Long-term outcomes of nasopharyngeal carcinoma patients with T1-2 stage in intensity-modulated radiotherapy era.

Objectives: To evaluate long-term outcomes and late toxicities of nasopharyngeal carcinoma (NPC) patients with T1-2N0-3M0 stage in intensity-modulated radiotherapy (IMRT) era. Materials and Methods: From June 2005 to October 2013, 276 patients confirmed T1-2N0-3M0 NPC treated with IMRT were reviewed, with 143 (51.8%) N0-1 disease and 133 (48.2%) N2-3 disease. Among them, 76.4% received chemotherapy. The prescribed doses given to the primary tumor and lymph nodes were 66Gy in 30 fractions. Results: After a median follow-up of 103 months, the 5-year and 10-year overall survival (OS) were 90.6% and 79.2%. The 5-year and 10-year local control (LC) rate, regional control (RC) rate and distant metastasis free survival (DMFS) were 97.0% and 91.9%, 94.1% and 92.2%, 89.4% and 87.0%, respectively. The 5-year and 10-year OS, RC rate and DMFS of N0-1 compared with those of N2-3 were 98.6% vs. 82.0% and 86.8% vs. 70.9% (P=0.000), 99.3% vs. 88.3% and 99.3% vs. 84.1% (P=0.000), 97.9% vs. 80.1% and 95.7% vs. 77.5% (P=0.000). The incidence of 3-4 late toxicities were low and mainly xerostomia and hearing deficit. The rates of radiation-induced cranial nerve palsy and temporal necrosis were 2.5% and 2.5%, respectively. Eighteen patients had the second primary tumor, of whom eight were lung cancer, six were head and neck cancer, four were others. Conclusions: Satisfactory locoregional control was achieved in T1-2N0-3M0 NPC treated with IMRT. Distant metastasis was the main failure cause and N2-3 was the main adverse prognostic factor. Second primary tumor occurred 6.5% and negatively impacted OS in NPC.

Perioperative outcomes of carotid endarterectomy and transfemoral and transcervical carotid artery stenting in radiation-induced carotid lesions.

OBJECTIVE: Limited data are available to guide the choice of intervention for patients with radiation-induced carotid stenosis (RICS), either transcarotid artery revascularization (TCAR), transfemoral carotid artery stenting (TFCAS), or carotid endarterectomy (CEA). The purpose of the present study was to evaluate patients who had undergone these carotid artery interventions for RICS and the associated outcomes. METHODS: Patients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) carotid artery stenting surveillance project registry and the SVS VQI CEA modules who had undergone carotid artery intervention (TCAR, TFCAS, or CEA) for RICS were included. Those aged >90 years and those with concomitant interventions (eg, coronary bypass) were excluded. A composite of death, myocardial infarction (MI), and stroke was the primary outcome. The secondary outcomes included death, MI, stroke, cranial nerve injury (CNI), and other local and systemic complications. Multivariable logistic regression controlling for presenting symptomatic status and comorbid medical conditions was conducted for the outcome variables, except for death, which was analyzed using Cox regression modeling. RESULTS: A total of 1927 patients with RICS had undergone CEA (n = 1172), TCAR (n = 253), or TFCAS (n = 502). The CEA group had a higher rate of diabetes (31% vs 25% for TCAR and 25% for TFCAS; P = .01), hypertension (85% vs 82% for TCAR and 79% for TFCAS; P < .01), and peripheral vascular disease (8% vs 4% for TCAR and 4% for TFCAS; P < .01). The TCAR and TFCAS groups had higher rates of coronary artery disease (21% for CEA vs 30% for TCAR and 29% for TFCAS; P < .01). The patients who had undergone TFCAS were more likely to have had symptomatic lesions (57% for TFCAS vs 47% for CEA and 41% for TCAR; P < .01) and prior stroke (55% for TFCAS vs 47% for CEA and 40% for TCAR; P < .001). The composite outcome occurred in 3.2% of TCAR patients, 11.2% of TFCAS patients, and 11.1% of CEA patients (P < .01) with an odds ratio of 0.27 for TCAR, 0.91 for TFCAS, and 1.00 for CEA. However, no differences in the individual outcomes were noted for any procedure. TCAR exhibited the lowest odds ratio for CNI (0.15) compared with TFCAS at 0.9, both relative to CEA (P = .03). CONCLUSIONS: RICS patients treated by TCAR in the SVS VQI had the lowest risk of the composite of stroke, death, and MI and CNI. Therefore, TCAR might be the preferred treatment modality. Further comparative studies are needed to evaluate the long-term outcomes in this population and to elucidate the relationship of these procedures to the individual outcomes of stroke, MI, and death.

