BACKGROUND Ado-trastuzumab emtansine (T-DM1) is indicated for use in both early-stage and metastatic breast cancer. This antibody-drug conjugate uses a toxic payload, emtansine, which is delivered directly to the malignant cells via the covalently linked trastuzumab antibody. Emtansine is a microtubule inhibitor and this targeted therapy is used to decrease adverse events. While the package insert acknowledges that it is an irritant with infusion site extravasation injury as a known adverse event, it does not give clear guidance on extravasation treatment. This case report describes the case of a 38-year-old woman with breast cancer being treated with T-DM1 who experienced extravasation and soft-tissue injury, and the medical management she received. CASE REPORT A 38-year-old woman with no previous medical history was diagnosed with hormone receptor-negative and human epidermal growth receptor 2 breast cancer. After refusing port placement, she was treated with T-DM1 via peripheral intravenous injection. She experienced infiltration of T-DM1 and developed widespread erythema, blistering, and pain. She was treated with a topical steroid (clobetasol), topical calcineurin inhibitor (tacrolimus), oral antibiotic (cefadroxil), high-dose vitamin D (ergocalciferol), and pain management (gabapentin) with almost complete resolution in 4 weeks. CONCLUSIONS This case report describes a T-DM1 skin extravasation treated with multimodal medical measures as opposed to a more conservative approach. We reaffirm that the use of port access when administering T-DM1 is critical to prevent extravasation, and we recommend multimodal management, including antibiotics and topical therapies, to prevent infection and expedite wound healing if extravasation occurs.

Prostate-specific membrane antigen positron emission tomography (PSMA-PET), a form of molecular imaging, increases detection of advanced and metastatic prostate cancer, but its potential to increase treatment costs due to increased detection is poorly defined.

To estimate lifetime health and cost outcomes and evaluate the cost-effectiveness associated with implementing PSMA-PET in the clinical evaluation of a patient with a biochemical recurrence (BCR) of prostate cancer, with evaluation of sources of uncertainty in the underlying evidence and assessment of the need and focus of additional data collection.

This economic evaluation developed a decision-analytic model consisting of a decision tree and a Markov model informed by published literature and a study of patients with BCR prostate cancer undergoing PSMA-PET after definitive surgery or radiation therapy at 2 high-volume US academic centers. The analysis was performed between August 1, 2024, and May 1, 2025.

Patients underwent (1) PSMA-PET, (2) PSMA-PET imaging as a reflex test if computed tomography plus bone scan (CTBS) was negative or equivocal (CTBS + PSMA-PET), and (3) CTBS alone.

Lifetime quality-adjusted life-years (QALYs) and costs, incremental cost-effectiveness ratio (ICER), and value of information estimates were assessed, with 95% uncertainty intervals (UIs). We assumed a willingness-to-pay threshold of $150 000 per QALY.

The model simulated 1000 patients with BCR (median age, 66 years) and estimated that up-front PSMA-PET is expected to have the highest mean QALYs (7.12 QALYs [95% UI, 6.71-7.51 QALYs]) compared with 6.55 QALYs (95% UI, 6.08-7.03 QALYs) for CTBS; it was also estimated to have higher mean costs ($451 000 [95% UI, $336 000-$577 000]) compared with $351 000 (95% UI, $263 000-$455 000]) for CTBS; consequently, PSMA-PET had mean increments of $99 000 (95% UI, $55 000-153,000) in costs and 0.58 QALYs (95% UI, 0.35-0.82 QALYs) compared with CTBS, leading to an ICER of $172 000 per QALY, which exceeded the assumed $150 000/QALY willingness-to-pay threshold. In patients with lower prostate-specific antigen levels (<2 ng/mL), PSMA had mean increments of $61 000 (95% UI, $21 000-$104 000) in costs and 0.54 QALYs (95% UI, 0.34-0.77 QALYs) compared with CTBS, leading to an ICER of $113 000/QALY, suggesting it had the potential to be cost-effective. Because of high decisional uncertainty, additional information regarding outcomes and diagnostic characteristics may be associated with reduced uncertainty and a gain of 15 747 QALYs.

