Palliative short-course radiotherapy (RAPASH study) in patients with rectal cancer.

Background: Palliative radiation therapy (RT) is used to treat symptomatic rectal cancer although clinical benefits and toxicities are poorly documented. There is no consensus about the optimal RT regimen and clinical practice undergoes significant changes. Our aim was to evaluate the efficacy and toxicity of short-course (SC) RT in this setting of patients. Materials and methods: Charts from patients with locally advanced disease not candidates for standard treatment or with symptomatic metastatic rectal cancer treated with SCRT (25 Gy/5 fractions in 5 consecutive days) were retrospectively reviewed. Clinical outcome measures were symptomatic response rate and toxicity. Results: From January 2007 to December 2017, 59 patients (median age 80 years) received SCRT; 53 were evaluable. The median follow-up was 8 months (range, 1-70). Clinical response to RT for bleeding, pain and tenesmus was 100%, 95% and 89%, respectively. The compliance with the treatment was 100% and no patient experienced acute severe (≥ grade 3) toxicities. Median time to symptoms recurrence was 11 months (range 3-69). Globally, the median overall survival was 12 months. Conclusions: SCRT is a safe and effective regimen in symptomatic rectal cancer and may be considered the regimen of choice for standard treatment in unfit patients.

Quantitative-qualitative analyses of patient-reported pain response after palliative radiation therapy.

PURPOSE: While the 0-10 pain scale is often used to assess treatment response, it may not accurately reflect change in pain over time. The purpose of this study is to correlate pain improvement using the 0-10 pain scale to patients' perceived improvement in pain following palliative radiation therapy (RT), and to qualitatively characterize themes of pain assessment. METHODS: Patients age ≥ 20 receiving RT for spinal metastases were enrolled. Patients rated their pain (0-10) at the treatment site at RT start, and 1 and 4 weeks post-RT completion. At 1 and 4 weeks post-RT, patients reported their perceived percent improvement in pain (pPIP) (0-100%), which was compared to calculated percent improvement in pain (cPIP) based on the 0-10 pain scores. At 4 weeks post-RT, 20 randomly selected patients participated in a qualitative pain assessment. RESULTS: Sixty-four patients treated at 1-2 sites were analyzed. At 1 week post-RT completion, 53.7% (36/67) reported pPIP within 10 percentage points of cPIP, 32.8% (22/67) reported pPIP > 10 percentage points higher than cPIP, and 13.4% (9/67) reported pPIP > 10 percentage points lower than cPIP. Similar degrees of discordance were seen at 4 weeks post-RT. Qualitative analysis revealed five themes: pain quality (n = 19), activities (n = 9), function (n = 7), medication use (n = 2), and radiation side effects (n = 1). CONCLUSIONS: About half of patients reported a pPIP substantially disparate from their cPIP, and the change in pain measured by the 0-10 scale tended to underestimate the degree of perceived pain improvement. Multiple themes were identified in qualitative analysis of pain response.

Practice patterns of palliative radiation therapy in pediatric oncology patients in an international pediatric research consortium.

BACKGROUND/OBJECTIVES: The practice of palliative radiation therapy (RT) is based on extrapolation from adult literature. We evaluated patterns of pediatric palliative RT to describe regimens used to identify opportunity for future pediatric-specific clinical trials. DESIGN/METHODS: Six international institutions with pediatric expertise completed a 122-item survey evaluating patterns of palliative RT for patients ≤21 years old from 2010 to 2015. Two institutions use proton RT. Palliative RT was defined as treatment with the goal of symptom control or prevention of immediate life-threatening progression. RESULTS: Of 3,225 pediatric patients, 365 (11%) were treated with palliative intent to a total of 427 disease sites. Anesthesia was required in 10% of patients. Treatment was delivered to metastatic disease in 54% of patients. Histologies included neuroblastoma (30%), osteosarcoma (18%), leukemia/lymphoma (12%), rhabdomyosarcoma (12%), medulloblastoma/ependymoma (12%), Ewing sarcoma (8%), and other (8%). Indications included pain (43%), intracranial symptoms (23%), respiratory compromise (14%), cord compression (8%), and abdominal distention (6%). Sites included nonspine bone (35%), brain (16% primary tumors, 6% metastases), abdomen/pelvis (15%), spine (12%), head/neck (9%), and lung/mediastinum (5%). Re-irradiation comprised 16% of cases. Techniques employed three-dimensional conformal RT (41%), intensity-modulated RT (23%), conventional RT (26%), stereotactic body RT (6%), protons (1%), electrons (1%), and other (2%). The most common physician-reported barrier to consideration of palliative RT was the concern about treatment toxicity (83%). CONCLUSION: There is significant diversity of practice in pediatric palliative RT. Combined with ongoing research characterizing treatment response and toxicity, these data will inform the design of forthcoming clinical trials to establish effective regimens and minimize treatment toxicity for this patient population.