Combined effect of oral famotidine and cimetidine on the survival of lethally irradiated mice: An in vivo study.

AIMS: The study aims at evaluating the effects of the combinatory famotidine/cimetidine diet on radiated mice's survival. MATERIALS AND METHODS: Two hundred and seventy male mice were categorized into 11 groups, a number of which were comprised of subgroups too. The groups under analysis were posed to varying doses of gamma-radiation, including 6, 7, 8, and 9 Gy, followed by treatments using various drug doses 2, 4, and 8 mg/kg, with survival fractions as long as a month after irradiation being measured and recorded. RESULTS: LD50/30 was calculated as 7.47 Gy for the group with radiation only. Following mouse treatment with a concentration of 4 and 20 mg/kg for famotidine and cimetidine, respectively, the survival fraction for the mice grew significantly compared to LD50/30. The combinatory famotidine/cimetidine diet had a higher dose-reduction factor (DRF) than single doses of the drug in radioprotection. The DRF for combinatory famotidine/cimetidine, famotidine, and cimetidine diets was 08.09, 1.1, and 1.01, respectively. CONCLUSIONS: Results imply that the combined regimen of famotidine + cimetidine in radioprotection had no significant higher DRF than with regimens including each of them separately. In addition, we did not find a synergic effect of combined oral famotidine and cimetidine on irradiated mice.

Predicted Risks of Cardiovascular Disease Following Chemotherapy and Radiotherapy in the UK NCRI RAPID Trial of Positron Emission Tomography-Directed Therapy for Early-Stage Hodgkin Lymphoma.

PURPOSE: The contemporary management of early-stage Hodgkin lymphoma (ES-HL) involves balancing the risk of late adverse effects of radiotherapy against the increased risk of relapse if radiotherapy is omitted. This study provides information on the risk of radiation-related cardiovascular disease to help personalize the delivery of radiotherapy in ES-HL. METHODS: We predicted 30-year absolute cardiovascular risk from chemotherapy and involved field radiotherapy in patients who were positron emission tomography (PET)-negative following three cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy within a UK randomized trial of PET-directed therapy for ES-HL. Cardiac and carotid radiation doses and chemotherapy exposure were combined with established dose-response relationships and population-based mortality and incidence rates. RESULTS: Average mean heart dose was 4.0 Gy (range 0.1-24.0 Gy) and average bilateral common carotid artery dose was 21.5 Gy (range 0.6-38.1 Gy), based on individualized cardiovascular dosimetry for 144 PET-negative patients receiving involved field radiotherapy. The average predicted 30-year radiation-related absolute excess overall cardiovascular mortality was 0.56% (range 0.01%-6.79%; < 0.5% in 67% of patients and > 1% in 15%), whereas average predicted 30-year excess incidence was 6.24% (range 0.31%-31.09%; < 5% in 58% of patients and > 10% in 24%). For cardiac disease, the average predicted 30-year radiation-related absolute excess mortality was 0.42% (0.79% with mediastinal involvement and 0.05% without) and for stroke, it was 0.14%. CONCLUSION: Predicted excess cardiovascular risk is small for most patients, so radiotherapy may provide net benefit. However, for a minority of patients receiving high doses of radiation to cardiovascular structures, it may be preferable to consider advanced radiotherapy techniques to reduce doses or to omit radiotherapy and accept the increased relapse risk. Individual assessment of cardiovascular and other risks before treatment would allow personalized decision making about radiotherapy in ES-HL.

Development and Validation of a Risk Score Model for Predicting the Cardiovascular Outcomes After Breast Cancer Therapy: The CHEMO-RADIAT Score.

