Publications by authors named "Pierfrancesco Franco"

147 Publications

Radiotherapy with Intensity-Modulated (IMRT) Techniques in the Treatment of Anal Carcinoma (RAINSTORM): A Multicenter Study on Behalf of AIRO (Italian Association of Radiotherapy and Clinical Oncology) Gastrointestinal Study Group.

Cancers (Basel) 2021 Apr 15;13(8). Epub 2021 Apr 15.

Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University of Chieti-Pescara, 66100 Chieti, Italy.

A multi-institutional retrospective study was conducted to evaluate the pattern of care and clinical outcomes of anal cancer patients treated with intensity-modulated radiotherapy (IMRT) techniques. In a cohort of 987 patients, the clinical complete response (CR) rate (beyond 6 months) was 90.6%. The 3-year local control (LC) rate was 85.8% (95% CI: 84.4-87.2), and the 3-year colostomy-free survival (CFS) rate was 77.9% (95% CI: 76.1-79.8). Three-year progression-free survival (PFS) and overall survival (OS) rates were 80.2% and 88.1% (95% CI: 78.8-89.4) (95% CI: 78.5-81.9), respectively. Histological grade 3 and nodal involvement were associated with lower CR ( = 0.030 and = 0.004, respectively). A statistically significant association was found between advanced stage and nodal involvement, and LC, CFS, PFS, OS and event-free survival (EFS). Overall treatment time (OTT) ≥45 days showed a trend for a lower PFS ( = 0.050) and was significantly associated with lower EFS ( = 0.030) and histological grade 3 with a lower LC ( = 0.025). No statistically significant association was found between total dose, dose/fraction and/or boost modality and clinical outcomes. This analysis reports excellent clinical results and a mild toxicity profile, confirming IMRT techniques as standard of care for the curative treatment of anal cancer patients. Lymph node involvement and histological grade have been confirmed as the most important negative prognostic factors.
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http://dx.doi.org/10.3390/cancers13081902DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8071256PMC
April 2021

Treatment Volume, Dose Prescription and Delivery Techniques for Dose-intensification in Rectal Cancer: A National Survey.

Anticancer Res 2021 Apr;41(4):1985-1995

Radiation Oncology Unit, "SS Annunziata" Hospital, "G. D'Annunzio" University, Chieti, Italy.

Background/aim: The aim of the study was to investigate boost volume definition, doses, and delivery techniques for rectal cancer dose intensification.

Patients And Methods: An online survey was made on 25 items (characteristics, simulation, imaging, volumes, doses, planning and treatment).

Results: Thirty-eight radiation oncologists joined the study. Twenty-one delivered long-course radiotherapy with dose intensification. Boost volume was delineated on diagnostic magnetic resonance imaging (MRI) in 18 centres (85.7%), and computed tomography (CT) and/or positron emission tomography-CT in 9 (42.8%); 16 centres (76.2%) performed co-registration with CT-simulation. Boost dose was delivered on gross tumor volume in 10 centres (47.6%) and on clinical target volume in 11 (52.4%). The most common total dose was 54-55 Gy (71.4%), with moderate hypofractionation (85.7%). Intensity-modulated radiotherapy (IMRT) was used in all centres, with simultaneous integrated boost in 17 (80.8%) and image-guidance in 18 (85.7%).

Conclusion: A high quality of treatment using dose escalation can be inferred by widespread multidisciplinary discussion, MRI-based treatment volume delineation, and radiation delivery relying on IMRT with accurate image-guided radiation therapy protocols.
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http://dx.doi.org/10.21873/anticanres.14966DOI Listing
April 2021

Alexithymia and professional quality of life in radiation oncology: The moderator effect of the professional profile.

Radiother Oncol 2021 Feb 10;158:48-54. Epub 2021 Feb 10.

Department of Psychology, "ReMind the Body" Research Group, University of Turin, Italy.

Background And Purpose: Cancer care can be taxing. Alexithymia, a personality construct characterized by difficulties in identifying and describing feeling and emotions, an externally-oriented thinking style and scarcity of imagination and fantasy, is significantly correlated with higher levels of both secondary traumatic stress (STS) and burnout and lower levels of compassion satisfaction in medical professionals in radiation oncology. In this study, we aimed to assess the difference in professional quality of life (QoL) and the association with alexithymia in this multidisciplinary field depending on the specific profession (radiation/clinical oncologist, RO; medical physicist, MP; radiation therapist, RTT).

Material And Methods: The study was conducted via an online questionnaire, receiving 1500 submissions between May and October 2018. Alexithymia was assessed via the Toronto Alexithymia Scale (TAS-20) and professional QoL was evaluated using the Professional Quality of Life Scale (ProQoL) version 5. Comparisons between the RO, RTT, and MP groups were performed by ANOVA or MANOVA, followed by Bonferroni corrected ANOVAs for continuous variables, and Pearson's chi-square test for categorical variables. The effect size was determined by calculating partial eta-squared (η).

Results: Profession had a moderator role on the correlation between alexithymia and STS, with RO being at a higher risk than MP and RTT. Further, the results of this study demonstrate the relevant point prevalence of decreased well-being at work even for professional categories such as MP despite the more technical profile and reduced interaction with patients.

Conclusions: This study demonstrates the importance of alexithymia as a factor contributing to decreased professional QoL amongst radiation oncology professionals. Alexithymic ROs are impacted to a higher extent compared to MPs and RTTs by the indirect exposure to patients suffering. It is worth addressing these observations in professional education, aiming to improve QoL for healthcare personnel.
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http://dx.doi.org/10.1016/j.radonc.2021.01.033DOI Listing
February 2021

The Prognostic Value of the New Combined Hemo-Eosinophil Inflammation Index (HEI Index): A Multicenter Analysis of Anal Cancer Patients Treated with Concurrent Chemo-Radiation.