Postoperative Course and Supportive Care in Very Elderly Cecum Cancer Patients.

In developed countries like Japan, the size of the older population is rapidly increasing. Malignant neoplasms rank as the leading cause of death among the geriatric population of Japan, emphasizing the rising demand for cancer care in this demographic. Older patients, besides facing physical and cognitive challenges, are also affected by their social environment, necessitating tailored interventions. Few case reports have detailed the progress of cancer treatment in nonagenarian patients. This study presents the progress of two very old patients with cancer. The first case, a 95-year-old female with chronic constipation underwent emergency surgery for a cecal tumor. Despite initial improvements, her mobility declined after surgery, leading to institutionalization. Recurrent hospitalizations ensued with complications culminating in her death approximately 20 months after surgery. In the second case, a 94-year-old male, initially declining aggressive treatment for a suspected ileocecal malignancy, later opted for supportive care. Despite stable conditions, he eventually died at home after experiencing progressive weakness, which was approximately 20 months after the initial diagnosis. These cases shed light on the management of elderly patients with ileocecal cancer, illustrating the divergent trajectories between surgical intervention and supportive care. The tumor did not recur in the patient who underwent surgery; however, the independence in performing daily living activities declined significantly. In the case managed with the best-supportive care, progression was slow; however, severe anemia became a concern toward the end of life.

Hemibody Irradiation for Bone Metastases: A Systematic Review and Meta-Analysis.

Hemibody irradiation (HBI) is a radiation therapy technique that involves treating one-half of the patient's skeletal system in a single radiation field. It is mostly given as upper hemibody irradiation (UHBI), lower hemibody irradiation (LHBI), or sequential UHBI and LHBI. It is used to treat extensive bone metastases from solid tumors. It was primarily utilized in the 1980s and 1990s and has since fallen out of favor. However, it is a potentially cost-effective treatment for widespread bone metastases. To determine its efficacy, we performed a meta-analysis of all available published articles on the efficacy of HBI to relieve pain from bone metastases. Twenty-seven articles involving 1318 patients were identified and analyzed. Our findings show that 80% of the patients had complete or partial pain relief and 29% had complete pain relief. The trials were of poor quality, but the results showed minimal heterogeneity in the response rates. These response rates are consistent with those seen with focal irradiation of bone metastases and for radionuclide treatment of bone metastases. The toxicity of the treatments decreased when delivered with modern treatment techniques. In light of this, we propose that this technique warrants re-evaluation with modern treatment methods.

Evaluating Peer Review of Palliative Radiation Plans at a Canadian Tertiary Care Cancer Center.

INTRODUCTION: Peer review (PR) of palliative-intent radiation plans is an important but understudied component of quality assurance. This retrospective review aims to improve our understanding of palliative PR by examining the characteristics of reviewed plans and peer feedback along with the associated time burden of two different types of PR processes. METHODS: This single-institution, quality assurance project assessed palliative PR between 2018 and 2020. Initially, the PR involved a multi-disciplinary team PR. Subsequently, it transitioned to independent PR by a single physician. Characteristics of reviewed plans and feedback on PR were captured and abstracted. Time requirements of PR were based on self-reported estimates and attendance records. RESULTS: A total of 1942 cases were reviewed, representing 85.7% (1942/2266) of all palliative-intent plans between 2018 and 2020. A total of 41.1% (n=799) were simple (2D/3D) radiation plans while 56.0% (n=1087) were complex (volumetric modulated arc therapy (VMAT) or tomotherapy) plans. Approximately one-third (30.4%, n=590) of all plans were stereotactic treatments. The rate of any peer feedback was 2.3% (n=45), while the rate of a specific recommended or implemented change was 1.2% (n=24) and 0.9% (n=18), respectively. PR before the start of treatment was associated with more frequent recommended (p=0.005) and implemented changes (p=0.008). Most other factors, including plan complexity and use of stereotactic radiation, were not predictive in this analysis. Comparing the independent versus team PR approach, there was no significant difference in recommended or implemented changes. The mean±standard deviation (SD) staff time required per plan reviewed was 36±6 and 37±6 minutes, including 21±6 and 10±6 minutes of physician time, for team and independent PR, respectively. CONCLUSION: This work highlights the high frequency of complex and stereotactic radiation in the palliative setting, along with the importance of timely PR and the potential benefit of reviewing even simple, 2D/3D radiation plans. Additionally, from a process perspective, our work showed that independent PR may require less dedicated physician time.

