Radiotherapy for Lung Cancer During the COVID Pandemic – A Narrative Review of Practical Recommendations

"Background: The coronavirus disease pandemic produced changes in the treatment approach of lung cancer patients. They represent a vulnerable population due to the negative impact of delays in diagnosis and treatment and also because of the impaired immune system. Radiation Therapy plays a crucial role in both curative and palliative settings, so finding the best approach for these patients in this context was attempted by many professionals. The aim of this study was to make a synthesis of the current published literature on this topic and summarize the recommendations. Material and methods: We searched the PubMed database for articles published between 20th December 2019 and 30th August 2020. We used 14 key words related to COVID 19 and Lung Cancer. The articles were selected by two senior clinicians who excluded overlapping information and prioritized original research reports and professional organization’s official recommendations. Results: There were 562 papers corresponding to the search criteria, of which 64 were analyzed. Treatment decision must be tailored according to the status of SARS CoV-2 positivity, the aim of the treatment (curative VS palliative), pathological type and clinical stage, disease complications, symptoms, prognostic, performance status, and alternative treatments. Hypofractionation is preferred whenever possible in order to minimize risk for patients and staff. Safety measures have to be implemented, with extra cautions if SARS CoV-2 positive patients have to be treated. Cone beam CT can be used early identification of lung infiltrates and special attention is recommended to differentiate Radiation pneumonitis from COVID-19 pneumonia. Journal of Medical and Radiation Oncology Journal homepage: www.jmedradonc.org Review 94 Conclusion: For SARS CoV-2 positive lung cancer patients the treatment should be postponed, until they are tested negative. For patients which are SARS CoV-2 negative treated with curative intent, hypofractionated schedules are preferred. Palliative treatments should be given according to the life threatening risk."

Proton re-irradiation of Sinonasal Esthesioneuroblastoma: a Case Report

"Head and neck (H&N) cancers are in the 7-8th place among all types of cancer. Despite novel approaches in cancer treatment, most of the patients have a high risk of loco-regional recurrence. Esthesioneuroblastoma (ENB) is a very rare H&N neoplasm, accounting for only 3-6% of all intranasal tumors. These tumors usually are presented with locally advanced stages and required radiotherapy as a part of the comprehensive treatment. Loco-regional failures represent a challenge, and re-irradiation can be effective for some groups of patients. We present a case of re-irradiation with protons of sinonasal tumor in a 49-years old patient with recurrent ENB, involving visual structures. We achieved a 5-year positive local control after the proton therapy (PT), without significant toxicity.The case shows an example of re-irradiation as an essential area for PT application,given the need to maximize the treatment's efficacy and minimize the risk of severetoxicity."

Hepatic Disfunction in Renal Cell Carcinoma: A Stauffer Syndrome Variant

Cholestatic jaundice is usually linked to a malignant disease when it is secondary to a mechanical obstruction of the bile duct or due to hepatic metastasis. As a paraneoplastic syndrome, cholestasis has been described in lymphoproliferative disorders, in prostate cancer and as the Stauffer syndrome with non-metastatic dysfunction in patients with renal cell carcinoma (RCC). We present the case of a 61 year old patient with a paraneoplastic manifestation with cholestatic jaundice due to RCC with kindney and lung metastases. Clinical characteristics of patients with RCC vary and sometimes manifest in a peculiar way. Cholestatic jaundice is a rare paraneoplastic syndrome associated with RCC and with the exclusion of more frequent causes, it should be taken into account in the differential diagnosis. This rare but possible association requires prompt recognition, as prognosis correlates with disease stage and influences patient’s overall survival, and an early recognition of this syndrome may improve, sometimes, patients’ outcome.

SARS-CoV-2 – the Hidden Agonist of the Pressor Arm Within the Renin-Angiotensin System: Considerations for Statins and Propionate Derivatives

"Coronavirus disease 2019 (COVID-19) has become a serious healthcare problem, causing more than 2 million fatalities worldwide. Several treatments used for the management of chronic diseases such as hypertension, cardiovascular disease, diabetes and arthritis were shown to increase the expression of the receptor exploited by the virus, the angiotensin-converting enzyme 2 (ACE2), in vitro. This raises concerns on the safety of continuing such drugs or switching to other classes that don’t interfere with the receptor exploited by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Here we emphasize the mechanisms behind the regulation of ACE2 expression by several widely used drugs with possible interactions with COVID-19. Moreover, we discuss how the physiological mechanisms of attenuating inflammation and fibrosis can lead to increased expression of the receptor exploited by the virus and how this expression is further influenced be statins, propionate derivative nonsteroidal antiinflamatory drugs (NSAIDs) and renin-angiotensin system (RAS) blockers."

