Intra-prostatic recurrences after radiotherapy with focal boost: Location and dose mapping in the FLAME trial.

INTRODUCTION: The FLAME trial demonstrated that the dose to the gross tumor volume (GTV) is associated with tumour control in prostate cancer patients. This raises the question if dose de-escalation to the remaining prostate gland can be considered. Therefore, we investigated if intraprostatic recurrences occur at the location of the GTV and which dose was delivered at that location. MATERIALS AND METHODS: For FLAME trial patients with an intra-prostatic recurrence, we collected pre-treatment images, GTV delineations, dose distributions and post-recurrence images. Pre-treatment images were registered to the post-recurrence images (PSMA-PET CT). An overlap between GTV and PSMA-PET activity was considered an intra-prostatic recurrence at the location of the primary tumor. RESULTS: Twenty eight out of 535 patients in the FLAME trial had an intra-prostatic recurrence. Its location could be determined for 24 patients. One patient recurred in the prostate gland outside the GTV. The median near-minimum dose to the GTV (D98%) was 76.5 Gy (range: 73.3-86.5 Gy). Only one patient with a recurrence in the GTV received a substantial focal boost of 86.5 Gy. The D98% of all remaining patients was < 81 Gy. CONCLUSION: Intra-prostatic recurrences of intermediate- and high-risk prostate cancer patients treated with radiotherapy appeared predominantly at the location of the primary tumor. All but one patient did not receive a high dose to the GTV. Intra-prostatic failure is likely a consequence of the undertreatment of the primary tumor rather than the undertreatment of the remaining prostate gland.

Pancreatic cancer: ESMO clinical practice guideline for diagnosis, treatment and follow-up

The opportunity to detect pancreatic cancer (PC) when potentially curable depends on early diagnosis and an ability to identify and screen high-risk populations before symptoms arise. Identification of a high-risk population is challenging and optimal screening tools remain unclear.1 Older age is the strongest risk factor; incidence peaks at 65-69 years in males and 75-79 years in females.2 A pooled analysis of 117 meta-analyses assigned a relative risk to a number of common risk factors (Supplementary Table S1, available at https://doi.org/10.1016/j.annonc.2023.08.009).3 The vast majority (>80%) of PCs arise due to sporadically occurring somatic mutations. Only a small proportion are due to inherited deleterious germline mutations.1 Familial PC, defined as at least two first-degree relatives with PC, accounts for only 4%-10% of all cases. Variants in BRCA2 are the most common genetic abnormalities seen in familial PC. Other familial syndromes linked to PC are listed in Supplementary Table S2, available at https://doi.org/10.1016/j.annonc.2023.08.009. Individuals from families at risk should receive genetic counselling and be considered for enrolment in investigational screening registries. Currently, in high-risk individuals, annual endoscopic ultrasound (EUS) and/or pancreatic magnetic resonance imaging (MRI) are the procedures of choice for surveillance.4 Surveillance programmes usually begin at age 50 years (or 10 years earlier than the age of the youngest affected relative). Prospective surveillance data in high-risk individuals demonstrated high rates of resectability and encouraging observations of long-term survival.5, 6, 7, 8, 9 In sporadic PC, the major risk factors are tobacco, Helicobacter pylori infection and factors related to dietary habits (high red meat, high alcohol intake, low fruit and vegetable intake, overweight/obesity and type 2 diabetes mellitus).2,3,10 Chronic pancreatitis, irrespective of the cause (alcohol abuse, smoking, genetic mutations), is a risk factor for PC. A proportion of the risk factors associated with PC are potentially modifiable, affording a unique opportunity for primary prevention that is yet to be realised.

Patients' needs in proton therapy: A survey among ten European facilities.

Aims: The number of Proton Therapy (PT) facilities is still limited worldwide, and the access to treatment could be characterized by patients' logistic and economic challenges. Aim of the present survey is to assess the support provided to patients undergoing PT across Europe. Methods: Through a personnel contact, an online questionnaire (62 multiple-choice and open-ended questions) via Microsoft Forms was administered to 10 European PT centers. The questionnaire consisted of 62 questions divided into 6 sections: i) personal data; ii) general information on clinical activity; iii) fractionation, concurrent systemic treatments and technical aspects of PT facility; iv) indication to PT and reimbursement policies; v) economic and/ or logistic support to patients vi) participants agreement on statements related to the possible limitation of access to PT. A qualitative analysis was performed and reported. Results: From March to May 2022 all ten involved centers filled the survey. Nine centers treat from 100 to 500 patients per year. Paediatric patients accounted for 10-30%, 30-50% and 50-70% of the entire cohort for 7, 2 and 1 center, respectively. The most frequent tumours treated in adult population were brain tumours, sarcomas and head and neck carcinomas; in all centers, the mean duration of PT is longer than 3 weeks. In 80% of cases, the treatment reimbursement for PT is supplied by the respective country's Health National System (HNS). HNS also provides economic support to patients in 70% of centers, while logistic and meal support is provided in 20% and 40% of centers, respectively. PT facilities offer economic and/or logistic support in 90% of the cases. Logistic support for parents of pediatric patients is provided by HNS only in one-third of centers. Overall, 70% of respondents agree that geographic challenges could limit a patient's access to proton facilities and 60% believe that additional support should be given to patients referred for PT care. Conclusions: Relevant differences exist among European countries in supporting patients referred to PT in their logistic and economic challenges. Further efforts should be made by HNSs and PT facilities to reduce the risk of inequities in access to cancer care with protons.

The management of hepatocellular carcinoma. Current expert opinion and recommendations derived from the 24th ESMO/World Congress on Gastrointestinal Cancer, Barcelona, 2022.

This article summarises expert discussion on the management of patients with hepatocellular carcinoma (HCC), which took place during the 24th World Gastrointestinal Cancer Congress (WGICC) in Barcelona, July 2022. A multidisciplinary approach is mandatory to ensure an optimal diagnosis and staging of HCC, planning of curative and therapeutic options, including surgical, embolisation, ablative strategies, or systemic therapy. Furthermore, in many patients with HCC, underlying liver cirrhosis represents a challenge and influences the therapeutic options.

The use of patient reported outcome measures (PROMs) in palliative radiotherapy: A topical review.

Radiotherapy (RT) can be used to palliate cancer-related symptoms and improve quality of life (QoL). Patient Reported Outcome Measures (PROMs) could be a reliable, minimally invasive method to monitor patients after palliative radiotherapy. This review was performed to provide an overview of the way PROMs are currently used in follow-up after palliative RT, regarding the goal of the PROM, the type of PROMs, PROM selection, PROM completion as well as the follow-up schemes and patient adherence and attrition. Pubmed, EMBASE and the Cochrane Library were systematically searched for articles published between 2008 and 2020. Titles and abstracts were reviewed to find relevant studies, which were advanced to full-text review. The reference lists of review articles were screened for correctness of the search and additional studies. No meta-analysis was performed. This search strategy identified 5733 studies, with 94 ultimately selected for inclusion in this topical review. We discovered a great variety of studies that used PROMs after palliative RT. We found no articles describing PROMs in routine clinical care. PROMs were exclusively used as a benchmarking tool and never to improve symptom control or QoL for individual patients. The selection process for the questionnaires, completion method and/or follow-up scheme was seldom described. We did not find any studies referencing patients' experience on PROMs. Although clear guidelines on the use of PROMs in palliative RT may be difficult to establish, more attention should be paid to the PROM aspect when writing study protocols. Furthermore, efforts should be made to introduce PROMs in routine clinical care in the context of palliative RT.