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Backgrounds/Aims This study explored the initial institutional experience of using gold fiducial markers for stereotactic body radiotherapy (SBRT) in treating malignant hepatic tumors using real-time ultrasound-computed tomography (CT)/magnetic resonance (MR) imaging fusion-guided percutaneous placement. Methods From May 2021 to August 2023, 19 patients with 25 liver tumors that were invisible on pre-contrast CT received fiducial markers following these guidelines. Postprocedural scans were used to confirm their placement. We assessed technical and clinical success rates and monitored complications. The implantation of fiducial markers facilitating adequate treatment prior to SBRT, which was achieved in 96% of the cases (24 of 25 tumors), was considered technical success. Clinical success was the successful completion of SBRT without evidence of marker displacement and was achieved in 88% of cases (22 of 25 tumors). Complications included one major subcapsular hematoma and marker migration into the right atrium in two cases, which prevented SBRT. Results Among the treated tumors, 20 of 24 (83.3%) showed a complete response, three of 24 (12.5%) remained stable, and one of 24 (4.2%) progressed during an average 11.7-month follow-up (range, 2-32 months). Conclusions This study confirms that percutaneous gold fiducial marker placement using real-time CT/MR guidance is effective and safe for SBRT in hepatic tumors, but warns of marker migration risks, especially near the hepatic veins and in subcapsular locations. Using fewer markers than traditionally recommended-typically two per patient, the outcomes were still satisfactory, particularly given the increased risk of migration when markers were placed near major hepatic veins.

Abstract The ongoing coronavirus disease 2019 (COVID-19) pandemic presents serious public health threats. Omicron, the current most prevalent strain of COVID-19, has a low fatality rate and very high transmissibility, so the number of patients with mild symptoms of COVID-19 is rapidly increasing. This change of pandemic challenges medical systems worldwide in many aspects, including sharp increases in demands for hospital infrastructure, critical shortages in medical equipment, and medical staff. Predicting deterioration in mild patients could alleviate these problems. A novel scoring system was proposed for predicting the deterioration of patients whose condition may worsen rapidly and those who all still mild or asymptomatic. Retrospective cohorts of 954 and 2,035 patients that quarantined in the Residential Treatment Center were assembled for derivation and external validation of mild COVID-19, respectively. Deterioration was defined as transfer to a local hospital due to worsening condition of the patients during the 2-week isolation period. A total of 15 variables: sex, age, seven pre-existing conditions (diabetes, hypertension, cardiovascular disease, respiratory disease, liver disease, kidney disease, and organ transplant), and five vital signs (systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), body temperature, and oxygen saturation (SpO2)) were collected. A scoring system was developed using seven variables (age, pulse rate, SpO2, SBP, DBP, temperature, and hypertension) with significant differences between the transfer and not transfer groups in logistic regression. The proposed system was compared with existing scoring systems that assess the severity of patient conditions. The performance of the proposed scoring system to predict deterioration in patients with mild COVID-19 showed an area under the receiver operating characteristic (AUC) of 0.868. This is a statistically significant improvement compared to the performance of the previous patient condition assessment scoring systems. During external validation, the proposed system showed the best and most robust predictive performance (AUC = 0.768; accuracy = 0.899). In conclusion, we proposed a novel scoring system for predicting patients with mild COVID-19 who will experience deterioration which could predict the deterioration of the patient’s condition early with high predictive performance. Furthermore, because the scoring system does not require special calculations, it can be easily measured to predict the deterioration of a patients’ condition. This system can be used as effective tool for early detection of deterioration in mild COVID-19 patients.

Background: Interest in the oligometastatic prostate cancer (OMPC) is increasing, and various clinical studies have reported the benefits of metastasis-directed radiation therapy (MDRT) in OMPC. However, the recognition regarding the adopted definitions, methodologies of assessment, and therapeutic approaches is diverse among radiation oncologists. This study aims to evaluate the level of agreement for issues in OMPC among radiation oncologists. Methods: We generated 15 key questions (KQs) for OMPC relevant to definition, diagnosis, local therapies, and endpoints. Additionally, three clinical scenarios representing synchronous metastatic prostate cancer (mPC) (case 1), metachronous mPC with visceral metastasis (case 2), and metachronous mPC with castration-resistance and history of polymetastasis (case 3) were developed. The 15 KQs were adapted according to each scenario and transformed into 23 questions with 6–9 per scenario. The survey was distributed to 80 radiation oncologists throughout the Republic of Korea. Answer options with 0.0–29.9%, 30–49.9%, 50–69.9%, 70–79.9%, 80–89.9%, and 90–100% agreements were considered as no, minimal, weak, moderate, strong, and near perfect agreement, respectively. Results: Forty-five candidates voluntarily participated in this study. Among 23 questions, near perfect (n = 4), strong (n = 3), or moderate (n = 2) agreements were shown in nine. For the case recognized as OMPC with agreements of 93% (case 1), near perfect agreements on the application of definitive radiation therapy (RT) for whole metastatic lesions were achieved. While ≥70% agreements regarding optimal dose-fractionation for metastasis-directed RT (MDRT) has not been achieved, stereotactic body RT (SBRT) is favored by clinicians with higher clinical volume. Conclusion: For the case recognized as OMPC, near perfect agreement for the application of definitive RT for whole metastatic lesions was reached. SBRT was more favored as a MDRT by clinicians with a higher clinical volume.

