Validation of the prognostic model for palliative radiotherapy in older patients with cancer

BACKGROUND Older patients are more likely to have a poor performance status and comor-bidities.There is a reluctance to extensively investigate and treat older patients.As elderly individuals and patients with neoplasms each increase in number,palliative treatment of older patients is expected to grow as an issue.AIM To investigated the role of palliative radiotherapy in older patients and patients who were expected to demonstrate a therapeutic effect.METHODS From February 2019 to February 2022,33 patients aged≥80 years underwent palliative radiotherapy.The prognosis in palliative care study predictor(PiPS),palliative prognostic index(PPI),and delirium-palliative prognostic score(D-PaP)models were used for prognosis prediction.D-PaP scores calculated according to the doctor's prediction of clinical prediction of survival(CPS)were excluded and then analyzed for comparison.Radiation was prescribed at a dose of 2.5-7 Gy per fraction,up to a median of 39 Gy10(range,28-75 Gy10).RESULTS The median follow-up was 2.4 months(range,0.2-27.5 months),and 28 patients(84.8%)showed subjective symptom improvements following treatment.The 2-and 6-month survival rates of all patients were 91.5%and 91.5%,respectively.According to regression analysis,the performance status index,symptom type,and radiation dose all showed no significant correlation with the treatment re-sponse.When survival was expected for>55 days in the PiPS model,the 2-month survival rate was 94.4%.For patients with PPI and D-PaP-CPS values of 0-3.9 points,the 2-month survival rates were 90.0%and 100%,respectively.For patients with a score of≥4 points,the 2-month survival rates were 37.5%and 0%,res-pectively.Core Tip:This is a retrospective study to investigate the role of palliative radiotherapy in older patients and patients who were expected to demonstrate a great therapeutic effect.The prognosis in palliative care study predictor,palliative prognostic index,and delirium-palliative prognostic score models were used for prognosis prediction.Most of patients showed subjective symptom improvements following treatment.The prognosis prediction model showed good correlation with survival.In order to increase the therapeutic effectiveness in palliative radiotherapy,it is necessary to assess a patient's exact prognosis and select appropriate patients accordingly.INTRODUCTION The incidence of cancer is high among individuals 60-69 years old and is 11 times greater among those≥65-years-old compared to those<65-years-old.For this reason,about half of all cancer cases are diagnosed in individuals aged≥70 years,and older patients account for a large portion of the total population regarding the prevalence of cancer[1].Cancer is one of the most significant diseases in older patients.About 60%of all cancer-related deaths occur in older patients aged 70 years[1,2].Moreover,cancer accounts for about one-third of the causes of death in the elderly population[1,2].When choosing a cancer treatment,both the characteristics of the cancer and the overall health status of the patient,such as their general condition and any underlying diseases,should be considered[2].Older patients have a shorter life expectancy than younger patients;moreover,they typically have many accompanying underlying diseases and have a poorer general condition.For this reason,older patients are often rejected from receiving active testing and treatment services.Therefore,even if other factors,such as the underlying disease,are the same in young and old patients,older patients typically receive less treatment due to the simple fact that they are older[3].Palliative treatment is a treatment approach that improves the pain and symptoms of a patient and their quality of life.Although palliative treatment is applicable regardless of patient age and the type and severity of their disease,most patients requiring palliative treatment are cancer patients.Palliative radiotherapy is relatively effective for cancer patients and tends to be a well-tolerated treatment.Although some studies have reported the usefulness of palliative radiotherapy in elderly patients,a large number of patients and caregivers are not receiving treatment due to fears of treatment,the risks of side effects,and doubts about treatment effectiveness[1].Since actual age is not always associated with physical ability,the determination of treatment based solely on age can be an obstacle preventing appropriate treatment opportunities.The importance of palliative care is increasing due to the recent growth of the elderly population,as well as,the increase in cancer incidence,and the changes in traditional views or perceptions,such as a growing acceptance of the pursuit of a dignified death[4].Therefore,in this study,we investigated the role of palliative radiotherapy in older patients and in patients who are expected to show a great therapeutic effect.

