Is There an Opportunity to De-Escalate Treatments in Selected Patients with Metastatic Hormone-Sensitive Prostate Cancer?

The treatment landscape for metastatic hormone-sensitive prostate cancer continues to evolve, with systemic treatment being the mainstay of current treatment. Prognostic and predictive factors such as tumour volume and disease presentation have been studied to assess responses to different treatments. Intensification and de-escalation strategies arouse great interest, so several trials are being developed to further personalize the therapy in these populations. Is there an optimal sequence and a possible option to de-intensify treatment in selected patients with a favourable profile? This and other goals will be the subject of this review

Coronavirus disease 2019 and lung cancer: where are we?

Oncology patients are more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection due to hospital contact and an immunological system that can be compromised by antineoplastic therapy and supportive treatments. Certain similarities have been described in the physiopathology of coronavirus disease 2019 (COVID-19) and lung cancer (LC) that may explain the higher probability of these patients of developing a more serious disease with more frequent hospitalizations and even death, especially with the addition of smoking, cardiovascular and respiratory comorbidities, old age and corticosteroids use. Pre-existing lesions and cancer therapies change the normal architecture of the lungs, so diagnostic scales such as COVID-19 Reporting and Data System (CO-RADS) are of vital importance for a correct diagnosis and patient homogenization, with a high inter-observer correlation. Moreover, anticancer treatments have required an adaptation to reduce the number of visits to the hospital [hypofractionated radiotherapy (RT), larger intervals between chemotherapy cycles, delay in follow-up tests, among others]. In a way, this has also caused a delay in the diagnosis of new cancers. On the other hand, vaccination has had a positive impact on the mortality of these patients, who maintain a similar seroprevalence to the rest of the population, with a similar impact in mortality

Technical recommendations for implementation of Volumetric Modulated Arc Therapy and Helical Tomotherapy Total Body Irradiation

As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their technical setup from a conventional TBI technique to multi-isocenter conformal arc therapy techniques such as Volumetric Modulated Arc Therapy (VMAT) or Helical Tomotherapy (HT). These techniques allow better homogeneity and control of the target prescription dose, and provide more freedom for individualized organ-at-risk sparing. The technical design of multi-isocenter/multi-plan conformal TBI is complex and should be developed carefully. A group of early adopters with conformal TBI experience using different treatment machines and treatment planning systems came together to develop technical recommendations and share experiences, in order to assist departments wishing to implement conformal TBI, and to provide ideas for standardization of practices

ESTRO ACROP and SIOPE recommendations for myeloablative total body irradiation in children

Background and purpose: Myeloablative Total Body Irradiation (TBI) is an important modality in conditioning for allogeneic hematopoietic stem cell transplantation (HSCT), especially in children with high-risk acute lymphoblastic leukemia (ALL). TBI practices are heterogeneous and institution-specific. Since TBI is associated with multiple late adverse effects, recommendations may help to standardize practices and improve the outcome versus toxicity ratio for children. Material and methods: The European Society for Paediatric Oncology (SIOPE) Radiotherapy TBI Working Group together with ESTRO experts conducted a literature search and evaluation regarding myeloablative TBI techniques and toxicities in children. Findings were discussed in bimonthly virtual meetings and consensus recommendations were established. Results: Myeloablative TBI in HSCT conditioning is mostly performed for high-risk ALL patients or patients with recurring hematologic malignancies. TBI is discouraged in children <3–4 years old because of increased toxicity risk. Publications regarding TBI are mostly retrospective studies with level III–IV evidence. Preferential TBI dose in children is 12–14.4 Gy in 1.6–2 Gy fractions b.i.d. Dose reduction should be considered for the lungs to <8 Gy, for the kidneys to ≤10 Gy, and for the lenses to <12 Gy, for dose rates ≥6 cGy/min. Highly conformal techniques i.e. TomoTherapy and VMAT TBI or Total Marrow (and/or Lymphoid) Irradiation as implemented in several centers, improve dose homogeneity and organ sparing, and should be evaluated in studies. Conclusions: These ESTRO ACROP SIOPE recommendations provide expert consensus for conventional and highly conformal myeloablative TBI in children, as well as a supporting literature overview of TBI techniques and toxicities