Cancers (Basel) 2021 Feb 7;13(4). Epub 2021 Feb 7.

Department of Oncology, IRCCS San Raffaele Scientific Institute Hospital, 20019 Milan, Italy.

Anal squamous cell carcinoma (SCC) is a rare tumor, and bio-humoral predictors of response to chemo-radiation (CT-RT) are lacking. We developed a prognostic score system based on laboratory inflammation parameters. We investigated the correlation between baseline clinical and laboratory variables and disease-free (DFS) and overall (OS) survival in anal SCC patients treated with CT-RT in five institutions. The bio-humoral parameters of significance were included in a new scoring system, which was tested with other significant variables in a Cox's proportional hazard model. A total of 308 patients was included. We devised a prognostic model by combining baseline hemoglobin level, SII, and eosinophil count: the Hemo-Eosinophils Inflammation (HEI) Index. We stratified patients according to the HEI index into low- and high-risk groups. Median DFS for low-risk patients was not reached, and it was found to be 79.5 months for high-risk cases (Hazard Ratio 3.22; 95% CI: 2.04-5.10; < 0.0001). Following adjustment for clinical covariates found significant at univariate analysis, multivariate analysis confirmed the HEI index as an independent prognostic factor for DFS and OS. The HEI index was shown to be a prognostic parameter for DFS and OS in anal cancer patients treated with CT-RT. An external validation of the HEI index is mandatory for its use in clinical practice.
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http://dx.doi.org/10.3390/cancers13040671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7914854PMC
February 2021

Decreasing treatment burden in HPV-related OPSCC: A systematic review of clinical trials.

Crit Rev Oncol Hematol 2021 Apr 29;160:103243. Epub 2021 Jan 29.

Department of Oncology, Radiation Oncology, University of Turin, Turin, Italy.

Introduction: Favorable outcomes are observed after treatment with standard chemoradiotherapy (CRT) for Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) patients. The consistent growing interest on treatment-related toxicity burden, potentially jeopardizing survivors' quality of life, led clinicians to investigate possible de-escalation strategies.

Materials And Methods: A comprehensive systematic literature search of clinical trials was performed through the EMBASE database to provide an overview of the de-escalation strategies spectrum. Additionally, hand searching and clinicaltrials.gov were also used.

Results: Herein, we report and discuss different approaches to de-escalation of therapy, with respect to both local and systemic strategies.

Conclusions: Several promising de-escalation experiences have been published. However, while further evidence is awaited, no changes in the management nor deviation from the standard of care should be made outside of clinical trials.
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http://dx.doi.org/10.1016/j.critrevonc.2021.103243DOI Listing
April 2021

Radiation treatment for adult rare cancers: Oldest and newest indication.

Crit Rev Oncol Hematol 2021 Mar 27;159:103228. Epub 2021 Jan 27.

Radiation Oncology Department, Azienda Ospedaliera San Camillo-Forlanini, Roma, Italy.

Aim: Aim of this analysis is to review the role of RT in the management of several rare tumors for adult patients.

Methods: Collection data regarding RT and rare tumors was made by Pubmed.

Results: For mucosal melanomas, RT is prescribed, being associated with lower local recurrence rate. For trachea tumors, RT was used as adjuvant or salvage treatment for unresectable disease. For pNET, RT can be a suitable option for post-surgical or unresectable/borderline. For bronchopulmonary neuroendocrine tumors the role of adjuvant treatments is uncertain. For hepatobiliary and ovarian malignancy, stereotactic body RT (SBRT) is a promising approach. For soft tissue sarcoma, perioperative treatments are indicated, and a growing role of SBRT in oligometastatic disease is recognized. For endocrine tumors, adjuvant RT has demonstrated benefits through reducing recurrence risk.

Conclusion: The radiotherapy is a frequent indication in adult rare cancers; thus the role of Radiation Oncologist must not be neglected.
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http://dx.doi.org/10.1016/j.critrevonc.2021.103228DOI Listing
March 2021

Professional quality of life and burnout among medical physicists working in radiation oncology: The role of alexithymia and empathy.

Phys Imaging Radiat Oncol 2020 Jul 15;15:38-43. Epub 2020 Jul 15.

European Society for Radiotherapy&Oncology (ESTRO) Young Committee, Brussels, Belgium.

Background And Purpose: The professional quality of life of radiation oncology professionals can be influenced by different contributing factors, including personality traits. Alexithymia involves deficits in emotion processing and awareness. Empathy is the ability to understand another's 'state of mind/emotion'. We investigated professional quality of life, including burnout, in radiation oncology, exploring the role of alexithymia and empathy and targeting the population of medical physicists (MPs), since this professional category is usually underrepresented in surveys exploring professional well-being in radiation oncology and MPs may experience professional distress given the increasing complexity of multimodal cancer care.

Material And Methods: An online survey was addressed to ESTRO members. Participants filled out three questionnaires to evaluate alexithymia, empathy and professional quality of life: a) Toronto Alexithymia Scale (TAS-20); b) Interpersonal Reactivity Index (IRI); c) Professional Quality of Life Scale (ProQoL). Professional quality of life as per ProQoL was considered as dependent variable. The three domains of the ProQoL, namely compassion satisfaction (CS), secondary traumatic stress (STS) and burnout were correlated with alexithymia (as per TAS-20) and empathy (as per IRI with three subcategories: empathic concern, perspective taking and personal distress) and demographic/professional characteristics as independent variables. Generalized linear modeling was used. Significant covariates on univariate linear regression analysis were included in the multivariate linear regression model.