Factors influencing comfort level in head and neck neoplasm patients receiving radiotherapy

Objective:To determine factors that influence comfort in head and neck neoplasm patients receiving radiotherapy.Methods:In total,200 head and neck neoplasm patients receiving radiotherapy were recruited from three tertiary first class hospitals.They were assessed by Radiotherapy Comfort Questionnaire for patients with head and neck neoplasm,Social Support Scale,and Medical Coping Modes Questionnaire.Results:The total score of comfort was 60.54±8.32.Multiple linear regression analysis indicated that number of radiation treatments,family accompaniment,educational level,resignation coping mode,complications due to diabetes,accompanying chemotherapy,and the utilization of social support significantly influenced comfort level(p<0.05).Among these,number of radiation treatments,complications due to diabetes,accompanying chemotherapy,and resignation coping were negative factors.Conclusion:Encouraging utilization of social support systems and a positive coping mode is important for increasing comfort level in head and neck neoplasm patients during radiotherapy.Nurses should pay particular attention to those patients during later stages of radiotherapy or chemotherapy,with diabetes,without family accompaniment,and with lower education level.

Modified simultaneous integrated boost radiotherapy for an unresectable huge refractory pelvic tumor diagnosed as a rectal adenocarcinoma

A clinical trial of radiotherapy with modified simultaneous integrated boost(SIB)technique against huge tumors was conducted.A 58-year-old male patient who had a huge pelvic tumor diagnosed as a rectal adenocarcinoma due to familial adenomatous polyposis was enrolled in this trial.The total dose of 77 Gy(equivalent dose in 2Gy/fraction)and 64.5 Gy was delivered to the center of the tumor and the surrounding area respectively,andapproximately 20%dose escalation was achieved with the modified SIB technique.The tumor with an initial maximum size of 15 cm disappeared 120 d after the start of the radiotherapy.Performance status of the patient improved from 4 to 0.Radiotherapy with modified SIB may be effective for patients with a huge tumor in terms of tumor shrinkage/disappearance,improvement of QOL,and prolongation of survival.

Concomitant treatment of ureteral calculi and ipsilateral pelvic sciatic nerve schwannoma with transperitoneal laparoscopic approach: A case report

BACKGROUND Schwannomas are rare peripheral neural myelin sheath tumors that originate from Schwann cells.Of the different types of schwannomas,pelvic sciatic nerve schwannoma is extremely rare.Definite preoperative diagnosis of pelvic schwannomas is difficult,and surgical resection is the gold standard for its definite diagnosis and treatment.CASE SUMMARY We present a case of pelvic schwannoma arising from the sciatic nerve that was detected in a 40-year-old man who underwent computed tomography for intermittent right lower back pain caused exclusively by a right ureteral calculus.Subsequently,successful transperitoneal laparoscopic surgery was performed for the intact removal of the stone and en bloc resection of the schwannoma.The total operative time was 125 min,and the estimated blood loss was inconspicuous.The surgical procedure was uneventful.The patient was discharged on postoperative day 5 with the simultaneous removal of the urinary catheter.However,the patient presented with motor and sensory disorders of the right lower limb,caused by partial damage to the right sciatic nerve.No tumor recurrence was observed at the postoperative appointment.CONCLUSION Histopathological examination of the specimen confirmed the diagnosis of a schwannoma.Thus,laparoscopic surgery is safe and feasible for concomitant extirpation of pelvic schwannomas and other pelvic and abdominal diseases that require surgical treatment.

Genitourinary toxicity after pelvic radiation:Prospective review of complex urological presentations

Objective:Recent randomised controlled trials underestimated the incidence of genitourinary (GU) complications occurring more than 5 years following pelvic radiotherapy. This study aimed to determine the burden of treatment at a single institution from late GU complications after pelvic radiotherapy.Methods:A prospective study of all presentations for GU complications following pelvic radiotherapy at a tertiary urology department between November 2018 and November 2019 was performed. Subgroup analyses was performed on patients with prostate cancer (PCa) with late toxicity to compare patient demographics, radiotherapy, complications, and management factors.Results:There were 117 hospital encounters involving 46 patients with a 56.4% repeat encounter rate. Patients with PCa were the predominant group (n=39, 84.8%). External beam radiotherapy was the most common treatment modality (n=41, 89.1%). The median time from radiotherapy to encounter was 8 (range 0–23) years. Radiation-induced haemorrhagic cystitis was the most common presentation (n=70, 59.8%). Forty-four (42.7%) encounters for GU toxicity were managed operatively and 33 (32.0%) involved a non-operative procedure. Nine patients required packed red cell transfusion, with a total of 154 units transfused. Patients with PCa who presented with late GU toxicity had higher median Radiotherapy Oncology Group grades (p=0.020), proportion of emergency admissions (p=0.047), and frequency of clot urinary retention (p<0.001).Conclusion:There is a high burden of elective and emergency urology workload attributed to late pelvic radiation toxicity. Late GU toxicity occurring ≥5 years after radiotherapy is common and often more severe.

