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Background In patients with cancer, the current gold standard for assessing response to treatment involves measuring cancer lesions on computed tomography (CT) imaging. The percentage change in size of specific lesions determines whether patients have had a complete/partial response or progressive disease, according to RECIST criteria. Dual Energy CT (DECT) permits additional measurements of iodine concentration, a surrogate marker of vascularity. Here we explore the role of changes in iodine concentration within cancer tissue on CT scans to assess its suitability for determining treatment response in patients with high grade serous ovarian cancer (HGSOC). Methods Suitable RECIST measurable lesions were identified from the CT images of HGSOC patients, taken at 2 different time points (pre and post treatment). Changes in size and iodine concentration were measured for each lesion. PR/SD were classified as responders, PD was classified as non-responder. Radiological responses were correlated with clinical and CA125 outcomes. Results 62 patients had appropriate imaging for assessment. 22 were excluded as they only had one DECT scan. 32/40 patients assessed (113 lesions) had received treatment for relapsed HGSOC. RECIST and GCIG (Gynaecologic Cancer Inter Group) CA125 criteria / clinical assessment of response for patients was correlated with changes in iodine concentration, before and after treatment. The prediction of median progression free survival was significantly better associated with changes in iodine concentration (p = 0.0001) and GCIG Ca125 / clinical assessment (p = 0.0028) in comparison to RECIST criteria (p = 0.43). Conclusion Changes in iodine concentration from dual energy CT imaging may be more suitable than RECIST in assessing response to treatment in patients with HGSOC. Trial Registration CICATRIx IRAS number 198179, 14 Dec 2015, https://www.myresearchproject.org.uk/ .

We review our 10-year experience of mitral valve (MV) repair in comparison with MV replacement in the elderly for floppy mitral valves/mitral valve prolapse (FMV/MVP). The use of MV repair for this entity has not been fully utilized by surgeons. Two hundred ninety-two consecutive patients aged ≥70 years receiving mitral surgery for regurgitation due to FMV/MVP were reviewed from our prospective database between January 1, 1992, and December 31, 2002. Patients receiving concomitant coronary artery bypass grafting (CABG) were included. Two hundred eighteen patients underwent repairs and 74 replacements. Postoperative and long-term follow-up data were obtained. Mean follow-up time for survivors was 6.2 ± 2.5 years for MV repair and 6.8 ± 2.7 years for MV replacement. Patients with isolated MV repair showed lower inhospital mortality compared with MV replacement (0.7% vs 13.9%, P = .002) with reduced length of stay (8.7 ± 7.6 vs 9.6 ± 5.2 days, P = .049). There was improvement in 5-year mortality favoring repair versus replacement (81% ± 3% vs 63% ± 3%, P = .001). With concomitant CABG, there was minimal difference in survival up to 5 years. Freedom from valve replacement was 93.9% ± 1.3% for MV repair and 98.2% ± 0.4% for MV repair with CABG at 10 years. Mitral valve repair was an independent protector of long-term mortality within multivariate correlates (hazard ratio 0.43, 95% CI 0.19-0.97, P = .041). In elderly patients, MV repair reduced inhospital mortality and length of stay and increased long-term survival. With concomitant CABG, survival was similar to replacement. The preferred option for elderly patients with FMV/MVP is MV repair, especially in those without coronary artery disease.

Treatment for advanced renal cell carcinoma (aRCC) comprises single agent or combinations of immune checkpoint inhibitors and/or anti-angiogenic agents. Pazopanib is a multitargeted anti-angiogenic tyrosine kinase inhibitor (TKI) approved as treatment for aRCC. We noted that a number of patients receiving pazopanib developed a radiological finding of small bowel lipomatosis. To evaluate the incidence of small bowel lipomatosis in patients with aRCC on treatment with pazopanib in comparison with other tyrosine kinase inhibitors. We identified 12 out of 208 patients receiving pazopanib to have small bowel lipomatosis and compared their clinic-radiological findings with 314 patients with aRCC receiving other TKIs (sunitinib, cabozantinib, axitinib, and tivozanib). No patients receiving these TKIs developed small bowel lipomatosis. We compared the radiological findings in patients receiving pazopanib for aRCC. The presence of lipomatosis should not be considered as a clinically relevant finding in these patients. The presence of lipomatosis has no relation with the response to treatment to pazopanib and this is a unique finding seen only in patients on pazopanib. Small bowel lipomatosis is an occasional finding in patients with advanced renal cancer on pazopanib and is not seen with other TKIs.

