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Background: The abscopal effect consists of distant metastases response after local treatment based on systemic immune stimulation. It is a rare event observed in many tumors, especially with radiotherapy and immunotherapy. Clinical case: We report the long-term abscopal effect in a metastatic renal cell carcinoma patient with lung metastasectomy, after hypofractionated radiotherapy on lymph node metastasis. The patient was pretreated with pazopanib, which was discontinued early owing to toxicity before radiotherapy. Methodology: Immunohistological analyses of the primary tumor and metastases were performed. Discussion: We supposed that radiotherapy, and maybe tyrosine kinase inhibitors, could act as immune-primers for abscopal effect modifying the immune tumor microenvironment. Conclusion: Future studies are needed to optimize the combination of radiotherapy with systemic therapy for better long-term tumor control in selected patients.

In craniospinal irradiation, field matching is very sensitive to intrafraction positional uncertainties in cranio-caudal direction, which could lead to severe overdoses/underdoses inside the planning target volume. During the last decade, significant efforts were made to develop volumetric-modulated arc therapy strategies, which were less sensitive to setup uncertainties. In this study, a treatment planning system-integrated method, named automatic feathering (AF) algorithm, was compared against other volumetric-modulated arc therapy strategies. Three patients were retrospectively included. Five different planning techniques were compared, including overlap (O), staggered overlap (SO), gradient optimization (GO), overlap with AF algorithm turned on (O-AF), and staggered overlap with AF algorithm turned on (SO-AF). Three overlapping lengths were considered (5 cm, 7.5 cm, and 10 cm). The middle isocenter was shifted of ±1 mm, ±3 mm, and ±5 mm to simulate setup uncertainties. Plan robustness against simulated uncertainties was evaluated by calculating near maximum and near minimum dose differences between shifted and nonshifted plans (ΔD2%, ΔD98%). Dose differences among combinations of techniques and junction lengths were tested using Wilcoxon signed-rank test. Higher ΔD2% and ΔD98% were obtained using the overlap technique (ΔD2% = 15.4%, ΔD98% = 15.0%). O-AF and SO-AF provided comparable plan robustness to GO technique. Their performance improved significantly for grater overlapping length. For 10-cm overlap and 5-mm shift, GO, O-AF, and SO-AF yielded to the better plan robustness (5.7%

Background in the setting of metastatic malignancies, the role of concurrent stereotactic radiosurgery (SRS)/stereotactic radiotherapy (SRT) and immune-checkpoint inhibitors (ICI) is increasing. Few data are available about effectiveness and safety of this strategy. Methods we used the PRISMA guidelines to perform a systematic review. We selected only articles reporting a “real” concurrent treatment, defined as SRS/SRT performed within 30 days of ICI administration. Results Despite several limits due to the heterogeneity and retrospective nature of the studies, 1-year local control for brain lesions ranged from 42 to 100% and 1-year regional brain control ranged from 31 to 83%. An interesting rate of local and distant control was reported for concurrent SBRT-ICI on extra-cranial lesions. No relevant signals about toxicity emerged. Conclusions Based on published evidence, concurrent SRS/SRT and ICI seems to lead intriguing outcomes, without increasing toxicity. Further investigations are warranted to obtain stronger prospective evidence.

In the present study, the influence of purely palliative radiotherapy (pRT) on the outcomes of patients with advanced cancer undergoing immune checkpoint blockade was evaluated. Patients were stratified into three groups: Patients who had received pRT within 6 months prior to the initiation of immunotherapy (previous pRT); patients who received pRT during immunotherapy (concurrent pRT); and patients who did not receive RT prior to or during immunotherapy (no RT group), and these groups were compared. The median overall survival (mOS), median progression free survival (mPFS) and median time-to-treatment failure (mTTF) for the previous pRT group were significantly shorter compared with the no RT group (mOS, 3.6 vs. 12.1 months, respectively, P=0.0095; mPFS 1.8 vs. 5.4 months, respectively, P=0.0016; mTTF 1.8 vs. 5.7 months, respectively, P=0.0035). The concurrent pRT group had a longer mTTF compared with the previous pRT group and similar outcomes to the no RT group. In the previous pRT group, 26.9% of the patients experienced immune-related adverse events compared with 40.1% of patients in the no RT group. Despite the use of pRT during immunotherapy being considered safe, the results of the present study suggest that pRT has a negative effect on immune balance.

OBJECTIVES To investigate the efficacy of stereotactic body radiotherapy in oligometastatic urothelial carcinoma with node-only involvement. METHODS We retrospectively collected data on the outcomes of patients who underwent stereotactic body radiotherapy for metastatic node lesions from oligometastatic urothelial carcinoma at Radiotherapy Unit of University Hospital of Parma, Parma, Italy. The investigated outcomes were lesion size, standardized uptake value, overall response rate, lesion control rate, lesion progression-free interval, progression-free survival and overall survival. RESULTS Among seven patients included in the study, a total of 14 node metastatic lesions were treated with stereotactic body radiotherapy. The mean total dose of stereotactic body radiotherapy was 32 Gy (range 25-40 Gy). At first imaging evaluation, a mean variation of -4% (P = 0.427) in major diameter, -16% (P = 0.048) in minor diameter and -76% in standardized uptake value (P

Non-small-cell lung cancer (NSCLC) occurs, approximately, in 80–85% of all cases of lung cancer. The majority of patients present locally advanced or metastatic disease when diagnosed, with poor prognosis. The discovery of activating mutations in the EGFR gene has started a new era of personalized treatment for NSCLC patients. To improve the treatment outcome in patients with unresectable NSCLC and, in particular, EGFR mutated, a combined strategy of radiotherapy and medical treatment can be undertaken. In this review we will discuss preclinical data regarding EGF receptor (EGFR) tyrosine kinase inhibitors (TKIs) and radiotherapy, available clinical trials investigating efficacy and toxicity of combined treatment (thoracic or whole brain radiotherapy and EGFR-TKIs) and, also, the role of local radiation in mutated EGFR patients who developed EGFR-TKI resistance.

