Investigating Predictive Factors of Dysphagia and Treatment Prolongation in Patients with Oral Cavity or Oropharyngeal Cancer Receiving Radiation Therapy Concurrently with Chemotherapy.

Radiation therapy (RT) treatment for head and neck cancer has been associated with dysphagia manifestation leading to worse outcomes and decrease in life quality. In this study, we investigated factors leading to dysphagia and treatment prolongation in patients with primaries arising from oral cavity or oropharynx that were submitted to radiation therapy concurrently with chemotherapy. The records of patients with oral cavity or oropharyngeal cancer that received RT treatment to the primary and bilateral neck lymph nodes concurrently with chemotherapy were retrospectively reviewed. Logistic regression models were used to analyze the potential correlation between explanatory variables and the primary (dysphagia ≥ 2) and secondary (prolongation of total treatment duration ≥ 7 days) outcomes of interest. The Toxicity Criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC) were used to evaluate dysphagia. A total of 160 patients were included in the study. Age mean was 63.31 (SD = 8.24). Dysphagia grade ≥ 2 was observed in 76 (47.5%) patients, while 32 (20%) experienced treatment prolongation ≥ 7 days. The logistic regression analysis showed that the volume in the primary site of disease that received dose ≥ 60 Gy (≥118.75 cc, p < 0.001, (OR = 8.43, 95% CI [3.51-20.26]) and mean dose to the pharyngeal constrictor muscles > 40.6 Gy (p < 0.001, OR = 11.58, 95% CI [4.84-27.71]) were significantly associated with dysphagia grade ≥ 2. Treatment prolongation ≥ 7 days was predicted by higher age (p = 0.007, OR = 1.079, 95% CI [1.021-1.140]) and development of grade ≥ 2 dysphagia (p = 0.005, OR = 4.02, 95% CI [1.53-10.53]). In patients with oral cavity or oropharyngeal cancer that receive bilateral neck irradiation concurrently with chemotherapy, constrictors mean dose and the volume in the primary site receiving ≥ 60 Gy should be kept below 40.6 Gy and 118.75 cc, respectively, whenever possible. Elderly patients or those that are considered at high risk for dysphagia manifestation are more likely to experience treatment prolongation ≥ 7 days and they should be closely monitored during treatment course for nutritional support and pain management.

COVID-19 Emotional and Mental Impact on Cancer Patients Receiving Radiotherapy: An Interpretation of Potential Explaining Descriptors.

Background: Significant changes in the accessibility and viability of health services have been observed during the COVID-19 period, particularly in vulnerable groups such as cancer patients. In this study, we described the impact of radical practice and perceived changes on cancer patients' mental well-being and investigated potential outcome descriptors. Methods: Generalized anxiety disorder assessment (GAD-7), patient health (PHQ-9), and World Health Organization-five well-being index (WHO-5) questionnaires were used to assess anxiety, depression, and mental well-being. Information on participants, disease baseline information, and COVID-19-related questions were collected, and related explanatory variables were included for statistical analysis. Results: The mean score values for anxiety, depression, and mental well-being were 4.7 ± 5.53, 4.9 ± 6.42, and 72.2 ± 18.53, respectively. GAD-7 and PHQ-9 scores were statistically associated (p < 0.001), while high values of GAD-7 and PHQ-9 questionnaires were related to low values of WHO-5 (p < 0.001).Using the GAD-7 scale, 16.2% of participants were classified as having mild anxiety (GAD-7 score: 5−9).Mild to more severe anxiety was significantly associated with a history of mental health conditions (p = 0.01, OR = 3.74, 95% CI [1.372−10.21]), and stage category (stage III/IV vs. I/II, p = 0.01, OR = 3.83, 95% CI [1.38−10.64]. From the participants, 36.2% were considered to have depression (PHQ-9 score ≥ 5). Depression was related with older patients (p = 0.05, OR = 1.63, 95% CI [1.16−2.3]), those with previous mental health conditions (p = 0.03, OR = 14.24, 95% CI [2.47−81.84]), those concerned about the COVID-19 impact on their cancer treatment (p = 0.027, OR = 0.19, 95% CI [0.045−0.82]) or those who felt that COVID-19 pandemic has affected mental health (p = 0.013, OR = 3.56, 95% CI [1.30−9.72]). Additionally, most participants (86.7%) had a good well-being score (WHO-5 score ≥ 50). Mental well-being seemed more reduced among stage I−III patients than stage IV patients (p = 0.014, OR = 0.12, 95% CI [0.023−0.65]). Conclusion: There is a necessity for comprehensive cancer care improvement. These patients' main concern related to cancer therapy, yet the group of patients who were mentally affected by the pandemic should be identified and supported.

"One Shot" Sample Evaluation of 22G, 22G upgraded, 21G and 19G needle for Endobronchial Ultrasound-EBUS-TBNA.

