Revisiting the role of radiotherapy in the treatment of neuroblastoma 4S: 30 years of institutional experience and systematic review.

Background and purpose: Neuroblastoma 4S is a rare subtype of metastatic neuroblastoma found in children younger than 12 months, characterized by liver, skin, or bone marrow metastases. While the prognosis for patients is generally favorable, rapid progression of liver metastases can lead to life-threatening organ insufficiency. In such cases, immediate treatment with chemotherapy or radiotherapy is necessary. Given the recent decline in radiotherapy utilization, this study aims to reassess its role, evaluating its effectiveness and toxicity. Materials and methods: We conducted a systematic review and an institutional retrospective analysis to assess the use of radiotherapy for hepatomegaly in patients with neuroblastoma 4S. The study included data from 164 patients from the literature and 16 patients from our institutional cohort. We extracted and analyzed data on short- and long-term outcomes, as well as reports of radiotherapy-induced toxicity. Results: Our institutional data showed that 81 % of patients responded to low-dose radiotherapy administered at a median dose of 450 cGy in three fractions, resulting in liver shrinkage and symptom resolution. Based on the systematic review, 1-year survival rate was 80 %, while 5-year survival rate was 75 %. No serious toxicity was observed with the current low-dose radiotherapy; however, one case of induced secondary malignancy was reported. Conclusion: Radiation therapy is an effective treatment modality for hepatomegaly in patients with neuroblastoma 4S, with a success rate of about 80 %. Despite being administered to infants, a low dose of 450-600 cGy does not result in toxicity related to the kidneys, liver, or posture defects.

Reirradiation for diffuse intrinsic pontine glioma: prognostic radiomic factors at progression.

PURPOSE: Diffuse intrinsic pontine glioma (DIPG) is a lethal pediatric brain tumor. Radiation therapy (RT) is the standard treatment, with reirradiation considered in case of progression. However, the prognostic factors for reirradiation are not well understood. This study aims to investigate the outcomes of DIPG patients undergoing reirradiation and identify clinical and radiomic prognostic factors. METHODS: We conducted a retrospective analysis of patients with DIPG who underwent reirradiation at our institution between January 2016 and December 2023. Using PyRadiomics, we extracted radiomic features of tumors at the time of progression from FLAIR MRI images and collected clinical data. We used the least absolute shrinkage and selection operator (lasso) for Cox's proportional hazard model with leave-one-out cross-validation to select optimal prognostic factors for survival after reirradiation. RESULTS: The study included 18 patients who underwent reirradiation at first progression, receiving a total dose of 20 Gy or 24 Gy in 2­Gy fractions. Reirradiation was well tolerated, with no severe toxicity. Most patients (78%) showed neurological improvement after treatment. Median survival after progression was 29.2 weeks. The Cox model demonstrated a concordance of 0.81 (95% CI: 0.75-0.88), revealing that tumor sphericity and structural gray-level heterogeneity in FLAIR MRI images were associated with longer survival of reirradiated patients. CONCLUSION: Reirradiation is a safe and effective approach for patients with DIPG. MRI-based radiomic models could be helpful in predicting survival after reirradiation.

The rise of negative portrayals of radiation oncology: A textual analysis of media news.

BACKGROUND AND PURPOSE: There has been growing concern about the media's negative portrayal of radiation oncology in recent years. Our study shows changes in media sentiment toward radiotherapy over the years, identifies prevalent themes, and analyzes their shifts over time. MATERIALS AND METHODS: We analyzed articles about radiation oncology published in The New York Times since the journal's inception in 1851. Initially, we collected 30 427 articles containing the keywords "radiation" or "radiotherapy" up to July 2023. In the next step, we selected 342 articles on radiation oncology using keyword searches, prompting the Chat GPT language model and manual assessment. Ultimately, we created a codebook summarizing the media topics related to radiotherapy and categorized the articles into these categories. RESULTS: Our analysis identified ten distinct categories representing media themes related to radiation oncology: five negative, three positive, and two neutral. Our findings indicate a rising negative sentiment toward radiotherapy. In the 21st century, over 50% of articles negatively described radiation oncology. The media coverage has shifted its focus away from describing scientific breakthroughs and the implementation of new techniques and toward treatment errors, toxicity, and ineffectiveness. CONCLUSION: The increasing negative media sentiment surrounding radiation oncology may influence public perceptions and impact patients' decisions. Radiation oncologists should remain vigilant about this situation, ensuring the dissemination of accurate information and addressing negative portrayals.