A Case Report of EGFR-mutated Metastatic Lung Adenocarcinoma with Long-term Survival on Systemic Treatment

"Metastatic non-small cell lung cancer has historically been associated with a poor prognosis. The introduction of targeted agents against certain molecules involved in cellular pathways has shown improved responses, but long-term survivors are still rare. We present the case of a patient with lung adenocarcinoma harboring sensitizing EGFR mutations who showed an impressive survival of more than 9 years following a combination of systemic therapies consisting of cytotoxic drugs and EGFR TKIs that were very well tolerated."

Hypofractionated Postoperative Radiation Therapy for Breast Cancer – Do We Need More Evidence or Adapted Reimbursement Policies?

"More than 10 years ago, two pivotal trials, the Ontario Clinical Oncology Group trial and START B trial, firmly established that hypofractionated radiation therapy (RT) of 40–42.5 Gy in 15–16 fractions over 3 weeks after breast conserving surgery or mastectomy results in similar rates of local recurrence and normal tissue effects. This led to a new standard for postoperative whole breast and chest wall RT. Further trials confirmed these findings and show that hypofractionated RT can also be applied for other indications, including regional nodal RT and for ductal carcinoma in situ (DCIS). More recently, a so-called ultra-fractionation trial demonstrated that 26 Gy in 5 fractions over 1 week was non-inferior to 40 Gy, in 15 fractions in 3 weeks for local recurrence at 6 years and that late effects were similar between fractionation schedules being a treatment option for most patients with early breast cancer. Several countries and departments are now adopting hypofractionated schedules as a new standard for breast, chest wall or partial breast RT. In addition to the improvement in convenience and reduction in resources required, hypofractionated RT offers important benefits with respect to acute and late toxicity that can improve the quality of life of patients receiving breast RT."

Metastasis Directed Therapy and/or Systemic Therapy in Hormone-naive Oligometastatic Prostate Cancer Patient: an Emerging Dilemma

"The hormone-naive oligometastatic prostate cancer is a challenging setting for the radiation oncology community, as it represents a sort of transition scenario potentially suitable for two different approaches: a local ablative treatment alone vs a metastasisdirected treatment with the addition of hormone therapy. The choice to add androgen deprivation therapy in the oligorecurrent hormone-sensitive patient is a matter of debate, given the detrimental impact on quality of life and the number of adverse events. To date, there is no clear agreement on the optimal management of this subset of patients. As some authors highlight the attractiveness of a local approach alone, as well tolerated, easily repeatible and with very limited costs, on the other hand, other authors focus the need to cover the micrometastatic disease, often not detectable, even with the newly available imaging modalities. In this commentary, we briefly summarize the literature data in support of both therapeutic strategies."

Critical Issues in Melanoma Follow-up and Treatment, Safety of Patients and Communication with Healthcare Professionals During Covid-19 Pandemic in Romania

"Background: The Covid-19 pandemic has significantly impacted cancer care worldwide. The aim of this study was to capture the impact of Covid-19 on melanoma patients during the national state of emergency. Material and methods: We sent a survey to the members of the Romanian Melanoma patient community between April - May 2020. Results: We received feedback from 108 patients. Forty percent of the respondents experienced difficulties in accessing healthcare services, while 56% found it difficult or impossible to speak with their physician. With regard to feeling safe in healthcare facilities, 60% of patients felt safe in the private sector, versus 48% in public hospitals. Over half of the respondents delayed investigations such as dermoscopy, imaging, and laboratory tests by their own initiative, while a third saw investigation delayed upon their physician’s initiative. We found no significant delays in the administration of systemic therapies for advanced disease. While e-prescriptions for melanoma treatments were not communicated and implemented consistently, we noted an increased interest in telemedicine and social media networks by physicians. Spontaneous patient reports collected in the same period further show the lack of access to melanoma diagnostic surgery, insufficient management of side effects of different treatments, difficulties in obtaining pain medication, alterations in the administration schemes of both immunotherapies and target therapies, and cumbersome access to Covid-19 testing. Conclusions: Our results provide a melanoma-specific perspective on the impact of Covid-19 on patients that is unexpectedly nuanced with regards to patient subpopulations and captures differences in impact between systemic treatment and Journal of Medical and Radiation Oncology Journal homepage: www.jmedradonc.org Original research 16 other interventions. In addition, this proof-of-concept study demonstrates the ability of virtual patient communities to sensitively detect and report issues in health care provision, offering the opportunity for timely intervention. Based on our findings, we formulate a set of recommendations on how to save-guard melanoma care during the pandemic, some of which we believe to be generalizable to other patient communities."