Results: A total of 308 medical physicists completed all questionnaires. Alexithymia as per TAS-20 was correlated to decreased CS ( = -0.25,  < 0 0.001), increased likelihood for STS ( = 0.26,  < 0 0.001) and burnout ( = 0.47,  < 0 0.001). With respect to empathy, the 'Empatic Concern' subscale of the IRI was found to be a significant predictor for increased CS ( = 0.19,  = 0 0.001) and increased STS ( = 0.19,  < 0 0.001), without significant correlation with burnout. The individual's perception of being valued by own's supervisor was correlated to increased CS ( = 0.23,  < 0.001), and decreased burnout ( = -0.29,  < 0.001).

Conclusions: Alexithymic personality trait increased the likelihood to develop burnout, with less professional satisfaction amongst MPs working in radiation oncology. Empathy results in higher professional fulfilment. These results may be used to benchmark preventing strategies, including peer support, debriefing sessions, leadership initiatives and work-load limitation strategies.
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http://dx.doi.org/10.1016/j.phro.2020.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7807595PMC
July 2020

Loco-regional adjuvant radiation therapy in breast cancer patients with positive axillary lymph-nodes at diagnosis (CN2) undergoing preoperative chemotherapy and with complete pathological lymph-nodes response. Development of GRADE (Grades of recommendation, assessment, Development and Evaluation) recommendation by the Italian Association of radiation therapy and Clinical Oncology (AIRO).

Breast 2021 Feb 2;55:119-127. Epub 2021 Jan 2.

Radiotherapy, Dipartimento di Biomedicina e Prevenzione, Università Degli Studi di Roma Tor Vergata, Rome, Italy.

Objective: To perform a meta-analysis to determine the effect of loco-regional radiation therapy (RT) compared to no loco-regional RT for operated patients in clinical stage cN2 breast cancer at diagnosis and ypN0 after preoperative chemotherapy (PST).

Material And Methods: Eligible studies were identified through a systematic search of the medical literature performed independently by two researchers using a validated search strategy. An electronic search of Medline via PubMed and Embase (Breast cancer AND preoperative chemotherapy AND radiation therapy) was conducted with no language or publication status restrictions. The effect of loco-regional RT on overall (OS), disease free (DFS), loco-regional recurrence-free (LRRFS) survival and local recurrence was evaluated. An electronic search of Medline via PubMed and Embase (Toxicity AND radiation therapy breast cancer AND preoperative therapy; toxicity AND breast surgery AND preoperative chemotherapy) was conducted for outcomes of harm: major acute and late skin toxicity, lymphedema and cardiac events.

Results: Of 333 studies identified, 4 retrospective studies reporting on a total of 1107 patients were included in the meta-analysis. Six and 3 reported data of acute and late skin toxicity, while 2 studies provided information on cardiac events. Pooled results showed no difference in terms of hazard ratio for loco-regional RT versus no loco-regional RT [hazard ratio (HR) = 0.82, 95% confidence interval (CI) 0.63-1.68]. Loco-regional RT was associated with an OS benefit in the subgroup analysis: IIIB-C (loco-regional RT 79.3% vs no loco-regional RT 71.2%, p = 0.027) and T3-T4 (loco-regional RT 82.6% vs no loco-regional RT 76.6%, p = 0.025). No difference was shown in terms of 5-year DFS (loco-regional RT 91.2% vs no loco-regional RT 83%, p = 0.441) and LRRFS (loco-regional RT 98.1% vs no loco-regional RT 92.3%, p = 0.148). There was no significant difference between the groups in terms of acute and late skin toxicities, lymphedema and cardiac events.

Conclusions: Because of the limitations due to the small number of studies and heterogeneity in the analysis, the present study does not allow to draw any definitive conclusion, highlighting the need for well-controlled trials to determine the effect of loco-regional RT in patients with cN2 having a pathological complete response in the axillary nodes after preoperative chemotherapy.
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http://dx.doi.org/10.1016/j.breast.2020.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808946PMC
February 2021

Comparing hypofractionated and conventionally fractionated whole breast irradiation for patients with ductal carcinoma in situ after breast conservation: a propensity score-matched analysis from a national multicenter cohort (COBCG-02 study).

J Cancer Res Clin Oncol 2021 Jan 2. Epub 2021 Jan 2.

Radiotherapy and Radiosurgery Department, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milano, Italy.

Background And Purpose: Randomized trials confirmed the efficacy and the safety of hypofractionated whole breast irradiation (HF-WBI) in patients with early-stage breast cancer. However, the role of HF-WBI in patients with DCIS after breast conserving surgery has not yet been clearly established in prospective randomized trials. The aim of this study was to evaluate if HF-WBI can be considered comparable to conventionally fractionated (CF)-WBI in DCIS patients.

Materials And Methods: The analysis included DCIS patients from four Italian centers treated with CF-WBI 50 Gy/25 fractions or HFRT 40.5 Gy/15 fractions, without tumor bed boost. A propensity score matching (PSM) analysis was performed using a logistic regression that considered age, grading, presence of necrosis, resection margin status and adjuvant endocrine therapy.