Risk-Adapted Treatment Strategies with Pre-Irradiation Chemotherapy in Pediatric Medulloblastoma: Outcomes from the Polish Pediatric Neuro-Oncology Group.

Craniospinal irradiation (CSI) has been a major component of the standard of care treatment backbone for childhood medulloblastoma. However, chemotherapy regimens have varied based on protocol, patient age, and molecular subtyping. In one of the largest studies to date, we analyzed treatment outcomes in children with newly-diagnosed medulloblastoma treated with pre-irradiation chemotherapy followed by risk-adapted radiotherapy and maintenance chemotherapy. A total of 153 patients from the Polish Pediatric Neuro-Oncology Group were included in the analysis. The median age at diagnosis was 8.0 years, and median follow-up time was 6.4 years. Sixty-seven patients were classified as standard-risk and eighty-six as high-risk. Overall survival (OS) and event-free survival (EFS) for standard-risk patients at 5 years (±standard error) were 87 ± 4.3% and 84 ± 4.6%, respectively, while 5-year OS and EFS for high-risk patients were 81 ± 4.3% and 79 ± 4.5%, respectively. Only one patient had disease progression prior to radiotherapy. This study demonstrates promising survival outcomes in patients treated with pre-irradiation chemotherapy followed by risk-adapted CSI and adjuvant chemotherapy. Such an approach may be useful in cases where the initiation of radiotherapy may need to be delayed, a common occurrence in many institutions globally.

COVID-19 Vaccinations: Summary Guidance for Cancer Patients in 28 Languages: Breaking Barriers to Cancer Patient Information.

BACKGROUND: Covid-19 vaccination has started in the majority of the countries at the global level. Cancer patients are at high risk for infection, serious illness, and death from COVID-19 and need vaccination guidance and support. Guidance availability in the English language only is a major limit for recommendations' delivery and their application in the world's population and generates information inequalities across the different populations. METHODS: Most of the available COVID-19 vaccination guidance for cancer patients was screened and scrutinized by the European Cancer Patients Coalition (ECPC) and an international oncology panel of 52 physicians from 33 countries. RESULTS: A summary guidance was developed and provided in 28 languages in order to reach more than 70 percent of the global population. CONCLUSION: Language barrier and e-guidance availability in the native language are the most important barriers when communicating with patients. E-guidance availability in various native languages should be considered a major priority by international medical and health organizations that are communicating with patients at the global level.

Radiotherapy in the Management of Pediatric and Adult Osteosarcomas: A Multi-Institutional Cohort Analysis.

BACKGROUND: Due to the rarity of osteosarcoma and limited indications for radiotherapy (RT), data on RT for this tumor are scarce. This study aimed to investigate the utilization of RT for osteosarcomas in the recent 20 years and to identify factors related to patients' response to radiation. METHODS: We performed a retrospective analysis of patients irradiated for osteosarcoma treatment. We planned to assess differences in the utilization of RT between the periods of 2000-2010 and 2011-2020, identify the risk factors associated with local progression (LP), determine whether RT-related parameters are associated with LP, and calculate patients' survival. RESULTS: A total of 126 patients with osteosarcoma who received 181 RT treatments were identified. We found a difference in RT techniques between RT performed in the years 2000-2010 and that performed in the years 2011-2020. LP was observed after 37 (20.4%) RT treatments. Intent of RT, distant metastases, and concomitant systemic treatment affected the risk of LP. Five-year overall survival was 33% (95% confidence interval (26%-43%)). CONCLUSIONS: RT for osteosarcoma treatment has evolved from simple two-dimensional palliative irradiation into more conformal RT applied for new indications including oligometastatic and oligoprogressive disease. RT may be a valuable treatment modality for selected patients with osteosarcoma.

Radical radiotherapy for paediatric solid tumour metastases: An overview of current European protocols and outcomes of a SIOPE multicenter survey.