BackgroundDuring the height of the COVID-19 pandemic, the Korean government temporarily allowed full scale telehealth care for safety and usability. However, limited studies have evaluated the impact of telehealth by analyzing the physical and/or mental health data of patients with COVID-19 diagnosis collected through telehealth targeting Korean population.ObjectiveThis study aimed to identify subgroup of depressive symptom trajectories in patients with clinically mild COVID-19 using collected longitudinal data from a telehealth-based contactless clinical trial.MethodsA total of 199 patients with COVID-19 were accrued for contactless clinical trial using telehealth from March 23 to July 20, 2022. Depressive symptoms were measured using the patient health questionnaire-9 on the start day of quarantine, on the final day of quarantine, and 1 month after release from quarantine. Additionally, acute COVID-19 symptoms were assessed every day during quarantine. This study used a latent class mixed model to differentiate subgroups of depressive symptom trajectories and a logistic regression model with Firth’s correction to identify associations between acute COVID-19 symptoms and the subgroups.ResultsTwo latent classes were identified: class 1 with declining linearity at a slow rate and class 2 with increasing linearity. Among COVID-19 symptoms, fever, chest pain, and brain fog 1 month after release from quarantine showed strong associations with class 2 (fever: OR, 19.43, 95% CI, 2.30–165.42; chest pain: OR, 6.55, 95% CI, 1.15–34.61; brain fog: OR, 7.03, 95% CI 2.57–20.95). Sleeping difficulty and gastrointestinal symptoms were also associated with class 2 (gastrointestinal symptoms: OR, 4.76, 95% CI, 1.71–14.21; sleeping difficulty: OR, 3.12, 95% CI, 1.71–14.21).ConclusionThese findings emphasize the need for the early detection of depressive symptoms in patients in the acute phase of COVID-19 using telemedicine. Active intervention, including digital therapeutics, may help patients with aggravated depressive symptoms.

Abstract Background For locally advanced rectal cancer (LARC), total neoadjuvant therapy (TNT) may enhance tumour response, reduce recurrence, and improve patient compliance compared to upfront surgery. Recent studies have shown that chemoradiotherapy (CRT) followed by consolidation chemotherapy leads to higher rate of pathologic complete response (pCR) than induction chemotherapy followed by CRT. However, an optimal TNT regimen that maximise the pCR rate and minimise toxicity has not been established. Therefore, the aim of this trial was to investigate whether preoperative short-course radiotherapy followed by chemotherapy with four cycles of CAPOX can double the pCR rate compared to a standard schedule of long-course preoperative CRT in patients with LARC. Methods This is a multi-centre, prospective, open label, randomised controlled trial. Patients with clinical primary tumour stage 3 and higher or regional node-involved rectal cancer located within 10 cm from the anal verge were randomly assigned equally to short-course radiotherapy (25 Gy in 5 fractions over 1 week) followed by four cycles of CAPOX (intravenous oxaliplatin [130 mg/m2, once a day] on day 1 and capecitabine [1,000 mg/m2, twice a day] from days 1 to 14) (TNT) or CRT (50.4 Gy in 28 fractions over 5 weeks, concurrently with concomitant oral capecitabine 825 mg/m2 twice a day). After preoperative treatment, total mesorectal excision was performed 2–4 weeks in the TNT group and 6–10 weeks in the CRT group, followed by optional additional adjuvant chemotherapy. The primary endpoint is the pCR rate, and secondary endpoints include disease-related treatment failure, quality of life, and cost-effectiveness. Assuming a pCR rate of 28% and 15% in the TNT and CRT groups, respectively, and one-side alpha error rate of 0.025 and power of 80%, 348 patients will be enrolled considering 10% dropout rate. Discussion The TV-LARK trial will evaluate the superiority of employed TNT regimen against the standard CRT regimen for patients with LARC. We aimed to identify a TNT regimen that will improve the pCR rate and decrease systemic recurrence in these patients. Trial registration Cris.nih.go.kr ID: KCT0007169 (April 08, 2022). The posted information will be updated as needed to reflect the protocol amendments and study progress.

Objectives In the era of the Fourth Industrial Revolution, where an ecosystem is being developed to enhance the quality of healthcare services by applying information and communication technologies, systematic and sustainable data management is essential for medical institutions. In this study, we assessed the data management status and emerging concerns of three medical institutions, while also examining future directions for seamless data management. Methods To evaluate the data management status, we examined data types, capacities, infrastructure, backup methods, and related organizations. We also discussed challenges, such as resource and infrastructure issues, problems related to government regulations, and considerations for future data management. Results Hospitals are grappling with the increasing data storage space and a shortage of management personnel due to costs and project termination, which necessitates countermeasures and support. Data management regulations on the destruction or maintenance of medical records are needed, and institutional consideration for secondary utilization such as long-term treatment or research is required. Government-level guidelines for facilitating hospital data sharing and mobile patient services should be developed. Additionally, hospital executives at the organizational level need to make efforts to facilitate the clinical validation of artificial intelligence software. Conclusions This analysis of the current status and emerging issues of data management reveals potential solutions and sets the stage for future organizational and policy directions. If medical big data is systematically managed, accumulated over time, and strategically monetized, it has the potential to create new value.

Abstract Purpose To explore genomic biomarkers in rectal cancer by performing whole‐exome sequencing. Materials and Methods Pre‐chemoradiation (CRT) biopsy and post‐CRT surgical specimens were obtained from 27 patients undergoing neoadjuvant CRT followed by definitive resection. Exomes were sequenced to a mean coverage of 30×. Somatic single‐nucleotide variants (SNVs) and insertions/deletions (indels) were identified. Tumor mutational burden was defined as the number of SNVs or indels. Mutational signatures were extracted and fitted to COSMIC reference signatures. Tumor heterogeneity was quantified with a mutant‐allele tumor heterogeneity (MATH) score. Genetic biomarkers and frequently occurred copy number alterations (CNAs) were compared between pre‐ and post‐CRT specimens. Their associations with tumor regression grade (TRG) and clinical outcomes were explored. Results Top five mutated genes were APC, TP53, NF1, KRAS, and NOTCH1 for pre‐CRT samples and APC, TP53, NF1, CREBBP, and ATM for post‐CRT samples. Several gene mutations including RUNX1, EGFR, and TP53 in pre‐CRT samples showed significant association with clinical outcomes, but not with TRG. However, no such association was found in post‐CRT samples. Discordance of driver mutation status was found between pre‐ and post‐CRT samples. In tumor mutational burden analysis, higher number of SNVs or indels was associated with worse treatment outcomes. Six single‐base substitution (SBS) signatures identified were SBS1, SBS30, SBS29, SBS49, SBS3, and SBS44. The MATH score decreased after CRT on paired analysis. Less than half of CNAs frequent in post‐CRT samples were present in pre‐CRT samples. Conclusion Pre‐ and post‐CRT samples showed different genomic landscape. Potential genetic biomarkers of pre‐CRT samples found in the current analysis call for external validation.