Results: Five hundred twenty-seven patients was included (367 in the CF-WBI-group and 160 in the HR-WBI group). After 1:1 matching, 101 patients were allocated to the CF-WBI-group and 104 to the HF-WBI group. No correlation was observed between the type of RT schedule and LRFS (HR 1.68, 95% CI 0.82-3.45; p = 0.152). After PSM, no statistical difference was observed between the two RT group (HR 1.11, 95% CI 0.40-3.04; p = 0.833), with 3- and 5-years LRFS rates of 100% and 97.9% for CF-WBI and 95.6% and 94% for HF-WBI.

Conclusion: A short course of radiation therapy seems to be comparable to CF-WBI in terms of clinical outcomes. These data support the use of hypofractionated schedules in DCIS patients, but considering the remaining uncertainties.
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http://dx.doi.org/10.1007/s00432-020-03483-5DOI Listing
January 2021

Metastatic salivary gland carcinoma: A role for stereotactic body radiation therapy? A study of AIRO-Head and Neck working group.

Oral Dis 2020 Dec 15. Epub 2020 Dec 15.

Radiation Oncology Unit 2, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy.

Objectives: The role of radiotherapy (RT) for oligometastases is currently established in different oncological settings but data on salivary gland cancer (SGC) are lacking. We evaluated the role of RT in oligometastatic SGC patients, focusing on stereotactic body radiation therapy (SBRT).

Materials And Methods: We performed a retrospective, multicentric study of oligometastatic SGC treated with palliative RT or SBRT. Endpoints included response evaluation and local control (LC).

Results: Between 2006 and 2016, 64 patients were collected from 9 Italian Cancer Centers, on behalf of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) Head and Neck Working Group. 37 patients (57.8%) were suffering from adenoid cystic carcinoma (ACC) and 27 patients (42.2%) had non-ACC. Thirty-four patients underwent palliative RT (53,1%), and 30 received SBRT (46,9%). Most common metastatic sites were bone for palliative RT and lung for SBRT. Among patients treated with SBRT, an objective response or a stability was observed in all treated lesions. After a median follow-up of 29.2 months (range 2.3-117.1), LC at 12 months was 57.5% for patients treated with SBRT and was higher in ACC subgroup.

Conclusion: We confirmed the potential role of SBRT in the management of oligometastatic SGC patients to control limited burden of disease considering the absence of effective systemic therapies.
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http://dx.doi.org/10.1111/odi.13755DOI Listing
December 2020

Moderately Hypofractionated Radiotherapy with Simultaneous Integrated Boost in Prostate Cancer: A Comparative Study with Conventionally Fractionated Radiation.

J Oncol 2020 28;2020:3170396. Epub 2020 Nov 28.

Department of Oncology, Radiation Oncology, School of Medicine, University of Turin, Turin, Italy.

Background: To report 5-year clinical outcomes and toxicity in organ-confined prostate cancer (PCa) for low- and intermediate-risk patients treated with a moderately hypofractionated schedule of radiotherapy (RT) delivered with simultaneous integrated boost (SIB) compared to a conventionally fractionated RT regimen.

Methods: Data of 384 patients with PCa treated between August 2006 and June 2017 were retrospectively reviewed. The treatment schedule consisted of hypofractionated RT (HYPO FR) with SIB up to 70 Gy to the prostate gland and 63 Gy to seminal vesicles delivered in 28 fractions or in conventionally fractionated RT (CONV FR) up to a total dose of 80 Gy in 40 fractions. Patient allocation to treatment was based on the time period considered. For intermediate-risk patients, androgen deprivation was given for a median duration of 6 months. The 5-year biochemical relapse-free survival (bRFS), cancer-specific survival (CSS), and overall survival (OS) were assessed. Furthermore, we evaluated gastrointestinal (GI) and genitourinary (GU) toxicities. Uni- and multivariate Cox regression analyses were used to test the impact of clinical variables on both outcome and toxicity.

Results: A total of 198 patients was treated with hypofractionated RT and 186 with the conventional schedule. At a median follow-up of 5 years, no significant differences were observed in terms of GI toxicity and outcome between the two groups. Early GU toxicity was significantly increased in HYPO FR, while late GU toxicity was significantly higher in CONV FR. In HYPO FR, a biochemical relapse occurred in 12 patients (6.1%), and 9 patients (4.5%) reported a clinical relapse (4 local, 2 locoregional, and 3 systemic recurrence). In CONV FR, 15 patients (8.1%) experienced a biochemical relapse and 11 patients (5.9%) showed a clinical relapse (5 local, 4 locoregional, and 3 systemic recurrences). Early grades 1-2 GU and GI toxicities were observed in 60 (30.3%) and 37 (18.7%) patients, respectively, in the hypofractionated group and in 33 (17.7%) and 27 (14.5%) patients, respectively, in the conventionally fractionated RT group. Late GU and GI toxicities occurred in 1 (0.51%) and 8 (4.1%) patients, respectively, in HYPO FR. In CONV FR, 5 (2.7%) and 6 (3.2%) patients experienced late GU and GI toxicities, respectively. The 5-year OS, bRFS, and CSS were 98.9%, 94.1%, and 99.5%, respectively, in HYPO FR, and 94.5%, 92.1%, and 99.0%, respectively, in CONV FR.

Conclusions: Results obtained in this study showed that moderately hypofractionated RT employing SIB can be an effective approach providing valuable clinical outcomes with an acceptable toxicity profile.
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http://dx.doi.org/10.1155/2020/3170396DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719538PMC
November 2020

Bone Marrow-Sparing IMRT in Anal Cancer Patients Undergoing Concurrent Chemo-Radiation: Results of the First Phase of a Prospective Phase II Trial.

Cancers (Basel) 2020 Nov 9;12(11). Epub 2020 Nov 9.

Department of Oncology, Radiation Oncology, University of Turin, 10126 Turin, Italy.