Background Cardiovascular disease is an important cause of mortality among survivors of breast cancer (BC). We developed a prediction model for major adverse cardiovascular events after BC therapy, which is based on conventional and BC treatment-related cardiovascular risk factors. Methods and Results The cohort of the study consisted of 1256 Asian female patients with BC from 4 medical centers in Korea and was randomized in a 1:1 ratio into the derivation and validation cohorts. The outcome measures comprised cardiovascular mortality, myocardial infarction, congestive heart failure, and transient ischemic attack/stroke. To correct overfitting, a penalized Cox proportional hazards regression was performed with a cross-validation approach. Number of cardiovascular diseases (myocardial infarction, peripheral artery disease, heart failure, and transient ischemic attack/stroke), number of baseline cardiovascular risk factors (hypertension, age ≥60, body mass index ≥30 kg/m2, estimated glomerular filtration rate <60 mL/min per 1.73 m2, dyslipidemia, and diabetes mellitus), radiation to the left breast, and anthracycline dose per 100 mg/m2 were included in the risk prediction model. The time-dependent C-indices at 3 and 7 years after BC diagnosis were 0.876 and 0.842, respectively, in the validation cohort. Conclusions A prediction score model, including BC treatment-related risk factors and conventional risk factors, was developed and validated to predict major adverse cardiovascular events in patients with BC. The CHEMO-RADIAT (congestive heart failure, hypertension, elderly, myocardial infarction/peripheral artery occlusive disease, obesity, renal failure, abnormal lipid profile, diabetes mellitus, irradiation of the left breast, anthracycline dose, and transient ischemic attack/stroke) score may provide overall cardiovascular risk stratification in survivors of BC and can assist physicians in multidisciplinary decision-making regarding the BC treatment.

Endovascular Treatment of Carotid Blowout Syndrome.

BACKGROUND: Carotid blowout syndrome (CBS) is a life-threatening disease characterized by compromise of the carotid artery by head and neck cancer (HNC). MATERIALS AND METHODS: We reviewed the characteristics and outcomes of all patients with carotid blowout syndrome who were treated between April 2010 and December 2019. Twelve patients with a history of HNC and radiation therapy were investigated. The balloon occlusion test (BOT) was performed in all patients to confirm collateral circulation. We placed a stent in patients who were intolerant to the BOT. RESULTS: The patients' ages ranged from 50 to 81 years (mean: 68.1 years). Therapeutic occlusion of the affected internal carotid artery was performed in nine patients, while stenting was performed in three patients. Immediate hemostasis was achieved in all patients. Patients treated using stents were administered perioperative DAPT. One patient experienced rebleeding after surgery. Two patients had procedure-related cerebral infarctions. One patient died, but the others survived without major neurological deficits. One patient had persistent aneurysm after surgery that resolved over time. CONCLUSION: Endovascular treatment via occlusion or stent-based reconstruction of the internal carotid artery resulted in immediate hemostasis. Carotid occlusion and covered stent application are safe and efficient techniques to treat CBS secondary to HNC. Surgeons may obtain better outcomes if they perform BOT before occlusion and design treatment accordingly.

Outcomes and toxicities of re-irradiation for prostate cancer: A systematic review on behalf of the Re-Irradiation Working Group of the Italian Association of Radiotherapy and Clinical Oncology (AIRO).

AIMS: The best therapeutic approach for local relapses of previously irradiated prostate cancer (PC) is still not defined. Re-irradiation (Re-I) could offer a chance of cure for highly selected patients, although high quality evidences are lacking. The aim of our study is to provide a literature review on efficacy and safety of Re-I. METHODS: Only studies where Re-I field overlaps with previous radiotherapy were considered. To determine 2 and 4 years overall mortality (OM), 2 and 4 years biochemical failure (BF) and pooled acute and late G ≥ 3 toxicities rate, a meta-analysis over single arm study was performed. RESULTS: Thirty-eight studies with 1194 patients were included. Median follow-up from Re-I was 30 months (10-94 months). Brachytherapy (BRT) was the most used Re-I technique (27 studies), followed by Stereotactic Body Radiotherapy (SBRT) (9) and External Beam Radiation Therapy (EBRT) (2). Re-I prescription doses ranged from 19 Gy in single HDR fraction to 145 Gy (interstitial BRT). The pooled 2 and 4 years OM rates were 2.1% (95%CI:1.1-3.7%, P < 0.001) and 12.5% (95%CI:8.1-19.5%; P < 0.001). The pooled 2 years BF rate was 24% (95% CI: 19.1-30.2%, P < 0.001). The pooled 4 years BF was 35.6% (95% CI: 28.7-44.3%, P < 0.001). The pooled result of G ≥ 3 acute toxicity was 1.4% (95%CI: 0.7-3%, P < 0.001). One hundred and three G ≥ 3 late adverse events were reported, with a pooled result of G ≥ 3 late toxicity of 8.7% (95%CI: 5.8-13%, P < 0.001). CONCLUSIONS: Re-I of local failures from PC showed promising OM and biochemical control rates with a safe toxicity profile.