Trombosis arterial múltiple: Fotografía médica

Paciente femenino de 86 a&ntilde;os de edad con antecedentes de hipertensi&oacute;n arterial y diabetes mellitus tipo II. Refiere dolor abdominal en flanco derecho desde hace una semana. Al examen f&iacute;sico: abdomen blando, doloroso, sin irritaci&oacute;n peritoneal. En los an&aacute;lisis de laboratorio: leucocitosis 11.150uL, fibrin&oacute;geno 1200mg/dL, LDH 859mg/dL, PCR 233,7mg/L. En tomograf&iacute;a computarizada angiogr&aacute;fica se evidencia: trombosis de la arteria mesent&eacute;rica superior con repermeabilizaci&oacute;n distal, trombosis de la arteria renal izquierda con infartos renales y trombo a&oacute;rtico flotante en el plano renal y aorta infrarrenal. Es valorada por Radiolog&iacute;a Intervencionista quienes realizan trombectom&iacute;a mec&aacute;nica con dispositivo de aspiraci&oacute;n, sin complicaciones. La fibrilaci&oacute;n auricular est&aacute; relacionada con la enfermedad tromboemb&oacute;lica [1], siendo, los trombos a&oacute;rticos poco frecuentes [2], estos pueden originarse por enfermedad ateroescler&oacute;tica o aneurism&aacute;tica, generando embolismos a distancia [3]. El tratamiento habitual es anticoagulaci&oacute;n o fibrinol&iacute;ticos [4]. La trombectom&iacute;a endovascular constituye una alternativa segura y eficaz.&nbsp;&nbsp;86 year old female patient with a history of arterial hypertension and diabetes mellitus type II. Refers abdominal pain in right flank for one week. On physical exam: soft abdomen, painful, no peritoneal irritation. On laboratory tests: leukocytosis 11,150uL, fibrinogen 1200mg/dL, LDH 859mg/ dL, CRP 233.7mg/L.&nbsp; Angiographic computerized tomography showed: thrombosis of the superior mesenteric artery with distal repermeabilization, thrombosis of the left renal artery with renal infarcts and floating aortic thrombus in the renal and infrarenal aorta plane. It is assessed by Interventional Radiology who performs mechanical thrombectomy with an aspiration device, without complications. Atrial fibrillation is related to thromboembolic disease [1], being, aortic thrombi infrequent [2], these can be originated by atherosclerotic or aneurysmal disease, generating distant embolisms [3]. The usual treatment is anticoagulation or fibrinolytics [4]. Endovascular thrombectomy is a safe and effective alternative

Quimioradioterapia neoadyuvante en cáncer de recto localmente avanzado

El tratamiento neoadyuvante con radioterapia y quimioterapia radiosensibilizante es el est&aacute;ndar de tratamiento para el c&aacute;ncer de recto localmente avanzado (CRLA). El objetivo de este estudio es analizar la respuesta patol&oacute;gica tras el tratamiento neoadyuvante. Se realiz&oacute; un estudio observacional descriptivo y retrospectivo en pacientes con diagn&oacute;stico de adenocarcinoma de recto desde enero 2018 a diciembre 2018 en el Servicio de Oncolog&iacute;a Radioter&aacute;pica del Hospital Universitario La Paz. Se incluyeron 51 pacientes. Un grupo de pacientes (82,4%) se trat&oacute; con radioterapia tridimensional conformada (3D-CRT)con una dosis de 45 Gray (Gy) sobre pelvis y una sobreimpresi&oacute;n de 5,4 Gy sobre tumor primario y otro grupo (17,6%) se trat&oacute; con radioterapia con t&eacute;cnica de arcoterapia volum&eacute;trica de intensidad modulada (VMAT) y verificaci&oacute;n diaria con radioterapia guiada por im&aacute;genes (IGRT) con una dosis de 53,7 Gy en pelvis con sobreimpresi&oacute;n concurrente al tumor. La dosis de capecitabina oral fue de 850 mg/m2 dos veces al d&iacute;a durante el tratamiento. Todos los pacientes fueron reevaluados con resonancia magn&eacute;tica (RM) post-neoadyuvancia. Los pacientes se operaron entre 6-8 semanas tras quimioradioterapia. La respuesta patol&oacute;gica completa fue de 15,6% y la respuesta patol&oacute;gica parcial de 80,5% con una tasa global de&nbsp;downstaging&nbsp;de 33%. Se concluye que la quimioradioterapia neoadyuvante es un tratamiento seguro con aceptables tasas de control local en los pacientes con CRLA con escasa toxicidad aguda.&nbsp;Neoadjuvant treatment with radiotherapy and radiosensitizing chemotherapy is the standard of treatment for locally advanced rectal cancer (LARC). The objective of this study is to analyze the pathological response after neoadjuvant treatment. This is a descriptive and retrospective observational study in patients diagnosed with rectal adenocarcinoma from January 2018 to December&nbsp;2018 at the Radiation Oncology Department of Hospital Universitario La Paz. 51 patients were included. One group of patients (82.4%) was treated with threedimensional conformal radiotherapy (3D-CRT) with a dose of 45 Gray (Gy) on the pelvis and an boost of 5.4 Gy on the primary tumor and another group (17.6%) was treated with radiotherapy with volumetric arcotherapy technique (VMAT) and daily verification with image-guided radiotherapy (IGRT) with a dose of 53.7 Gy in the pelvis with concurrent tumor boost. The oral capecitabine dose was 850 mg/m2 twice daily during treatment. All patients were reevaluated with postneoadjuvant magnetic resonance imaging (MRI). The patients underwent surgery 6-8 weeks after chemoradiotherapy. Complete pathological response was of 15.6% and partial pathological response of 80.5% with an overall downstaging rate of 33%. It is concluded that neoadjuvant chemoradiotherapy is a safe treatment with acceptable local control rates in patients with LARC with little acute toxicity.&nbsp

