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Febrile neutropenia (FN) is the most common complication of childhood cancer treatment with mortality rates of untreated patients up to 21%. The recognition and management of FN is fundamental to preserve the children health status and avoid life-threatening complications. Physical and laboratory assessments should be performed in every patient with FN to identify any potential site of infection to be promptly treated. Hence, an empiric antimicrobial therapy remains the gold standard for the management of these patients. Antimicrobial treatment should be based on local epidemiological data and antibiotic susceptibility; a combination of a fourth-generation antipseudomonal cephalosporin with an aminoglycoside is generally adopted. Empirical administration of glycopeptides, in absence of documented Gram-positive bacterial infection is not recommended for routine use. Despite the progress in the management of febrile neutropenia and its relatively low mortality, the emergence of resistant pathogens is increasing, and the development of new effective antimicrobials are needed. Established criteria for a risk adapted approach is still lacking and no definitive data supporting the duration of empiric treatment are present. De-escalation strategies should be implemented to reduce both antibiotic exposure and resistance as well as hospital stay. [ABSTRACT FROM AUTHOR]

Introduction: Platinum compounds, which are considerably effective for the treatment of childhood malignancies, have significantly contributed to the increase in long-term survival of children with cancer. Unfortunately, children receiving cisplatin-based chemotherapy have been known to be at risk for severe disabling adverse effects, such as nephrotoxicity. Methods: A literature research of the MEDLINE PubMed database was conducted to identify articles published between 1980 and 2019 reviewing "Cisplatin AND mannitol." Results: The primary pharmacodynamics and clinical characteristics of cisplatin were described, focusing on its renal toxic effects and potential preventive strategies, in order to improve clinical outcomes among children with cancer aged 1 to 14 years. Currently, selecting either hydration alone or hydration plus mannitol for preventing nephrotoxicity has been controversial considering the lack of guidelines to provide treatment recommendations both among adults and children. Conclusions: Appropriate knowledge regarding the pharmacokinetics and toxicological profile of cisplatin may help physicians prevent renal toxicity. Unfortunately, published data regarding the nephroprotective utility of adding mannitol appear to be inconclusive. As such, appropriate hydration remains the main fundamental strategy for reducing the risk of cisplatin-induced nephrotoxicity. Considering the increasing number of children safely cured of their tumours, it is imperative that those treated with cisplatin receive the most appropriate nephroprotective strategy for reducing the negative impact of platinum compounds on quality of life. [ABSTRACT FROM AUTHOR]

Background: Prostate re-irradiation is an attractive treatment option in the case of local relapse after previous radiotherapy, either in the definitive or in the post-operative setting. In this scenario, the introduction of MR-linacs may represent a helpful tool to improve the accuracy and precision of the treatment. Methods: This study reports the preliminary data of a cohort of 22 patients treated with 1.5T MR-Linacs for prostate or prostate bed re-irradiation. Toxicity was prospectively assessed and collected according to CTCAE v5.0. Survival endpoints were measured using Kaplan-Meier method. Results: From October 2019 to October 2021, 22 patients received 1.5T MR-guided stereotactic body radiotherapy for prostate or prostate-bed re-irradiation. In 12 cases SBRT was delivered to the prostate, in 10 to the prostate bed. The median time to re-RT was 72 months (range, 12-1460). SBRT was delivered concurrently with ADT in 4 cases. Acute toxicity was: for GU G1 in 11/22 and G2 in 4/22; for GI G1 in 7/22, G2 in 4/22. With a median follow-up of 8 months (3- 21), late G1 and G2 GU events were respectively 11/22 and 4/22. Regarding GI toxicity, G1 were 6/22, while G2 3/22. No acute/late G≥3 GI/GU events occurred. All patients are alive. The median PSA-nadir was 0.49 ng/ ml (0.08-5.26 ng/ml), for 1-year BRFS and DPFS rates of 85.9%. Twenty patients remained free from ADT with 1-year ADT-free survival rates of 91.3%. Conclusions: Our experience supports the use of MR-linacs for prostate or prostate bed re-irradiation as a feasible and safe treatment option with minimal toxicity and encouraging results in terms of clinical outcomes. [ABSTRACT FROM AUTHOR]