Abstract Purpose This study aimed to define the gene signature associated with response to neoadjuvant chemoradiotherapy (nCRT), or chemoradiosensitivity (CRS) signature, in rectal cancer, and investigate the correlation between the CRS signature and characteristics of tumor. Materials and Methods Three public microarray datasets of pre‐nCRT rectal cancer were used to discover and validate the CRS signature, and the pathway analysis of the CRS signature was performed. Patients in The Cancer Genome Atlas (TCGA) dataset were stratified according to the CRS signature enrichment score, and mutational profile and proportions of infiltrated immune cells were compared. Results In the discovery dataset (GSE53781), 95 genes were upregulated in complete responders compared to non‐complete responders and defined as the CRS signature. Pathways regarding DNA replication and repair processes as well as inflammatory response were enriched in the CRS signature. In the validation datasets (GSE35452 and GSE45404), patients with favorable response to nCRT exhibited higher enrichment score of the CRS. In TCGA‐READ cohort, patients with high CRS signature harbored KRAS mutation in lower frequency than those with low CRS signature. In addition, proportions of proinflammatory immune cells were higher, but proportion of immunosuppressive M2 macrophages was lower in patients with high CRS signature than those with low CRS signature. Conclusions The current integrative bioinformatic analysis suggests the CRS signature and showed that the CRS signature is associated with dissimilar mutational profile and increased immune response. The discovered CRS signature and related characteristics may serve as candidate of stratification factor in upcoming studies for rectal cancer.

Abstract Multi-cancer early detection remains a key challenge in cell-free DNA (cfDNA)-based liquid biopsy. Here, we perform cfDNA whole-genome sequencing to generate two test datasets covering 2125 patient samples of 9 cancer types and 1241 normal control samples, and also a reference dataset for background variant filtering based on 20,529 low-depth healthy samples. An external cfDNA dataset consisting of 208 cancer and 214 normal control samples is used for additional evaluation. Accuracy for cancer detection and tissue-of-origin localization is achieved using our algorithm, which incorporates cancer type-specific profiles of mutation distribution and chromatin organization in tumor tissues as model references. Our integrative model detects early-stage cancers, including those of pancreatic origin, with high sensitivity that is comparable to that of late-stage detection. Model interpretation reveals the contribution of cancer type-specific genomic and epigenomic features. Our methodologies may lay the groundwork for accurate cfDNA-based cancer diagnosis, especially at early stages.

Adrenal and spinal metastases of hepatocellular carcinoma (HCC) are rare entities with significant morbidity and mortality, particularly after liver transplantation (LT). We report a case of a 49-year-old man who underwent LT for hepatitis B-related end-stage liver disease and HCC (single 4.5 cm lesion [T1N0], without vascular invasion) in 2016. Eighteen months later, adrenal metastasis and hepatitis B seropositive conversion were developed with normal serum tumor. Adrenal metastasis was treated with radiation therapy (RT) and hepatitis B showed spontaneous seronegative conversion. However, 35 months later, spinal metastasis occurred with elevation of the protein induced by vitamin K absence or antagonist-II (PIVKA-II) level (197 mAU/mL), along with hepatitis B seropositive conversion. After sorafenib, sequential regorafenib with RT led to partial response of the spinal lesions, along with hepatitis B seronegative conversion and normal PIVKA-II levels. After 9 months of regorafenib combined with RT, two recurrent lesions were found, as well as hepatitis B seropositive conversion and lesions were treated with transarterial chemoembolization. The patient survived for more than 71 months after LT and 53 months after recurrence under various combinations of therapy. Combined systemic and locoregional therapies can be a treatment option for HCC recurrence, even in LT patients.

The research on multi-task learning has been steadily increasing due to its advantages, such as preventing overfitting, averting catastrophic forgetting, solving multiple inseparable tasks, and coping with data shortage. Here, we question whether to incorporate different orderings of feature levels based on distinct characteristics of tasks and their interrelationships in multitask learning. While in many classification tasks, leveraging the features extracted from the last layer is common, we thought that given different characteristics of tasks there might be a need to encompass different representation levels, i.e., different orderings of feature levels. Hence, we utilized the knowledge of different representation levels by features extracted from the various blocks of the main module and applied trainable parameters as weights on the features. This indicates that we optimized the solution to the question by learning to weigh the features in a task-specific manner and solving tasks with a combination of newly weighted features. Our method SimPara presents a modular topology of multitask learning that is efficient in terms of memory and computation, effective, and easily applicable to diverse tasks or models. To show that our approach is task-agnostic and highly applicable, we demonstrate its effectiveness in auxiliary task learning, active learning, and multilabel learning settings. This work underscores that by simply learning weights to better order the features learned by a single backbone, we can incur better task-specific performance of the model.

Coronavirus has caused many casualties and is still spreading. Some people experience rapid deterioration that is mild at first. The aim of this study is to develop a deterioration prediction model for mild COVID-19 patients during the isolation period. We collected vital signs from wearable devices and clinical questionnaires. The derivation cohort consisted of people diagnosed with COVID-19 between September and December 2021, and the external validation cohort collected between March and June 2022. To develop the model, a total of 50 participants wore the device for an average of 77 h. To evaluate the model, a total of 181 infected participants wore the device for an average of 65 h. We designed machine learning-based models that predict deterioration in patients with mild COVID-19. The prediction model, 10 min in advance, showed an area under the receiver characteristic curve (AUC) of 0.99, and the prediction model, 8 h in advance, showed an AUC of 0.84. We found that certain variables that are important to model vary depending on the point in time to predict. Efficient deterioration monitoring in many patients is possible by utilizing data collected from wearable sensors and symptom self-reports.

