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Purpose: To determine the performance of texture analysis (TA), diffusion-weighted imaging, and perfusion MR (pMRI) in predicting tumoral response in patients treated with neoadjuvant chemoradiotherapy (CRT)., Methods: 12 consecutive patients (8 females, 4 males, 63.2 ± 13.4 years) with rectal cancer were prospectively enrolled, and underwent pre-treatment 3T MRI. Treatment protocol consisted of neoadjuvant CRT with oxaliplatin and 5-fluorouracile. Unenhanced T2-weighted images TA (kurtosis), apparent diffusion coefficient (ADC), and pMRI parameters (Ktrans, Kep, Ve, IAUGC) were quantified by manually delineating a region of interest around the tumor outline. After CRT, all patients underwent complete surgical resection and the surgical specimen served as the gold standard. Receiver operating characteristic (ROC) curve analysis was performed to assess the discriminatory power of each quantitative parameter to predict complete response., Results: Pathological complete response (pCR) was reported in six patients and partial response (PR) in three patients. Three patients were classified as non-responders (NR). Pre-treatment kurtosis was significantly lower in the pCR sub-group in comparison with PR + NR (p = .01). Among ADC and pMRI parameters, only Ve was significantly lower in the pCR sub-group compared with PR + NR (p = .01). A significant negative correlation between kurtosis and ADC (r = -0.650, p = .022) was observed. Pre-treatment area under the ROC curves (AUC), to discriminate between pCR and PR + NR, was significantly higher for kurtosis (0.861, p = .001) and Ve (0.861, p = .003) compared to all other parameters. The optimal cutoff value for pre-treatment kurtosis and Ve was ≤0.19 (100% sensitivity, 67% specificity) and ≤0.311 (83% sensitivity, 83% specificity), respectively., Conclusion: Pre-treatment kurtosis derived from T2w images and Ve from pMRI have the potential to act as imaging biomarkers of rectal cancer response to neoadjuvant CRT.

Background: The aim of this study was to evaluate treatment-related toxicity and clinical outcomes of total body irradiation (TBI) in patients with acute lymphoblastic leukemia (ALL)., Patients and Methods: We performed a retrospective review of all patients with ALL who underwent TBI-based conditioning regimen at our Institution between 2000 and 2012., Results: A total of 211 patients were included. The median follow-up was 40 months. The 5-year overall survival and disease-free survival were 64.7% and 62.8%, respectively. The 5-year overall survival rate for the 163 children was 67.6% (95% confidence interval=55-77%). Disease status at time of transplant did not improve disease-free survival. Gastrointestinal acute toxicity was the most common early side-effect (19.9%). Acute graft-versus-host disease was reported in 31 patients (14.7%). Main late toxicities were cataract induction (12.8%) and growth, gonadal and endocrine effects (36%)., Conclusion: TBI-based conditioning regimen led to a high survival rate with remarkably low radiation-related toxicity, suggesting that TBI provides a feasible therapeutic option in patients with ALL., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Aim: To compare gross tumor volume (GTV) definition in locally advanced head and neck squamous cell carcinoma (LAHNSCC) using diffusion-weighted magnetic resonance imaging (DW-MRI) and computed tomography (CT) with intravenous contrast., Patients and Methods: Patients with LAHNSCC were imaged with CT and DW-MRI before treatment. GTV was delineated in both CT and DW-MRI images by two investigators. CT and MRI images were co-registered and volume data were extracted for statistical analysis., Results: In general, DW-MRI volumes [based on the apparent diffusion coefficient (ADC)] were smaller than CT-based volumes. For all patients, GTV delineation based on pre-treatment DW-MRI was significantly smaller than that based on CT scan (CT-GTV) (p=0.0078). The mean difference (95% limits of agreement) between the two investigators was -0.37 cm(3) for CT-GTV and 0.17 cm(3) for ADC-GTV measurements, respectively., Conclusion: DW-MRI radiotherapy GTVs are smaller than CT-based targets with less interobserver variability. Further validation of these preliminary results is necessary in a much larger patient group., (Copyright© 2016 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

The increasing growth of population with cardiac implantable electronic devices (CIEDs) such as Pacemaker (PM) and Implantable Cardiac Defibrillators (ICD), requires particular attention in management of patients needing radiation treatment. This paper updates and summarizes some recommendations from different international guidelines. Ionizing radiation and/or electromagnetic interferences could cause device failure. Current approaches to treatment in patients who have these devices vary among radiation oncology centres. We refer to the German Society of Radiation Oncology and Cardiology guidelines (ed. 2015); to the Society of Cardiology Australia and New Zealand Statement (ed. 2015); to the guidelines in force in the Netherlands (ed. 2012) and to the Italian Association of Radiation Oncology recommendations (ed. 2013) as reported in the guidelines for the treatment of breast cancer in patients with CIED. Although there is not a clear cut-off point, risk of device failure increases with increasing doses. Cumulative dose and pacing dependency have been combined to categorize patients into low-, medium- and high-risk groups. Measures to secure patient safety are described for each category. The use of energy ≤6MV is preferable and it's strongly recommended not to exceed a total dose of 2 Gy to the PM and 1 Gy for ICD. Given the dangers of device malfunction, radiation oncology departments should adopt all the measures designed to minimize the risk to patients. For this reason, a close collaboration between cardiologist, radiotherapist and physicist is necessary.