Idiopathic thrombocytopenic purpura (ITP) is the most common cause of acquired thrombocytopenia in children. In 20% of cases, this condition is classified as chronic when the thrombocytopenia is persistent 6 months after diagnosis. The aim of the present study is to identify the potential factors correlating with a favorable outcome in patients with chronic ITP. Some 71 patients affected by ITP were retrospectively analyzed. Results show a higher rate of spontaneous recovery that is statistically significant for patients with platelet count at diagnosis <20,000/µL. These observations suggest the possibility to delay or avoid aggressive surgical treatment for these patients. [ABSTRACT FROM AUTHOR]

Children with malignancy present an important alteration of the immune system functionality caused by the illness itself and by the therapy they undergo. Therefore, they are at high risk of contracting vaccine-preventable diseases and of developing important complications. Vaccinations represent valid devices against these infections but this condition involves two main problems: are vaccines safe in these patients? Are vaccines effective in these patients? The aim of this review is to discuss the principles of vaccination management in children with cancer. [ABSTRACT FROM AUTHOR]

Childhood aplastic anaemia (AA) is an uncommon but potentially fatal haematological disorder. Patients with AA receive supportive care based on transfusions and timely treatment of opportunistic infections, along with specific therapies, which may be bone marrow transplantation and immunosuppressive therapy. Early diagnosis and supportive therapy are required to prevent fatal complications like overwhelming sepsis or life threatening haemorrhages. We report two cases of aplastic anaemia having a different aetiology. The diagnostic work-up and the therapeutic management for each case are described below. [ABSTRACT FROM AUTHOR]

Purpose: We report the retrospective data of a cohort of patients who received stereotactic body radiotherapy for pulmonary oligometastases aiming to assess the clinical factors potentially affecting the clinical outcomes. Methods: The present series reports the outcomes of a cohort of 71 patients with pulmonary oligometastases. All patients were treated with SBRT performed with VMATIGRT, up to 5 secondary lesions. Survival estimates were performed using Kaplan-Meier method. Results: A total of 98 lesions in 71 patients were treated from February 2014 to August 2020. The most frequent histologies were: colo-rectal in 37.7%, lung cancer in 44.8%, head and neck cancer in 8.1%, other in 9.4%. Median age was 71 (range, 32-93 years). Concurrent systemic therapy was administered in 32.3%. SBRT was delivered for a median total dose of 60 Gy (range, 55-70 Gy) in 3-10 fractions for a median BED10=105 Gy (range, 96-180 Gy). Median follow-up was 29.5 months (range, 6-81), with no acute or late G>2 adverse event. Our LC rates at 2 and 4-years were 92.4% and 89.8%. DPFS rates at 2- and 4- years were 45.3% and 27.2%. A second SBRT course was proposed in 21 cases (29.5%) who developed an oligoprogression, resulting in median time to second progression of 9 months (range, 2-44) and 2-year PFS2 rate of 42.4%. At univariate analysis, patients with sequential oligometastases reported better OS rates (p=0.002), also confirmed at multivariate analysis, where also distant progression related with worse OS (p=0.022). Higher local control rates relate to better PFS (p=0.04). The 2- and 4- OS rates were 61% and 39.7% Conclusions: SBRT is feasible for pulmonary oligometastases with favorable outcomes and toxicity. At multivariate analysis, patients with sequential oligometastatic progression maintain a survival advantage. Also, local control was found to be related to improved PFS rates. [ABSTRACT FROM AUTHOR]