Purpose: to investigate the role of selective avoidance of hematopoietically active BM within the pelvis, as defined with FDG-PET, employing a targeted IMRT approach, to reduce acute hematologic toxicity (HT) profile in anal cancer patients undergoing concurrent chemo-radiation.

Methods: a one-armed two-stage Simon's design was selected to test the hypothesis that BM-sparing approach would improve by 20% the rate of G0-G2 (vs. G3-G4) HT, from 42% of RTOG 0529 historical data to 62% (α = 0.05 and the β = 0.20). At the first stage, among 21 enrolled patients, at least 9 should report G0-G2 acute HT to further proceed with the trial. We employed FDG-PET to identify active BM within the pelvis. Acute HT was assessed via weekly blood counts and scored as per the Common Toxicity Criteria for Adverse Effects version 4.0.

Results: from December 2017 to October 2019, 21 patients were enrolled. Maximum observed acute HT comprised 9% rate of ≥G3 leukopenia and 5% rate of ≥G3 neutropenia and anemia. Overall, only 4 out of 21 treated patients (19%) experienced ≥G3 acute HT. Conversely, 17 patients (81%) experienced G0-G2 events, way above the threshold set by the trial design.

Conclusion: FDG-PET-guided BM-sparing IMRT was able to reduce acute HT in anal cancer patients treated with concomitant chemo-radiation. These results prompted us to conclude the second part of this prospective phase II trial.
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http://dx.doi.org/10.3390/cancers12113306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7696305PMC
November 2020

Ocular Complications After Radiation Therapy: An Observational Study.

Clin Ophthalmol 2020 9;14:3153-3166. Epub 2020 Oct 9.

Department of Oncology, University of Turin, Turin, Italy.

Aim Of The Study: The study aims to quantify the incidence of ocular complications in patients irradiated on the head and neck area in our medical center, stratified by type of neoplasm and radiation dose received.

Materials And Methods: From an existing database of patients radio-treated in our center, we selected 25 patients irradiated in the 2011-2018 period. The patients had been treated for orbital lymphoma, nasopharyngeal carcinoma and cranial base meningioma. The selected patients received an ophthalmologic evaluation which included a complete ophthalmological and orthoptic assessment.

Results: Our results showed a significantly higher incidence of DES (dry eye syndrome) and corneal complications for eyes receiving a Dmax higher than 40 Gy, as well as for cataract incidence in eyes that had received a Dmax to the lens higher than 5 Gy. We found an overall thinning of the RNFL (retinal nerve fiber layer) in eyes that had received a Dmax higher than 50 Gy, as well as a greater MD (mean deviation) from normal visual field values.

Conclusion: In conclusion, we can say that the study confirms the presence of a correlation between the received radiation dose and the onset of eye complications, despite the small sample.
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http://dx.doi.org/10.2147/OPTH.S263291DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7555281PMC
October 2020

Hypofractionated radiation therapy for breast cancer: Preferences amongst radiation oncologists in Europe - Results from an international survey.

Radiother Oncol 2021 02 13;155:17-26. Epub 2020 Oct 13.

Iridium Kankernetwerk, Wilrijk-Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Wilrijk-Antwerp, Belgium.

Background And Purpose: We aimed to assess the prescription preference about hypofractionated radiation therapy (HFRT) for breast cancer (BC) patients amongst radiation oncologists (ROs) practicing in Europe and to identify restraints on HFRT utilisation.

Materials And Methods: An online survey was circulated amongst ROs in Europe through personal, RO and BC societies' networks, from October 2019 to March 2020. The statistical analyses included descriptive statistics, chi-squared testing, and logistic regression analysis.

Results: We received 412 responses from 44 countries. HFRT was chosen as the preferred schedule for whole breast irradiation (WBI) by 54.7% and for WBI with regional nodes irradiation (RNI) by 28.7% of the responding ROs. In the case of postmastectomy RT with or without reconstruction, HFRT was preferred by 21.1% and 29.6%, respectively. Overall, 69.2% of the responding ROs selected at least one factor influencing the decision to utilise HFRT, the most frequent of which included age (51.4%), RNI (46.9%), internal mammary lymph nodes irradiation (39.7%), BC stage (33.5%) and implant-based breast reconstruction (31.6%). ROs working in academic centres (odds ratio, (OR), 1.7; 95% confidence interval, (CI); 1.1-2.6, p = 0.019), practicing in Western Europe (OR, 4.2; 95%CI; 2.7-6.6, p < 0.0005) and/or dedicating >50% of clinical time to BC patients (OR, 2.5; 95%CI; 1.5-4.2, p = 0.001) more likely preferred HFRT.

Conclusion: Although HFRT is recognised as a new standard, its implementation in routine RT clinical practice across Europe varies for numerous reasons. Better dissemination of evidence-based recommendations is advised to improve the level of awareness about this clinical indication.
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http://dx.doi.org/10.1016/j.radonc.2020.10.008DOI Listing
February 2021

A snapshot on radiotherapy for head and neck cancer patients during the COVID-19 pandemic: a survey of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) head and neck working group.

Radiol Med 2021 Feb 6;126(2):343-347. Epub 2020 Oct 6.

National Center of Oncological Hadrontherapy (Fondazione CNAO), Strada Campeggi, 53, 27100, Pavia, Italy.

Objectives: The objective of the paper was to assess real-life experience in the management of head and neck cancer (HNC) patients during the COVID-19 pandemic in radiotherapy departments and to evaluate the variability in terms of adherence to American Society of Radiation Oncology (ASTRO) and European Society for Radiotherapy and Oncology (ESTRO) recommendations.