Postoperative chemoradiotherapy with capecitabine and oxaliplatin vs.capecitabine for pathological stage N2 rectal cancer

Objective:Several studies have been conducted on the effects and toxicity of adding oxaliplatin to fluorouracilbased or capecitabine-based chemoradiotherapy(CRT)regimens as significantly increasing the toxic response without benefit to survival.In this study,we further explored the role of these two postoperative CRT regimens in patients with pathological stage N2 rectal cancer.Methods:This study was a subgroup analysis of a randomized clinical trial.A total of 180 patients with pathological stage N2 rectal cancer were eligible,85 received capecitabine with radiotherapy(RT),and 95 received capecitabine and oxaliplatin with RT.Patients in both groups received adjuvant chemotherapy[capecitabine and oxaliplatin(XELOX);or fluorouracil,leucovorin,and oxaliplatin(FOLFOX)]after CRT.Results:At a median follow-up of 59.2[interquartile range(IQR),34.0−96.8]months,the three-year diseasefree survival(DFS)was 53.3%and 64.9%in the control group and the experimental group,respectively[hazard ratio(HR),0.63;95%confidence interval(95%CI),0.41−0.98;P=0.04].There was no significant difference between the groups in overall survival(OS)(HR,0.62;95%CI,0.37−1.05;P=0.07),the incidence of locoregional recurrence(HR,0.62;95%CI,0.24−1.64;P=0.33),the incidence of distant metastasis(HR,0.67;95%CI,0.42−1.06;P=0.09)and grade 3−4 acute toxicities(P=0.78).For patients with survival longer than 3 years,the conditional overall survival(COS)was significantly better in the experimental group(HR,0.39;95%CI,0.16−0.96;P=0.03).Conclusions:Our results indicated that adding oxaliplatin to capecitabine-based postoperative CRT is safe and effective in patients with pathological stage N2 rectal cancer.

Signal intensity changes of dentate nucleus on plain MR T1WI innasopharyngeal carcinoma patients after radiotherapy andmultiple injections of gadolinium-base contrast agent

Objective To observe changes of plain MR T1WI signal intensity of dentate nucleus in nasopharyngeal carcinoma patients after radiotherapy and multiple times of intravenous injection of gadolinium-based contrast agent(GBCA).Methods Fifty patients with pathologically confirmed nasopharyngeal carcinoma and received intensity-modulated radiotherapy were retrospectively enrolled as the nasopharyngeal carcinoma group,and 50 patients with other malignant tumors and without history of brain radiotherapy were retrospectively enrolled as the control group.All patients received yearly GBCA enhanced MR examinations for the nasopharynx or the head.T1WI signal intensities of the dentate nucleus and the pons on same plane were measured based on images in the year of confirmed diagnosis(recorded as the first year)and in the second to the fifth years.T1WI signal intensity ratio of year i(ranging from 1 to 5)was calculated with values of dentate nucleus divided by values of the pons(ΔSI i),while the percentage of relative changes of year j(ranging from 2 to 5)was calculated withΔSI j compared toΔSI 1(Rchange j).The values of these two parameters were compared,and the correlation ofΔSI and GBCA injection year-time was evaluated within each group.Results No significant difference of gender,age norΔSI 1 was found between groups(all P>0.05).The second to the fifth yearΔSI and Rchange in nasopharyngeal carcinoma group were all higher than those in control group(all P<0.05).Within both groups,ΔSI was positively correlated with GBCA injection year-time(both P<0.05).Conclusion Patients with nasopharyngeal carcinoma who underwent radiotherapy and multiple times of intravenous injection of GBCA tended to be found with gradually worsening GBCA deposition in dentate nucleus,for which radiotherapy might be a risk factor.