Purpose: In the present series we report preliminary acute and late toxicity of the first 100 patients who received 1.5T MR-guided daily-adaptive stereotactic body radiotherapy for prostate cancer. Methods: We report the outcomes of the first 100 patients treated from October 2019 to December 2020. All the patients were enrolled in a prospective study (MR Linac n°XXXX). Before the treatment, the insertion of the rectal spacer was proposed as optional and applied in 37 patients. Hormone therapy was prescribed according to international guidelines in 32 patients. Toxicity was prospectively collected and assessed using Common Terminology Criteria for Adverse Events (CTCAE v5.0). Quality of life was assessed using IPSS, ICIQ-SF, IIEF-5, EORTC QLQ-C30, QLQ-PR25 and EPIC-26 questionnaires. Results: 100 patients were treated: 34 were low risk, 29 were favorable intermediate-risk, 31 were unfavorable intermediate-risk, 2 high risk, 4 were low-volume M1 patients. The median age was 71 years (range, 52- 84 years), median IPSS was 3 (range, 0-7); SBRT was delivered using 1.5T MR-guided daily adaptive radiotherapy in 5 sessions for a median total dose of 35 Gy (35-36.25 Gy) on consecutive (n=75) or alternate days (n=25). The adapt-to-shape workflow was mainly adopted (480/500 sessions). The median treatment time was 40 minutes (range, 33-83 minutes). The median PTV volume was 105.8 cc (range, 13.98-196.4cc). Acute toxicity rates were as follows: 5 acute G2 genitourinary tract pain events, and two cases of urethral stenosis requiring catheterization fully resolved within the first follow-up. For gastrointestinal toxicity, only 4 cases of G2 events (rectal tenesmus or proctitis) were observed. All the G≥2 events occurred after an average time of 30 days from the end of RT. With a median follow-up of 12 months (range, 3-20 months), for late events, we have recorded 3 late G2 GU events (urinary tract pain) and one G3 GU event for a patient who received a TURP 8 months after radiotherapy. For late GI events, we have recorded 3 G≥2 GI proctitis, including one patient treated with argon laser for radiation-induced proctitis. All patients are alive and in disease control except for one M1- low volume patient who developed distant progression two months after RT. Preliminary QoL assessment revealed a transient decline in fatigue, fully recovered after first follow-up. Conclusions: Our preliminary report on the first 100 patients who received 1.5T MR-guided daily-adaptive SBRT for prostate cancer reports excellent results in terms of acute toxicity, and minimal impact on QoL. [ABSTRACT FROM AUTHOR]

Anemia is a common cause of co-morbidity in children with cancer. We reviewed a series of 124 children with non-metastatic cancer to assess the relationship between chemotherapy intensity, severe anemia, and frequency of transfusion. In more than 60% of children who received intensive chemotherapy, transfusions were prescribed compared to 38% and 21% of children treated with standard and mild chemotherapy, respectively. In conclusion, our data suggest that the intensity and duration of chemotherapy constitute important factors in determining the onset of anemia. [ABSTRACT FROM AUTHOR]

Opioids are essential for the treatment of pain, which is a serious symptom for children and adolescents affected by cancer. Intranasal opioids may be very useful for the treatment of breakthrough pain in children and adolescents with cancer, for their little invasiveness, ease of administration, rapid onset of action, and high bioavailability. Intranasal drug delivery may be influenced by anatomical and physiological factors (nasal mucosa absorption area, mucociliary clearance, enzymatic activity, anatomical anomalies, chronic or inflammatory alterations of nasal mucosa), drug-related factors (molecular weight, solubility), and delivery device. Fentanyl is a lipophilic opioid commonly proposed for intranasal use among pediatric patients, but no studies have been conducted yet about intranasal use of other available opioids for management of pediatric cancer pain. In this review, we analyze several elements which may influence absorption of intranasal opioids in children and adolescents, with a focus on pharmacokinetics and therapeutic aspects of each opioid currently available for intranasal use. [ABSTRACT FROM AUTHOR]

Simple Summary: This study aimed to evaluate how the COVID-19 pandemic affected the psychological well-being of parents of pediatric oncology patients two years after the pandemic started. The authors' objective was to make a detailed comparison between the data collected in the current study and the data gathered in the previous research with the aim of observing any changes, whether for better or worse, at the psychological level in the caregivers of the patients in question. This research could be of great use for monitoring the psychological health of the sample and for being able to intervene promptly in the event of the worsening of the reported symptoms. Background: Family members dealing with the devastating impact of a cancer diagnosis are now facing even greater vulnerability due to the COVID-19 pandemic. Alongside the already overwhelming trauma, they must also bear the distressing burden of the infection risks. The purpose of this study was to examine and explore the effects in parents of pediatric cancer patients two years after the start of the COVID-19 pandemic to compare these data with the previous data. Methods: We conducted a single-center prospective observational study, enrolling 75 parents of 42 pediatric oncology patients. Four questionnaires (IES-R; PSS; STAI-Y and PedsQL) were given to the parents 2 years after the first evaluation. Results: The bivariate matrix of correlation found a strong significant positive correlation between IES-R and PSS scores (r = 0.526, p < 0.001) as in T1. Stress symptoms (t = 0.00, p < 0.001) and levels of anxiety (trait) (t = 0.32, p < 0.001) remained unchanged; anxiety state levels appeared to have increased (t = 0.425, p < 0.001); there was a significant decrease in the PedsQL tot (t = 5.25, p < 0.001). Conclusions: The COVID-19 pandemic has influenced the levels of stress and anxiety of parents and the quality of life of patients, also correlating with the traumatic impact of the diagnosis. [ABSTRACT FROM AUTHOR]