Magnetic Resonance Imaging of Radiation-Induced Brachial Plexopathy.

This report illustrates the case of a 37-year-old woman following chemoradiotherapy for invasive ductal carcinoma of the right breast. The patient underwent surgery and received a radiation dose of 50 gray to the chest wall and 45 gray to the regional lymph nodes in 25 total fractions. She developed motor and sensory weakness in the right upper limb eight years after treatment. Brachial plexus neuropathy in cancer patients may result from either trauma to the plexus during surgery, the spread of cancer, or radiation therapy, and distinguishing between them may be difficult. The case highlights the importance of recognizing the signs, symptoms, and possible differential diagnosis of radiation-induced brachial plexopathy in cancer patients post-radiation therapy. It emphasizes the role of magnetic resonance imaging in the careful assessment and diagnosis of such a case.

Thymic Carcinoma Presenting as a Mediastinal Mass Resembling a Cardiac Tumor.

Thymoma and thymic carcinomas are a few of the rarest malignancies seen in humankind. They are mostly seen in the Asian population, many of which are reported in the Southeast Asia region like Japan, China, Vietnam, etc. They usually can be a sequela of other underlying conditions such as myasthenia gravis or some unknown mutations that express later in life.   Our patient is a young 41-year-male, a healthy and active individual who presented for evaluation of acute shortness of breath, two months after recovering from SARS-CoV-19 infection. His shortness of breath progressed while on oxygen and diuretics, a Point of Care Ultrasound (POCUS) showed cardiac tamponade and moderate pleural effusion. A Computerized Tomographic (CT) scan of the chest/abdomen/pelvis showed cardiomegaly, pleural effusion, and a mass abutting the heart. A pericardiocentesis revealed malignant cells. Thymic carcinoma was confirmed with a core biopsy and the patient was initiated on treatment rapidly to help improve symptoms and contain the growing mass.  .

Palliative Radiotherapy in Non-small Cell Lung Cancer: Patterns of Use and Predictors of 30-Day Mortality in End-of-Life Care.

