Immunotherapy and radiotherapy for older patients with locally advanced rectal cancer unfit for surgery or decline surgery: a practical proposal by the International Geriatric Radiotherapy Group.

The standard of care for locally advanced rectal cancer is total neoadjuvant therapy followed by surgical resection. Current evidence suggests that selected patients may be able to delay or avoid surgery without affecting survival rates if they achieve a complete clinical response (CCR). However, for older cancer patients who are too frail for surgery or decline the surgical procedure, local recurrence may lead to a deterioration of patient quality of life. Thus, for clinicians, a treatment algorithm which is well tolerated and may improve CCR in older and frail patients with rectal cancer may improve the potential for prolonged remission and potential cure. Recently, immunotherapy with check point inhibitors (CPI) is a promising treatment in selected patients with high expression of program death ligands receptor 1 (PD- L1). Radiotherapy may enhance PD-L1 expression in rectal cancer and may improve response rate to immunotherapy. We propose an algorithm combining immunotherapy and radiotherapy for older patients with locally advanced rectal cancer who are too frail for surgery or who decline surgery.

First case of 18F-choline uptake in acoustic schwannoma after stereotactic radiotherapy.

A 69-year-old male patient, with bilateral hypoacusia and tinnitus, had a diagnosis of left vestibular schwannoma with synchronous meningioma on the left frontal lobe. After partial surgical resection of the acoustic schwannoma, this was followed by stereotactic radiosurgery on the residual lesion. The patient had a metachronous prostate cancer treated with conformal radiotherapy associated to 6 months of hormone therapy with luteinizing hormone/releasing hormone analog. During follow-up, prostate-specific antigen value increased to 0.27 ng/mL and the patient underwent 18F-methylcholine positron emission tomography/computed tomography (18F-choline PET/CT). The whole-body scan demonstrated a focus of increased uptake at level of the left cerebellopontine angle and at the left frontal lobe, corresponding to the known vestibular schwannoma and meningioma. A subsequent brain contrast-enhanced magnetic resonance imaging (MRI) showed an increased dimension of the left cerebellopontine neuroma and dimensional stability of the left frontal meningioma compared with previous MRI of 6 months earlier. To the best of our knowledge, we describe the first case of a 18F-choline PET/CT demonstrating a relapse of a vestibular schwannoma after stereotactic radiotherapy.

Positron emission tomography with computed tomography imaging (PET/CT) for the radiotherapy planning definition of the biological target volume: PART 2.

AIM: Positron Emission Tomography with Computed Tomography (PET/CT) has been proven to be useful in the definition of Radiotherapy (RT) target volume. In this regard, the present expert review summarizes existing data for pancreas, prostate, gynecological and rectum/anal cancer. METHODS: A comprehensive search of published original article was made, based on SCOPUS and PubMed database, selecting the paper that evaluated the role of PET/CT in the definition of RT volume. RESULTS: FDG-PET has an important and promising role for pancreatic cancer. Choline PET/CT could be useful for identifying high-risk volumes for prostate cancer; while PSMA PET/CT is still under evaluation. FDG PET/CT in gynecological cancers has been shown to impact external-beam RT planning. The role of FDG-PET for Gross Tumor volume identification is crucial, representing a useful and powerful tool for anal and rectal cancer. CONCLUSION: Taken together, molecular and functional imaging approaches offer a major step to individualize radiotherapeutic approach.

Positron emission tomography with computed tomography imaging (PET/CT) for the radiotherapy planning definition of the biological target volume: PART 1.

AIM: Functional and molecular imaging, including positron emission tomography with computed tomography imaging (PET/CT) is increasing for radiotherapy (RT) definition of the target volume. This expert review summarizes existing data of functional imaging modalities and RT management, in terms of target volume delineation, for the following anatomical districts: brain (for primary and secondary tumors), head/neck and lung. MATERIALS AND METHODS: A collection of available published data was made, by PubMed a search. Only original articles were carefully and critically revised. RESULTS: For primary and secondary brain tumors, amino acid PET radiotracers could be useful to identify microscopic residual areas and to differ between recurrence and treatment-related alterations in case of re-irradiation. As for head and neck neoplasms may benefit from precise PET/CT-based target delineation, due to the major capability to identify high-risk RT areas. In primary and secondary lung cancer, PET/CT could be useful both to delimit a tumor and collapsed lungs and as a predictive parameter of treatment response. CONCLUSION: Taken together, molecular and functional imaging approaches offer a major step to individualize radiotherapeutic care going forward. Nevertheless, several uncertainties remain on the standard method to properly assess the target volume definition including PET information for primary and secondary brain tumors.

Target Therapies for Uterine Carcinosarcomas: Current Evidence and Future Perspectives.

Carcinosarcomas (CS) in gynecology are very infrequent and represent only 2-5% of uterine cancers. Despite surgical cytoreduction and subsequent chemotherapy being the primary treatment for uterine CS, the overall five-year survival rate is 30 ± 9% and recurrence is extremely common (50-80%). Due to the poor prognosis of CS, new strategies have been developed in the last few decades, targeting known dysfunctional molecular pathways for immunotherapy. In this paper, we aimed to gather the available evidence on the latest therapies for the treatment of CS. We performed a systematic review using the terms "uterine carcinosarcoma", "uterine Malignant Mixed Müllerian Tumors", "target therapies", "angiogenesis therapy", "cancer stem cell therapy", "prognostic biomarker", and "novel antibody-drug". Based on our results, the differential expression and accessibility of epithelial cell adhesion molecule-1 on metastatic/chemotherapy-resistant CS cells in comparison to normal tissues and Human Epidermal Growth Factor Receptor 2 (HER2) open up new possibilities in the field of target therapy. Nevertheless, future investigations are needed to clarify the impact of these new therapies on survival rate and medium-/long-term outcomes.

An Incidental Finding of Mucinous Colon Cancer by (18)F-Choline PET/CT Determining a Change in Clinical Management of a Patient with Recurrent Prostate Adenocarcinoma.

A 66-year-old-man underwent a PET/CT scan after a biochemical relapse for a prostate cancer previously treated with a laparoscopic surgical procedure which revealed a focal uptake in the posterior wall of sigmoid colon. The biopsy demonstrated a colon cancer with mucinous differentiation producing a shift in clinical priority. To the best of our knowledge this is the first report in the English literature describing the detection by (18)F-choline PET/CT of a colorectal cancer with mucinous differentiation.