BackgroundTo date, the association between acute signs and symptoms of COVID-19 and the exacerbation of depression and anxiety in patients with clinically mild COVID-19 has not been evaluated. ObjectiveThis study was designed to assess the correlation between acute signs and symptoms of COVID-19 and the exacerbation of depression and anxiety in patients with clinically mild COVID-19 at a residential treatment center in South Korea. MethodsThis retrospective study assessed 2671 patients with COVID-19 admitted to 4 residential treatment centers operated by Seoul National University Hospital, South Korea, from March 2020 to April 2022. Depression and anxiety were assessed using the 2-item Patient Health Questionnaire (PHQ-2) and 2-item Generalized Anxiety Disorder (GAD-2) scale, respectively. The exacerbation of depression and anxiety symptoms was identified from the differences in PHQ-2 and GAD-2 scores between admission and discharge, respectively. The patients’ clinical characteristics, including acute signs and symptoms of COVID-19, GAD-2 and PHQ-2 scores, were obtained from electronic health records. Demographic characteristics, a summary of vital signs, and COVID-19 symptoms were analyzed and compared between the patient groups with and those without exacerbated PHQ-2 and GAD-2 scores using the chi-square test. We applied logistic regression to identify the association between acute signs and symptoms of COVID-19 and the exacerbation of depression and anxiety. ResultsSleep disorders were associated with exacerbated depression (odds ratio [OR] 1.09, 95% CI 1.05-1.13) and anxiety (OR 1.1, 95% CI 1.06-1.14), and the sore throat symptom was associated with exacerbated anxiety symptoms (OR 1.03, 95% CI 1.00-1.07). Patients with abnormal oxygen saturation during quarantine were more likely to have exacerbated depression (OR 1.27, 95% CI 1.00-1.62), and those with an abnormal body temperature during quarantine were more likely to experience anxiety (OR 1.08, 95% CI 1.01-1.16). As anticipated, patients who experienced psychological symptoms at admission were more likely to experience depression (OR 1.91, 95% CI 1.52-2.41) and anxiety (OR 1.98, 95% CI 1.54-2.53). Meanwhile, the PHQ-2 and GAD-2 scores measured at admission revealed that lower the score, higher the possibility of exacerbation of both depression (OR 0.15, 95% CI 0.11-0.22) and anxiety (OR 0.13, 95% CI 0.10-0.19). ConclusionsResults from this study suggest the importance of further interventions for patients with abnormal oxygen saturation, abnormal body temperatures, sore throat, and sleep disorder symptoms or initial psychological symptoms to mitigate the exacerbation of depression and anxiety. In addition, this study highlights the usability of short and efficient scales such as the PHQ-2 and GAD-2 in the assessment of the mental health of patients with clinically mild COVID-19 symptoms who were quarantined at home during the pandemic era.

Background and purposeConsolidatory radiotherapy in form of stereotactic body radiation therapy (SBRT) with an ablative dose following induction chemotherapy is emerging as a promising treatment scheme for unresectable pancreatic cancer. Outcomes of given treatment at a single center for contiguous patients with unresectable pancreatic cancer were evaluated to build the optimal treatment strategy.Materials and methodsIn this retrospective study, a total of 50 patients with unresectable pancreatic cancer who underwent induction chemotherapy and ablative dose SBRT were included. SBRT dose was 40–50 Gy in five fractions. Two strategies were adopted to adhere to the organs at risk (OAR) dose constraints: simultaneous integrated protection (SIP) technique and magnetic resonance (MR)-guided adaptive technique. Overall survival (OS) and local progression-free survival (LPFS) were calculated from the start date of SBRT.ResultsThe median follow-up period for survivors was 21.1 months (range, 6.2–61.0 months). Eleven (22.0%) patients underwent resection after SBRT, which were all R0 resection. In patients with non-metastatic disease, the median OS was 26.5 months (range, 4.1–61.0 months), and the 1- and 3-year LPFS were 90.0% (95% confidence interval [CI], 72.0–96.7%) and 57.4% (95% CI, 31.7–76.4%), respectively. Patients with oligometastatic disease had inferior survival outcomes, but there was no survival difference among responders to induction chemotherapy. In the multivariable analysis, tumor size ≤4 cm, non-metastatic status, and good response to induction chemotherapy were associated with improved LPFS. In dosimetric analysis, GTV Dmin ≥50.5 Gy was the strongest prognosticator against local progression. Grade ≥3 adverse events occurred in two (4.0%) patients with non-adaptive RT, but none in patients with MR-guided adaptive RT.ConclusionAblative dose SBRT following induction chemotherapy is an effective strategy for selected patients with unresectable pancreatic cancer. The SIP technique and MR-guided adaptive RT were attributed to minimizing the risk of adverse events. Further studies are needed to identify the best candidates for consolidatory SBRT in unresectable pancreatic cancer.

BackgroundAlthough rectal cancer remains somewhat sanctuary to the contemporary immunotherapy, there is increasing knowledge on clinical implications of anti-tumor immunity. This study evaluated the prognostic relevance of two immune-inhibitory functions, myeloid-derived suppressor cells (MDSCs) and programmed cell death-1 (PD-1)/programmed death-ligand 1 (PD-L1) axis.MethodsStudy cohort is comprised of 165 patients with locally advanced rectal cancer who underwent neoadjuvant chemoradiotherapy followed by definitive resection. Using postsurgical tissue microarrays, the number of MDSCs, PD-1+/CD8+ tumor-infiltrating lymphocyte (TIL) ratio, and PD-L1 expression scores in stromal immune cells and tumor cells were assessed.ResultsPositive correlation was observed between the PD-1+/CD8+ TIL ratio and number of MDSCs (P < 0.001). The greater the immune infiltrates, the higher the PD-L1 immune cell score (P < 0.001). MDSCHigh, PD-1+/CD8+ TILHigh, PD-L1 immune cell scoreLow, and PD-L1 tumor H-scoreHigh were associated with worse disease-free survival (DFS) (P < 0.001, P = 0.042, 0.047, and P < 0.001, respectively). To integrate the adverse effects of MDSCHigh, PD-1+/CD8+ TILHigh, and either PD-L1 immune cell scoreLow (set I) or tumor H-scoreHigh (set II), prognostic risks were stratified according to the number of factors: 0, 1, and 2−3 (P < 0.001 for I and II). On multivariate analyses, patients with multiple risk factors for set I and II had worse prognosis (P < 0.001; 2−3 vs. 0 for models I and II), and the two prognostic models had acceptable predictability.ConclusionIn this study, integration of the prognostic impact of MDSCs and PD-1/PD-L1 stratified the long-term risks of patients with locally advanced rectal cancer. Thus, further exploration could be focused to the identified subset of patients carrying worse prognosis, where potential benefits could be derived by targeting the two components contributing to the immunosuppressive microenvironment.