Single Center Outcomes of Carotid Artery Stenting in Veterans with Prior Head and Neck Cancer.

BACKGROUND: Patients meeting criteria for intervention of carotid stenosis with a history of prior cervical radiation or neck dissection are considered "high risk" for carotid endarterectomy. This is a well-established indication for carotid artery stenting (CAS). The long-term outcomes of CAS in this population are less frequently published in the literature but are poor. The purpose of this study was to review long-term results of CAS in veteran patients with a prior history of treatment for head and/or neck cancer. METHODS: This is a retrospective review of a veteran patient population from 1998 to 2016. All patients at our institution with a prior history of treatment for head and/or neck cancer who underwent CAS were included in the analysis. During this time period, 44 patients met inclusion criteria and were treated with 57 carotid stenting interventions. The Kaplan-Meier analysis was used to determine survival and primary patency. The secondary aims were to analyze early outcomes and to identify predictive risk factors for mortality and reintervention. RESULTS: The mean follow-up was 42.9 ± 36.6 months. The cumulative survival at 1, 5, and 10 years was 91%, 67%, and 48%, respectively. The primary patency at 1, 5, and 10 years was 95%, 86%, and 86%, respectively. The reintervention rate was 11% (n = 6) with an assisted primary patency rate of 100%. No neurologic events occurred within 30 days. There were 3 strokes in late follow-up and no stroke-related deaths. Eighteen patients (41%) died during the follow-up period, 15 of whom died during the first 5 years of follow-up. Ten (66%) of those patients died of recurrent or active index cancer. On univariate analysis, tumor, node, metastasis stage IV was significantly associated with death (P = 0.02). Multivariate models were not statistically significant for predicting mortality or reintervention CONCLUSIONS: On the basis of the results in this series, CAS can be performed in these patients with low long-term rates of neurologic events and need for reintervention. However, the survival of patients with head and neck cancer undergoing CAS in this cohort is poor, which is consistent with other published series of patients undergoing CAS for head/neck cancer with at least 5-year follow-up. In this specific patient population, a more critical analysis of the patient's overall prognosis, especially as related to cancer, should be undertaken before offering CAS.

COMPARATIVE MATHEMATICAL ANALYSIS OF COLONY-FORMING ABILITYOF THE BONE MARROW OF MICE LETHALLY AND NON-LETHALLY IRRADIATED WITH EQUAL DOSE RATE INTENSITY. / PORIVNIaL'NYI MATEMATYChNYI ANALIZ KOLONIIeUTVORIuIuChOÏ ZDATNOSTI KISTKOVOGO MOZKU MYShEI, OPROMINENYKh Z ODNAKOVOIu POTUZhNISTIu U LETAL'NII I NELETAL'NII DOZAKh.

OBJECTIVE: To perform comparative analysis of the characteristics of population functioning process of mice bonemarrow colony-forming units after their prolonged irradiation in lethal and non-lethal doses with equal dose rateintensity with the aid of mathematical model. MATERIALS AND METHODS: Assigned task is solved by means of mathematical model of alterations in the number ofbone marrow colony-forming units after continuous irradiation, described in previous works, with the use of experimental results of K. S. Chertkov works (1972, 1973). Mathematical model is developed basing on the hematopoiesisscheme introduced by I. L. Chertkov (1984, 1991). RESULTS AND CONCLUSIONS: By applying original mathematical model, new scheme of hematopoiesis [6], with theuse of experimental results of γ-irradiation influence in the doses of 4 Gy and 8 Gy with the dose rate intensity of0.0028 Gy/min on the number of mice bone marrow colony-forming units, as well as experimental data concerningthe processes of their number recovery, obtained from literature references, we determined the parameters, whichcharacterize hematopoietic system reaction on the different stages of recovery processes of mice bone marrowcolony-forming units after the termination of ionizing radiation action; comparative analysis of obtained resultswas performed.