Materials And Methods: In May 2020, an anonymous 30-question online survey, comparing acute phase of outbreak and pre-COVID-19 period, was conducted. Two sections exploited changes in general management of HNC patients and different HNC primary tumors, addressing specific statements from ASTRO ESTRO consensus statement as well.

Results: Eighty-eight questionnaires were included in the demographic/clinical workflow analysis, and 64 were analyzed for treatment management. Forty-eight percent of radiotherapy departments became part of oncologic hubs. First consultations reduced, and patients were addressed to other centers in 33.8 and 18.3% of cases, respectively. Telematic consultations were used in 50% of follow-up visits and 73.9% of multidisciplinary tumor board discussions. There were no practical changes in the management of patients affected by different primitive HNCs. Hypofractionation was not favored over conventional schedules.

Conclusions: Compared to pre-COVID era, the clinical workflow was highly re-organized, whereas there were no consistent changes in RT indications and schedules.
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http://dx.doi.org/10.1007/s11547-020-01296-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538045PMC
February 2021

Tailoring the radiotherapy approach in patients with anal squamous cell carcinoma based on inguinal sentinel lymph node biopsy.

J Surg Oncol 2021 Jan 22;123(1):315-321. Epub 2020 Sep 22.

Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Background And Objectives: The aim of our study was to analyze the results of selective inguinal node irradiation in patients with anal cancer, based on the biopsy of the inguinal sentinel lymph node (SLN), in terms of local control and prognosis.

Methods: Records of patients with anal squamous cell carcinoma from January 2001 to December 2016 were retrospectively reviewed. Tc99 lymphoscintigraphy was performed in all the clinically inguinal negative patients, followed by radio-guided surgical removal of the inguinal SLN. All patients were treated with combined radiochemotherapy. In patients with negative sentinel nodes, the inguinal area was excluded in the radiotherapy field.

Results: A total of 123 patients, 76 females (61.8%), mean age 60.1 ± 12.19 years old, underwent intraoperative lymph node retrieval. The histological analysis showed metastasis in the SLN in 28 patients (22.8%). The mean follow-up was 43.44 ± 31.86 months. No inguinal recurrence was observed in patients with negative inguinal sentinel node(s). A statistically significant difference was observed for overall and disease-free survivals in a patient with positive and negative inguinal sentinel nodes.

Conclusions: In patients with anal canal cancer, the exclusion of the inguinal regions from the radiotherapy field, in patients with negative SLN, does not compromise locoregional control nor prognosis.
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http://dx.doi.org/10.1002/jso.26226DOI Listing
January 2021

The role of alexithymia and empathy on radiation therapists' professional quality of life.

Tech Innov Patient Support Radiat Oncol 2020 Sep 17;15:29-36. Epub 2020 Aug 17.

Department of Psychology, "ReMind the Body" Research Group, University of Turin, Italy.

Background And Purpose: Physical and mental well-being are crucial for oncology professionals as they affect performance at work. Personality traits, as alexithymia and empathy, may influence professional quality of life. Alexithymia involves diminished skills in emotion processing and awareness. Empathy is pertinent to the ability to understand another's 'state of mind/emotion'. The PROject on Burn-Out in RadiatioN Oncology (PRO BONO) investigates professional quality of life amongst radiation oncology professionals, exploring the role of alexithymia and empathy. The present study reports on data pertinent to radiation therapists (RTTs).

Material And Methods: An online survey targeted ESTRO members. Participants were asked to fill out 3 questionnaires for alexithymia, empathy and professional quality of life: (a) Toronto Alexithymia Scale (TAS-20); (b) Interpersonal Reactivity Index (IRI); (c) Professional Quality of Life Scale (ProQoL). The present analysis focuses on RTTS to evaluate compassion satisfaction (CS), secondary traumatic stress (STS) and Burnout and their correlation with alexithymia and empathy, using generalized linear modeling. Covariates found significant at univariate linear regression analysis were included in the multivariate linear regression model.

Results: A total of 399 RTTs completed all questionnaires. The final model for the burnout scale of ProQoL found, as significal predictors, the TAS-20 total score ( = 0.46,  < 0 0.001), and the individual's perception of being valued by supervisor ( = -0.29,  < 0.001). With respect to CS, the final model included TAS-20 total score ( = -0.33,  < 0.001), the Empatic Concern domain ( = 0.23,  < 0.001) of the IRI questionnaire and the individual's perception of being valued by colleagues ( = 0.22,  < 0.001).

Conclusions: Alexithymia increased the likelyhood to experience burnout and negatively affected the professional quality of life amongst RTTs working in oncology. Empathy resulted in higher professional fulfillment together with collegaues' appreciation. These results may be used to benchmark preventing strategies and implement organization-direct and/or individual-directed interventions.
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http://dx.doi.org/10.1016/j.tipsro.2020.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451808PMC
September 2020

In response to Chaturvedi: Professional quality of life, burnout and alexithymia.

Radiother Oncol 2021 02 29;155:e6-e7. Epub 2020 Aug 29.

European Society for Radiotherapy&Oncology (ESTRO) Young Committee, Brussels, Belgium; Department of Oncology, Radiation Oncology, University of Turin, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.radonc.2020.08.020DOI Listing
February 2021

Head and neck radiotherapy amid the COVID-19 pandemic: practice recommendations of the Italian Association of Radiotherapy and Clinical Oncology (AIRO).

Med Oncol 2020 Aug 17;37(10):85. Epub 2020 Aug 17.