Introduction Lung cancer is the leading cause of cancer-related deaths worldwide, with non-small cell lung cancer (NSCLC) being the most common type. More than half of patients require radiotherapy throughout their treatment. Palliative radiotherapy (PRT) is an important tool for symptom control and quality of life improvement in advanced NSCLC patients. However, the benefits of PRT must be balanced against possible disadvantages, especially in end-of-life (EOL) care. This study aims to describe the profile of PRT-treated deceased NSCLC patients, quantify the proportion of PRT recipients in the last 30 days of life and identify short-term survival prognostic factors in this group. Materials and methods This retrospective analysis was performed at two radiotherapy facilities within the Kent Oncology Centre, UK, for two years, running from January 1, 2022, to January 1, 2024. Data were collected from 857 deceased NSCLC patients who received PRT. Demographics, cancer diagnosis, histology, tumour, node, metastasis (TNM) staging, radiotherapy details, recent treatments, performance status (PS) and comorbidities were analysed. Patients have been stratified as long-term survivors (more than 30 days after PRT initiation, LTS group) along with short-term survivors (STS) (died within 30 days, STS group). Descriptive statistics, chi-squared tests, t-tests and multivariable logistic regression have been used in the data analysis. Results Out of 857 patients, 148 (17.3%) died within 30 days of PRT initiation. PS was considerably worse (p = 0.027), Adult Comorbidity Evaluation 27 (ACE-27) scores were higher (p = 0.018), and metastatic disease was more prevalent (60.1% vs. 47.5%, p = 0.02) in STS group patients. Fewer patients in the STS group completed their treatment compared to the LTS group (63.5% vs. 82.8%, p < 0.001). The STS group also received lower mean radiation dose (17.7 Gy vs. 19.6 Gy, p = 0.022) and fewer fractions (4.4 vs. 5.2, p = 0.019). The most common RT regimen in both cohorts was 20 Gy in five fractions, used in 55.4% of STS and 49.8% of LTS patients, with no significant difference in single fraction RT use between groups (33.1% in STS vs. 36.8% in LTS, p = 0.401). Multivariate logistic regression identified significant predictors of 30-day mortality: poorer PS (adjusted OR: 1.981, 95% CI: 1.33-3.12, p = 0.001), metastatic disease (adjusted OR: 2.02, 95% CI: 1.246-3.571, p = 0.002), incomplete PRT (adjusted OR: 0.337, 95% CI: 0.21-0.514, p < 0.001) and no recent chemotherapy (adjusted OR: 0.542, 95% CI: 0.342-0.941, p = 0.044). Conclusion This study demonstrated that compared with previous reports, a higher proportion of NSCLC patients who received PRT died within 30 days of treatment initiation, and low treatment adherence rates highlight challenges in EOL settings. Identification of poor PS and metastatic disease as predictors of short-term mortality would help inform PRT decision-making. The underutilisation of single-fraction radiotherapy and the link between recent chemotherapy and lower 30-day mortality warrant further study. These results highlight the need for better prognostic tools and more selective use of PRT, including increased consideration of single-fraction radiotherapy, in NSCLC patients approaching end of life and emphasise the importance of balancing benefit against treatment burden in this vulnerable population.

Carotid Sinus Syndrome With Convulsive Syncope in a Patient With Head and Neck Cancer.

This case report provides a comprehensive overview of a unique case of a 64-year-old male patient with head and neck (H&N) cancer who initially presented with compressive convulsive syncope, an initial manifestation of carotid sinus syndrome (CSS). CSS is an autonomic nervous system disease that often manifests as hypotension, dizziness, cerebral ischemia, or syncope, usually in elderly patients. In this case, the patient's laryngeal cancer led to lymphedema and encasement of the bilateral carotid arteries, inducing CSS and resulting in recurrent episodes of hypotension and bradycardia. These symptoms were managed through the administration of atropine and transcutaneous pacemaker placement, suggesting a probable mixed type of CSS. The patient was discharged on long-term theophylline treatment for symptomatic control of bradycardia episodes. Despite the promising outcomes of CSS cases treated with pacemakers, the efficacy is not universal and limitations may arise, particularly in H&N cancer patients. Therefore, the patient was managed with theophylline rather than a pacemaker due to its non-invasiveness and effectiveness in temporarily managing CSS. Although rare, CSS should be considered in patients experiencing convulsive syncope alongside H&N malignancies. As the evidence and consensus regarding CSS treatment in H&N cancer patients are scarce, additional research is necessary to evaluate and compare available options. This abstract concludes by emphasizing the need for further research and case reports to establish a consensus on the optimal management approach for patients affected by CSS due to compression from H&N cancers.

Patterns of practice in the prescription of palliative radiotherapy for the treatment of bone metastases at the Rapid Response Radiotherapy Program between 2005 and 2012.

OBJECTIVE: We examined whether patterns of practice in the prescription of palliative radiation therapy for bone metastases had changed over time in the Rapid Response Radiotherapy Program (rrrp). METHODS: After reviewing data from August 1, 2005, to April 30, 2012, we analyzed patient demographics, diseases, organizational factors, and possible reasons for the prescription of various radiotherapy fractionation schedules. The chi-square test was used to detect differences in proportions between unordered categorical variables. Univariate logistic regression analysis and the simple Fisher exact test were also used to determine the factors most significant to choice of dose-fractionation schedule. RESULTS: During the study period, 2549 courses of radiation therapy were prescribed. In 65% of cases, a single fraction of radiation therapy was prescribed, and in 35% of cases, multiple fractions were prescribed. A single fraction of radiation therapy was more frequently prescribed when patients were older, had a prior history of radiation, or had a prostate primary, and when the radiation oncologist had qualified before 1990. CONCLUSIONS: For patients with bone metastasis, a single fraction of radiation therapy was prescribed with significantly greater frequency.