CHRONIC MYELOID LEUKEMIA COURSE IN PERSONS EXPOSED TO IONIZING RADIATION AS A RESULT OF THE CHORNOBYL ACCIDENT. / PEREBIG KhRONIChNOÏ MIIeLOÏDNOÏ LEIKEMIÏ U OSIB, IaKI ZAZNALY DIÏ IONIZUIuChOGO VYPROMINIuVANNIa VNASLIDOK ChORNOBYL'S'KOÏ AVARIÏ.

OBJECTIVE: Describe and characterize the peculiarities of the chronic myeloid leukemia (CML) course and responseto treatment in patients irradiated as a result of the Chornobyl nuclear power plant (ChNPP) accident based on theassessment of clinical-laboratory and clinical parameters. MATERIALS AND METHODS: The CML patients (n = 33) exposed to ionizing radiation as a result of the ChNPP accidentwere enrolled. The comparison group consisted of CML patients (n = 725) with no history of radiation exposure. Allpatients were in the chronic phase of the disease. Clinical, hematological and molecular genetic research methodswere applied. RESULTS: Patients exposed to ionizing radiation as a result of the ChNPP accident had no differences in CML manifestation, as well as in classical genetic markers at the onset of the disease compared with patients with no historyof radiation exposure. Reduction of tumor clone on imatinib therapy was significantly less effective in the patientsexposed to ionizing radiation than in cases of no history of radiation exposure. Cases of primary resistance were statistically significantly prevalent in the ChNPP accident consequences clean-up workers while in the residents ofradiologically contaminated areas a statistically significant increase in probability of loss of complete cytogeneticresponse (development of secondary resistance) to imatinib therapy was found. An association was found betweenthe radiation exposure and probability of loss of complete cytogenetic response to imatinib therapy in this group ofpatients. CONCLUSION: The radiation exposure in the history even many years before the onset of CML is an unfavorable exogenous factor responsible for the development of resistance to imatinib therapy.

Bone marrow stromal cell therapy improves survival after radiation injury but does not restore endogenous hematopoiesis.

The only available option to treat radiation-induced hematopoietic syndrome is allogeneic hematopoietic cell transplantation, a therapy unavailable to many patients undergoing treatment for malignancy, which would also be infeasible in a radiological disaster. Stromal cells serve as critical components of the hematopoietic stem cell niche and are thought to protect hematopoietic cells under stress. Prior studies that have transplanted mesenchymal stromal cells (MSCs) without co-administration of a hematopoietic graft have shown underwhelming rescue of endogenous hematopoiesis and have delivered the cells within 24 h of radiation exposure. Herein, we examine the efficacy of a human bone marrow-derived MSC therapy delivered at 3 h or 30 h in ameliorating radiation-induced hematopoietic syndrome and show that pancytopenia persists despite MSC therapy. Animals exposed to radiation had poorer survival and experienced loss of leukocytes, platelets, and red blood cells. Importantly, mice that received a therapeutic dose of MSCs were significantly less likely to die but experienced equivalent collapse of the hematopoietic system. The cause of the improved survival was unclear, as complete blood counts, splenic and marrow cellularity, numbers and function of hematopoietic stem and progenitor cells, and frequency of niche cells were not significantly improved by MSC therapy. Moreover, human MSCs were not detected in the bone marrow. MSC therapy reduced crypt dropout in the small intestine and promoted elevated expression of growth factors with established roles in gut development and regeneration, including PDGF-A, IGFBP-3, IGFBP-2, and IGF-1. We conclude that MSC therapy improves survival not through overt hematopoietic rescue but by positive impact on other radiosensitive tissues, such as the intestinal mucosa. Collectively, these data reveal that MSCs could be an effective countermeasure in cancer patients and victims of nuclear accidents but that MSCs alone do not significantly accelerate or contribute to recovery of the blood system.

Radiotherapy and Late Effects.

Advances in multimodality care for patients with pediatric cancer continues to improve long-term survival. The use of surgery, chemotherapy, and radiotherapy may lead to debilitating late effects in childhood cancer survivors. It is critically important to understand, mitigate, and screen for late effects to improve the quality of life in childhood cancer survivors. This review summarizes the use of radiotherapy in children, radiobiology of tissue injury, impact of age on late effects, important organ systems affected by radiotherapy during survivorship, and screening for radiotherapy late effects.

Accelerated partial breast irradiation with 3-dimensional conformal and image-guided intensity-modulated radiotherapy following breast conserving surgery - 7-Year results of a phase II trial.