Purpose: To report the long-term follow-up data and determine the toxicity rate concerning patients with locally advanced rectal cancer (LARC) treated with an intensified neoadjuvant treatment regimen., Patients and Methods: Patients with histologically proven stage II to III adenocarcinoma of the rectum were included and treated with a trimodal approach. Intensified neoadjuvant treatment (chemoradiotherapy [CRT]) consisted of radiotherapy (total dose 50.4/54 Gy) and concomitant oxaliplatin (50 mg/m(2)/week) and 5-fluorouracil (200 mg/m(2)/5 daily continuous infusion). Surgery was planned 7 to 9 weeks after the end of CRT. Adjuvant chemotherapy was recommended in those patients with lymph node metastasis at diagnosis., Results: One hundred patients (median age, 64 years) were eligible. Overall, the 5-year overall survival and disease-free survival (DFS) were 76.4% and 74.5%, respectively. CRT was well tolerated, with only 17% grade 3/4 acute toxicity. Twenty-four patients (24%) had a pathologic complete response (pCR), and only 1 patient had perioperative metastasis. The 5-year DFS were 95.7% and 66.7% for pCR and no-pCR tumor histology, respectively (P = .0275)., Conclusion: Although oxaliplatin is not considered to be a standard treatment, the high 5-year rate of overall survival and DFS, the low severe toxicity rates, and the effective benefit on pCR and perioperative metastasis support an intensified treatment regimen for LARC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Predictive factors of pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT) in locally advanced rectal cancer (LARC) are still not identified. The purpose of this study was to define them., Materials and Methods: Data from consecutive LARC patients treated between January 2008 and June 2014 at our Institution were included in the analysis. All patients were treated with a long course of nCRT. Demographics, initial diagnosis and tumor extension details, as well as treatment modalities characteristics were included in the univariate and logistic regression analysis., Results: In total 99 patients received nCRT, of whom 23 patients (23.2%) achieved pCR. Patients with and without pCR were similar in term of age, sex, comobidities, BMI and tumor characteristics. Multivariate logistic regression indicated that pre-treatment tumor size ≤ 5 cm was a significant predictor for pCR (p = 0.035), whereas clinical N stage only showed a positive trend (p = 0.084)., Conclusions: Tumor size at diagnosis could be used to predict pCR, and thus to individualize therapy in LARC patients management. Validation in other studies is needed., Competing Interests: The authors declare that they have no competing interests.

Background: To analyze the efficacy and toxicity of bevacizumab on survival outcomes in recurrent ovarian cancer., Results: Bevacizumab was associated with significant improvement of PFS and OS compared with standard treatment with HRs of 0.53 (95% CI 0.44 - 0.63; p < 0.00001) and 0.87 (95% CI, 0.77 to 0.99; p = 0.03), respectively.Bevacizumab increased the incidence of G3/G4 hypertension (RR 19.01, 95% CI 7.77 - 46.55; p < 0.00001), proteinuria (RR 17.31, 95% CI 5.42 - 55.25; p < 0.00001), arterial thromboembolic events (ATE) (RR 4.99, 95% CI 1.29 - 19.27; p = 0.02) and bleeding (RR 3.14, 95% CI 1.35 - 7.32; p = 0.008)., Materials and Methods: Three randomized phase III trials representing 1502 patients were identified.Pooled hazard ratio (HR), odd ratio (OR), risk ratio (RR) with 95% confidence interval (CI) were calculated using fixed or random effects model., Conclusions: Adding bevacizumab to standard chemotherapy improved ORR, PFS and OS, and it had a higher, but manageable, incidence of toxicities graded 3 to 4.

Chyle leak after neck dissection is a relatively rare complication in head and neck cancer scenario.This review summarizes the basic knowledge of chyle leak underlying the potential benefit induced by low-dose radiation therapy and may serve as basis for future studies, necessary to optimize chyle leak management in head and neck cancer patients.

Background: Peritoneal metastasis (PM) is considered a terminal and incurable disease. In the last 30 years, cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) radically changed the therapeutic approach for these patients and is regarded as the standard of care for pseudomyxoma peritonei from appendiceal cancer and peritoneal mesotheliomas. Improved survival has also been reported in treating PM from ovarian, gastric, and colorectal cancers. However, PM often seriously complicates the clinical course of patients with other primary digestive and non-digestive cancers. There is increasing literature evidence that helped to identify not only the primary tumors for which CRS and HIPEC showed a survival advantage but also the patients who may benefit form this treatment modality for the potential lethal complications. Our goal is to report our experience with cytoreduction and HIPEC in patients with PM from rare or unusual primary tumors, discussing possible "unconventional" indications, outcome, and the peculiar issues related to each tumor., Methods: From a series of 253 consecutive patients with a diagnosis of peritoneal carcinomatosis and treated by CRS and HIPEC, we selected only those with secondary peritoneal carcinomatosis from rare or unusual primary tumors, excluding pseudomyxoma peritonei, peritoneal mesotheliomas, ovarian, gastric, and colorectal cancers. Complications and adverse effects were graded from 0 to 5 according to the WHO Common Toxicity Criteria for Adverse Events (CTCAE). Survival was expressed as mean and median., Results: We admitted and treated by CRS and HIPEC 28 patients with secondary peritoneal carcinomatosis from rare or unusual primary tumors. Morbidity and mortality rates were in line with those reported for similar procedures. Median survival for the study group was 56 months, and 5-year overall survival reached 40.3 %, with a difference between patients with no (CC0) and minimal (CC1) residual disease (52.3 vs. 25.7), not reaching statistical significance. Ten patients are alive disease-free, and eight are alive with disease., Conclusions: Cytoreduction and HIPEC should not be excluded "a priori" for the treatment of peritoneal metastases from unconventional primary tumors. This combined therapeutic approach, performed in an experienced center, is safe and can provide a survival benefit over conventional palliative treatments.