Purpose: To assess the prevalence of alterations in anthropometric parameters predictive of metabolic syndrome and cardiovascular risk among childhood brain tumor survivors. Methods: Anthropometric parameters predictive of metabolic syndrome and cardiovascular risk were analyzed [height, weight, BMI, waist circumference, hip circumference, waist-height ratio (WHtR), waist-hip ratio (WHR, blood pressure] of 25 patients who survived childhood brain tumors. Results: 21 patients (84%) showed alteration of at least one predictive anthropometric parameter. 11 patients (44%) showed a BMI > 75th percentile and 19 patients (76%) showed a pathological WHR value. A pathological WHtR (> 0.5), was identified in 17 patients (68%); the average WHtR observed was 0.53. 9 patients (36%) showed an alteration of all three anthropometric parameters considered. Comparing this subpopulation with the subpopulation with less than three altered parameters, a greater prevalence of the combined alteration was observed in the female sex compared to the male sex (67% vs. 26%). No significant differences were observed regarding the age of diagnosis and end of treatment nor the treatments carried out (chemotherapy, radiotherapy, steroid therapy) between the two groups. Conclusion: These results suggest that this population is at high risk of presenting pathological values of BMI, WHR and WHtR with consequent high risk of developing metabolic syndrome and cardiovascular diseases. [ABSTRACT FROM AUTHOR]

Simple Summary: Survivors of childhood brain tumors, because of the treatments they have undergone, have a greater risk of dying earlier from cardiovascular causes compared to the general population. The objective of this study was to evaluate differences between cardiovascular risk biomarkers and cardiopulmonary exercise test (CPET) results from childhood brain tumor survivors and healthy controls. We found worse CPET performance in survivors associated with higher endothelin-1 values compared to controls. Correlation analysis showed an inverse relationship between CPET results and leptin, emphasizing the role of radiotherapy as a possible cause in the genesis of a greater cardiovascular risk in survivors of childhood brain tumors. In recent decades, the improvement of treatments and the adoption of therapeutic protocols of international cooperation has led to an improvement in the survival of children affected by brain tumors. However, in parallel with the increase in survival, long-term side effects related to treatments have been observed over time, including the activation of chronic inflammatory processes and metabolic alterations, which can facilitate the onset of metabolic syndrome and increased cardiovascular risk. The aim of this study was to find possible statistically significant differences in the serum concentrations of early biomarkers of metabolic syndrome and in the results of cardiopulmonary exercise testing between survivors of childhood brain tumors and healthy controls. This is a prospective and observational study conducted on a group of 14 male patients who survived childhood brain tumors compared with the same number of healthy controls. The concentrations of early metabolic syndrome biomarkers [adiponectin, leptin, TNF-α, IL-1, IL-6, IL-10, endothelin-1, apolipoprotein B, and lipoprotein (a)] were measured and a cardiopulmonary exercise test (CPET) was performed. Results: Childhood brain tumor survivors performed worse on average than controls on the CPET. Furthermore, they showed higher endothelin-1 values than controls (p = 0.025). The CPET results showed an inverse correlation with leptin. The differences found highlight the greater cardiovascular risk of brain tumor survivors, and radiotherapy could be implicated in the genesis of this greater cardiovascular risk. [ABSTRACT FROM AUTHOR]

Background: During the last decade, there has been a growing number of cases of children born from pregnancy-associated cancer (PAC), however there are currently insufficient data on the follow up to be observed in this category of newborns. Objective of the study was to evaluate the neonatal outcomes of infants born to mother with PAC, the potential adverse effect of chemotherapy during pregnancy and the risk of metastasis to the fetus. Methods: Maternal clinical data and neonatal outcomes of child born to mothers diagnosed with PAC were collected; infants were divided into those were and were not exposed to chemotherapy during fetal life and their outcomes were compered. Results: A total of 37 newborn infants from 36 women with PAC were analyzed. Preterm delivery occurred in 83.8% of the cases. No significant differences in neonatal outcomes were found between infants who were and were not exposed to chemotherapy during pregnancy. The median follow-up period was 12 months. Conclusions: PAC treatment during the second or third trimester does not seem to be dangerous for the fetus, however infants born from PAC must be carefully evaluated for to rule out the consequences of chemotherapy and exclude the presence of metastasis. Long-term follow-up, especially in children exposed to chemotherapy, should be encouraged to obtain relevant data on long-term toxicity. [ABSTRACT FROM AUTHOR]