立体定向放疗联合信迪利单抗和贝伐珠单抗治疗不可切除原发性肝癌的效果分析

目的探讨立体定向放疗联合信迪利单抗和贝伐珠单抗治疗不可切除肝癌的效果、安全性及预后指标。方法选取2022年3月—12月在中国人民解放军总医院第五医学中心放射治疗科接受立体定向放疗联合信迪利单抗和贝伐珠单抗类似物(双达方案)治疗的42例不可切除原发性肝癌患者,给予计划靶区处方剂量为36~50 Gy,分5~6次,连续照射,后序贯双达方案治疗,每3周为1个疗程,直至出现肿瘤进展或严重不良反应。采用Kaplan-Meier法计算总生存率和无进展生存率,并采用Log-rank检验进行比较;Cox比例风险模型分析影响预后的相关因素。结果中位随访时间为21.6个月,客观缓解率为69%,疾病控制率为85.7%,中位无进展生存期为10.0个月(95%CI:6.7~13.0),中位总生存期为23.3个月(95%CI:14.7~31.8)。不良反应多为1~2级,未发生致命性不良反应。治疗后6~8周AFP应答组中位总生存期显著优于AFP未应答组(未达到vs 11.8个月,P=0.007)。多因素分析显示AFP应答与患者良好的预后相关(HR=0.31,95%CI:0.13~0.75,P=0.009)。结论对于不可切除肝癌患者,立体定向放疗联合双达方案可改善患者生存且安全性可控,治疗后6~8周AFP水平下降>50%可作为潜在预后指标。

AlignRT引导摆位流程在盆腔肿瘤放疗中的应用评估

目的:通过对比两种不同的盆腔肿瘤放疗摆位工作流程,评估光学体表引导系统AlignRT的定位准确性和可重复性,进一步探讨其替代皮肤标记线摆位的可行性。方法:选取2022年3月至2023年3月在中山大学肿瘤防治中心Infinity加速器放疗的40例盆腔肿瘤患者,其中20例采用传统的体表标记线摆位流程,另外20例采用AlignRT引导摆位流程。治疗前扫描锥形束CT(CBCT)与计划CT进行配准获得六维方向上的平移(左右LAT、头脚LNG、前后VRT)和旋转(冠状位Yaw、矢状位Pitch、横断位Roll)误差。比较两种摆位流程的CBCT配准误差、误差偏移量分布,计算计划靶区(PTV)外扩边缘,对6个维度误差、体质量指数和摆位误差之间进行相关性分析。结果:在传统标记线摆位流程中,平移和旋转误差的中位数范围分别为0.19~0.34 cm和0.50°~1.30°,最大偏移量范围分别为1.20~1.70 cm和2.00°~5.50°。在AlignRT引导摆位的工作流程中,平移和旋转误差的中位数范围为0.10~0.15 cm和0.50°~0.70°,最大偏移量范围为0.42~0.47 cm和1.80°~2.00°。此外,传统标记线摆位显示分次间误差>0.5 cm和>3°的比例分别为23.3%和9.8%。计算得到两组摆位方式在LR、SI、AP方向的PTV外扩值:AlignRT引导(0.37、0.38和0.34 cm),皮肤标记线摆位(0.67、1.22和0.95 cm)。两个摆位工作流程的6个维度的误差之间均没有发现相关性。当使用AlignRT引导摆位时,LAT、LNG和Pitch方向与体质量指数呈低度相关。结论:AlignRT引导盆腔肿瘤放疗可以减少六维平移和旋转误差,实现精准的摆位精度,治疗分次间的重复性和稳定性高,与CBCT联合使用可取代传统的皮肤标记线摆位流程。

Long-term outcomes and prognostic factors for patients with esophageal cancer following radiotherapy