IntroductionTo effectively manage patients with coronavirus disease 2019 (COVID-19) while minimizing contact between medical staff, clinical trial protocol that facilitates contactless patient management was designed to predict deterioration of disease condition and monitor mental health status.MethodsThrough consultation with infectious disease specialists and psychiatrists, this study identified main clinical indicators related to respiratory and non-respiratory outcomes, and mental health. Telehealth devices that could collect relevant data indicators were explored. The following three modes were identified: wearable devices, video calls, and online questionnaires. Clinical trial protocol was implemented to patients confirmed with COVID-19 infection and admitted to Seongnam residential treatment centers between September 1, 2021 and December 30, 2021. Data were collected from wearable devices, video calls, online questionnaires, and from electronic health records. Participant satisfaction was assessed through an online survey at the time of discharge.ResultsIn total, 120 asymptomatic and mildly symptomatic COVID-19 patients participated in this trial. Seven types of physiological and life log data were collected from 87 patients using wearable devices, video and audio recordings, and online mental health-related questionnaire. Most participants were satisfied with the overall trial process, but perceived difficulties in using telehealth devices.ConclusionThis trial collected simultaneously generated multimodal patient data using various telehealth devices in a contactless setting for COVID-19 patients. Data collected in this study will be used to build a remote patient management system based on the prediction algorithms.

Background/Aims: Although many studies have reported the promising effect of neoadjuvant treatment for borderline resectable pancreatic cancer (BRPC) to increase resectability, only a few studies have recommended the use of first-line chemotherapeutic agents as neoadjuvant treatment for BRPC. The current study compared clinical outcomes between gemcitabine and FOLFIRINOX (5-fluorouracil, leucovorin, oxaliplatin, and irinotecan) in patients with BRPC. Methods: In this single-center retrospective study, 100 BRPC patients treated with neoadjuvant chemotherapy and resection from 2008 to 2018 were reviewed. Clinical outcomes included overall survival, resectability, and recurrence patterns after gemcitabine or FOLFIRINOX treatment. Results: For neoadjuvant chemotherapy, gemcitabine was administered to 34 patients and FOLFIRINOX to 66. Neoadjuvant radiotherapy was administered to 27 patients (79.4%) treated with gemcitabine and 19 (28.8%) treated with FOLFIRINOX (p

BackgroundDepression and suicide are critical social problems worldwide, but tools to objectively diagnose them are lacking. Therefore, this study aimed to diagnose depression through machine learning and determine whether it is possible to identify groups at high risk of suicide through words spoken by the participants in a semi-structured interview.MethodsA total of 83 healthy and 83 depressed patients were recruited. All participants were recorded during the Mini-International Neuropsychiatric Interview. Through the suicide risk assessment from the interview items, participants with depression were classified into high-suicide-risk (31 participants) and low-suicide-risk (52 participants) groups. The recording was transcribed into text after only the words uttered by the participant were extracted. In addition, all participants were evaluated for depression, anxiety, suicidal ideation, and impulsivity. The chi-square test and student’s T-test were used to compare clinical variables, and the Naive Bayes classifier was used for the machine learning text model.ResultsA total of 21,376 words were extracted from all participants and the model for diagnosing patients with depression based on this text confirmed an area under the curve (AUC) of 0.905, a sensitivity of 0.699, and a specificity of 0.964. In the model that distinguished the two groups using statistically significant demographic variables, the AUC was only 0.761. The DeLong test result (p-value 0.001) confirmed that the text-based classification was superior to the demographic model. When predicting the high-suicide-risk group, the demographics-based AUC was 0.499, while the text-based one was 0.632. However, the AUC of the ensemble model incorporating demographic variables was 0.800.ConclusionThe possibility of diagnosing depression using interview text was confirmed; regarding suicide risk, the diagnosis accuracy increased when demographic variables were incorporated. Therefore, participants’ words during an interview show significant potential as an objective and diagnostic marker through machine learning.

BackgroundPreoperative chemoradiotherapy (CRT) is a standard treatment for locally advanced rectal cancer (LARC). However, individual responses to preoperative CRT vary from patient to patient. The aim of this study is to develop a scoring system for the response of preoperative CRT in LARC using blood features derived from machine learning.MethodsPatients who underwent total mesorectal excision after preoperative CRT were included in this study. The performance of machine learning models using blood features before CRT (pre-CRT) and from 1 to 2 weeks after CRT (early-CRT) was evaluated. Based on the best model, important features were selected. The scoring system was developed from the selected model and features. The performance of the new scoring system was compared with those of systemic inflammatory indicators: neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, lymphocyte-to-monocyte ratio, and the prognostic nutritional index.ResultsThe models using early-CRT blood features had better performances than those using pre-CRT blood features. Based on the ridge regression model, which showed the best performance among the machine learning models (AUROC 0.6322 and AUPRC 0.5965), a novel scoring system for the response of preoperative CRT, named Response Prediction Score (RPS), was developed. The RPS system showed higher predictive power (AUROC 0.6747) than single blood features and systemic inflammatory indicators and stratified the tumor regression grade and overall downstaging clearly.ConclusionWe discovered that we can more accurately predict CRT response by using early-treatment blood data. With larger data, we can develop a more accurate and reliable indicator that can be used in real daily practices. In the future, we urge the collection of early-treatment blood data and pre-treatment blood data.

BRAF mutations are frequent events in many different cancer types. Here, the authors highlight how distinct BRAF mutations affect the clonal dynamics and architecture of emergent tumours, with potential implications for therapeutic intervention.