PURPOSE/OBJECTIVE: About 20% of children with solid tumours (ST) present with distant metastases (DM). Evidence regarding the use of radical radiotherapy of these DM is sparse and open for personal interpretation. The aim of this survey was to review European protocols and to map current practice regarding the irradiation of DM across SIOPE-affiliated countries. MATERIALS/METHODS: Radiotherapy guidelines for metastatic sites (bone, brain, distant lymph nodes, lung and liver) in eight European protocols for rhabdomyosarcoma, non-rhabdomyosarcoma soft-tissue sarcoma, Ewing sarcoma, neuroblastoma and renal tumours were reviewed. SIOPE centres irradiating ≥50 children annually were invited to participate in an online survey. RESULTS: Radiotherapy to at least one metastatic site was recommended in all protocols, except for high-risk neuroblastoma. Per protocol, dose prescription varied per site, and information on delineation and treatment planning/delivery was generally missing. Between July and September 2019, 20/27 centres completed the survey. Around 14% of patients were deemed to have DM from ST at diagnosis, of which half were treated with curative intent. A clear cut-off for a maximum number of DM was not used in half of the centres. Regardless of the tumour type and site, conventional radiotherapy regimens were most commonly used to treat DM. When stereotactic radiotherapy was used, a wide range of fractionation regimens were applied. CONCLUSION: Current radiotherapy guidelines for DM do not allow a consistent approach in a multicentre setting. Prospective (randomised) trials are needed to define the role of radical irradiation of DM from paediatric ST.

Epithelioid Sarcoma-From Genetics to Clinical Practice.

Epithelioid sarcoma is a mesenchymal soft tissue sarcoma often arising in the extremities, usually in young adults with a pick of incidence at 35 years of age. Epithelioid sarcoma (ES) is characterized by the loss of SMARCB1/INI1 (integrase interactor 1) or other proteins of the SWI/SNF complex. Two distinct types, proximal and distal, with varying biology and treatment outcomes, are distinguished. ES is known for aggressive behavior, including a high recurrence rate and regional lymph node metastases. An optimal long-term management strategy is still to be defined. The best treatment of localized ES is wide surgical resection. Neo-adjuvant or adjuvant radiotherapy may be recommended, as it reduces the local recurrence rate. Sentinel lymph node biopsy should be considered in ES patients. Patients with metastatic ES have a poor prognosis with an expected median overall survival of about a year. Doxorubicin-based regimens are recommended for advanced ES. Tazemetostat, an EZH2 methyltransferase, has shown promising results in ES patients. Novel therapies, including immunotherapy, are still needed.

Spinal cord ependymoma in children--results of postoperative radiotherapy.

PURPOSE: A retrospective study was performed to evaluate the results of postoperative radiation therapy of spinal cord ependymoma in children. METHODS AND MATERIALS: Between 1984 and 2005, 28 children with spinal cord ependymoma were treated with radiotherapy, after surgery and in three cases after chemotherapy as well. Median age at diagnosis was 13.3 years (range from 4.7 to 16.2 years). Ependymoma myxopapillare was identified in 13, ependymoma in 12 and anaplastic ependymoma in 3 cases. RESULTS: With a median follow-up of 8.7 years (range from 3 to 25 years) 22 patients were alive. The overall survival rate of 2, 5 and 10 years was 93%, 85% and 77% respectively, whereas progression free survival rate was 82%, 74% and 74% respectively. Patients with myxopapillary ependymoma had significantly better 5-year overall survival rate 100% than those with other histopathological types 60% (p=0.016). There were 2 relapse incidences observed among 13 patients with myxopapillary ependymoma, both underwent repeated surgery and reirradiation. In the group of 20 patients with gross total resection the overall 5-year survival rate was 100% in comparison with 62.5% with partial surgery, but it did not achieve statistical significance. CONCLUSIONS: The histological type of ependymoma myxopapillary was a statistical significant favourable prognostic factor. The gross total resection with adjuvant radiotherapy allows obtaining a high total survival rate.

Reirradiation of relapsed brain tumors in children.