This study found that PSMA-PET may be associated with improved disease detection but may not be cost-effective due to high treatment costs offsetting moderate improvements in QALYs. Further research is needed to identify patient subsets and clinical scenarios in which molecular imaging provides the greatest value.

Updated estimates of oropharyngeal cancer (OPC) in the US are needed.

To calculate the most recent epidemiologic estimates of OPC in the US and provide projections for future trends up to 2040.

This cross-sectional epidemiological analysis used data from the recent National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. The SEER-22 (excluding Illinois and Massachusetts) database provided data for incidence, prevalence, survival, and initial treatment by OPC stage. Patients with OPC diagnosed according to International Classification of Diseases for Oncology, Third Edition morphology codes were included. The analysis was conducted from September to October 2024.

A diagnosis of OPC.

The primary outcomes were annual age-adjusted OPC incidence per 100 000 persons, limited-duration prevalence, survival rate, and initial treatment. The incidence rate and the estimated annual percentage change for the most recent period were determined according to trend analysis from 2006 to 2021 and were used to estimate the incidence rate up to 2040.

There were 103 107 new OPC cases (40 051 patients [38.8%] aged ≥65 years; 82 820 male patients [80.3%]) recorded during 2006 to 2021. From 2006 to 2021, the incidence of OPC increased from 3.8 to 4.4 cases per 100 000 person-years. The projected incidence rates indicated a significant decrease for both female (1.1 cases per 100 000 person-years) and younger (aged <65 years, 2.0 cases per 100 000 person-years) patients in 2040. The 10-year limited-duration prevalence increased from 0.024% in 2012 to 0.033% in 2021. The 1-year period survival rate of OPC was 88.2% (95% CI, 87.7%-88.7%), the 3-year period survival rate was 76.5% (95% CI, 75.9%-77.1%), and the 5-year period survival rate was 69.2% (95% CI, 68.5%-69.9%). Of 7495 patients with OPC in 2021, 1621 (21.6%) were classified as receiving no treatment, 1647 (22.0%) received single treatment, and 4227 (56.4%) received multiple treatments initially. The distribution of treatments was similar from 2006 to 2021. Of 15 648 patients with localized stage disease, 7171 (45.8%) received no treatment. In 2021, more patients aged 65 years and older received no treatment compared with patients younger than 65 years (865 of 3525 patients [24.5%] vs 756 of 3970 patients [19.0%]).

In this cross-sectional study of OPC, the incidence of OPC in the US increased rapidly from 2006 to 2021 among male individuals, particularly among those aged 65 years and older. Although the distribution of treatment was similar through the assessed years, increased limited-duration prevalence and higher than previously reported survival were observed. A smaller proportion of patients with localized stage OPC were treated, especially among those aged 65 years and older, suggesting that further research is needed for optimal patient outcomes.

Globally, millions of cancer cases are diagnosed annually and mortality rates continue to rise with breast (BC), colorectal (CRC) and prostate (PC) cancer among the most prevalent. Race and ethnic disparities in cancer outcomes have been well-documented; however, the underlying factors contributing to these disparities are currently unknown.

This study utilised the Genomic Data Commons (GDC) Portal, a publicly accessible repository, therefore ethical approval was not required. Cancer incidence data were collected by prevalent gene mutations associated with BC, CRC and PC within White, Black and Asian populations. Rolling one-year survival rates were constructed for each genetic mutation.

For BC, Black and Asian individuals exhibited higher percentages of cases associated with TP53 mutations compared to Whites. CRC incidence showed Black individuals exhibited higher percentages of cases associated with APC, KRAS and PIK3CA mutations compared to Whites and Asians. PC incidence demonstrated that Black individuals had elevated percentages of cases associated with SPOP, ATM and SYNE1 mutations compared to Whites and Asians. Asian individuals displayed significantly lower survival percentages over 10 years compared to White and Black populations across genetic mutations associated with BC. White individuals exhibited significantly higher survival percentages over 10 years compared to Black individuals across genetic mutations associated with CRC.