In the era of personalized medicine, head and neck squamous cell carcinoma (HNSCC) represents a critical oncologic topic. Conventional chemotherapy regimens consist of drugs administration in cycles near or at the maximum tolerated dose (MDT), followed by a long drug-free period to permit the patient to recover from acute toxicities. Despite this strategy is successful in controlling the cancer process at the beginning, a significant number of HNSCC patients tend to recurred or progress, especially those patients with locally advanced or metastatic disease. The repertoire of drugs directed against tumor cells has greatly increased and metronomic chemotherapy (MC) could be an effective treatment option.It is the purpose of this article to review the concept of MC and describe its potential use in HNSCC. We provide an update of ongoing progress and current challenges related to this issue.

Background: Women with BRCA1 and BRCA2 mutations have substantially elevated risk of developing breast cancer. The aim of this study was to clarify the role of bilateral risk-reducing mastectomy (BRRM) in reducing breast cancer risk in women carriers of BRCA1 and BRCA2 mutations., Methods: The Pubmed, MEDLINE and Scopus databases were searched to retrieve articles written in the English language. Two investigators independently extracted the characteristics and results of the selected studies. Only prospective trials with available absolute numbers of breast cancer and death events were included. Pooled hazard ratio (HR) with 95 % confidence interval (CI) was calculated using fixed or random effects model., Results: Meta-analysis of four prospective studies, including 2635 patients, demonstrated a significant risk reduction of breast cancer incidence in BRCA1 and BRCA2 mutation carriers receiving BRRM (HR 0.07; 95 % CI 0.01-0.44; p = 0.004). Among patients without previous risk-reducing salpingo-oophorectomy, a significant benefit was similarly recorded (HR 0.06; 95 % CI 0.01-0.41; p = 0.005)., Conclusions: Performing BRRM may lead to highly significant risk reduction of breast cancer in BRCA1 and BRCA2 mutation carriers. These data allow clinicians to discuss more in-depth with patients all the available options in order to design better management strategies.

Aneurysms of the anterior tibial artery are rare. We will describe a case of a woman with an asymptomatic true aneurysm of the anterior tibial artery. The patient presented with a pulsatile mass in the lateral face of the distal portion of the left leg, and both ultrasound examination and computed tomography angiography scan showed a giant aneurysm of the anterior tibial artery. We chose open treatment., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine whether texture features of rectal cancer on T2-weighted (T2w) magnetic resonance images can predict tumoral response in patients treated with neoadjuvant chemoradiotherapy (CRT)., Materials and Methods: We prospectively enrolled 15 consecutive patients (6 women, 63.2 ± 13.4 years) with rectal cancer, who underwent pretreatment and midtreatment 3-T magnetic resonance imaging. Treatment protocol consisted of neoadjuvant CRT with oxaliplatin and 5-fluorouracile. Texture analysis using a filtration-histogram technique was performed using a commercial research software algorithm (TexRAD Ltd, Somerset, England, United Kingdom) on unenhanced axial T2w images by manually delineating a region of interest around the tumor outline for the largest cross-sectional area. The technique selectively filters and extracts textures at different anatomic scales followed by quantification of the histogram using kurtosis, entropy, skewness, and mean value of positive pixels. After CRT, all patients underwent complete surgical resection and the surgical specimen served as the gold standard., Results: Six patients showed pathological complete response (pCR), and 4 patients, partial response (PR). Five patients were classified as nonresponders (NRs). Pretreatment medium texture-scale quantified as kurtosis was significantly lower in the pCR subgroup in comparison with the PR + NR subgroup (P = 0.01). Midtreatment kurtosis without filtration was significantly higher in pCR in comparison with PR + NR (P = 0.045). The change in kurtosis between midtreatment and pretreatment images was significantly lower in the PR + NR subgroup compared with the pCR subgroup (P = 0.038). Pretreatment area under the receiver operating characteristic curves, to discriminate between pCR and PR + NR, was significantly higher for kurtosis (0.907, P < 0.001) compared with all other parameters. The optimal cutoff value for pretreatment kurtosis was 0.19 or less. Using this value, the sensitivity and specificity for pCR prediction were 100% and 77.8%, respectively., Conclusion: Texture parameters derived from T2w images of rectal cancer have the potential to act as imaging biomarkers of tumoral response to neoadjuvant CRT.

Ovarian cancer is the most important cause of gynecological cancer-related mortality, with the majority of women presenting with advanced disease. Although surgery and chemotherapy can improve survival rates, it is necessary to integrate alternative strategies to improve the outcomes. Advances in understanding the role of immune system in the pathogenesis of cancer have led to the rapid evolvement of immunotherapy, which might establish a sustained immune system response against recurring cancer cells. Recently, it has emerged that powerful immunologic effector cells may be blocked by inhibitory regulatory pathways controlled by specific molecules often called "immune checkpoints," which turn off the immune system. Similarly, cancer cells are able to use these checkpoints to avoid immune control and rejection. Inhibition of these inhibitory pathways represents a potent strategy in the fight against cancer and is currently under investigation with encouraging results in some cancers, such as melanoma. In ovarian cancer researches are still in an early phase, but with promising results. In this review we will explore the rationale of immunotherapy in ovarian cancer with a special focus on these emerging molecules.