AIM:To evaluate long-term outcomes and prognostic factors for esophageal squamous cell carcinoma(SCC) treated with three dimensional conformal radiotherapy(3D-CRT).METHODS:Between January 2005 and December 2006,153 patients(120 males,33 females) with pathologically confirmed esophageal SCC and treated with 3D-CRT in Cancer Hospital of Shantou University were included in this retrospective analysis.Median age was 60 years(range:37-84 years).The proportion of tumor location was as follows:upper thorax(including the cervical region),73(48%);middle thorax,73(48%);lower thorax,7(5%),respectively.The median radiation dose was 64 Gy(range:50-74 Gy).Fifty four cases(35%) received cisplatin-based concurrent chemotherapy.Univariate and multivariate analysis were performed to determine the association between the correlative factors and prognosis.RESULTS:The five-year overall survival rate was 26.3%,with a median follow-up of 49 mo(range:3-66 mo) for patients who were still alive.On univariate analysis,lesion location,lesion length by barium esophagogram,computed tomography imaging characteristics including Y diameter(anterior-posterior,AP,extent of tumor),gross tumor volume of primary lesion(GTV-E),volume of positive lymph nodes(GTV-LN),and the total target volume(GTV-T = GTV-E + GTVLN) were prognostic for overall survival.By multivariate analysis,only the Y diameter [hazard ratio(HR) 2.219,95%CI 1.141-4.316,P = 0.019] and the GTV-T(HR 1.372,95%CI 1.044-1.803,P = 0.023) were independent prognostic factors for survival.CONCLUSION:The overall survival of esophageal carcinoma patients undergoing 3D-CRT was promising.The best predictors for survival were GTV-T and Y diameter.

Radiotherapy of double primary esophageal carcinoma

INTRODUCTIONDouble primary esophageal carcinoma is defined ashaving two loci of squamous cell cancersimultaneously or consecutively developing indifferent sites of esophagus.This rare diseaseappears mostly in the literature as case reports,reports about its treatment are even moreinfrequent.Here we present our experiences

Effect of neoadjuvant chemoradiotherapy on prognosis and surgery for esophageal carcinoma

AIM:To investigate the role of neoadjuvant chemoradiotherapy in prognosis and surgery for esophageal carcinoma by a meta-analysis.METHODS:PubMed and manual searches were done to identify all published randomized controlled trials(RCTs) that compared neoadjuvant chemoradiotherapy plus surgery(CRTS) with surgery alone(S) for esophageal cancer.According to the test of heterogeneity,a fi xed-effect model or a random effect model was used and the odds ratio(OR) was the principal measure of effects.RESULTS:Fourteen RCTs that included 1737 patients were selected with quality assessment ranging from A to C(Cochrane Reviewers' Handbook 4.2.2).OR(95% CI,P value),expressed as CRTS vs S(values>1 favor CRTS arm),was 1.19(0.94-1.48,P=0.28) for 1-year survival,1.33(1.07-1.65,P=0.69) for 2-year survival,1.76(1.42-2.19,P=0.11) for 3-year survival,1.41(1.06-1.87,P=0.11) for 4-year survival,1.64(1.28-2.12,P=0.40) for 5-year survival,0.82(0.39-1.73,P<0.0001) for rate of resection,1.53(1.33-2.84,P=0.007) for rate of complete resection,1.78(1.14-2.78,P=0.79) for operative mortality,1.12(0.89-2.48,P=0.503) for all treatment mortality,1.33(0.94-1.88,P=0.04) for the rate of adverse treatment,1.38(1.23-1.63,P=0.0002) for local-regional cancer recurrence,1.28(0.85-1.58,P=0.60) for distant cancer recurrence,and 1.27(0.86-1.65,P=0.19) for all cancer recurrence.A complete pathological response to chemoradiotherapy occurred in 10%-45.5% of patients.The 5-year survival benefi t was most pronounced when chemotherapy and radiotherapy were given concurrently(OR:1.45,95% CI:1.26-1.79,P=0.015) instead of sequentially(OR:0.85,95% CI:0.64-1.35,P=0.26).CONCLUSION:Compared with surgery alone,neoadjuvant chemoradiotherapy can improve the long-term survival and reduce local-regional cancer recurrence.Concurrent administration of neoadjuvant chemoradiotherapy was superior to sequential chemoradiotherapy.

The Inhibitory Effects of Rh-endostatin(YH-16) in Combination with Radiotherapy on Lung Adenocarcinoma A549 in Mice and the Underlying Mechanisms

In order to investigate the inhibitory effects of Endostar(rh-endostatin,YH-16)in combination with radiotherapy on lung adenocarcinoma A549 in mice and the interaction mechanisms of combined therapy,the transplantation tumor models of A549 lung adenocarcinoma were established.When the largest diameter of tumor reached 1.0cm,all nude mice were randomly divided into 4 groups:Endostar group,radiotherapy group,radiotherapy plus Endostar(combined treatment)group,and control group(n=6 in each group).The largest d...