Significant disparities exist in cancer incidence and survival rates across White, Black and Asian populations. These findings demonstrate the importance of targeted approaches in cancer prevention, diagnosis and treatment to address disparities and the need for equitable healthcare. Further research is needed to identify mechanisms driving such disparities and to develop effective strategies to improve cancer outcomes across diverse ethnic populations.

Ultrahypofractionated proton stereotactic ablative radiotherapy (SABR) is an emerging treatment for localized prostate cancer (PCa), with efforts ongoing to further condense treatment regimens to fewer than five fractions. However, proton SABR is highly susceptible to interfractional anatomical variations due to its steep dose gradients, requiring adaptive strategies to ensure robust clinical target volume (CTV) coverage while minimizing dose to organs at risk (OARs). Traditional margin-based approaches introduce unnecessary OAR exposure, while online re-optimization methods can be computationally expensive and resources-intensive.

This study aims to develop and evaluate a knowledge-based (KB) adaptive proton SABR workflow that accounts for prostate interfraction motion and density uncertainty (DU) by selecting the most clinically optimal plan from a set of pre-generated KB plans.

We retrospectively analyzed 42 prostate cancer patients treated with five-fraction proton SABR and 45 treated with 28-fraction proton therapy, using cone-beam CT (CBCT) imaging to evaluate interfraction motion and anatomical variations. Gaussian process regression (GPR) models were trained on these datasets to predict patient-specific prostate motion in the anterior-posterior (AP) and superior-inferior (SI) directions. Three KB treatment plans were generated per patient: KB-Nominal, KB-AS (Anterior-Superior), and KB-PI (Posterior-Inferior), all with 2 mm isotropic setup uncertainty, compared to a clinical plan with 5 mm (3 mm posterior) setup margins. The KB framework was tested on 10 randomly selected patients from the SABR cohort to evaluate plan quality and selection performance. Plans were evaluated using Monte Carlo (MC) dose calculations under nominal and ±3.5% DU conditions. Plan quality was assessed using ProKnow scoring, incorporating CTV coverage, dose conformity (Paddick Conformity Index and D2cm), and OAR doses (bladder, rectum, and bladder neck constraints). The optimal plan per fraction was selected based on the highest weighted-average ProKnow score across DU scenarios.

Across all DU conditions, KB plans reduced bladder and bladder neck dose compared to the clinical plan, while maintaining robust CTV coverage (D₉₈ ≥ prescription dose). Compared to the clinical plan, KB-AS and KB-PI reduced bladder V_20.8Gy by 26% (5.3% vs. 7.2%) and rectum V_17.6Gy by 17% (2.7% vs. 3.3%), with bladder neck V_100%Rx demonstrating the largest reduction at ±3.5% DU. KB plan selection was stable across DU variations, with KB plans consistently achieving higher ProKnow scores than the clinical plan. Benchmarking against Online Adaptive plans confirmed comparable plan quality, further validating the clinical robustness of the KB framework.

This study establishes the feasibility of a KB plan-driven adaptive proton SABR workflow for prostate cancer. By pre-generating motion-informed treatment plans and selecting the most optimal plan using ProKnow scoring, this framework ensures robust target coverage while substantially improving bladder and bladder neck sparing.

Radiotherapy techniques have advanced significantly over the past few decades. Whole-brain radiotherapy combined with a simultaneous integrated boost (WBRT+SIB) is increasingly used to treat limited brain metastases.

To retrospectively compare helical tomotherapy and coplanar volumetric modulated arc therapy (VMAT) for WBRT with a SIB-WBRT in patients with multiple brain metastases. Additionally, it emphasizes the importance of selecting appropriate evaluation indices when comparing SIB plans.