Department of Radiotherapy, Policlinico Umberto I, "Sapienza" University of Rome, Rome, Italy.

Management of patients with head and neck cancers (HNCs) is challenging for the Radiation Oncologist, especially in the COVID-19 era. The Italian Society of Radiotherapy and Clinical Oncology (AIRO) identified the need of practice recommendations on logistic issues, treatment delivery and healthcare personnel's protection in a time of limited resources. A panel of 15 national experts on HNCs completed a modified Delphi process. A five-point Likert scale was used; the chosen cut-offs for strong agreement and agreement were 75% and 66%, respectively. Items were organized into two sections: (1) general recommendations (10 items) and (2) special recommendations (45 items), detailing a set of procedures to be applied to all specific phases of the Radiation Oncology workflow. The distribution of facilities across the country was as follows: 47% Northern, 33% Central and 20% Southern regions. There was agreement or strong agreement across the majority (93%) of proposed items including treatment strategies, use of personal protection devices, set-up modifications and follow-up re-scheduling. Guaranteeing treatment delivery for HNC patients is well-recognized in Radiation Oncology. Our recommendations provide a flexible tool for management both in the pandemic and post-pandemic phase of the COVID-19 outbreak.
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http://dx.doi.org/10.1007/s12032-020-01409-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7430932PMC
August 2020

National societies' needs as assessed by the ESTRO National Societies Committee survey: A European perspective.

Radiother Oncol 2020 10 7;151:176-181. Epub 2020 Aug 7.

Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy; Division of Radiotherapy, IEO European Institute of Oncology, IRCCS, Milan, Italy.

Purpose: To determine how ESTRO can collaborate with Radiation Oncology National Societies (NS) according to its mission and values, and to define the new roadmap to strengthen the NS network role in the forthcoming years.

Materials And Methods: The ESTRO NS committee launched a survey addressed to all European National Societies, available online from June 5th to October 30th 2018. Questions were divided into three main sections: (1) general information about NS; (2) relevant activities (to understand the landscape of each NS context of action); (3) relevant needs (to understand how ESTRO can support the NS). Eighty-nine European NS were invited to participate. Respondents were asked to rank ESTRO milestones in order of importance, indicating the level of priority to their society.

Results: A total of 58 out of 89 NS (65.2%) from 31 European countries completed the questionnaire. The majority of NS ranked "Optimal patient care to cure cancer and to reduce treatment-related toxicity" as the highest level of priority. This aligns well with the ESTRO vision 2030 "Optimal health for all together." NS also indicated a high need for more consensus guidelines and exchange of best practices, access to high quality accredited education, implementation of the ESTRO School Core Curriculum at the national level, and defining quality indicators and standard in Radiation Oncology, improved communication and increased channelling of information.

Conclusion: The results of this survey will be used to strengthen the relations between ESTRO and European NS to promote and develop initiatives to improve cancer care.
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http://dx.doi.org/10.1016/j.radonc.2020.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410806PMC
October 2020

In response to Leung.

Radiother Oncol 2021 01 16;154:e23-e24. Epub 2020 Jul 16.

Department of Psychology, "ReMind the Body" Research Group, University of Turin, Italy.

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http://dx.doi.org/10.1016/j.radonc.2020.07.024DOI Listing
January 2021

The importance of IL-6 blockade beyond the COVID-19 pandemic: Consideration for cancer care.

Radiother Oncol 2020 10 13;151:24-25. Epub 2020 Jul 13.

Department of Oncology, Radiation Oncology, University of Turin, Italy.

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http://dx.doi.org/10.1016/j.radonc.2020.07.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355317PMC
October 2020

Conducting research in Radiation Oncology remotely during the COVID-19 pandemic: Coping with isolation.

Clin Transl Radiat Oncol 2020 Sep 18;24:53-59. Epub 2020 Jun 18.

European Society for Radiotherapy & Oncology (ESTRO) Young Committee, Brussels, Belgium.

Introduction: With the COVID-19 pandemic, individuals have been forced to follow strict social isolation guidelines. While crucial to control the pandemic, isolation might have a significant impact on productivity and mental health. Especially for researchers working in healthcare, the current situation is complex. We therefore carried out a survey amongst researchers in the field of radiation oncology to gain insights on the impact of social isolation and working from home and to guide future work.

Materials And Methods: An online survey was conducted between March 27th and April 5th, 2020. The first part contained 14 questions intended to capture an overview of the specific aspects related to research while in isolation. The second (optional) part of the questionnaire was the validated Hospital Anxiety and Depression Scale (HADS), a self-reported measure used to assess levels of anxiety and depressive symptoms.

Results: From 543 survey participants, 48.8% reported to work full-time from home. The impact on perceived productivity, with 71.2% of participants feeling less productive, caused 58% of participants to feel some level of guilt.Compared to normative data, relatively high levels of anxiety and depressive symptoms were recorded for the 335 participants who filled out the HADS questionnaire. Group comparisons found the presence of a supportive institutional program as the sole factor of statistical significance in both anxiety and depressive symptom levels. People having to work full-time on location showed higher depressive symptom levels than those working from home. Anxiety scores were negatively correlated with the number of research years.

Conclusion: Results of the survey showed there is a non-negligible impact on both productivity and mental health. As the radiation oncology research community was forced to work from home during the COVID-19 pandemic, lessons can be learned to face future adverse situations but also to improve work-life balance in general.
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http://dx.doi.org/10.1016/j.ctro.2020.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7299875PMC
September 2020

Suggestions for Radiation Oncologists during the COVID-19 Pandemic.

Biomed Res Int 2020 26;2020:4892382. Epub 2020 May 26.