Synovial Metastasis From Urothelial Carcinoma of the Renal Pelvis Causing Recurrent Hemarthrosis: A Rare Presentation.

Synovial metastases are rare for any malignancy. This case report discusses a case of synovial metastasis from urothelial carcinoma of the renal pelvis presenting with recurrent hemarthrosis. The diagnosis of malignant synovitis can be obtained by synovial fluid aspiration, which is a quick and minimally invasive method, especially when imaging is unyielding or unspecific. Unfortunately, the diagnosis is associated with a poor prognosis of about five months, and treatment is often palliative. While no clinical guidelines exist, a multimodal and multidisciplinary management approach can help address the physical and psychosocial losses suffered.

Bony Metastasis to the Radius as the Initial Presentation of a Lung Adenocarcinoma.

When considering tumors of the bone, metastatic disease from a distant primary is more common than primary tumors of the bone itself. The commonest sites to which skeletal metastasis occur are in the axial skeleton, and with regard to the appendicular skeleton, metastasis to the forearm bones is uncommon. Almost a third of patients who present with skeletal metastases do not have any evidence of their primary tumor at presentation. We report a case of a 68-year-old female diagnosed with lung adenocarcinoma after presenting with metastatic deposits involving the right radius as the first clinical manifestation of her disease. She presented initially complaining of painful swelling of her right forearm for a duration of one year. Imaging investigations of her right forearm showed an expansile mixed lytic and sclerotic lesion involving the full length of the right radius. A contrast-enhanced computed tomography scan of her chest to investigate the possible site of primary malignancy showed a peripherally located, well-defined, irregularly shaped mass lesion with enlarged mediastinal lymph nodes. A fluorodeoxyglucose positron emission tomography (FDG-PET) bone scan also noted oligometastatic disease in her right proximal humerus. She was started on palliative docetaxel for six cycles with palliative external beam radiotherapy. Although a variety of tumors metastasize to the bone, metastasis to the appendicular skeleton, and in particular the forearm bones, is a rare phenomenon that is poorly described in the existing literature. Skeletal metastasis may also be the primary presenting feature in a minority of cases. Lung cancer is among the more commonly associated primary sites, and further workup should include appropriate imaging to evaluate for a lung primary as well as an FDG-PET/CT or a bone scan to detect occult metastatic disease.

Proton therapy in the palliative setting.

Given its sharp dose fall off and ability to spare healthy surrounding tissue, proton beam therapy (PBT) has traditionally been used to treat various types of malignancies in the definitive setting, with strong, empirical data supporting its utility and safety. In the palliative setting, however, photon therapy has generally remained the standard of care in radiation treatment delivery due to lower cost, and greater availability. However, recent data suggest that the use of PBT may provide benefit in terms of symptom management and disease control in patients with locally advanced or recurrent disease who do not qualify for definitive therapy or with metastatic disease. Additionally, due to its unique dosimetric properties, PBT may confer less overall toxicity, thus helping preserve or improve the quality of life in this patient population, especially for those who are nearing end of life. While there is a need for further study, initial data analyzed from both retrospective and prospective single-institution and multi-institution trials are promising. This review aims to explore the efficacy and safety of PBT in the palliative setting among adults and to summarize pertinent studies that support its usage. To the authors' knowledge, this is the first review of the literature pertaining to PBT used in the palliative setting across multiple disease sites.

Palliative Radiation Therapy in the Treatment of Desmoplastic Small Round Cell Tumors.

An early adolescent male presented with six months of nausea, vomiting, and constipation. A chest computed tomography (CT) scan revealed multiple pulmonary nodules of varying sizes and a 3.1 cm pleural-based mass-like density in the right lower pulmonary lobe suspicious for metastatic disease. A CT scan of the abdomen and pelvis revealed diffuse metastatic disease involving the lungs, liver, and peritoneum. An ultrasound (US)-guided core needle biopsy of the liver was performed, and the morphology and immunohistochemistry were consistent with a poorly differentiated carcinoma. Further workup was performed, and the patient was diagnosed with a desmoplastic small round cell tumor (DSRCT). The patient underwent eight cycles of chemotherapy, but his tumor metastasized to distant sites. He then underwent two courses of palliative radiation therapy to the pelvis. His cancer continued to progress, and he eventually succumbed to his disease. This case report evaluates the evidence, data, radiation dosages, and techniques for palliative radiation therapy for DSRCTs.