Breast cancer is the most frequent tumour in women around the world and it accounts for 25% of all cases of cancer. It may spread through the body in various districts, and as a consequence pulmonary, bone, liver, cerebral, lymph node and skin metastases are commonly seen. Skin metastases can be both locoregional (near the tumor) and distant. The skin appearance should not be underestimated in multi-metastatic patients, as tumorous progression in the skin inevitably causes ulceration, extreme difficulty in cicatrization and consequent pain. In this study, we describe the case of a multiple treated patient for destructive cutaneous metastases (Oncology).

The recent advances in the treatment of metastatic renal cell carcinoma (mRCC), from the introduction of the first antiangiogenic tyrosine kinase inhibitor (TKI) sorafenib in 2005 to the most recent approval of the first immune checkpoint inhibitor (CKI) nivolumab in 2015, allowed to improve the management of the disease and most importantly to prolong overall survival (OS) (1,2). In this era, especially after the publication of recent pivotal trials introducing three new therapeutic combinations in the first-line treatment setting (3-5), we can properly talk about the “embarrassment of riches” for the systemic therapy for clear-cell mRCC.

IntroductionProstate embryonal rhabdomyosarcoma (ERMS) is a common tumour in infants and children, with a median occurrence age of 5 years, but it is rare in adults. It is characterized by a high degree of malignancy, both local rapid growth with formation of large pelvic masses, often leading to renal failure due to urethral obstruction, and systemic spread, commonly to the lungs, liver and bone. Several therapeutic approaches have been employed in the effort to treat prostate ERMS, but all of them have failed to gain a significant survival benefit in adult patients.Case reportWe report on a case of a stage IV prostate ERMS, approached with combined-modality treatment, with the administration of 5 courses of doxorubicin, ifosfamide and 2-mercaptoethane sulfonate sodium (mesna), and, subsequent radiotherapy to the prostatic bed (60Gy/30fxs). The patient remained free of progression of disease for about 1 year to finally experience a systemic relapse with multiple lung metastases and pleural effusion. The patient died for metastatic disease 27 months following the initial diagnosis.ConclusionWhile it remains questionable which therapeutic approach for prostate ERMS in adults is the most appropriate, our report demonstrates that a chemo-radiation combined treatment can control the prostate disease, reducing the symptoms and improving the quality of life of these patients, for the most part destined to die for systemic progression of disease.

Intensity-modulated arc therapy (IMAT) is an arc-based approach to intensity-modulated radiotherapy (IMRT) that can be delivered on a conventional linear accelerator using multiple overlapping arcs. As with other rotational IMRT techniques, IMAT is capable of producing highly conformal dose distributions that are able to compete with the simplest three-dimensional (3D) conformal radiotherapy (CRT) and the most effective static IMRT. Despite its potential, the clinical application of IMAT technique has gone largely unrealized due to the lack of robust and commercially available inverse- planning tools. To overcome this limitation, an in-house forward-planning strategy for planning the IMAT technique, called intensity modulated multiple arcs (IMMA) was developed. This planning approach was implemented for lung and cranial treatments with the aim of generating superior treatment plans compared to the 3D CRT technique. Two treatments plans, on a lung and a cranial tumour respectively, were analyzed as important examples of this new approach. The IMMA plans achieve a similar coverage of the target volumes as well as the 3D CRT technique (coplanar and noncoplanar), but with a better sparing of the critical organs and a delivery efficiency that is superior to that of 3D CRT. This result changes when the comparison is made with the fixed gantry IMRT technique, since the inverse-planned (IP) treatments have a greater flexibility in conforming the dose to the complex targets and in controlling the dose to the critical structures. To improve the IMMA forward-planned procedure, a new IMAT-IP approach has been proposed to obtain treatment plans that approach, in term of tumour dose coverage and dose sparing of the critical organs, the plan quality reached by the IMRT technique.

Background Glioblastoma (GBM) is the most common malignant primary brain tumor in adults. Tumor control and survival have improved with the use of radiotherapy (RT) plus concomitant and adjuvant chemotherapy, but the prognosis remain poor. In most cases the recurrence occurs within 7–9 months after primary treatment. Currently, many approaches are available for the salvage treatment of patients with recurrent GBM, including resection, re-irradiation or systemic agents, but no standard of care exists. Methods We analysed a cohort of patients with recurrent GBM treated with frame-less hypofractionated stereotactic radiation therapy with a total dose of 25 Gy in 5 fractions. Results Of 91 consecutive patients with newly diagnosed GBM treated between 2007 and 2012 with conventional adjuvant chemo-radiation therapy, 15 underwent salvage RT at recurrence. The median time interval between primary RT and salvage RT was 10.8 months (range, 6–54 months). Overall, patients undergoing salvage RT showed a longer survival, with a median survival of 33 vs. 9.9 months (p= 0.00149). Median overall survival (OS) from salvage RT was 9.5 months. No patients demonstrated clinically significant acute morbidity, and all patients were able to complete the prescribed radiation therapy without interruption. Conclusion Our results suggest that hypofractionated stereotactic radiation therapy is effective and safe in recurrent GBM. However, until prospective randomized trials will confirm these results, the decision for salvage treatment should remain individual and based on a multidisciplinary evaluation of each patient.