[Display omitted] Prognosis of high-risk neuroblastoma is dismal, despite intensive induction chemotherapy, surgery, high-dose chemotherapy, radiotherapy, and maintenance. Patients who do not achieve a complete metastatic response, with clearance of bone marrow and skeletal NB infiltration, after induction have a significantly lower survival rate. Thus, it's necessary to further intensify treatment during this phase. 131-I-metaiodobenzylguanidine (131-I-MIBG) is a radioactive compound highly effective against neuroblastoma, with 32% response rate in relapsed/resistant cases, and only hematological toxicity. 131-I-MIBG was utilized at different doses in single or multiple administrations, before autologous transplant or combined with high-dose chemotherapy. Subsequently, it was added to consolidation in patients with advanced NB after induction, but an independent contribution against neuroblastoma and for myelotoxicity is difficult to determine. Despite results of a 2008 paper demonstrated efficacy and mild hematological toxicity of 131-I-MIBG at diagnosis, no center had included it with intensive chemotherapy in first-line treatment protocols. In our institution, at diagnosis, 131-I-MIBG was included in a 5-chemotherapy drug combination and administered on day-10, at doses up to 18.3 mCi/kg. Almost 87% of objective responses were observed 50 days from start with acceptable hematological toxicity. In this paper, we review the literature data regarding 131-I-MIBG treatment for neuroblastoma, and report on doses and combinations used, tumor responses and toxicity. 131-I-MIBG is very effective against neuroblastoma, in particular if given to patients at diagnosis and in combination with chemotherapy, and it should be included in all induction regimens to improve early responses rates and consequently long-term survival. [ABSTRACT FROM AUTHOR]

Aminoglycosides are broad-spectrum antibiotics largely used in children, but they have potential toxic side effects, including ototoxicity. Ototoxicity from aminoglycosides is permanent and is a consequence of its action on the inner ear cells via multiple mechanisms. Both uncontrollable risk factors and controllable risk factors are involved in the pathogenesis of aminoglycoside-related ototoxicity and, because of the irreversibility of ototoxicity, an important undertaking for preventing ototoxicity includes antibiotic stewardship to limit the use of aminoglycosides. Aminoglycosides are fundamental in the treatment of numerous infectious conditions at neonatal and pediatric age. In childhood, normal auditory function ensures adequate neurocognitive and social development. Hearing damage from aminoglycosides can therefore strongly affect the normal growth of the child. This review describes the molecular mechanisms of aminoglycoside-related ototoxicity and analyzes the risk factors and the potential otoprotective strategies in pediatric patients. [ABSTRACT FROM AUTHOR]

Purpose: To assess the main imaging and clinical features in adult- and pediatric-onset atypical teratoid rhabdoid tumor (ATRT) in order to build a predefined pathway useful for the diagnosis. Methods: We enrolled 11 ATRT patients (10 children, one adult) and we conducted a literature search on PubMed Central using the key terms "adult" or "pediatric" and "atypical teratoid/rhabdoid tumor". We collected clinical and neuroradiological data reported in previous studies and combined them with those from our case series. A three step process was built to reach diagnosis by identifying the main distinctive clinical and imaging features. Results: Clinical evaluation: neurological symptoms were nonspecific. ATRT was more frequent in children under 3 years of age (7 out of 10 children) and infratentorial localization was reported more frequently in children under the age of 24 months. Midline/off-midline localization was influenced by the age. Imaging findings: Preferential location near the ventricles and liquor spaces and the presence of eccentric cysts were hallmark for ATRT; higher frequency of peripheral cysts was detected in children and in the supratentorial compartment (five out of eight patients with solid-cystic ATRT). Leptomeningeal dissemination at diagnosis was common (5 out of 10 children), while intratumoral hemorrhage, calcifications, and high cellularity were non-specific findings. Histopathological analysis: specific immunohistochemical markers were essential to confirm the diagnosis. Conclusion: In younger children, a bulky, heterogeneous mass with eccentric cystic components and development near ventricles or cisternal spaces may be suggestive of ATRT. ATRT diagnosis is more challenging in adults and relies exclusively on neuropathological examination. [ABSTRACT FROM AUTHOR]