Three-dimensional conformal radiotherapy combined with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer

AIM： To investigate the effect of three-dimensional conformal radiotherapy （3-DCRT） in combination with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer. METHODS： Forty-eight patients with unresectable recurrent rectal cancer were randomized and treated by 3-DCRT or 3-DCRT combined with FOLFOX4 chemotherapy between September 2001 and October 2003. For the patients without prior radiation history, the initial radiation was given to the whole pelvis by traditional methods with tumor dose of 40 Gy, followed by 3-DCRT for the recurrent lesions to the median total cumulative tumor dose of 60 Gy （range 56-66 Gy）; for the post-radiation recurrent patients, 3-DCRT was directly given for the recurrent lesions to the median tumor dose of 40 Gy （36-46 Gy）. For patients in the study group, two cycles chemotherapy with FOLFOX4 regimen were given concurrently with radiotherapy, with the first cycle given simultaneously with the initiation of radiation and the second cycle given in the fifth week for patients receiving conventional pelvis radiation or given in the last week of 3-DCRT for patients receiving 3-DCRT directly. Another 2-4 cycles （average 3.6 cycles） sequential FOLFOX4 regimen chemotherapy were given to the patients in the study group, beginning at 2-3 wk after chemoradiation. The outcomes of symptoms relieve, tumor response, survival and toxicity were recorded and compared between the study group and the control group. RESULTS： For the study group and the control group, the pain-alleviation rates were 95.2% and 91.3%（P〉 0.05）; the overall response rates were 56.5% and 40.0% （P〉0.05）; the 1-year and 2-year survival rates were 86.9%, 50.2% and 80.0%, 23.9%, with median survival time of 25 mo and 16 mo （P〈 0.05）; the 2-year distant metastasis rates were 39.1% and 56.0% （P= 0.054）, respectively. The side effects, except peripheral neuropathy which was relatively severer in the study group, were similar in the the two groups and well tolerated. CONCLUSION： Three-dimensional conformal radiotherapy combined with FOLFOX4 chemotherapy for unresectable recurrent rectal cancer is a feasible and effective therapeutic approach, and can reduce distant metastasis rate and improve the survival rate.

Stereotactic conformal radiotherapy of hepatic metastases:clinical analysis of 8 cases

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Prevention of pelvic radiation disease

Pelvic cancers are among the most frequently diagnosed cancers worldwide. Treatment of patients requires a multidisciplinary approach that frequently includes radiotherapy. Gastrointestinal(GI) radiation-induced toxicity is a major complication and the transient or long-term problems, ranging from mild to very severe, arising in non-cancerous tissues resulting from radiation treatment to a tumor of pelvic origin, are actually called as pelvic radiation disease. The incidence of pelvic radiation disease changes according to the radiation technique, the length of follow up, the assessmentmethod, the type and stage of cancer and several other variables. Notably, even with the most recent radiation techniques, i.e., intensity-modulated radiotherapy, the incidence of radiation-induced GI side effects is overall reduced but still not negligible. In addition, radiation-induced GI side effects can develop even after several decades; therefore, the improvement of patient life expectancy will unavoidably increase the risk of developing radiation-induced complications. Once developed, the management of pelvic radiation disease may be challenging. Therefore, the prevention of radiation-induced toxicity represents a reasonable way to avoid a dramatic drop of the quality of life of these patients. In the current manuscript we provide an updated and practical review on the best available evidences in the field of the prevention of pelvic radiation disease.