Abstract Background To develop and compare delta-radiomics signatures from 2- (2D) and 3-dimensional (3D) features that predict treatment outcomes following preoperative chemoradiotherapy (CCRT) and surgery for locally advanced rectal cancer. Methods In total, 101 patients (training cohort, n = 67; validation cohort, n = 34) with locally advanced rectal adenocarcinoma between 2008 and 2015 were included. We extracted 55 features from T2-weighted magnetic resonance imaging (MRI) scans. Delta-radiomics feature was defined as the difference in radiomics feature before and after CCRT. Signatures were developed to predict local recurrence (LR), distant metastasis (DM), and disease-free survival (DFS) from 2D and 3D features. The least absolute shrinkage and selection operator regression was used to select features and build signatures. The delta-radiomics signatures and clinical factors were integrated into Cox regression analysis to determine if the signatures were independent prognostic factors. Results The radiomics signatures for LR, DM, and DFS were developed and validated using both 2D and 3D features. Outcomes were significantly different in the low- and high-risk patients dichotomized by optimal cutoff in both the training and validation cohorts. In multivariate analysis, the signatures were independent prognostic factors even when considering the clinical parameters. There were no significant differences in C-index from 2D vs. 3D signatures. Conclusions This is the first study to develop delta-radiomics signatures for rectal cancer. The signatures successfully predicted the outcomes and were independent prognostic factors. External validation is warranted to ensure their performance.

Abstract Background To investigate the patterns of post-lumpectomy seroma volume (SV) change and related clinical factors to determine the benefits of adaptive planning in magnetic resonance imaging (MRI)-guided partial breast irradiation (PBI). Methods MRI data obtained from 37 women with early breast cancer acquired at simulation and at the 1st, 6th, and 10th fractions were analyzed. The planning target volume (PTV) was defined as unequal margins of 10–15 mm added according to the directional surgical margin status of each seroma. Treatment was performed using a 0.35 T MRI-guided radiotherapy system. Univariate analysis was performed to assess the correlations between SV change rate and clinical factors. Seroma and PTV for adaptive planning were based on the images obtained at the 6th fraction. Results The average time intervals between surgery-simulation, simulation-1st, 1st-6th, and 6th-10th fractions were 23.1, 8.5, 7.2, and 5.9 days, respectively. Of the 37 patients, 33 exhibited decreased SV over the treatment period. The mean SV of these 33 patients decreased from 100% at simulation to 60, 48, and 40% at each MRI scan. In most cases (26/33), the logarithm of SV was inversely proportional to the elapsed time from surgery (R 2 > 0.90, Pearson’s correlation test). The volume of spared normal tissue from adaptive radiotherapy was proportional to the absolute change in SV (R 2 = 0.89, Pearson’s correlation test). Conclusion Seromas exhibit exponential shrinkage over the course of PBI. In patients receiving PBI, frequent monitoring of SV could be helpful in decision-making regarding adaptive planning, especially those with a large seroma.

PURPOSEWe aimed to compare various tumor-related radiologic morphometric changes and computed tomography (CT) perfusion parameters before and after treatment, and to determine the optimal imaging assessment technique for the prediction of early response in a rat tumor model treated with radiotherapy.METHODSAmong paired tumors of FN13762 murine breast cancer cells implanted bilaterally in the necks of eight Fischer rats, tumors on the right side were treated with a single 20 Gy dose of radiotherapy. Perfusion CT studies were performed on day 0 before radiotherapy, and on days 1 and 5 after radiotherapy. Variables based on the size, including the longest diameter, tumor area, and volume, were measured. Quantitative perfusion analysis was performed for the whole tumor volume and permeabilities and blood volumes (BVs) were obtained. The area under the curve (AUC) difference in the histograms of perfusion parameters and texture analyses of uniformity and entropy were quantified. Apoptotic cell density was measured on pathology specimens immediately after perfusion imaging on day 5.RESULTSOn day 1 after radiotherapy, differences in size between the irradiated and nonirradiated tumors were not significant. In terms of percent changes in the uniformity of permeabilities between tumors before irradiation and on day 1 after radiotherapy, the changes were significantly higher in the irradiated tumors than in the nonirradiated tumors (0.085 [−0.417, 0.331] vs. −0.131 [−0.536, 0.261], respectively; P = 0.042). The differences in AUCs of the histogram of voxel-by-voxel vascular permeability and BV in tumors between day 0 and day 1 were significantly higher in treated tumors compared with the control group (permeability, 21.4 [−2.2, 37.5] vs. 9.5 [−8.9, 33.8], respectively, P = 0.030; BV, 52.9 [−6186.0, 419.2] vs. 11.9 [−198.3, 346.7], respectively, P = 0.049). Apoptotic cell density showed a significantly positive correlation with the AUC difference of BV, the percent change of uniformity in permeability and BV (r=0.202, r=0.644, and r=0.706, respectively).CONCLUSIONBy enabling earlier tumor response prediction than morphometric evaluation, the histogram analysis of CT perfusion parameters appears to have a potential in providing prognostic predictive information in an irradiated rat model.

The variability in patient response to radiation treatment is difficult to predict. Here, using more than 500 cell lines the authors measure response to radiation exposure and a large panel of compounds, and show that response can be predicted by genetic alterations of the cells.

Although the adrenal glands are not common sites of metastasis from hepatocellular carcinoma (HCC), this metastasis can be met in patients with advanced HCC in some clinical settings. However, the effectiveness of radiotherapy against such metastases is unclear. Therefore, we performed the present multi-institutional study to investigate tumor response, overall survival (OS), treatment-related toxicity, and prognostic factors after radiotherapy. We retrospectively reviewed 134 patients who completed a planned radiotherapy for their adrenal metastases. Complete response was noted in 6 (4.3%), partial response in 48 (34.0%), and stable disease in 78 patients (55.3%). The median OS was 12.8 months, and the 1-, 2-, and 5-year OS rates were 53.1%, 23.9%, and 9.3%, respectively. Grade 3 anorexia occurred in 2 patients, grade 3 diarrhea in 1, and grade 3 fatigue in 1. Multivariate analyses revealed that the following factors had significant effects on OS: controlled intrahepatic tumor; controlled extrahepatic metastasis; and Child-Pugh class A. Although patients with adrenal metastasis from HCC had poor OS, radiotherapy provided an objective response rate of 38.3% and disease stability of 93.6%, with minimal adverse events. Therefore, radiotherapy for these patients could represent a good treatment modality, especially for patients with controlled intrahepatic tumors, controlled extrahepatic metastasis, and good hepatic function.