Photopic negative response (PhNR), an index of retinal ganglion cell (RGC) function, is impaired in patients with optic pathway gliomas (OPGs). The aim of this longitudinal study was to evaluate whether PhNR deteriorates over time in OPG patients. Fourteen pediatric patients affected by OPG (4 males and 10 females, mean age 12.4 ± 5.7 years, 8 with neurofibromatosis type 1 [NF1]) with ≥12 months of follow-up and ≥2 evaluations, were included in this retrospective study. All patients had received chemotherapy, with or without OPG surgical resection, at least 5 years prior to the study. At baseline, all patients underwent a complete ophthalmological examination. Follow-up included clinical examination and PhNR measurement as well as brain MRI (according to pediatric oncologist indications) every 6 or 12 months. Mean follow-up duration was 16.7 ± 7.5 months (range 12–36 months). Photopic electroretinograms were elicited by 2.0 cd-s/m2 Ganzfeld white flashes presented on a steady 20 cd/m2 white background. The PhNR amplitude was measured as the difference between baseline and the maximal negative amplitude (minimum) of the negative wave, following the photopic b-wave. Compared to baseline, mean PhNR amplitude was significantly decreased at the end of follow-up (p = 0.008). NF1-related OPGs exhibited a decline in PhNR amplitude (p = 0.005) and an increase in PhNR peak-time during the follow-up (p = 0.013), whereas sporadic OPGs showed no significant changes. Tumor size remained stable in all patients on MRI. PhNR amplitude decreased over the observation period, suggesting progressive RGC dysfunction in NF1-related pediatric OPGs, despite stable size on MRI imaging. PhNR could serve as a non-invasive objective tool for assessing longitudinal changes in RGC function in the clinical management of childhood OPG. • Photopic negative response (PhNR) reflects retinal ganglion cell (RGC) function. • PhNR is impaired in patients with optic pathway glioma (OPG). • PhNR deteriorates over time in children with NF1-related OPG, despite stable MRI. • PhNR could serve as a non-invasive objective tool to monitor RGC function in OPG. [ABSTRACT FROM AUTHOR]

Shwachman Diamond Syndrome is a rare congenital disorder characterized by pancreatic insufficiency, bone marrow dysfunction and skeletal abnormalities. No specific test is available for a definitive diagnosis for SDS. In the presence of clinical features of SDS, pancreatic insufficiency should be tested for or lipomatosis radiologically demonstrated. New directions might be found in genetic analysis. Sometimes, a life-threatening event may be the first clinical manifestation of the syndrome. [ABSTRACT FROM AUTHOR]

Background: The use of stereotactic radiotherapy (SBRT) for oligometastases is supported by several literature studies, but in the setting of gynecological malignancies, this scenario remains quite unexplored. This study reports a preliminary assessment of clinical outcomes in a cohort of 40 patients with oligometastatic gynecological neoplasms. Methods: Radiotherapy was delivered in 3–10 fractions with VMAT-IGRT technique. Toxicity was retrospectively collected according to CTCAE v4.0. Data were retrospectively collected and analyzed. Univariate and multivariate analyses were performed for assessing any potential predictive factor for clinical outcomes. Results: A total of 63 oligometastases were treated from December 2014 to February 2021. Median age was 63 years (range 30–89). Most frequent primary tumors were ovarian cancer in 42.5% and endometrium cancer in 42.5%. With a median follow-up of 27 months (range 6–69), no local failures were observed, our progression-free survival rates were 43.6% and 23% at one and 2 years, respectively, while 1 and 2-year overall survival rates were both 70%. No acute or late G ≥ 2 adverse events were observed. Conclusions: In our experience, SBRT for oligometastatic gynecological malignancies resulted in promising results in terms of clinical outcomes, with excellent local control and no evidence of severe toxicity, highlighting the effectiveness of this therapeutic option. Prospective studies to further explore this approach in this setting are advocated. [ABSTRACT FROM AUTHOR]