AIM: The aim of this study was to evaluate toxicity and response to fractionated reirradiation (FR) of relapsed primary brain tumors in children. BACKGROUND: The treatment options for recurrent brain tumors in children previously irradiated are limited. Reirradiation is performed with fear due to the cumulative late CNS toxicity and the lack of a significant chance of cure. MATERIALS AND METHODS: Between 2008 and 2009, eight children with a median age of 14.5 years with a diagnosis of a recurrent brain tumor underwent reirradiation. Initially, all patients were treated with surgery, chemotherapy and radiotherapy. The median time to the first recurrence after the initial treatment was 19.5 months. Intervals between radiotherapy courses were in the range of 5-51 mos. All retreatments were carried out with 3D image-based conformal methods. The total prescription dose was 40 Gy in a fraction of 5 × 2 Gy/week. The total cumulative dose ranged from 65 to 95 Gy (median: 75 Gy). The median cumulative biologically effective dose was 144 Gy (range: 126-181 Gy). RESULTS: The median overall survival and progression free survival measured from the beginning of reirradiation was 17.5 and 6.5 months, respectively. During the first evaluation, four patients showed a complete or partial response, two did not respond radiologically. Two children were progressive at the time of reirradiation. Among children with progression that occurred during the first year after reirradiation, only two progressed in the treatment area. The repeated irradiation was well tolerated by all patients. No late complications have been observed. CONCLUSION: In the absence of other treatment possibilities, the fractionated reirradiation with highly conformal three-dimensional planning could be a therapeutic choice in case of recurrent brain tumors in children. The control of craniospinal dissemination remains to be the main problem.

Craniospinal radiotherapy in children: Electron- or photon-based technique of spinal irradiation.

BACKGROUND: The prone position and electron-based technique for craniospinal irradiation (CSI) have been standard in our department for many years. But this immobilization is difficult for the anaesthesiologist to gain airway access. The increasing number of children treated under anaesthesia led us to reconsider our technique. AIM: The purpose of this study is to report our new photon-based technique for CSI which could be applied in both the supine and the prone position and to compare this technique with our electron-based technique. MATERIALS AND METHODS: Between November 2007 and May 2008, 11 children with brain tumours were treated in the prone position with CSI. For 9 patients two treatment plans were created: the first one using photons and the second one using electron beams for spinal irradiation. We prepared seven 3D-conformal photon plans and four forward planned segmented field plans. We compared 20 treatment plans in terms of target dose homogeneity and sparing of organs at risk. RESULTS: In segmented field plans better dose homogeneity in the thecal sac volume was achieved than in electron-based plans. Regarding doses in organs at risk, in photon-based plans we obtained a lower dose in the thyroid but a higher one in the heart and liver. CONCLUSIONS: Our technique can be applied in both the supine and prone position and it seems to be more feasible and precise than the electron technique. However, more homogeneous target coverage and higher precision of dose delivery for photons are obtained at the cost of slightly higher doses to the heart and liver.

Screening Evaluation System--Europe (SESy_Europe) met skin cancer screening.

Skin tumors are the most frequent malignancies in the white population worldwide and have reached the proportion of an epidemic disease. Since non-melanocytic skin cancers can be cured when timely detected, given that still malignant melanoma may have good prognosis if early diagnosed, and considering the key role of primary care in cancer screening advising and implementation, the international PACMeR study group (trial_01.3) adjourned SESy_Europe database in a version comprehensive of skin-malignancies screening indexing. The novel database provides standardized pre-codified translations of 2,331 parameters in eight languages (English, French, German, Greek, Italian, Romanian, Spanish and Turkish) and records the time elapsed from last skin examination, cause and frequency of skins examinations and stratifies skin cancer risk patterns by a systematic registering of risk factors. A comprehensive indexing of skin cancer screening practices among European countries may in fact turn helpful in programming future health policy and tailoring interventions.

Patterns of failure in children with medulloblastoma treated with 3D conformal radiotherapy.