Adenocarcinoma de cérvix con metástasis esplénica: reporte de un caso

Los tumores s&oacute;lidos hacen met&aacute;stasis excepcionalmente al bazo, con una incidencia que oscila entre 2,9 a 9%. En la literatura se han descrito pocos casos de met&aacute;stasis espl&eacute;nicas de c&aacute;ncer de cuello uterino. Se presenta el caso de paciente femenina de 59 a&ntilde;os, con diagn&oacute;stico de adenocarcinoma de cuello uterino en estadio IVB seg&uacute;n la estadificaci&oacute;n de la Federaci&oacute;n Internacional de Ginecolog&iacute;a y Obstetricia, pobremente diferenciado, tratada con quimioterapia de inducci&oacute;n, seguida de radioterapia externa concomitante con cisplatino y 5 fracciones de braquiterapia endocavitaria de alta dosis, con respuesta morfol&oacute;gica y metab&oacute;lica completa. Dos a&ntilde;os despu&eacute;s, la Tomograf&iacute;a Computarizada mostr&oacute; dos lesiones sugestivas de met&aacute;stasis espl&eacute;nica sin encontrar enfermedad a otro nivel. Se realiz&oacute; esplenectom&iacute;a, confirmando la histolog&iacute;a de adenocarcinoma cervical pobremente diferenciado con positividad a la prote&iacute;na p16. Tras un a&ntilde;o de la cirug&iacute;a, la paciente est&aacute; viva en remisi&oacute;n de la enfermedad. Las met&aacute;stasis espl&eacute;nicas son inusuales y, a menudo, se diagnostican de manera incidental. Por tanto, es importante un correcto seguimiento oncol&oacute;gico con examen f&iacute;sico y pruebas de im&aacute;genes. La esplenectom&iacute;a es el tratamiento m&aacute;s adecuado.&nbsp;&nbsp;Solid tumors exceptionally metastasize to the spleen, with an incidence ranging from 2,9 to 9%. Few cases of splenic metastases from cervical cancer have been described in the literature. Fifty-nine-year-old female patient is presented, with diagnosis of cervical adenocarcinoma in stage IVB according to the staging of the International Federation of Gynecology and Obstetrics, poorly differentiated, treated with induction chemotherapy, followed by external beam radiotherapy concomitantly with cisplatin and 5 fractions of high dose rate endocavitary brachytherapy, with a complete morphological and metabolic response. Two years later, Computed Tomography showed two lesions suggestive of splenic metastasis without finding disease at another level. Splenectomy was performed, confirming the histology of a poorly differentiated cervical adenocarcinoma with positivity for p16 protein. One year after surgery, the patient is alive in remission of the disease. Splenic metastases are rare and are often diagnosed incidentally. Therefore, a correct oncological follow-up with a physical examination and imaging tests is important. Splenectomy is the most appropriate treatment