Rectal carcinoma represents the 30% of all colorectal cancers, with about 40000 new cases/years. In the past two decades, the management of rectal cancer has made important progress, highlighting the main role of a multimodality strategy approach, combining surgery, radiation therapy and chemotherapy. Nowadays, surgery remains the primary treatment and neo-adjuvant chemoradiotherapy, based on fluoropyrimidine (5-FU) continuous infusion, is considered the standard in locally advanced rectal carcinoma. The aim is to reduce the incidence of local recurrence and to perform a conservative surgery. To improve these purposes different drugs combination have been tested in the neo-adjuvant setting. At American Society of Clinical Oncology 2014 an important abstract was presented focusing on the role of adding oxaliplatin to concomitant treatment, in patients with locally advanced rectal carcinoma. Rodel et al reported on the CAO/ARO/AIO-04 randomized phase III trial that compared standard treatment with 5-FU and radiation therapy, to oxaliplatin plus 5-FU in association with radiation therapy. The addition of oxaliplatin to the neo-adjuvant treatment has been shown to improve disease-free survival from 71.2% to 75.9% (P = 0.03). This editorial was planned to clarify the optimal treatment in patients with locally advanced rectal cancer, considering the results from CAO/ARO/AIO-04 study.

Background: Women with BRCA1 and BRCA2 mutation carriers are at substantially elevated risk of developing ovarian cancer. The aim of the meta-analysis is to clarify the role of risk-reducing salpingo-oophorectomy (RRSO) to reduce ovarian cancer risk and mortality in women with BRCA 1 and BRCA 2 mutation carriers., Methods: Pubmed, Medline and Scopus were searched to select English-language articles. Two investigators independently extracted characteristics and results of selected studies. Articles were included only if prospective and if absolute numbers of ovarian cancer and death events were available or derivable from the test. Pooled hazard ratio (HR) with 95% confidence interval (CI) was calculated using fixed effects model., Results: Meta-analysis of 3 prospective studies demonstrated a significant risk reduction of ovarian cancer with RRSO in BRCA 1 and BRCA 2 mutation carriers, as well as benefit in all-causes mortality incidence., Conclusions: It may be justified to recommend RRSO to reduce ovarian cancer risk and all-causes mortality in women with a mutation in BRCA 1 and BRCA 2.

Systemic neo-adjuvant therapy plays a primary role in the management of locally advanced breast cancer. Without having any negative effect in overall survival, induction chemotherapy potentially assures a surgery approach in unresectable disease or a conservative treatment in technically resectable disease and acts on a well-vascularized tumor bed, without the modifications induced by surgery. A specific issue has a central function in the neo-adjuvant setting: lymph nodes status. It still represents one of the strongest predictors of long-term prognosis in breast cancer. The discussion of regional radiation therapy should be a matter of debate, especially in a pathological complete response. Currently, the indication for radiotherapy is based on the clinical stage before the surgery, even for the irradiation of the loco-regional lymph nodes. Regardless of pathological down-staging, radiation therapy is accepted as standard adjuvant treatment in locally advanced breast cancer.

Objective: To correlate 3-T magnetic resonance spectroscopic imaging (MRSI) with prostate-specific antigen (PSA) levels in patients with prostate cancer treated with external beam radiation therapy to assess the potential advantages of MRSI., Materials and Methods: A total of 50 patients (age range 65-83 years) underwent PSA and MRSI surveillance before and at 3, 6, 12, 18 and 24 months after radiotherapy., Results: Of the 50 patients examined, 13 patients completely responded to therapy showing metabolic atrophy (MA), defined as a choline-plus-creatine/citrate (CC/C) ratio <0.2, at 3 months; in this group none had biochemical relapse (PSA nadir + 2 ng/mL) by the end of the follow-up. Of the 50 patients, 35 showed a partial response to therapy (CC/C ratio between 0.2 and 0.8) at 3 and 6 months and, of these 35 patients, 30 reached MA at 12 months, while five developed a recurrence (CC/C ratio >0.8). Three of those patients with recurrence had a biochemical relapse at 18 months and the other two at 24 months. Two of the 50 patients did not respond to the treatment, showing persistent disease from the 3rd month (CC/C ratio >0.8); one patient had biochemical relapse at 6 and the other at 12 months., Conclusions: MRSI was shown to have a greater potential than PSA level in monitoring patients after radiotherapy, because it anticipates PSA nadir, and biochemical relapse in particular., (© 2013 The Authors. BJU International © 2013 BJU International.)

Brain metastases represent an important healthcare problem. Approximately 20%-40% of patients develop disease metastatic to the brain over the course of their cancer history. Palliative treatment of brain metastases requires for immediate control and, at least temporarily, a remission of the symptoms because many of the symptoms associated with brain metastases reduce the patient's quality of life. Radiation therapy is used to treat this clinical circumstance. The aim of this review is to assess the efficacy and the toxicity of radiotherapeutic treatment approaches and to provide treatment recommendation for brain metastases., (Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Due to substantial improvement in diagnosis and treatment of oral cavity cancer, a better understanding of the patient care needs to be revised. We reviewed literature related to OCC and discussed current general management approaches and related long-term radiation toxicities to emphasize the multidisciplinary team involvement. New technical modalities and patient quality of life parameters should be an integral and paramount state in the clinical evaluation to significantly contribute to reduce secondary side effects.