Department of Radiation Oncology, Réseal Hospitalier Neuchâtelois, La-Chaux-de Fonds, Switzerland.

SARS-CoV-2 pandemic and COVID-19 diffusion have recently become an international public health emergency. Cancer patients, as a frail population, are particularly exposed to the risk related to infections. The clinical decision-making process and the organizational workflow of radiotherapy department should be revised in the light of the critical situation. We herein provide practical suggestions derived from the available literature and discussed during an online session held within the e-learning educational program of the European School of Oncology on March 31st 2020.
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http://dx.doi.org/10.1155/2020/4892382DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7254074PMC
June 2020

The 2018 assisi think tank meeting on breast cancer: International expert panel white paper.

Crit Rev Oncol Hematol 2020 Jul 22;151:102967. Epub 2020 Apr 22.

Radiation Oncology, University of Perugia and Perugia General Hospital, Perugia, Italy. Electronic address:

We report on the second Assisi Think Tank Meeting (ATTM) on breast cancer which was held under the auspices of the European Society for RadioTherapy & Oncology (ESTRO). In discussing in-depth current evidence and practice it was designed to identify grey areas in diverse forms of the disease. It aimed at addressing uncertainties and proposing future trials to improve patient care. Before the meeting, three key topics were selected: 1) primary systemic therapy, mastectomy, breast reconstruction and post-mastectomy radiation therapy, 2) therapeutic options in ductal carcinoma in situ, and 3) therapy de-escalation in early stage breast cancer. Clinical practice in these areas was investigated by means of an online questionnaire. The time lapse period between the survey and the meeting was used to review the literature and on-going clinical trials. At the ATTM both were discussed in depth and research protocols were proposed.
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http://dx.doi.org/10.1016/j.critrevonc.2020.102967DOI Listing
July 2020

Professional quality of life and burnout amongst radiation oncologists: The impact of alexithymia and empathy.

Radiother Oncol 2020 06 15;147:162-168. Epub 2020 May 15.

Department of Psychology, "ReMind the Body" Research Group, University of Turin, Italy.

Background And Purpose: Different factors may influence the professional quality of life of oncology professionals. Among them, personality traits, as alexithymia and empathy, are underinvestigated. Alexithymia is about deficits in emotion processing and awareness. Empathy is the ability to understand another's 'state of mind'/emotion. The PROject on BurnOut in RadiatioN Oncology (PRO BONO) assesses professional quality of life, including burnout, in the field of radiation oncology and investigates alexithymia and empathy as contributing factors.

Material And Methods: An online survey was conducted amongst ESTRO members. Participants completed 3 validated questionnaires for alexithymia, empathy and professional quality of life: (a) Toronto Alexithymia Scale; (b) Interpersonal Reactivity Index; (c) Professional Quality of Life Scale. The present analysis, focusing on radiation/clinical oncologists, evaluates Compassion Satisfaction (CS), Secondary Traumatic Stress (STS) and Burnout and correlates them with alexithymia and empathy (empathic concern, perspective taking and personal distress) with generalized linear modeling. Significant covariates on univariate linear regression analysis were included in the multivariate linear regression model.

Results: A total of 825 radiation oncologists completed all questionnaires. A higher level of alexithymia was associated to decreased CS (β: -0.101; SE: 0.018; p < 0.001), increased STS (β: 0.228; SE: 0.018; p < 0.001) and burnout (β: 0.177; SE: 0.016; p < 0.001). A higher empathic concern was significantly associated to increased CS (β: 0.1.287; SE: 0.305; p = 0.001), STS (β: 0.114; SE: 0.296; p < 0.001), with no effect on burnout. Personal distress was associated to decreased CS (β: -1.423; SE: 0.275; p < 0.001), increased STS (β: 1.871; SE: 0.283; p < 0.001) and burnout (β: 1.504; SE: 0.245; p < 0.001).

Conclusions: Alexithymic personality trait increased burnout risk, with less professional satisfaction. Empathic concern was associated to increased stress, without leading to burnout, resulting in higher professional fulfillment. These results may be used to benchmark preventing strategies, such as work-hour restrictions, peer support, debriefing sessions, and leadership initiatives for professionals at risk.
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http://dx.doi.org/10.1016/j.radonc.2020.05.017DOI Listing
June 2020

COVID-19 outbreak and cancer radiotherapy disruption in Italy: Survey endorsed by the Italian Association of Radiotherapy and Clinical Oncology (AIRO).

Radiother Oncol 2020 08 12;149:89-93. Epub 2020 May 12.

Radiation Oncology Division, Oncology and Speciality Medicine Department, San Camillo-Forlanini Hospital, Roma, Italy; President of AIRO (Italian Association of Radiotherapy and Clinical Oncology), Italy.

Italy experienced one of the world's deadliest COVID-19 outbreaks and healthcare systems had to instantly reorganise activity. The Italian Radiation Oncology Departments adapted numerous solutions to minimize the disruptions. Information technologies, treatment prioritization and implementation of hypofractionation and protection procedures allowed balancing between cancer patient care and patient/healthcare workers safety.
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http://dx.doi.org/10.1016/j.radonc.2020.04.061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7215158PMC
August 2020

The Effect of COVID-19 on Radiation Oncology Professionals and Patients With Cancer: From Trauma to Psychological Growth.

Adv Radiat Oncol 2020 Jul-Aug;5(4):705-706. Epub 2020 May 11.

Department of Oncology, Radiation Oncology, University of Turin, Turin, Italy.

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http://dx.doi.org/10.1016/j.adro.2020.04.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7211720PMC
May 2020