BACKGROUND:Ampulla of Vater cancer (AoV Ca) is a rare tumor, and its adjuvant treatment has not been established. The purpose of this study was to find out prognostic factors including host immunity and role of adjuvant treatment in AoV Ca. METHODS AND FINDINGS:We reviewed 227 AoV Ca patients with curative resection. Clinical characteristics, adjuvant treatment, disease-free survival (DFS) and overall survival (OS) were analyzed. Among all patients, 63.9, 36.1 and 33.9% had T1/T2, T3/T4 stage and lymph node-positive disease (LN+), respectively. OS of all patients was 90.9 months (95% CI: 52.9-129.0). OS was different according to neutrophil-to-lymphocyte ratio (HR 1.651, 95% CI: 1.11-2.47), platelet-to-lymphocyte ratio (HR 1.488, 95% CI: 1.00-2.21) and systemic inflammatory index (HR 1.669, 95% CI: 1.13-2.47). In multivariate analysis, adverse prognostic factors for OS included vascular invasion (HR 2.571, 95% CI: 1.20-5.53) and elevated CA 19-9 (HR 1.794, 95% CI: 1.07-3.05). A total of 104 patients (46.3%) received adjuvant treatment (25 out of 111of T1/T2 & LN (-), 79 out of 116 of T3/T4 or LN (+)). In T3/T4 or LN (+) stage, adjuvant CCRT with maintenance chemotherapy provided the longest OS (5-year OS rate: 47.0 vs. 41.4%). CONCLUSIONS:Vascular invasion and elevated CA 19-9 were adverse prognostic factors in resected AoV Ca. In T3/T4 or LN (+) stage, adjuvant CCRT with maintenance chemotherapy provided the best survival outcome. Adjuvant treatment should be further defined in AoV Ca, especially with poor prognostic factors.

ObjectivesAdoption of hospital information systems offers distinctive advantages in healthcare delivery. First, implementation of consolidated hospital information system in Seoul National University Hospital led to significant improvements in quality of healthcare and efficiency of hospital management.MethodsThe hospital information system in Seoul National University Hospital consists of component applications: clinical information systems, clinical research support systems, administrative information systems, management information systems, education support systems, and referral systems that operate to generate utmost performance when delivering healthcare services.ResultsClinical information systems, which consist of such applications as electronic medical records, picture archiving and communication systems, primarily support clinical activities. Clinical research support system provides valuable resources supporting various aspects of clinical activities, ranging from management of clinical laboratory tests to establishing care-giving procedures.ConclusionsSeoul National University Hospital strives to move its hospital information system to a whole new level, which enables customized healthcare service and fulfills individual requirements. The current information strategy is being formulated as an initial step of development, promoting the establishment of next-generation hospital information system.

To evaluate the prognostic impact of the lymph node ratio (LNR) in ypStage III rectal cancer patients who were treated with neoadjuvant chemoradiotherapy (NCRT).We retrospectively reviewed the data of 638 consecutive patients who underwent NCRT followed by total mesorectal excision, and postoperative adjuvant chemotherapy for rectal cancer from 2004 to 2011. Of these, 125 patients were positive for lymph node (LN) metastasis and were analyzed in this study.The median numbers of examined and metastatic LNs were 17 and 2, respectively, and the median LNR was 0.143 (range, 0.02-1). Median follow-up time was 55 months. In multivariate analyses, LNR was an independent prognostic factor for overall survival (OS) (hazard ratio [HR] 2.17, p = 0.041), disease-free survival (DFS) (HR 2.28, p = 0.005), and distant metastasis-free survival (DMFS) (HR 2.30, p = 0.010). When ypN1 patients were divided into low (low LNR ypN1 group) and high LNR (high LNR ypN1 group) according to a cut-off value of 0.152, the high LNR ypN1 group had poorer OS (p = 0.043) and DFS (p = 0.056) compared with the low LNR ypN1 group. And there were no differences between the high LNR ypN1 group and the ypN2 group in terms of the OS (p = 0.703) and DFS (p = 0.831).For ypN-positive rectal cancer patients, the LNR was a more effective prognostic marker than the ypN stage, circumferential resection margin, or tumor regression grade after NCRT, and could be used to discern the high-risk group among ypN1 patients.

Purpose: There is increasing interest in the efficacy of stereotactic ablative radiotherapy (SABR) for treating colorectal cancer (CRC) patients with oligometastases (OM), recently. The purpose of this meta-analysis was to evaluate local control (LC), progression-free survival (PFS), and overall survival (OS) of CRC patients with pulmonary OM treated with SABR and toxicities. Materials and Methods: Studies that reported SABR for CRC patients with pulmonary OM were searched from MEDLINE and Embase. Treatment outcomes including LC, PFS, OS, and toxicities of grade 3 or higher were assessed. Results: A total of 19 studies with 1,668 patients were chosen for this meta-analysis. Pooled 1-, 2-, and 3-year LC rates were 83.1%, 69.3%, and 63.9%, respectively. PFS rates were 44.8%, 26.5%, and 21.5% at 1, 2, and 3 years, respectively. OS rates at 1-, 2-, and 3-year were 87.5%, 69.9%, and 60.5%, respectively. The toxicity rate of grade 3 or higher was 3.6%. The effect of dose escalation was meta-analyzed using available studies. Conclusion Application of SABR to CRC patients with pulmonary OM achieved modest local control with acceptable toxicity according to the present meta-analysis. Further studies establishing the clinical efficacy of SABR are guaranteed. [ABSTRACT FROM AUTHOR]