Pancreatoduodenectomy remains the recommended treatment in potentially curative strategies for pancreatic carcinoma. Due to high local failure rates even after complete resection, a multi-modality treatment approach is paramount in the management of resectable disease. Despite there being insufficient evidence to recommend a specific neoadjuvant strategy, several studies have tested the use of preoperative chemoradiotherapy in this sub-group of patients, achieving promising results. The treatment is well-tolerated, with higher rates of negative margins and lower rates of lymph node positivity at resection, a decrease in local failure and benefit in overall survival. Considering the poor oncological results after primary surgical treatment, neoadjuvant strategy should be considered as a valid alternative in resectable pancreatic carcinoma., (Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Aim: To compare toxicity profiles of two different intensity-modulated radiation therapy (IMRT) strategies in patients with high-risk prostate cancer., Patients and Methods: From May 2010 to September 2012, 43 patients with high-risk prostate cancer were treated with IMRT and concurrent hormone therapy; 23 patients were treated by conventional fractionation (IMRT/C) and 20 patients by simultaneous integrated boost (IMRT/SIB). Acute and late toxicities were compared for each group., Results: Severe acute genitourinary toxicity was recorded in 8.6% and 2% of patients in the IMRT/C and IMRT/SIB group, respectively. Genitourinary toxicity G2 was observed in 39.1% (IMRT/C group) and 25% (IMRT/SIB group) of patients. Severe acute gastrointestinal toxicity was not observed; Grade 2 acute gastrointestinal toxicity was recorded in 21.7% (IMRT/C group) and 10% (IMRT/SIB group). Grade 2 late genitourinary toxicity was observed in 26% (IMRT/C group) and 15% (IMRT/SIB group), whereas G2 late gastrointestinal toxicity in 34.5% and 30% of patients, respectively. No significant differences in incidence and severity of genitourinary and gastrointestinal toxicity were detected between the two IMRT treatment strategies., Conclusion: IMRT/SIB was well-tolerated with favorable rates of acute and late toxicity, both genitourinary and gastrointestinal. Compared to IMRT/C, IMRT/SIB maintained the same efficacy and reduced the overall treatment time., (Copyright© 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Aim: The aim of our study was to evaluate the earlier and long term survival as well the postoperative complications in high-risk patients who received endovascular aortic repair (EVAR) as first choice, or open repair when anatomical requirements for EVAR were not met., Methods: Between January 2005 and January 2010, 593 patients underwent procedures for elective abdominal aortic aneurysm (AAA) repair; 172 of these were considered at high risk according to the American Society of Anesthesiology (ASA) score (ASA III and IV): 150 high-risk patients were males (mean age 72.7, range 53-93 years) and 22 females (mean age 72.9 years, range 60-90 years). The median AAA diameter was 64 (53-75) mm in the open repair group and 62 (55-70) mm in the EVAR group. 121 patients underwent open repair and 51 EVAR, respectively., Results: The 30-day mortality rate was 0% in the EVAR group and 2.4% (3/121) in the open repair group (P=0.26). Long-term results showed: no EVAR-related mortality, no late conversion to open repair in the EVAR group was required during follow-up. No aneurysmal expansion was observed. In the open repair group, no graft-related events were observed during follow-up. The mean follow-up for survival analysis was 1542 days. Overall 5-year survival was 71.7% (SE=4.2%). Survival during follow-up was 92.2%, 86.1%, 76.2%, 65.9% and 61.8% at 12, 24,36,48,60 months respectively in EVAR Group. Open Group present long term survival of 95%, 88.9%, 83.9%, 79.7%, 76% at 12, 24, 36, 48, 60 months respectively., Conclusion: Our results in open repair surgery show a perioperative low mortality rate with high survival rate in long term. This result could be successfully achieved even in high-risk patients unsuitable for EVAR.

Anal canal carcinoma is a rare gastro-intestinal cancer. Radiochemotherapy is the recommended primary treatment for patients with non-metastatic carcinoma; surgery is generally reserved for persistent or recurrent disease. Follow-up and surveillance after primary treatment is paramount to classify patients in those with complete remission, persistent or progressive disease. Locally persistent disease represents a clinically significant problem and its management remains subject of some controversy.The aim of this systematic review is to summarise recommendations for the primary treatment of anal canal carcinoma, to focus on the optimal time to consider residual disease as genuine persistence to proceed with salvage treatment, and to discern how this analysis might inform future clinical trials in management in this class of patients.

Currently the diagnosis of local recurrence of prostate cancer (PCa) after radical prostatectomy (RT) is based on the onset of biochemical failure which is defined by two consecutive values of prostate-specific antigen (PSA) higher than 0.2 ng/mL. The aim of this paper was to review the current roles of advanced imaging in the detection of locoregional recurrence. A nonsystematic literature search using the Medline and Cochrane Library databases was performed up to November 2013. Bibliographies of retrieved and review articles were also examined. Only those articles reporting complete data with clinical relevance for the present review were selected. This review article is divided into two major parts: the first one considers the role of PET/CT in the restaging of PCa after RP; the second part is intended to provide the impact of multiparametric-MRI (mp-MRI) in the depiction of locoregional recurrence. Published data indicate an emerging role for mp-MRI in the depiction of locoregional recurrence, while the performance of PET/CT still remains unclear. Moreover Mp-MRI, thanks to functional techniques, allows to distinguish between residual glandular healthy tissue, scar/fibrotic tissue, granulation tissue, and tumour recurrence and it may also be able to assess the aggressiveness of nodule recurrence.