Elevated D-Dimer and acute pulmonary embolism in COVID-19 patients

Introduction. It has been determined that patients with SARS-CoV-2 infection and severe pneumonia with elevated D-dimer values can develop acute pulmonary thromboembolism (APE) as a complication, being one  of the causes related to mortality in this group of patients. Methods. A retrospective analysis of 12 patients diagnosed with SARS-CoV-2 infection with high clinical suspicion of APE confirmed by computed tomography pulmonary angiopgraphy (CTPA) was performed and  the described findings are described. Results. 12 patients with diagnosis of severe pneumonia, elevated D-dimer 9.2 μg / ml (1.4 - ˃20 μg / mL) and confirmation of SARS-CoV-2 infection through real-time reverse transcription polymerasa chain reaction (RT- PCR). APEs were observed mainly in segmental arteries (75%) and main arteries (25%). Pneumonia with  patched areas of bilateral ground glass opacities was observed in 100% of the sample as a typical finding of  SARS-CoV-2 infection. Conclusion. SARS-CoV-2 infection is related to elevation of D-dimer and APE. The CTPA determines the  diagnosis, severity and timely management (anticoagulation) of patients with APE. Therefore CTPA should be  considered in all patients with elevated D-dimer or clinical worsening.  Introducción. Se ha determinado que los pacientes con infección por SARS-CoV-2 y neumonía severa con  valores elevados de dímero-D, pueden desarrollar tromboembolismo pulmonar agudo (TEP) como  complicación, siendo una de las causas relacionada con la mortalidad en este grupo de pacientes. Material y métodos. Se realizó un análisis retrospectivo de 12 pacientes con diagnóstico de infección por  SARS-CoV-2 con alta sospecha clínica de APE confirmado por angio tomografia computarizada (AngioTC) y se  describen los hallazgos descritos. Resultados. 12 pacientes con diagnóstico de neumonía severa, dímero-D elevado 9,2 μg/ml (1,4 - ˃20 μg/ml)  y confirmación de infección de SARS-CoV-2 a través de reacción en cadena de polimerasa reversa (RT-PCR).  Se objetivaron TEP principalmente en arterias segmentarias (75%) y arterias principales (25%). En el 100% de  la muestra se objetivó neumonía con áreas parcheadas de vidrio deslustrado bilaterales como hallazgo típico de infección por SARS-CoV-2. Conclusión. La infección por SARS-CoV-2 está relacionada con elevación del dímero-D y con TEP. La angioTC  determina el diagnóstico, severidad y manejo oportuno (anticoagulación) de los pacientes con TEP. Por tanto el angioTC debe ser considerado en todos los pacientes con dímero-D elevado o empeoramiento clínico.