BACKGROUND AND PURPOSE: Craniospinal irradiation for medulloblastoma is one of the most complex techniques employed in radiotherapy. Many reports stress the impact of irradiation quality on survival in these patients. Our report presents the outcome and patterns of failure for 95 patients treated with 3D conformal radiotherapy (3D-CRT). MATERIALS AND METHODS: From 1998 to 2003, 95 children with medulloblastoma received 3D conformal radiotherapy. All of them were previously treated with surgery and chemotherapy. The brain and upper spinal cord were treated with two lateral 6MV photon fields. In four patients, the cribriform plate was irradiated by the additional field. For primary tumour bed we applied two or three photon beams. Spinal cord was irradiated either with 18-20MeV electron fields or with a mixed beam. RESULTS: With a median follow-up of 48 months, 32/95 patients suffered a multifocal (21) or isolated (11) recurrence. We evaluated every primary site of failure. In all patients, the recurrence appeared within the isodose level of 95-100%. CONCLUSIONS: Patterns of failure in medulloblastoma patients treated with 3D conformal radiotherapy indicated that the relapse was mainly associated with poor response to pre-irradiation chemotherapy. We believe that 3D conformal radiotherapy allows avoiding failures, related to radiotherapy uncertainties.

Inflammatory prostate cancer: an underestimated paraneoplastic clinical manifestation.

PURPOSE: To identify the incidence of prostate cancer associated-systemic inflammatory syndrome (SIS), and to characterize further this entity, we searched our database as well as the medical literature. METHODS: We retrospectively analyzed all patients with prostate cancer admitted to the Department of Medical Oncology of the Ioannina University Hospital during the last 3 years. Systematic review of peer-reviewed medical literature was further performed at 3 major libraries (i.e., MEDLINE, ISI Web of Science, and Cochrane Central Register of Controlled Trials). No publication year or language restriction was set in the literature search. RESULTS: Retrospective analysis of our patient population identified 4 patients with a SIS (of 63 patients who were metastatic hormone resistant), in whom fever was a sign of disease progression. Inversely, only 4 cases of prostate cancer-related fever were found in the literature, in all of them at disease presentation. Consequently, the incidence of inflammatory syndrome in metastatic prostate cancer seems to be strongly underestimated. A SIS can be an early or late event during the course of the disease, and is generally associated with rapid progression and bad prognosis. Back pain, fatigue, night sweats, anemia, bone metastases, and bone marrow infiltration are the most commonly associated signs and symptoms. Because of occasional responses to hormonal or chemotherapeutic treatment, prompt differential diagnosis and therapy are required. CONCLUSIONS: The role of proinflammatory cytokines in biochemical pathways of neoplastic growth has been established in prostate cancer, along with evidence for high levels of interleukin (IL)-6 among patients with hormone refractory disease. However, little is known about the frequency of a SIS in patients with prostatic carcinoma.

Evaluation of quality of life in long-term survivors of paediatric brain stem tumors, treated with radiotherapy.

The quality of life in long-term survivors of paediatric brain stem tumors, treated with radiotherapy is evaluated. They suffer predominantly from pre-treatment neurological impairments, which seriously influence their quality of life. The most often observed treatment sequelae are pituitary insufficiency and hearing loss.

Medulloblastoma in childhood: Impact of radiation technique upon the outcome of treatment.

BACKGROUND: Medulloblastoma is an infratentorial primitive neuroectodermal tumour, diagnosed in paediatric population. The radiotherapy is an essential method of treatment for these tumours. The impact of technical quality of radiation therapy on survival was recently considered. In this study treatment-related variables are analysed with a special focus on radiotherapy technical factors. PROCEDURE: The population of 158 children with a diagnosis of medulloblastoma had been undergoing postoperative radiotherapy at MCMCC in Warsaw in the period 1983-1997. The medical data of these patients were analysed. Simulation films of the whole-brain irradiation fields were retrospectively reviewed at 112 patients. The distance from the field margin to the cribriform plate and to the floor of the temporal fossa was assessed and correlated with supratentorial relapse. RESULTS: Five-year overall survival (OS) and 5-year disease free survival (DFS) were 46% and 40%, respectively. In multivariate analysis gender (P = 0.008), neurological status before radiotherapy (P = 0.029), M-stage (P < 0.001) and sequence of craniospinal irradiation (P = 0.019) were significant prognostic factors for OS. For DFS significant factors were M-stage (P < 0.001) and neurological status (P < 0.001). The cranial fields were not fully correctly covered at 43% patients. The field incorrectness was correlated with isolated supratentorial failure (P = 0.049). CONCLUSIONS: Our results are similar to those published in literature. M0-stage was the most powerful favourable prognostic factor. Male gender and neurological status before radiation treatment were associated with poor survival. Also protracted radiotherapy and quality of radiation technique may have an impact on the outcome.