Background: There are still diagnostic issues with lung cancer and mediastinum lymphadenopathy. Endobronchial ultrasound (EBUS) is a state of the art equipment for the diagnosis of lymphadenopathy and central lesions. Objective: To investigate the sample size with one pass. Patients and Methods: 248 Stage IV patients were included in our study. All patients had a CT of the thorax with either lymphadenopathy or lyphadenopathy plus pulmonary lesions. Patients had a biopsy with endobronchial ultrasound with 22G Mediglope, 22G Mediglope Sonotip, 21G Olympus and 19G Olympus needle. We collected information regarding the cancer type, cell block, tissue, age, sex, lesion size and needle type. Results: The cancer type diagnosis was associated with the needle diameter. The number of cell-blocks were associated with the lesion size and needle diameter. Slices from the tissue and cell-blocks were again associated with the lesion size and needle diameter. Conclusion: One pass is enough for cancer diagnosis, however; careful selection has to be made among patients regarding the needle diameter. In the case of lymphoma suspicion we should use 19G needle.

Investigating factors associated to dysphagia and need for percutaneous endoscopic gastrostomy in patients with head and neck cancer receiving radiation therapy.

Purpose: In this study we sought to investigate factors associated to dysphagia and subsequent need for percutaneous gastrostomy (PEG) usage, in patients with head and neck cancer receiving radiation therapy. Methods: The records of 123 patients with non-metastatic, stage I-IV head and neck cancer who were submitted to radiation therapy were retrospectively reviewed. Logistic regression models were used to investigate for associations between the outcomes of interest (grade ≥2 dysphagia and need for [PEG] usage) and potential predictive factors. Results: Mean dose to pharyngeal constrictor muscles (OR=1.08, p=.002), concurrent chemotherapy (OR=3.78, p=0.015) and upper aerodigestive tract malignancies (OR=3.27, p=0.044) were associated with dysphagia grade≥2. A threshold of constrictors mean dose for dysphagia manifestation was also identified at 43 Gy (OR=4.51, p=0.002). Need for PEG use was correlated with definitive treatment (OR=7.03, p=.022), nasopharyngeal (OR=12.62, p=0.003), upper aerodigestive tract (OR=9.12, p=0.007) or occult primary malignancies (OR=10.78, p=0.016). Conclusion: Patients suffering from upper aerodigestive tract malignancies, those with calculated constrictors mean dose >43 Gy, or planned to receive concurrent chemotherapy-radiotherapy should be closely monitored during treatment for dysphagia manifestation. Prophylactic PEG could be considered for patients receiving definitive therapy of the nasopharynx, upper aerodigestive tract or occult primary malignancies.

Role of minimally invasive surgery in the treatment of gallbladder metastatic melanoma. A review of the literature and a case report.

BACKGROUND: Primary and secondary gallbladder melanomas are rare, and only 58 cases have been reported in scientific literature to date. This paper aimed to explore the role of minimally invasive surgery in the management of gallbladder metastatic melanomas. CASE: Herein, we present the case of a 68-year-old man with metastatic gallbladder melanoma who was treated with laparoscopic cholecystectomy. Our case management was then compared with that of other cases reported in the literature. CONCLUSION: Currently, metastatic melanomas can be considered as a potentially curable disease. Palliation of symptoms and fast recovery following minimally invasive procedures could be beneficial for these patients. Particularly, laparoscopic procedures appear to prolong the survival of gallbladder melanoma patients.

Calculating interfractional prostate motion during radiation therapy course using fiducial markers.

PURPOSE: In this study we evaluated the day to day prostate displacement during radiation therapy by using implanted radiopaque fiducials and daily image guided position verification. METHODS: The data of 10 patients that received radiation therapy to the prostate were analyzed. Three fiducial markers were implanted in the prostate before treatment initiation for everyday verification of the target's position. Daily X ray images (kilovolt/KV films) of the pelvis were acquired for verification and were matched with baseline images produced during treatment preparation using bony structures and fiducials as landmarks. We calculated the mean difference between the two methods and the prostate displacement derived from these measurements. RESULTS: A total of 208 KV films were obtained. Our results showed a non-uniform prostate motion, with most of the displacements observed in the caudal direction followed by anterior, posterior, cranial, right and left. The mean target motion in each of the above directions was 3.5 mm, 3.5 mm, 3.3 mm, 3.9 mm, 2 mm and 2.4 mm. Based on the cumulative frequency of the target's displacement, a margin of 8 mm, 7mm, 5 mm, 4 mm, 9 mm and 7 mm in the anterior, posterior, left, right, cranial and caudal direction respectively would account for 95% of prostate's motion, provided that every day KV image guidance is performed. CONCLUSION: A non-isotopic margin of 8 mm, 7mm, 5 mm, 4 mm, 9 mm and 7 mm around the prostate can be considered safe for treatment delivery.

The Fluctuations of Melatonin and Copeptin Levels in Blood Serum During Surgical Stress Regarding the Pediatric Population.