PURPOSE: To present the 7-year results of accelerated partial breast irradiation (APBI) using three-dimensional conformal (3D-CRT) and image-guided intensity-modulated radiotherapy (IG-IMRT) following breast-conserving surgery (BCS). PATIENTS AND METHODS: Between 2006 and 2014, 104 patients were treated with APBI given by means of 3D-CRT using 3-5 non-coplanar, isocentric wedged fields, or IG-IMRT using kV-CBCT. The total dose of APBI was 36.9 Gy (9 × 4.1 Gy) using twice-a-day fractionation. Survival results, side effects and cosmetic results were assessed. RESULTS: At a median follow-up of 90 months three (2.9%) local recurrences, one (0.9%) regional recurrence and two (1.9%) distant metastases were observed. The 7-year local (LRFS), recurrence free survival was 98.9%. The 7-year disease-free (DFS), metastases free (MFS) and overall survival (OS) was 94.8%, 97.9% and 94.8%, respectively. Late side effects included G1 skin toxicity in 15 (14.4%), G1, G2, and G3 fibrosis in 26 (25%), 3 (2.9%) and 1 (0.9%) patients respectively. Asymptomatic (G1) fat necrosis occurred in 10 (9.6%) patients. No ≥ G2 or higher late side effects occurred with IMRT. The rate of excellent/good and fair/poor cosmetic results was 93.2% and 6.8%, respectively. CONCLUSION: 7-year results of APBI with 3D-CRT and IG-IMRT are encouraging. Toxicity profile and local tumor control are comparable to other series using multicatheter interstitial brachytherapy. Therefore, these external beam APBI techniques are valid alternatives to whole breast irradiation and brachytherapy based APBI.

Assessment of toxicities and outcomes in patients with breast cancer treated with hypofractionated radiotherapy.

BACKGROUND: Hypofractionation is now becoming the standard of care in breast irradiation. The aim of this study was to assess the toxicities and outcomes in patients with breast cancer treated with hypofractionated radiotherapy (HFRT). METHODS: Patients with localized breast cancer who received adjuvant HFRT between 2013 and 2015 with a minimum follow-up of 6 months following radiation were included in this prospective study. Late toxicities were assessed using CTCAE v 4 and included chest/breast pain, limb pain, limb edema, skin pigmentation, skin fibrosis, and shoulder movement restriction. Outcomes assessed included locoregional control, disease-free survival, and overall survival. Statistical analysis was done using Microsoft Excel and SPSS v22. RESULTS: A total of 81 patients fulfilled the inclusion criteria, of which 19 patients had died during follow-up. Regional nodal irradiation was done in 63 (77.8%) patients using the same hypofractionated schedule of 40 Gy in 15 fractions. Late toxicities were assessed for 62 patients. The median follow-up following the course of hypofractionated radiation was 45 months (range 14 - 65 months). Late toxicities were assessed for 62 patients. Grade 1/2 chest/breast pain, limb pain, limb edema, skin pigmentation, skin fibrosis, and shoulder movement restriction were seen in 11%, 12%, 7%, 6%, 8%, and 11% of cases, respectively. Distant recurrences were seen in 8% of cases, and there were no locoregional recurrences. Five-year overall survival was 76.5%. CONCLUSION: HFRT to whole breast or chest wall and the regional nodal areas was well-tolerated with acceptable rates of late toxicities on follow-up.

Heart dose linked with cardiac events and overall survival in lung cancer radiotherapy: A meta-analysis.