Treatment of anorectal Buschke-Löwenstein tumor (BLT) with squamous cell carcinoma (SCC) transformation is not univocal given the rarity of the disease. BLT is characterized by its large size and tendency to infiltrate into underlying tissues. Malignant transformation can occur and it is important to identify the presence of neoplastic foci to decide the proper treatment. Our aim was to assess the effectiveness of neo-adjuvant chemo-radiation therapy (CRT) and local excision in order to avoid abdomino-perineal resection (APR). Three cases of anorectal BLT with SCC transformation are presented. All patients were HIV positive and treated with antiretroviral drugs. They underwent preoperative endoanal ultrasound, biopsies, total body tomography and anal brushing. Treatment consisted of neo-adjuvant chemo-radiation therapy (45 Gy to the pelvis plus a boost with 14.40 Gy to the primary tumor for a total of 59.40 Gy, and mitomycin-C in bolus on the first day, plus 5-fluorouracil by continuous infusion in the first and in the sixth week) and subsequent local surgical excision. During the follow-up, patients were subjected to the same preoperative diagnostic investigations and high resolution anoscopy. All patients showed a complete regression of the lesion after CRT and were treated by local surgical excision, thus avoiding permanent colostomy. In conclusion neo-adjuvant chemo-radiation therapy with local surgical excision could be considered an effective therapy in the treatment of anorectal BLT with SCC transformation to avoid APR.

Aim: To test if fotemustine administrated at low doses during the maintenance phase of gioblastoma therapy could improve the toxicity profile, without reducing progression-free survival at six months (PFS-6)., Patients and Methods: Patients enrolled were affected by recurrent glioblastoma multiforme, proven by magnetic resonance imaging (MRI), at least six months after radiochemotherapy completion. Fotemustine was administered at an induction dose of 100 mg/m(2) followed by a maintenance dose of 75 mg/m(2)., Results: All 15 patients completed the induction phase. Eight patients began maintenance-phase therapy and received a median of three cycles (range=2-6). Grade 3 or more haematological toxicity was not documented. The PFS-6 was 5/15 and the median overall survival was 7.5 months., Conclusion: Haematological toxicity compares favourably with trials using the conventional scheme: no grade 3-4 adverse effects were recorded. This low-dose approach could be considered a compromise treatment whilst waiting for definitive standardization of second-line therapy, in order to reduce severe hematological toxicity.

Objectives: To validate the role of 3-T diffusion-weighted imaging (DWI) in the detection of local prostate cancer recurrence after radical prostatectomy (RP)., Methods: T2-weighted imaging, DWI and dynamic contrast-enhanced MRI (DCE-MRI) were performed with a 3-T magnet in 262 patients after RP. Twenty out of 262 patients evaluated were excluded. MRI results were validated by prostate-specific antigen (PSA) reduction after external beam radiotherapy in group A (126 patients, local recurrence size range 4-8 mm) and by transrectal ultrasound biopsy in group B (116 patients, local recurrence size range 9-15 mm)., Results: In group A combined T2-weighted and DCE-MRI (T2+DCE) shows 98 % sensitivity, 94 % specificity and 93 % accuracy in identifying local recurrence; combined T2-weighted and DWI with a b value of 3,000 s/mm(2) (T2+DW3) displays 97 % sensitivity, 95 % specificity and 92 % accuracy, while with a b value of 1,000 s/mm(2) (T2+DW1) affords 93 % sensitivity, 89 % specificity and 88 % accuracy. In group B T2+DCE shows 100 % sensitivity, 97 % specificity and 91 % accuracy in detecting local cancer recurrence; T2+DW3 displays 98 % sensitivity, 96 % specificity and 89 % accuracy; T2+DW1 has 94 % sensitivity, 92 % specificity and 86 % accuracy., Conclusion: DCE-MRI is the most reliable technique in detecting local prostate cancer recurrence after RP, though DWI can be proposed as a reliable alternative., Key Points: • Diffusion-weighted magnetic resonance imaging (DWI-MRI) is being increasingly used in oncology. • PSA analysis does not distinguish prostate cancer recurrence from distant metastasis. • DWI-MR can diagnose local prostate cancer recurrence after radical prostatectomy. • DWI-MR is almost comparable to DCE-MRI in detecting local recurrence.