Pelvic radiation disease:Updates on treatment options

Pelvic cancers are among the most frequently diagnosed neoplasms and radiotherapy represents one of the main treatment options. The irradiation field usually encompasses healthy intestinal tissue,especially of distal large bowel,thus inducing gastrointestinal(GI) radiation-induced toxicity. Indeed,up to half of radiationtreated patients say that their quality of life is affected by GI symptoms(e.g.,rectal bleeding,diarrhoea). The constellation of GI symptoms- from transient to longterm,from mild to very severe- experienced by patients who underwent radiation treatment for a pelvic tumor have been comprised in the definition of pelvic radiation disease(PRD). A correct and evidence-based therapeutic approach of patients experiencing GI radiation-induced toxicity is mandatory. Therapeutic non-surgical strategies for PRD can be summarized in two broad categories,i.e.,medical and endoscopic. Of note,most of the studies have investigated the management of radiation-induced rectal bleeding. Patients with clinically significant bleeding(i.e.,causing chronic anemia) should firstly be considered for medical management(i.e.,sucralfate enemas,metronidazole and hyperbaric oxygen); in case of failure,endoscopic treatment should be implemented. This latter should be considered the first choice in case of acute,transfusion requiring,bleeding. More well-performed,high quality studies should be performed,especially the role of medical treatments should be better investigated as well as the comparative studies between endoscopic and hyperbaric oxygen treatments.

Pelvic radiation therapy: Between delight and disaster

In the last few decades radiotherapy was established as one of the best and most widely used treatmentmodalities for certain tumours. Unfortunately that came with a price. As more people with cancer survive longer an ever increasing number of patients are living with the complications of radiotherapy and have become, in certain cases, difficult to manage. Pelvic radiation disease(PRD) can result from ionising radiationinduced damage to surrounding non-cancerous tissues resulting in disruption of normal physiological functions and symptoms such as diarrhoea, tenesmus, incontinence and rectal bleeding. The burden of PRDrelated symptoms, which impact on a patient's quality of life, has been under appreciated and sub-optimally managed. This article serves to promote awareness of PRD and the vast potential there is to improve current service provision and research activities.

Indications of external radiotherapy for hepatocellular carcinoma from updated clinical guidelines: Diverse global viewpoints

The etiology and disease patterns of hepatocellular carcinoma(HCC)significantly vary among regions. Modern standard treatments commonly require multidisciplinary approaches, including applications of up-to date medicine and advanced procedures, and necessitate the support of socioeconomic systems. For these reasons, a number of clinical guidelines for HCC from different associations and regions have been presented. External beam radiation therapy was contraindicated for HCC until a few decades ago, but with the development of new technologies, its application has rapidly increased as selective irradiation for tumorous lesions became possible. Most of the guidelines had been opposed or indifferent to radiotherapy in the past, but several guidelines have introduced indications and recommendations for radiotherapy in their updated versions. This review will discuss the characteristics of important guidelines and their contents regarding radiotherapy and will also provide guidance to physicians who are considering applications of locoregional modalities that include radiotherapy.

Radiotherapy combined with nimotuzumab for elderly esophageal cancer patients:A phaseⅡclinical trial

Objective:To investigate the safety and efficacy of nimotuzumab combined with radiotherapy for elderly patients with non-resectable esophageal carcinoma(EC).Methods:Eligible patients were aged 70 years or older and had treatment-naive,histologically proven inoperable locally advanced EC.Enrolled patients received radiotherapy with a total dose of 50-60 Gy in 25-30 fractions,concurrent with weekly infusion of nimotuzumab.The primary end point was the rate of more than grade 3 toxicities.Results:From June 2011 to July 2016,46 patients with stageⅡ-IV EC with a median age of 76.5 years were enrolled.There were 10,28 and 8 patients with stageⅡ,III and IV disease,respectively.The common acute toxicities included esophagitis(grade 1-2,75.4%;grade 3,8.7%),pneumonitis(grade 1,4.3%;grade 2,6.5%;grade3,2.2%),leukopenia(grade 1-2,60.9%;grade 3-4,4.4%),gastrointestinal reaction(grade 1-2,17.3%;grade 3,2.2%),thrombocytopenia(grade 1-2,21.7%;grade 3,2.2%),and radiothermitis(grade 1-2,39.2%).The incidence of grade 3-4 adverse effects was 17.4%.No grade 5 toxicities were observed.Clinical complete response,partial response,stable disease,and progressive disease were observed in 1(2.2%),31(67.4%),12(26.1%),and 2(4.3%)patients,respectively.The median overall survival(OS)and progression-free survival(PFS)were 17 and 10 months,respectively.The 2-,3-,and 5-year OS and PFS rates were 30.4%,21.7%,19.6%,and 26.1%,19.6%,19.6%,respectively.Conclusions:Nimotuzumab combined with radiotherapy is a safe and effective therapy for elderly patients who are not surgical candidates.Further studies are warranted to confirm its therapeutic effects in elderly EC patients.