancer patients: a 20-year experience.

PURPOSE: The purpose of this study was to report on the use of high-dose-rate (HDR) endobronchial interventional radiotherapy (brachytherapy) for isolated endobronchial tumor recurrence in patients with non-small-cell lung cancer, in whom a surgery or external radiation treatment is not possible. METHODS AND MATERIALS: A retrospective review of the patients with endobronchial tumors treated with HDR-endobronchial interventional radiotherapy at our institution (1995-2015) was performed. Treatment results and treatment-related toxicity were recorded. Clinical response was evaluated by bronchoscopy 3 months after treatment. Disease-free survival and overall survival were analyzed. RESULTS: One hundred twenty-six patients were identified. The median age was 63 years, and median followup time was 67.2 months. Three-month complete local response was 86.5%. At 5 years, disease-free survival was 41.4% and overall survival was 23.6%. 12.7% of the patients died from massive hemoptysis. CONCLUSION: HDR-endo brochial brachytherapy is an effective treatment option with acceptable toxicity for patients with endobronchial tumor recurrence in whom surgery and external beam radiotherapy are contraindicated.

Impact of bladder volume on acute genitourinary toxicity in intensity modulated radiotherapy for localized and locally advanced prostate cancer.

BACKGROUND AND PURPOSE: To evaluate the effect of changes in bladder volume during high-dose intensity-modulated-radiotherapy (IMRT) of prostate cancer on acute genitourinary (GU) toxicity and prospectively evaluate a simple biofeedback technique for reproducible bladder filling with the aim of reducing acute GU toxicity. METHODS: One hundred ninety-three patients were trained via a biofeedback mechanism to maintain a partially filled bladder with a reproducible volume of 200-300 cc at planning CT and subsequently at each fraction of radiotherapy. We prospectively analyzed whether and to what extent the patients' ability to maintain a certain bladder filling influenced the degree of acute GU toxicity and whether cut-off values could be differentiated. RESULTS: We demonstrated that the ability to reach a reproducible bladder volume above a threshold volume of 180 cc and maintain that volume via biofeedback throughout treatment predicts for a decrease in acute GU toxicity during curative high-dose IMRT of the prostate. Patients who were not able to reach a partial bladder filling to that cut-off value and were not able to maintain a partially filled bladder throughout treatment had a significantly higher risk of developing ≥grade 2 GU acute toxicity. CONCLUSION: Our results support the hypothesis that a biofeedback training for the patient is an easy-to-apply, useful, and cost-effective tool for reducing acute GU toxicity in high-dose IMRT of the prostate. Patients who are not able to reach and maintain a certain bladder volume during planning and treatment-two independent risk factors-might need special consideration.

Lymph node upstaging for non-small cell lung cancer after uniportal video-assisted thoracoscopy.

BACKGROUND: Radical lymph node dissection (LND) plays a major role in the treatment of non-small cell lung cancer (NSCLC). This study presents the analysis of the results after uniportal video-assisted thoracoscopy (VATS) lymphadenectomy during anatomical lung resections for NSCLC, focusing on pathological nodal upstaging. Any possible risk factor affecting nodal upstaging was also investigated. METHODS: The prospectively collected clinical data of 136 patients undergone uniportal VATS anatomical lung resections, from June 2012 to September 2017, were reviewed. In particular, all details inherent the clinical and pathological node stage and any possible risk factor affecting nodal upstaging were analyzed. RESULTS: The patient population consisted of 90 males and 46 females; their mean age was 67.42±10.64 years. The mean number of lymph nodes retrieved during uniportal VATS lymphadenectomy was 20.14±10.73 (7.27±5.90 and 12.60±7.96 in N1 and N2 stations, respectively). The incidence of nodal upstaging was 13.3% (18 cases). In particular there was a N0-1 upstaging in 10 cases (7.4%), a N1-2 upstaging in 3 (2.2%) and a N0-2 in 4 (3%). The ROC analysis showed that the resection of 18 lymph nodes was the best predictor of a general upstaging with an AUC-ROC of 0.595, while the resection of 7 hilar lymph nodes was the best predictor of N1 upstaging (AUC-ROC: 0.554) and 11 mediastinal nodes was the best predictor of N2 upstaging (AUC-ROC: 0.671). The number of positive lymph nodes of stations 5-6 (OR: 2.035, 95% CI: 1.082-3.826, P=0.027) and stations 2-3-4 (OR: 6.198, 95% CI: 1.580-24.321, P=0.009) were confirmed to be the only independent risk factors for N2 upstaging by multivariate analysis. CONCLUSIONS: According to our experience, uniportal VATS allows a safe and effective radical lymphadenectomy, with a satisfactory pathological nodal upstaging, comparable to other minimally invasive techniques.

Uniportal video-assisted thoracoscopy major lung resections after neoadjuvant chemotherapy.

BACKGROUND: The combination of neoadjuvant chemotherapy and surgery in lung cancer therapy is well established. The role of uniportal video assisted thoracoscopy (VATS) is still not described in literature. This study presents the preliminary short-term results of uniportal VATS after neoadjuvant therapy in our series. METHODS: The prospectively collected data of 154 patients after uniportal VATS anatomical lung resection (18 patients after neoadjuvant chemotherapy and 136 surgeries alone) were retrospectively reviewed. The perioperative results and follow-up of patients after neoadjuvant therapy were analyzed and compared to those after surgery alone. RESULTS: The mean age of population was 67.51±10.63 years. The mean operative time was overlapping in both groups: 248.97±118.17 min in surgery group and 287.17±94.13 min in chemotherapy + surgery group (P=0.190), with no difference in terms of types of anatomical lung resections performed and number of lymph nodes retrieved. The intraoperative mortality was null in both groups. The incidence of all complications was the same in both groups and no correlations was found with any possible risk factor evaluated (age, gender, comorbidities, type of resection, histology, etc.). Among minor complications, the incidence of parenchymal fistula was significantly higher in the 18 patients underwent chemotherapy (22.2% vs. 5.1% respectively, P=0.013). The overall survival of the series was 93% at 1 year follow-up and 88% at 5-year. The 1- and 2-year survival in only surgery group was 94% and 89% respectively vs. 85% and 85% in Chemotherapy + surgery, without any significant difference (P=0.324). CONCLUSIONS: According to our experience, uniportal VATS after neoadjuvant therapy is feasible and quite safe. The oncological results and postoperative complications are comparable to those of other techniques. Uniportal VATS can be performed even for complicated cases in experienced centers.