Involved-Field Radiation Therapy for Patients With Unresectable Pancreatic Adenocarcinomas: Failure Pattern Analysis.

Introduction Unresectable pancreatic tumors are frequently diagnosed. Initial treatment is carried out with chemotherapy. Eventually, in selected cases, radiotherapy may be used to improve local control rates and relieve the symptoms. The volume of radiotherapy treatment fields is the subject of controversy in the literature. The use of involved fields with the gross tumor volume encompassing the primary tumor and lymph nodes considered clinically positive is associated with a lower rate of side effects, but can lead to a higher rate of regional loco failures, especially in regional lymph nodes. The purpose of this article is to analyze the failure pattern of chemotherapy and involved-field radiation therapy (IFRT) for treating patients with unresectable pancreatic adenocarcinomas. Methods Clinical records of thirty consecutive patients treated from March 2016 to June 2020 for unresectable pancreatic adenocarcinoma were analyzed. The patients were treated with initial systemic chemotherapy (median: 6 cycles) with regimens based on gemcitabine or oxaliplatin-irinotecan (folfirinox/folfox) followed by radiotherapy (total dose of 50-54 Gy/with fractionation of 2 Gy/day). The patients were treated with IFRT. Local failure (LF) was defined as an increase in radiographic abnormality within the planning target volume (PTV). Elective nodal failure (ENF) was defined as recurrence in any lymph node region outside the PTV. Any other failure was defined as distant failure (DF). Results The median age of the patients was 68 years (range: 44-80 years); 20 patients (66.7%) were men, and 11 (36.6%) and 19 (63.4%) patients presented with tumors of stage II and III, respectively. Most patients (63.3%) had tumors in the pancreatic head. The median survival was 17.2 months. Tumor recurrences were classified as LF, DF, LF and DF in 7 (23.3%), 17 (56.7%), and 5 (16.7%) patients, respectively. Only one patient (3.3%) had both LF and ENF. No severe side effects related to radiotherapy were reported. Conclusion The use of IFRT did not cause a significant amount of ENF, besides presenting low morbidity, which is of special importance for patients with locally advanced tumors or low performance status. The predominant failure pattern was distant metastases.

Salvage Radiosurgery for Recurrent Cardiac Sarcoma: A Case Report.

Primary cardiac sarcoma is a rare malignant tumor that arises from the cardiac myocardium. Surgical resection is the standard of care, and median survival ranges from 6 to 12 months. The role of salvage chemotherapy and radiation is not well defined. A 53-year-old female presented with acute congestive heart failure and underwent complete surgical resection of an undifferentiated pleomorphic sarcoma of the left atrium, followed by six cycles of adjuvant doxorubicin/hydroxydaunorubicin and ifosfamide. An MRI scan demonstrated an asymptomatic, 24 mm, recurrent atrial mass. The patient was treated with frameless robotic radiation therapy over three weeks. The tumor was treated with a dose of 72 Gy in 15 fractions to the 84% isodose line. A repeat cardiac MRI at four weeks showed in-field local progression with greater protrusion into the left atrium and invasion of the left ventricle. The patient therefore elected to proceed with salvage single-fraction frameless robotic radiosurgery. 25 Gy in one fraction was prescribed to the 76% isodose line. She tolerated treatment well without any acute toxicity and was subsequently treated with a variety of chemotherapy regimens, including tyrosine kinase inhibitors (TKIs) and immunotherapy. Unfortunately, the patient relapsed with metastases in the spine and pelvis. She underwent palliative radiation therapy at multiple bony sites with a partial response. She resumed chemotherapy treatment with TKIs but passed away due to septic shock without evidence of local failure. Fractionated SBRT was ineffective at controlling our patient's cardiac sarcoma. Our patient demonstrated local control of disease at 12 months after salvage of 25 Gy in one fraction of radiosurgery without any evidence of cardiac toxicity. High-dose single-fraction radiosurgery is a reasonable palliative option for long-term local control of unresectable cardiac sarcomas.