Fifteen patients with 2- 3 metastatic lesions were retrospectively analyzed in this study. Treatment planning was performed using TomoHD and eclipse planning systems for tomotherapy and VMAT, respectively. Dose-volume histograms were used to assess the doses delivered to the target volumes and organs at risk (OARs). Quantitative metrics, including the homogeneity index (HI), conformity index (CI), and plan quality index (PQI), were used for the evaluation.

Tomotherapy yielded significantly higher D98% values for both the planning target volume (PTV) WB and PTV_met compared with VMAT (p < 0.05). It also provided lower D_max and D_mean values for the lenses and eyes (p < 0.001 and p < 0.02, respectively). Tomotherapy was superior in terms of PTV whole-brain CI and PTV_met HI and CI (p < 0.05). However, no significant difference was observed in the PQI values between the techniques (p > 0.05).

Both tomotherapy and VMAT achieved acceptable target volumes and OAR doses in SIB applications. Tomotherapy showed advantages in terms of dose conformity and critical organ sparing. Moreover, this study highlights the impact of selecting appropriate evaluation indices on interpreting plan quality, particularly for complex treatment approaches such as SIB.

This retrospective study evaluated outcomes and toxicity in patients with WHO Grade II and III meningiomas treated with modern photon or particle radiotherapy, with emphasis on skull base versus non-skull base tumors.

Ninety-seven patients received photon (58.2%) or particle therapy (41.8%). Median age was 61 years (range, 15-88). Tumor location was non-skull base in 69.1% and skull base in 30.9%. All patients underwent fractionated radiotherapy with a median dose of 59.4 Gy (range, 34-68). Follow-up included MRI and assessment of local control (LC), progression-free survival (PFS), overall survival (OS), and toxicity (CTCAE v5).

At last follow-up, 94 patients (96.9%) were alive. Median OS was not reached, with survival rates of 100% at 2 and 5 years and 99% at 8 years. Median PFS was 32.0 months, with 2- and 5-year rates of 88.7% and 66.0%. Median LC was 33.0 months, with 2- and 5-year rates of 91.8% and 72.2%. Disease progression occurred in 40 patients (41.2%), including 30 in-field and 22 outside the irradiated volume. Early toxicities were mainly Grade I-II, most commonly alopecia, fatigue, and headache. Late toxicities were less frequent, including headache, seizures, vertigo, and radiation-induced cerebral contrast enhancement (RICE). Severe late toxicity (Grade III) was rare (n = 3). Particle therapy was associated with lower rates of vertigo and headache.

High-precision photon and particle radiotherapy achieved effective long-term control with favorable safety in high-grade meningiomas. Most adverse effects were mild and manageable, supporting the role of particle therapy in reducing selected late toxicities.

Diffuse intrinsic pontine glioma is a lethal disease with a median overall survival (OS) of less than one year. Currently, no curative treatment exists, and radiotherapy primarily aims for symptom palliation. Hypofractionated radiotherapy (HR) has been proposed to enhance quality of life through shorter treatment duration, fewer hospital visits, and reduced costs, particularly in low- and middle-income countries (LMICs). However, many LMIC institutions continue to use 54 Gy in 30 fractions. The study aims to identify patients who may benefit from HR.

We reviewed data from MAHAK patients treated between April 2010 and February 2020. Diagnosis was based on clinical symptoms and MRI imaging; biopsy was not mandatory.

Among 108 identified patients, 34(32%) underwent a biopsy, with high-grade glioma or glioblastoma diagnosed in 18(53%). H3K27M mutation was found in two patients, while others were not evaluated. No seeding was detected at diagnosis. Thirty-one patients (29%) received 50-54 Gy using normal fractionation, while the remainder received HR. Median OS was 9.6 months (range 1-67). No significant impact of fractionation was observed. Seventy-eight (72%) patients received chemotherapy, which showed no benefit. Eleven patients received re-irradiation at progression, showing a post-progression OS of 6 months. Poor-risk factors included age over 4 years, symptom duration < 3months, simultaneous triad signs, and absence of hydrocephalus (p < 0.05).