BACKGROUND: The aim of this study was to investigate the link between heart dose and overall survival, the link between heart dose and cardiac events and whether radiation-induced heart diseases were associated with overall survival in lung cancer radiotherapy. METHODS: We performed a literature search by using Pubmed, Embase, China National Knowledge Infrastructure (CNKI) databases. Pairs of reviewers independently screened literature according to the inclusion criteria, extracted data, assessed methodological quality, and publication bias. The primary end points included overall survival and cardiac events. I was calculated in a heterogeneity assessment. Publication bias was evaluated by using Begg funnel plot and Egger test. RESULTS: Ten studies including 1 randomized controlled trial, 3 post hoc analysis of prospective trials, and 6 cohort studies were identified. The meta-analysis showed that heart volume receiving ≥5 Gy (HV5) (hazard ratio [HR] = 1.01; 95% confidence interval [CI]: 1.00-1.01), heart volume receiving ≥30 Gy (HV30) (HR = 1.01; 95% CI: 1.00-1.02), heart volume receiving ≥50 Gy (HV50) (HR = 1.05; 95%CI: 1.00-1.10), and mean heart dose (MHD) (HR = 1.01; 95%CI:1.00-1.02) all were associated with worse overall survival. In addition, the MHD (HR = 1.03; 95% CI: 1.02-1.05), HV5 (HR = 1.02; 95% CI: 1.01-1.03), and HV30 (HR = 1.02; 95% CI: 1.01-1.03) were significantly associated with all grade cardiac events. Meanwhile, compared with those who did not receive radiotherapy, the radiotherapy group experienced a significantly increased risk for cardiac-specific mortality (HR = 1.297; 95% CI: 1.213-1.387). However, the results did not show that cardiac events were associated with overall survival in lung cancer radiotherapy (HR = 1.472; 95% CI: 0.988-2.193). CONCLUSION: Exposure of the heart to radiation increased the risk of cardiac events during radiotherapy for lung cancer. Meanwhile, heart dose including HV5 and HV30 were predictors of overall survival in lung cancer radiotherapy. It is necessary to constrain the heart dose when perform thoracic radiation therapy to decrease the incidence of cardiac events and improve the overall survival.

Radiotherapy in Early-stage Gastric MALT: Improved Survival Without Increased Cardiac Death.

PURPOSE: Radiotherapy (RT) is an effective treatment for localized gastric mucosa-associated lymphoid tissue (MALT) lymphomas unresponsive to antibiotic therapy; however, irradiating the stomach can result in significant radiation to the heart, a risk factor for cardiac disease. We analyzed the Surveillance, Epidemiology, and End Results database to evaluate outcomes related to cardiac disease among patients treated with RT for stage I gastric MALT. MATERIALS AND METHODS: We identified adult patients treated between 1993 and 2014. The relationship between treatment modality (RT, chemotherapy, combination, and no treatment) and overall survival (OS), mucosa-associated lymphoid tissue-specific survival (MSS), non-mucosa-associated lymphoid tissue-specific survival (non-MSS), and cardiac-specific survival (CSS) was assessed using the Kaplan-Meier estimator and Cox proportional hazards analyses. RESULTS: A total of 2996 patients (median follow-up, 5.6 y) were analyzed: 27.5% had received RT alone, 12.1% chemotherapy alone, 3.9% chemoradiotherapy, and 56.5% no/unknown treatment (including antibiotic therapy). Compared with RT alone, patients who received chemotherapy alone exhibited worse OS (hazard ratio [HR]: 1.67; 95% confidence interval [CI]: 1.32-2.10; P<0.001) and MSS (HR: 2.10; 95% CI: 1.36-3.23; P=0.001). Although CSS appeared worse in patients who received chemotherapy (HR: 1.56; 95% CI: 0.92-2.66; P=0.10), it was not statistically significant. When comparing orbital and gastric MALT patients, there was no significant difference in CSS (HR: 0.80; 95% CI: 0.49-1.31; P=0.38). CONCLUSIONS: RT improved survival among patients with stage I gastric MALT without increasing the risk of cardiac death. Those with gastric MALT exhibited similar CSS to those with orbital MALT. Although we cannot analyze nonfatal cardiac toxicity, these results suggest that, absent antibiotic therapy, RT should remain first-line treatment for early-stage gastric MALT.

Sarcopenia and myosteatosis in patients undergoing curative radiotherapy for head and neck cancer: Impact on survival, treatment completion, hospital admission and cost.