An Unusual Case of Hip Flexion Failure Caused by Bone Metastasis From Hepatocellular Carcinoma Infiltrating the Psoas Muscle.

When malignant tumors infiltrate the psoas muscle, they can result in what is referred to as malignant psoas syndrome (MPS). We are reporting this case as the malignant tumor had invaded the psoas muscle, and the clinical course of the patient differed from that of typical MPS. A 75-year-old male patient with liver cancer presented with pain around the right hip joint and difficulty in flexing the right hip joint, resulting in gait disturbance. There was no painful immobilization of the right hip, and the patient was able to extend the lower extremity. A CT scan revealed multiple liver tumors, multiple bone metastases, and swelling of the psoas muscle contiguous with the tumor at the lesser trochanter of the right femur. There were no apparent intracranial or spinal cord lesions, and no obvious abnormalities were detected around the psoas muscle in the abdominal cavity. Palliative radiation therapy was administered at a dose of 20 Gy in five fractions for pain relief. One month later, a follow-up CT scan presented no change in the shape of the tumor; however, the swelling of the right psoas muscle had improved. Unfortunately, the patient passed away 1 month after irradiation because of progressive liver and renal failure. When a patient with a malignant tumor presents with periprosthetic hip pain and hip flexion failure, one should consider the possibility of a malignant tumor in the lesser trochanter.

Tapia Syndrome and Severe Pain Induced by Occipital Bone Metastasis of Prostate Cancer.

Tapia syndrome is characterized by unilateral tongue paralysis, hoarseness, and dysphagia. It is often associated with issues in the lower cranial nerves and is rarely caused by malignant tumors. A 71-year-old Japanese male with prostate cancer and bone metastases experienced severe headaches, oral discomfort, dysphagia, and hoarseness for a month. Neurological examination revealed left-sided tongue atrophy and left vocal cord paralysis, suggesting problems with cranial nerves IX and XII. CT scans showed bone metastasis in the left occipital bone. Brain MRI showed no brain or meningeal metastasis, but neck MRI revealed a mass near the left hypoglossal canal. His prostate-specific antigen (PSA) level was 53.2 ng/mL. Based on these findings, we diagnosed him with occipital bone metastasis of prostate cancer with Tapia syndrome. We treated him with palliative radiation therapy (RT), delivering 30 Gy in 10 fractions over two weeks. We did not use drug treatment or chemotherapy due to side effects and the patient's preferences. After just one day of RT, his severe headache and oral discomfort significantly improved. By the end of the two-week treatment, his hoarseness had also improved, and he was able to eat. However, tongue atrophy had not improved three months after RT. We presented a unique case of palliative RT for occipital bone metastasis of prostate cancer with Tapia syndrome. Within two weeks, the patient's headache and dysphagia had greatly improved, although tongue atrophy remained partially unresolved after palliative RT.

Considerations on surgery invasiveness and response and toxicity patterns in classic palliative radiotherapy for acrometastases of the hand: a hint for a potential role of stereotactic body radiation therapy? A case report and literature review.

Background: The rarity of hand acrometastases hampers the consensus-building for their optimal management among the involved oncology professionals. In the current literature, demolitive surgery overcomes the use of palliative radiotherapy, which proved to be ineffective in more than 30% of cases treated with classic palliative dose schemes, carrying also a not negligible radiation-related adverse event rate. Against this background, stereotactic body radiation therapy (SBRT) could emerge as a well-balanced therapeutic option. Case summary: Here we describe the methods and outcomes of a SBRT treatment of a painful and function-limiting hand acrometastasis in a patient with a history of stage IIIB lung adenocarcinoma. We delivered a total dose of 30 Gy in five daily fractions to a soft-tissue metastasis abutting the fifth metacarpal bone through the SBRT protocol generally used for intracranial treatments. A few weeks later, the patient reported a clinical complete response with acrometastasis and pain disappearance, function recovery, and no significant toxicity. The acrometastasis was the first sign of an atypical cancer progression. Conclusions: SBRT for hand acrometastases is feasible and might have the best therapeutic profile among the currently available treatment options for this rare clinical scenario. Larger investigations are needed to confirm the present single-case experience.