Purpose Risk factors predicting distant metastasis (DM) in extrahepatic bile duct cancer (EHBDC) patients treated with curative resection were investigated. Materials and Methods Medical records of 1,418 EHBDC patients undergoing curative resection between Jan 2000 and Dec 2015 from 14 institutions were reviewed. After resection, 924 patients (67.6%) were surveilled without adjuvant therapy, 297 (21.7%) were treated with concurrent chemoradiotherapy (CCRT) and 148 (10.8%) with CCRT followed by chemotherapy. To exclude the treatment effect from innate confounders, patients not treated with adjuvant therapy were evaluated. Results After a median follow-up of 36.7 months (range, 2.7 to 213.2 months), the 5-year distant metastasis-free survival (DMFS) rate was 57.7%. On multivariate analysis, perihilar or diffuse tumor (hazard ratio [HR], 1.391; p=0.004), poorly differentiated histology (HR, 2.014; p < 0.001), presence of perineural invasion (HR, 1.768; p < 0.001), positive nodal metastasis (HR, 2.670; p < 0.001) and preoperative carbohydrate antigen (CA) 19-9 ≥ 37 U/mL (HR, 1.353; p < 0.001) were significantly associated with inferior DMFS. The DMFS rates significantly differed according to the number of these risk factors. For validation, patients who underwent adjuvant therapy were evaluated. In patients with ≥ 3 factors, additional chemotherapy after CCRT resulted in a superior DMFS compared with CCRT alone (5-year rate, 47.6% vs. 27.7%; p=0.001), but the benefit of additional chemotherapy was not observed in patients with 0-2 risk factors. Conclusion Tumor location, histologic differentiation, perineural invasion, lymph node metastasis, and preoperative CA 19-9 level predicted DM risk in resected EHBDC. These risk factors might help identifying a subset of patients who could benefit from additional chemotherapy after resection. [ABSTRACT FROM AUTHOR]

Purpose Despite numerous studies on the optimal treatments for oligometastatic disease (OMD), there is no established interdisciplinary consensus on its diagnosis or classification. This survey-based study aimed to analyze the differential opinions of colorectal surgeons and radiation oncologists regarding the definition and treatment of OMD from the colorectal primary. Materials and Methods A total of 141 participants were included in this study, consisting of 63 radiation oncologists (44.7%) and 78 colorectal surgeons (55.3%). The survey consisted of 19 questions related to OMD, and the responses were analyzed using the chi-square test to determine statistical differences between the specialties. Results The radiation oncologists chose "bone" more frequently compared to the colorectal surgeons (19.2% vs. 36.5%, p=0.022), while colorectal surgeons favored "peritoneal seeding" (26.9% vs. 9.5%, p=0.009). Regarding the number of metastatic tumors, 48.3% of colorectal surgeons responded that "irrelevant, if all metastatic lesions are amendable to local therapy", while only 21.8% of radiation oncologist chose same answer. When asked about molecular diagnosis, most surgeons (74.8%) said it was important, but only 35.8% of radiation oncologists agreed. Conclusion This study demonstrates that although radiation oncologists and colorectal surgeons agreed on a majority of aspects such as diagnostic imaging, biomarker, systemic therapy, and optimal timing of OMD, they also had quite different perspectives on several aspects of OMD. Understanding these differences is crucial to achieving multidisciplinary consensus on the definition and optimal management of OMD. [ABSTRACT FROM AUTHOR]

Background/Aim: Although radiation therapy (RT) is an effective and safe treatment when administered locally for various stages of hepatocellular carcinoma (HCC), adequate biomarkers that are predictive of therapeutic efficacy have not been identified. We evaluated the clinical utility of circulating cell-free DNA (cfDNA) to predict treatment response of patients with HCC treated with RT. Patients and Methods: We prospectively recruited 37 patients diagnosed with HCC between March 2019 and May 2020. All patients were treated with RT as salvage therapy. Whole peripheral blood was collected twice, one before RT (baseline; V1) and another aliquot one week after the end of RT (V2). We determined whether cfDNA genomic copy number variations (CNVs) could predict treatment outcome. An I-score was calculated from the plasma cfDNA that reflected CNVs of cfDNA, which is evidence of genomic instability. Results: The I-score at V1 exhibited a strong correlation with the planning target volume (PTV) (coefficient=0.65) and was a predictive marker for progression-free survival (PFS). In particular, a mean Iscore value at V1 of ≥6.3 had a significant positive correlation with PFS (p=0.017). Compared with patients who had a complete response (CR) following RT, non-CR patients had a higher mean I-score value at V2 ≥6.2 (p=0.034). Furthermore, I-score values at V1 and V2 and the delta I-score ratio were significantly associated with a preRT alpha-fetoprotein level ≥200 among non-CR patients. Conclusion: I-score values calculated from plasma cfDNA represent a potential biomarker for predicting treatment outcomes in patients with advanced HCC receiving RT. [ABSTRACT FROM AUTHOR]

Introduction of the concept for oligometastasis led to wide application of metastasis-directed local ablative therapies for metastatic colorectal cancer (CRC). By application of the metastasis-directed local ablative therapies including surgical resection, radiofrequency ablation (RFA), and stereotactic ablative body radiotherapy (SABR), the survival outcomes of patients with metastatic CRC have improved. The liver is the most common distant metastatic site in CRC patients, and recently various metastasis-directed local therapies for hepatic oligometastasis from CRC (HOCRC) are widely used. Surgical resection is the first line of metastatic-directed local therapy for HOCRC, but its eligibility is very limited. Alternatively, RFA can be applied to patients who are ineligible for surgical resection of liver metastasis. However, there are some limitations such as inferior local control (LC) compared with surgical resection and technical feasibility based on location, size, and visibility on ultrasonography of the liver metastasis. Recent advances in radiation therapy technology have led to an increase in the use of SABR for liver tumors. SABR is considered complementary to RFA for patients with HOCRC who are ineligible for RFA. Furthermore, SABR can potentially result in better LC for liver metastases > 2-3 cm compared with RFA. In this article, the previous studies regarding curative metastasis-directed local therapies for HOCRC based on the radiation oncologist's and surgeon's perspective are reviewed and discussed. In addition, future perspectives regarding SABR in the treatment of HOCRC are suggested. [ABSTRACT FROM AUTHOR]