BACKGROUND: Computed tomography (CT) is the gold standard of body composition analysis at the tissue-organ level. The present study aimed to determine the impact of CT-defined sarcopenia and myosteatosis on outcomes, including overall survival, unplanned hospital admissions and related costs, in patients who had completed treatment of curative intent for head and neck cancer (HNC). METHODS: Retrospective observational study of patients undergoing radiotherapy of curative intent ± other treatment modalities for HNC. Tissue density data derived at the third lumbar vertebra (L3) were evaluated with sarcopenia defined per sex-specific published threshold values for skeletal muscle index, stratified by body mass index and mean skeletal muscle attenuation in HU (Hounsfield units). RESULTS: Pre- or post-treatment images were available for 79/98 patients (80.6%) and 61/98 patients (62.2%), respectively. Sarcopenia was present in 42/79 patients pre-treatment and 36/61 patients post-treatment, whereas myosteatosis was present in 63/79 patients pre-treatment and 48/61 patients post-treatment. In patients with pre- and post-treatment images (n = 60), the median (range) percentage weight change was -8.5% (-29.9 to +11.7). On multivariable analysis, a post-treatment sarcopenia hazard ratio of 3.87 (95% confidence interval = 1.22-12.24, P = 0.021) and a pre-treatment myosteatosis hazard ratio of 8.86 (95% confidence interval = 1.12-69.88, P = 0.038) were independent predictors of reduced overall survival. There was no difference in radiotherapy or chemotherapy treatment completion based on pre-treatment sarcopenia status. The mean (SD) difference unplanned hospital admission cost was $15 846 ($17 707) for patients without sarcopenia versus $47 945 ($82 688) for patients with sarcopenia at any time point (P = 0.077). CONCLUSIONS: As CT-defined sarcopenia and myosteatosis hold clinically meaningful prognostic value, muscle status evaluation is recommended in routine clinical practice.

Toxicity of internal mammary irradiation in breast cancer. Are concerns still justified in times of modern treatment techniques?

BACKGROUND: The purpose of this study was to estimate the additional risk of side effects attributed to internal mammary node irradiation (IMNI) as part of regional lymph node irradiation (RNI) in breast cancer patients and to compare it with estimated overall survival (OS) benefit from IMNI. MATERIAL AND METHODS: Treatment plans (n = 80) with volumetric modulated arc therapy (VMAT) were calculated for 20 patients (4 plans per patient) with left-sided breast cancer from the prospective GATTUM trial in free breathing (FB) and in deep inspiration breath hold (DIBH). We assessed doses to organs at risk ((OARs) lung, contralateral breast and heart) during RNI with and without additional IMNI. Based on the OAR doses, the additional absolute risks of 10-year cardiac mortality, pneumonitis, and secondary lung and breast cancer were estimated using normal tissue complication probability (NTCP) and risk models assuming different age and risk levels. RESULTS: IMNI notably increased the mean OAR doses. The mean heart dose increased upon IMNI by 0.2-3.4 Gy (median: 1.9 Gy) in FB and 0.0-1.5 Gy (median 0.4 Gy) in DIBH. However, the estimated absolute additional 10-year cardiac mortality caused by IMNI was <0.5% for all patients studied except 70-year-old high risk patients (0.2-2.4% in FB and 0.0-1.1% in DIBH). In comparison to this, the published oncological benefit of IMNI ranges between 3.3% and 4.7%. The estimated additional 10-year risk of secondary cancer of the lung or contralateral breast ranged from 0-1.5% and 0-2.8%, respectively, depending on age and risk levels. IMNI increased the pneumonitis risk in all groups (0-2.2%). CONCLUSION: According to our analyses, the published oncological benefit of IMNI outweighs the estimated risk of cardiac mortality even in case of (e.g., cardiac) risk factors during VMAT. The estimated risk of secondary cancer or pneumonitis attributed to IMNI is low. DIBH reduces the estimated additional risk of IMNI even further and should be strongly considered especially in patients with a high baseline risk.

The Effectiveness of Potential Probiotics Lactobacillus rhamnosus Vahe and Lactobacillus delbrueckii IAHAHI in Irradiated Rats Depends on the Nutritional Stage of the Host.

Several species of eukaryotic organisms living in the high mountain areas of Armenia with naturally occurring levels of radiation have high adaptive responses to radiation. We speculate on the role of the gastrointestinal microbiota in this protection against radiation. Therefore, seventeen microorganisms with high antagonistic activities against several multi-drug-resistant pathogens were isolated from the human and animal gut microbiota, as well as from traditional Armenian fermented products. These strains were tested in vivo on Wistar rats to determine their ability to protect the eukaryotic host against radiation damages. The efficiency of the probiotics' application and the dependence on pre- and post-radiation nutrition of rats were described. The effects of Lactobacillus rhamnosus Vahe, isolated from a healthy breastfed infant, and Lactobacillus delbrueckii IAHAHI, isolated from the fermented dairy product matsuni, on the survival of irradiated rats, and their blood leucocyte and glucose levels, were considered to be the most promising, based on this study's results.