Aim: To investigate whether neoadjuvant-intensified radiochemotherapy improved overall and disease-free survival in patients with locally advanced rectal cancer., Methods: Between January 2007 and December 2011, 80 patients with histologically confirmed rectal adenocarcinoma were enrolled. Tumors were clinically classified as either T3 or T4 and by the N stage based on the presence or absence of positive regional lymph nodes. Patients received intensified combined modality treatment, consisting of neoadjuvant radiation therapy (50.4-54.0 Gy) and infusional chemotherapy (oxaliplatin 50 mg/m(2)) on the first day of each week, plus five daily continuous infusions of fluorouracil (200 mg/m(2) per die) from the first day of radiation therapy until radiotherapy completion. Patients received five or six cycles of oxaliplatin based on performance status, clinical lymph node involvement, and potential risk of a non-sphincter-conserving surgical procedure. Surgery was planned 7 to 9 wk after the end of radiochemotherapy treatment; adjuvant chemotherapy treatment was left to the oncologist's discretion and was recommended in patients with positive lymph nodes. After treatment, all patients were monitored every three months for the first year and every six months for the subsequent years., Results: Of the 80 patients enrolled, 75 patients completed the programmed neoadjuvant radiochemotherapy treatment. All patients received the radiotherapy prescribed total dose; five patients suspended chemotherapy indefinitely because of chemotherapy-related toxicity. At least five cycles of oxaliplatin were administered to 73 patients. Treatment was well tolerated with high compliance and a good level of toxicity. Most of the acute toxic effects observed were classified as grades 1-2. Proctitis grade 2 was the most common symptom (63.75%) and the earliest manifestation of acute toxicity. Acute toxicity grades 3-4 was reported in 30% of patients and grade 3 or 4 diarrhoea reported in just three patients (3.75%). Seventy-seven patients underwent surgery; low anterior resection was performed in 52 patients, Miles' surgery in 11 patients and total mesorectal excision in nine patients. Fifty patients showed tumor downsizing ≥ 50% pathological downstaging in 88.00% of tumors. Out of 75 patients surviving surgery, 67 patients (89.33%) had some form of downstaging after preoperative treatment. A pathological complete response was achieved in 23.75% of patients and a nearly pathologic complete response (stage ypT1ypN0) in six patients. An involvement of the radial margin was never present. During surgery, intra-abdominal metastases were found in only one patient (1.25%). Initially, 45 patients required an abdominoperineal resection due to a tumor distal margin ≤ 5 cm from the anal verge. Of these patients, only seven of them underwent Miles' surgery and sphincter preservation was guaranteed in 84.50% of patients in this subgroup. Fourteen patients received postoperative chemotherapy. In the full analysis of enrolled cohort, eight of the 80 patients died, with seven deaths related to rectal cancer and one to unrelated causes. Local recurrences were observed in seven patients (8.75%) and distant metastases in 17 cases (21.25%). The five-year rate of overall survival rate was 90.91%. Using a median follow-up time of 28.5 mo, the cumulative incidence of local recurrences was 8.75%, and the overall survival and disease-free survival rates were 90.00% and 70.00%, respectively., Conclusion: The results of this study suggest oxaliplatin chemotherapy has a beneficial effect on overall survival, likely due to an increase in local tumor control.

Introduction: Our interest was to monitor treatment response using ADC value to predict response of rectal tumour to preoperative radiochemotherapy., Materials and Methods: Twenty-two patients were treated with long course of radiochemotherapy, followed by surgery. Patients were examined by diffusion-weighted imaging MRI at three-time points (prior, during, and after radiochemotherapy) and were classified as responders and nonresponders., Results: A statistical significant correlation was found between preradiochemotherapy ADC values and during treatment ADC values, in responders (F = 21.50, P value <0.05). An increase in ADC value during treatment was predictive of at least a partial response., Discussion: Response of tumour to neoadjuvant therapy cannot be easily evaluated, and such capability might be of great importance in clinical practice, because the number of irradiated and operated patients may be superior to the number of who will really benefit from this multimodal treatment. A reliable prediction of the final clinical TN stage would allow radiotherapist to adapt multidisciplinary approach to a less invasive management, sparing surgical procedure in responder patients or even allowing an early surgery in nonresponders, which would significantly reduce radiochemotherapy related toxicity. Conclusion. Early evaluation of response during neoadjuvant radiochemotherapy treatment shows great promise to predict tumour response.

Purpose: To evaluate the treatment tolerance and clinical outcomes in patients aged 70 and older with locally advanced rectal carcinoma treated with multimodality approach., Methods and Materials: We retrospectively analysed 20 consecutive elderly patients, with histologically proven rectal adenocarcinoma, staged T3-4, and/or node-positive tumour, who received chemoradiotherapy and proceeded to surgical approach. Performance status score and adult comorbidity evaluation-27 score were calculated, and their influence on treatment tolerance and clinical outcomes was analysed., Results: All patients completed programmed chemoradiotherapy treatment. Gastrointestinal toxicity was the most common acute side effects: proctitis in 70% of patients and diarrhoea in 55%, classified as Grade 3 in 3 patients only. Radiation dermatitis was reported in 7 patients (35%) and it was graded G3 in one patient. There was no haematological toxicity. Eighteen patients out of 20 underwent surgery. Sphincter preservation was assured in 13 patients. Comorbidity index was related to higher severe acute toxicity (P = 0.015) but no influenced treatment outcomes., Conclusion: Treatment tolerance with combined modality is good in elderly patients. Due to age, no dose reduction for radiation therapy and chemotherapy should be considered.

A desmoid tumor, also known as aggressive fibromatosis, is a rare benign neoplasm that arises from fascial or musculoaponeurotic tissues. It can occur in any anatomical location, most commonly the abdominal wall, shoulder girdle and retroperitoneum. The typical clinical presentation is a painless mass with a slow and progressive invasion of contiguous structures. It is associated with a high local recurrence rate after resection. Many issues regarding the optimal treatment of desmoid tumors remain controversial. Aggressive surgical resection with a wide margin (2-3 cm) remains the gold standard treatment with regard to preserving quality of life. Radiotherapy alone has been shown to be effective for the control of unresectable or recurrent lesions. Desmoid tumors tend to be locally infiltrative, therefore, the fields must be generous to prevent marginal recurrence. The radiation dose appropriate for treating desmoid tumors remains controversial. We present a 25-year-old Caucasian man with local recurrence of a desmoid tumor after repeated surgical resection, treated with radiotherapy. The patient achieved complete tumor regression at 4 mo after radiotherapy, and he is clinically free of disease at 12 mo after the end of treatment, with an acceptable quality of life. The patient developed short bowel syndrome as a complication of second surgical resection. Consequently, radiotherapy might have worsened an already present malabsorption and so led to steatohepatitis.