Quimioradioterapia en cáncer de recto y tasa de respuesta patológica

Introduction. Neoadjuvant treatment with radiotherapy and radiosensitizing chemotherapy in locally advanced rectal cancer (LARC) significantly decreases local recurrence rates. Therefore the objective of this  study is to analyze the pathological complete response (PCR) and partial response (PPR) of neoadjuvant  treatment with exclusive chemoradiotherapy in patients with locally advanced rectal cancer. Matherial and Method. It has been made a study descriptive, retrospective in a cohort of patients with LARC in the January 2016 to December 2018 period in the Radiation-Oncology Department of Hospital Universitario La Paz. 140 patients were included. A group of patients (92,9%) received treatment with radiotherapy 3D conformed technique with a dose administered the 45 Gy on pelvis and a boost of 5,4 Gy on tumor and other  group (7,1%) received treatment with volumetric archotherapy radiotherapy (VMAT) guided by image (IGRT)  with a dose administered of 53,7% on pelvis with concurrent boost and. The dose of capecitabine was 850  mg/m2, twice a day during the treatment. The patients were re-evaluated with post-neoadjuvant MRI.  Patients were operated 6 to 8 weeks post chemoradiotherapy. Results. CPR was obtained of 17,1% and pPR of 80,1% with a global rate downstaging of 31,8%. Conclusion. It concludes that chemoradiotherapy neoadjuvant is a safe treatment with acceptable rates of local control in patients with LARC.  Introducción. El tratamiento neoadyuvante con radioterapia y quimioterapia radiosensibilizante en el cáncer de recto localmente avanzado (CRLA) disminuye significativamente las tasas de recurrencia local. Por tanto el objetivo de este estudio es analizar la respuesta patológica completa (RPC) y parcial (RPP) tras el tratamiento  neoadyuvante con quimioradioterapia en pacientes con CRLA. Material y método. Se realizó un estudio descriptivo, retrospectivo en pacientes con diagnóstico de CRLA  desde enero 2016 a diciembre 2018 en el Servicio de Oncología-Radioterápica del Hospital Universitario La  Paz. Se incluyeron 140 pacientes. Un grupo de pacientes (92,9%) se trató con radioterapia 3D conformada  con una dosis de 45Gy sobre pelvis y una sobreimpresión de 5,4Gy sobre tumor primario y otro grupo (7,1%)  se trató con radioterapia con técnica volumétrica y en arcoterapia (VMAT) guiado por imagen (IGRT) con una  dosis de 53,7Gy en pelvis con sobreimpresión concurrente al tumor. La dosis de capecitabina oral fue de  850mg/m2 dos veces al día durante el tratamiento. Todos los pacientes fueron reevaluados con resonancia  magnética (RM) post-neoadyuvancia. Los pacientes se operaron entre 6-8 semanas tras quimioradioterapia. Resultados. Se obtuvo una RPC de 17,1% y RPP de 80,1% con una tasa global de downstaging de 31,8%. Conclusión. Se concluye que la quimioradioterapia neoadyuvante es un tratamiento seguro con aceptables  tasas de control local en los pacientes con CRLA.

Relación entre marcadores hematológicos y la respuesta patológica completa al tratamiento neoadyuvante en cáncer de recto localmente avanzado

Introduction. Multiple haematological markers of inflammation might be related with poor prognosis in  oncological patients. Purpose. This study evaluated whether changes of haematological markers before and after chemo- radiotherapy treatment in rectal cancer might be associated to pathological complete response. Material and Methods. Medical records of 140 patients with rectal cancer who received neoadjuvant  radiotherapy followed by surgical resection were retrospectively review. Complete bloods counts (CBC) was  measured days before and after period of RT. We assessed white blood cells count (WBC), hemoglobin levels  (Hb), neutrophils count, lymphocytes count, monocytes count, neutrophil-to-lymphocye ratio (NLR), platelet- to-lymphocyte ratio (PLR) and lymphocyte-to-monocyte ratio (LMR). Results. The overall rate of pCR was 17,5%. Hematological markers had a statistically significant decrease  after CRT treatment (p<0,05), however in our analysis they do not predict complete pathological response. Conclusion. Haematological markers before and after neoadjuvant treatment do not predict tumor  responses in this study. However, a larger sample can show statistically significant results, especially in  monocytes ratio.  Introducción. Múltiples marcadores hematológicos de inflamación pueden tener relación con un peor  pronóstico en los pacientes oncológicos. Propósito. Este estudio evaluó si los cambios en marcadores hematológicos antes y después del tratamiento  quimio-radioterápico (QT-RT) en cáncer de recto pueden estar asociados con la respuesta patológica  completa. Material y método. Se revisaron retrospectivamente las historias clínicas de 140 pacientes con cáncer de  recto que recibieron tratamiento radioterápico neoadyuvante seguido de resección quirúrgica fueron  revisados retrospectivamente. Se realizó analítica completa antes y después del tratamiento QT-RT. Se  evaluaron leucocitos, hemoglobina, neutrófilos, linfocitos, monocitos, ratio neutrófilo-linfocitos (NLR), ratio  plaqueta-linfocitos (PLR) y ratio linfocitos-monocitos (LMR). Resultados. La respuesta patológica completa fue de 17,5%. Los marcadores hematológicos tuvieron una  disminución significativa tras el tratamiento de QT-RT (p<0,05), sin embargo en nuestro análisis no se  relacionó con la respuesta patológica completa, salvo el PLR (p=0,027). Conclusión. Los marcadores hematológicos antres y después del tratamiento neoadyuvante no predicen la  respuesta tumoral tras QT-RT en este estudio. Sin embargo una muestra mayor puede presentar resultados  estadísticamente signifiacativos, especialmente con los monocitos.