Purpose: We report preliminary dosimetric data concerning the use of 1.5-T MR-guided daily-adaptive radiotherapy for abdomino-pelvic lymph-nodal oligometastases. We aimed to assess the impact of this technology on mitigating daily variations for both target coverage and organs-at-risk (OARs) sparing. Methods: A total of 150 sessions for 30 oligometastases in 23 patients were analyzed. All patients were treated with MR-guided stereotactic body radiotherapy (SBRT) for a total dose of 35 Gy in five fractions. For each fraction, a quantitative analysis was performed for PTV volume, V35Gy and Dmean. Similarly, for OARs, we assessed daily variations of volume, Dmean, Dmax. Any potential statistically significant change between baseline planning and daily-adaptive sessions was assessed using the Wilcoxon signed-rank test, assuming a p value < 0.05 as significant. Results: Average baseline PTV, bowel, bladder, and single intestinal loop volumes were respectively 8.9 cc (range 0.7–41.2 cc), 1176 cc (119–3654 cc), 95 cc (39.7–202.9 cc), 18.3 cc (9.1–37.7 cc). No significant volume variations were detected for PTV (p = 0.21) bowel (p = 0.36), bladder (p = 0.47), except for single intestinal loops, which resulted smaller (p = 0.026). Average baseline V35Gy and Dmean for PTV were respectively 85.6% (72–98.8%) and 35.6 Gy (34.6–36.1 Gy). We recorded a slightly positive trend in favor of daily-adaptive strategy vs baseline planning for improved target coverage, although not reaching statistical significance (p = 0.11 and p = 0.18 for PTV-V35Gy and PTV-Dmean). Concerning OARs, a significant difference was observed in favor of daily-adapted treatments in terms of single intestinal loop Dmax [23.05 Gy (13.2–26.9 Gy) at baseline vs 20.5 Gy (12.1–24 Gy); p value = 0.0377] and Dmean [14.4 Gy (6.5–18 Gy) at baseline vs 13.0 Gy (6.7–17.6 Gy); p value = 0.0003]. Specifically for bladder, the average Dmax was 18.6 Gy (0.4–34.3 Gy) at baseline vs 18.3 Gy (0.7–34.3 Gy) for a p value = 0.28; the average Dmean was 7.0 Gy (0.2–16.6 Gy) at baseline vs 6.98 Gy (0.2–16.4 Gy) for a p value = 0.66. Concerning the bowel, no differences in terms of Dmean [4.78 Gy (1.3–10.9 Gy) vs 5.6 Gy (1.4–10.5 Gy); p value = 0.23] were observed between after daily-adapted sessions. A statistically significant difference was observed for bowel Dmax [26.4 Gy (7.7–34 Gy) vs 25.8 Gy (7.8–33.1 Gy); p value = 0.0086]. Conclusions: Daily-adaptive MR-guided SBRT reported a significantly improved single intestinal loop sparing for lymph-nodal oligometastases. Also, bowel Dmax was significantly reduced with daily-adaptive strategy. A minor advantage was also reported in terms of PTV coverage, although not statistically significant. [ABSTRACT FROM AUTHOR]

Background: Approximately one third of cancer patients will develop spinal metastases, that can be associated with back pain, neurological symptoms and deterioration in performance status. Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) have been offered in clinical practice mainly for the management of oligometastatic and oligoprogressive patients, allowing the prescription of high total dose delivered in one or few sessions to small target volumes, minimizing the dose exposure of normal tissues. Due to the high delivered doses and the proximity of critical organs at risk (OAR) such as the spinal cord, the correct definition of the treatment volume becomes even more important in SBRT treatment, thus making it necessary to standardize the method of target definition and contouring, through the adoption of specific guidelines and specific automatic contouring tools. An automatic target contouring system for spine SBRT is useful to reduce inter-observer differences in target definition. In this study, an automatic contouring tool was evaluated.Methods: Simulation CT scans and MRI data of 20 patients with spinal metastases were evaluated. To evaluate the advantage of the automatic target contouring tool (Elements SmartBrush Spine), which uses the identification of different densities within the target vertebra, we evaluated the agreement of the contours of 20 spinal target (2 cervical, 9 dorsal and 9 lumbar column), outlined by three independent observers using the automatic tool compared to the contours obtained manually, and measured by DICE similarity coefficient.Results: The agreement of GTV contours outlined by independent operators was superior with the use of the automatic contour tool compared to manually outlined contours (mean DICE coefficient 0.75 vs 0.57, p = 0.048).Conclusions: The dedicated contouring tool allows greater precision and reduction of inter-observer differences in the delineation of the target in SBRT spines. Thus, the evaluated system could be useful in the setting of spinal SBRT to reduce uncertainties of contouring increasing the level of precision on target delivered doses. [ABSTRACT FROM AUTHOR]