Purpose: The aim of our study was to evaluate the feasibility and the effectiveness of an intensified neoadjuvant protocol with the addition of weekly oxaliplatin in the preoperative strategy of rectal cancer treatment., Patients and Methods: Patients with locally advanced rectal cancer received continous infusion 5-Fluorouracil (5-FU) 200 mg/m(2)/day in combination with weekly oxaliplatin at a dose of 50 mg/m(2). Doses of radiotherapy were 45 Gy to the whole pelvis plus 5.4-9 Gy to the tumour mass. The primary end-points of the study were evaluation of toxicity, compliance with radiotherapy and chemotherapy, downstaging, pathological complete response (pCR) and the rate of sphincter preservation for distal cancers. Secondary end-points were relapse-free and overall survival., Results: From November 2006 to June 2009, 51 patients were enrolled into the study. Compliance with chemotherapy was 80%. The incidence of G3 diarrhoea and proctitis were 17.6% and 21.5%, respectively. Surgery was performed in 48 patients with 100% R0 resection. 76.4% of low-lying tumours underwent conservative treatment. Seventy-nine percent of patients were downstaged: T and N downstaging were observed in 71% and 75% of patients, respectively. A pCR was obtained in 11 (22.9%) patients., Conclusions: Intensification of neoadjuvant treatment for rectal cancer with the addition of weekly oxaliplatin is feasible, with remarkable rates of downstaging and pathological complete response. Data on sphincter preservation for distal cancers were excellent. Phase III trials with a longer follow-up will establish whether this good outcome in terms of surrogate end-points will translate into better rates of disease-free and overall survival.

In this report, we present a case of advanced squamous cell cancer located in the rectum of a 78-year-old woman treated with chemoradiation with curative intent. The patient showed a complete clinical response to chemoradiation; multiple biopsies were performed at the site of the previous mass 5 mo after the end of treatment and histological examination showed no residual tumour in the specimens. Surgical intervention was avoided and the patient was free of disease 12 mo after the diagnosis of cancer. Primary chemoradiation should be considered as the treatment of choice for this rare malignancy.

Purpose: The determination of the best therapeutic approach in extraperitoneal rectal cancer patients is very complex both in the neoadjuvant/adjuvant and the metastatic setting. We tried to identify and summarize the current methods of diagnosis, staging and treatment from a multidisciplinary approach., Methods: Five sections can be indentified: diagnosis and staging; neoadjuvant treatment; adjuvant treatment; liver metastases treatment and local recurrence therapy Data were collected from international guidelines (NCCN) and MEDLINE search. The main aim was the identification of the beast diagnostic and therapeutic approach in extraperitoneal rectal cancer patients in case of local recurrence and metastatic disease., Results: Data from 2010 NCCN guidelines and 48 articles published in major international oncologic reviews were collected and evaluated from 1993 up to 2009. Three articles dealt with staging procedures, 24 dealt with neoadjuvant and adjuvant therapy; 18 were about with liver metastases and 3 about local recurrence treatment., Conclusions: The correct disease staging is necessary for pursuing the best therapeutic approach and it should involve different radiological techniques in order to evaluate the clinic TNM. Neoadjuvant treatment (chemo-radiotherapy) should be considered for stage II and stage III extraperitoneal rectal cancer patients, followed by post-operative adjuvant chemotherapy. Patients who underwent surgery and have a post-operative stage II or III disease, have to receive four months of adjuvant chemotherapy after surgical resection. Initial treatment options of asymptomatic patient with resectable liver metases include systemic chemotherapy in' order to obtain downstaging of the primary tumor and liver metastase shrinking followed by resection. The treatment of local recurrence is mainly surgical. If not previously administered, radiotherapy represents an alternative therapeutic treatment.

Objectives: The aim of the current study was to compare a neoadjuvant regimen containing oxaliplatin with standard preoperative treatment for rectal cancer., Methods: From December 2006 to December 2007, 20 patients with rectal cancer were treated at our Institution with the weekly addition of oxaliplatin (50 mg/m(2)) to radiotherapy (50.4-54.0 Gy in 28-30 daily fractions) and continuous infusion of 5-fluorouracil (200 mg/m(2)). The results of the regimen were compared with a historical control group including 21 consecutive patients previously treated with standard 5-fluorouracil treatment from December 2004 to October 2006., Results: Both the rate of sphincter preservation in low rectal cancer (91.7% vs 36.4%, P = 0.009) and the rate of downstaging (84.2% vs 47.6%, P = 0.023) were higher in the oxaliplatin group than in the control group. Pathological complete response was achieved in 8 patients (42.1%) in the oxaliplatin group and in 4 patients (19.0%) in the control group (P = 0.172). When ypT0-pT1 stages were analyzed together, the P value was 0.051. Acute toxicity was increased in the oxaliplatin group, with a higher incidence of G3 diarrhea and pelvic pain than in the control group (30.0% vs 14.3%, P = NS)., Conclusions: Our data seem to correlate the addition of oxaliplatin to the standard treatment for rectal cancer with higher rates of sphincter preservation, down-staging and complete response. Toxicity is increased and requires careful monitoring. However, our results refer to a retrospective comparison of a small series of patients and need to be validated by the large, phase III randomized trial currently ongoing.

Patients undergoing radiotherapy for the treatment of Hodgkin' disease (HD) occurred at young age present a higher risk to develop second cancer compared to general population. Among the possible second tumours, breast cancer is the most frequent and the age at presentation is younger than the "classic" form. Patients at risk for second cancer undergo a strict follow-up permitting often to diagnose breast cancer at early stages (I-II).The aim of this work is to review the various therapeutic options for the treatment of breast cancer in patients previously irradiated for HD, with particular attention to the possibility of reirradiation of mammary tissue thanks to the new radiotherapy techniques developed in the last years.