Given their shorter life expectancy, poor-risk patients may benefit from HR. We propose a scoring system based on prognostic factors to guide decisions between HR and normal fractionation.

Gross total resection is strived for in intramedullary spinal cord lesion surgery. Intraoperative neurophysiological monitoring (IONM) is the gold standard, but there is no consensus on the optimal IONM workflow. This study details our institutional workflow.

We retrospectively reviewed all adults who underwent intramedullary resection at Karolinska University Hospital, 2007-2021 (n = 70). Continuous multimodal IONM (somatosensory-evoked potentials (SSEP), motor-evoked potentials (MEP) and epidural D-waves) was conducted by an in-room neurophysiologist. Alarm thresholds were preset (≥ 50% SSEP amplitude drop/10% latency rise; ≥ 80% MEP reduction; ≥ 50% D-wave loss) and triggered a standardized four-step rescue protocol (halt manipulation, raise MAP to 80-90 mm Hg, topical papaverine, observation). Motor/sensory function, modified McCormick (mMC) grade, pain, and sphincter control were documented pre-operatively, at 3 months, and ≥ 12 months.

Seventy patients were included. Most harboured ependymoma (51%), hemangioblastoma (18%) and cavernoma (8.5%). A neurophysiologist was present during every procedure. A ≥ 50% intra-operative SSEP-amplitude decrease was not followed by a sensory deficit (OR:3.0, 95% CI 0.86-10.6; p = 0.085) or mMC deterioration (OR:1.6, 0.33-7.5; p = 0.57) at either short- or long-term follow-up. In contrast, complete SSEP loss markedly increased the risk of postoperative sensory deficit (3-months-OR:25.2, 4.7-135; p < 0.001; long-term-OR 11.0, 2.8-43.8; p < 0.001) and poorer mMC grade (3-months-OR:7.8, 2.0-31; p = 0.004; long-term-OR:11.0, 2.8-43.8; p < 0.001). Loss of MEPs predicted a decline in mMC at long-term follow-up (OR:4.0, 1.06-15.1; p = 0.041).

Live data from continuous intraoperative neurophysiological monitoring, expertly interpreted in the OR, could potentially be used to make surgical and anesthesiologic adjustments with the goal of minimizing the risk of negative neurological outcomes. Significant associations were found between decreased or lost IONM signals and poorer sensorimotor function and mMC score at short- and long-term follow-up. Implementation of the IONM workflow is suggested in all intramedullary surgery.

Distinguishing pseudoprogression (PsP) from true progression (TP) in glioblastoma (GBM) remains a diagnostic challenge, yet is essential for guiding treatment and counseling prognosis. This study retrospectively assessed the incidence, clinical predictors, and survival impact of PsP compared to TP.

Patients with surgically treated GBM and postoperative (chemo)radiotherapy in two Dutch hospitals (2006-2021) were included. Reports of magnetic resonance imaging (MRI) scans performed 4 months post-radiotherapy and at 3-month intervals, as well as reports of MRI scans prompted by neurological decline, were evaluated for PsP, TP, or mixed response (MR). Associations with clinical, tumor, and treatment characteristics and overall survival (OS) were analyzed.

Of 424 GBM patients, 175 were eligible for PsP analysis. The incidence of PsP was 29.1%, and PsP was associated with longer OS (median 16.6 months, 95% CI 12.0-21.2) compared to MR (14.1 months, 95% CI 11.1-17.2) and TP (11.6 months, 95% CI 10.0-13.2; p = 0.010). However, PsP occurring < 4 months after chemoradiotherapy was linked to shorter OS (11.3 months) than PsP > 4 months (17.4 months; p = 0.027). Male sex was significantly associated with outcome in univariate analysis, showing a trend toward significance in multivariate analysis. Treatment completion remained significant only in the multivariate model.

PsP is associated with improved survival compared to TP, though early-onset PsP portends poorer outcomes. None of the evaluated factors were a significant predictor of PsP in both univariate and multivariate analyses. Future research should focus on validating molecular markers, and refining PsP definitions using standardized criteria.