INTRODUCTION: Copeptin is known to be associated with heart damage, while melatonin is a regulatory hormone related to circadian rhythm and represents the levels of inflammation in the body. METHODS AND PATIENTS: The aim of the study was to measure in different surgeries the levels of copeptin and melatonin at different times before and after surgery in 56 patients aged from 5 days to 13.6 years. We measured copeptin in 50-microL serum and plasma samples from patients before surgery, immediately after surgery, and 24 hours after surgery. The measured levels are aligned with the published GC / MS data, and the sensitivity of the analysis is such that serum and plasma levels can only be measured by rapid extraction. The measurement was made before surgery, immediately after surgery, and 24 hours after surgery. RESULTS: The multifactorial statistical analysis revealed a statistically significant difference between the 24-hour postoperative copeptin values in group 1 (mild-moderate gravity surgery) and group 2 (severe surgery) of the severity of the surgery. Post-hoc tests with Tukey correction for age groups in multiple comparisons of the multifactorial analysis revealed a statistically significant difference (p <0.05) between 24-hour postoperative melatonin values in age groups 3 (3-6 years) and 5 (6-12 years old). The age group 3 showed significantly (p <0.05) lower 24 hours postoperative melatonin values compared to the age group 5 (6-12 years). Again, these 3-6-year-olds were more likely to have inflammation due to the severity of the surgery and the presence of inflammation after the surgery. DISCUSSION: In summary, copeptin is a reliable biomarker for assessing a patient's health both preoperatively and postoperatively. Copeptin and melatonin are two independent agents and are not related to each other, and more studies will be needed with more patients of the same age and with the same underlying disease to assess their diagnostic value. Finally, melatonin could be considered an indicator of inflammation on its own and based on pre-and post-surgery values to determine a patient's health status and take appropriate actions.

Late results of a randomized trial on the role of mild hypofractionated radiotherapy for the treatment of localized prostate cancer.

Background: Prostate cancer is considered to be highly sensitive to changes in radiation therapy dose per fraction, specifically to hypofractionation. An increase in the fractionation dose could cause a higher increase to the prostate than to the normal tissues leading to better disease control with less toxicity. Here we present the results of a randomized trial comparing mild hypofractionation to conventional fractionation after a median of 3,6 years follow up. Patients and Methods: 139 patients were randomized to receive either hypofractionated radiotherapy with 2,25 Gy/fr to a total of 72 Gy (arm 1) or conventionally fractionated treatment with 2Gy/fr to a total of 74 Gy (arm 2). 72 patients were assigned to arm 1 and 67 to arm 2. Results: After a median follow up of 3,6 years, 23 patients (31,9%) from arm 1 developed grade≥ 2 acute genitourinary toxicity and 21 (31,3%) from arm 2 (p=0,79). The corresponding values from gastrointestinal were 15 (20,8%) and 12 (17,9%) (p=0,6). For late toxicity from GU, 8 patients (11,1%) developed grade≥ 2 symptoms in arm 1 and 7 (10,4%) in arm 2 (p=0,92). late GI toxicity grade≥ 2 was observed in 8 (11,1%) patients in arm 1 and 8 (11,9%) in arm 2 (p=0,88). In multivariate analysis, hormone therapy was significantly associated with late GI events, while acute toxicity from both GU and GI was a prognostic factor of late adverse reaction. Conclusion: No difference in the toxicity profile could be identified between hypofractionation and conventional fractionation. Our schedule of 2,25Gy/fr seems safe and tolerable by the patients with acceptable rates of acute and late toxicity.

The role of hypofractionated radiotherapy for the definitive treatment of localized prostate cancer: early results of a randomized trial.

Background: Prostate cancer is considered to have a special biology which could affect the radiation therapy result based on the selected fractionation scheme. We present the preliminary results of a randomized trial comparing conventionally and hypofractionated radiation therapy for prostate cancer. Methods: Patients included in the study had localized prostate cancer (cT1c-T3bN0M0) and were randomly assigned to mild hypofractionated (72 Gy in 32 fractions, arm1) or conventionally fractionated (74 Gy in 37 fractions, arm2) radiation therapy treatment with Volumetric Arc Therapy technique. The treatment was delivered only to the prostate with or without the seminal vesicles according to physician's discretion and hormone therapy was optional according to the disease stage and comorbidities. Here we present the preliminary results of acute toxicity from the gastrointestinal (GI) and genitourinary (GU) system. Results: Between 2015 and 2016, 139 patients were enrolled. 67 patients were treated with conventional fractionation and 72 were treated with hypofractionation. Grade≥ 2 toxicity from GU and GI was observed in 23 and 21 patients (31,9% vs 31,3%, p=0,79) and 15 and 12 (20,8% vs 17,9%, p=0,6) for arm1 and arm2 respectively. No statistically significant differences were observed between arms in the incidence of early toxicity. There was no correlation observed between patient characteristics and toxicity from either GU or GI. Conclusions: Hypofractionated radiotherapy appears to be equally tolerated compared to conventional fractionation in the early setting. Longer follow up is needed to assess the late toxicity profile of the patients and any potential differences between the control and experimental arm.