Constitutional pathogenic variants in TP53 are associated with Li-Fraumeni syndrome or the more recently described heritable TP53-related cancer syndrome and are associated with increased lifetime risks of a wide spectrum of cancers. Due to the broad tumour spectrum, surveillance for this patient group has been limited. To date, the only recommendation in the UK has been for annual breast MRI in women; however, more recently, a more intensive surveillance protocol including whole-body MRI (WB-MRI) has been recommended by International Expert Groups. To address the gap in surveillance for this patient group in the UK, the UK Cancer Genetics Group facilitated a 1-day consensus meeting to discuss a protocol for the UK. Using a preworkshop survey followed by structured discussion on the day, we achieved consensus for a UK surveillance protocol for TP53 carriers to be adopted by UK Clinical Genetics services. The key recommendations are for annual WB-MRI and dedicated brain MRI from birth, annual breast MRI from 20 years in women and three-four monthly abdominal ultrasound in children along with review in a dedicated clinic.

A man in his mid-70s presented with a lump in his left testicle. He had previously been treated for prostate cancer with radical radiotherapy. He was on treatment for hypertension and type 2 diabetes. An ultrasound of the testes demonstrated a solid intratesticular mass for which he underwent left orchidectomy. Histology from the orchidectomy was moderately differentiated squamous cell carcinoma (SCC), positive for cytokeratin (CK) 5/6 and p63. A positron emission tomogram (PET) scan was clear of any metastatic disease. His surveillance CT, done at 12 months, revealed mediastinal, abdominal and hilar adenopathy. Biopsy of hilar lymph nodes showed SCC and this was treated with platinum-based chemotherapy. Unfortunately, the patient died after 18 months. To our knowledge, this is the first reported case of metastatic SCC of testes with extensive spread and with platinum-refractory disease.

The occurrence of somatic transformation in germ cell tumour (GCT) is rare, with increased incidence in teratomatous tumours. The aim of this study was to understand the clinical outcomes of patients with metastatic GCT with somatic transformation. A retrospective study was conducted in two tertiary cancer centres in London. Between 1998 and 2016, 30 cases of somatic transformation in GCT treated at the Mount Vernon Cancer Centre and St. Bartholomew's Hospital were identified. The median age at diagnosis was 34 years (range=18-56 years). The histological diagnosis at transformation was rhabdomyosarcoma, sarcomatoid yolk sac, sarcoma (non-specified), clear cell carcinoma, adenocarcinoma and primitive neuro ectodermal tumour (PNET). The 5-year survival rate of all patients was 47%, and that of patients with testicular primary (n=26 patients) was 37%. Somatic transformation component in testicular GCTs is generally considered to be an adverse prognostic factor, however, a reasonable 5-year overall survival rate (87.5%) was observed in patients who present with this at first diagnosis.

Background/Aim: The occurrence of germ cell tumour (GCT) in the elderly is rare, with scarce data available. The aim of this study was to understand the clinical outcomes of patients with GCT in patients aged > 45 years. Materials and Methods: A retrospective study was conducted in a large tertiary cancer centre in north-west London. Between 1 January 2003 and 31 March 2022, 108 cases of GCT in men aged > 45 years were identified and treated at the Mount Vernon Cancer Centre. The median age at diagnosis was 54 years (range = 45–70 years). Results: The 5-year survival rate of all patients was 96%, and the toxicity profile was similar to the younger age group. Conclusion: Older patients with GCT are able to tolerate chemotherapy; however, care must be taken to prevent life-threatening complications using appropriate dose modification.

Single-agent carboplatin at area under the curve 10 (AUC10) is an effective treatment for metastatic seminoma. As far as we are aware of, there have been no studies reporting its effects on short-term quality of life. The objective was to study the efficacy, safety and tolerability, using health-related quality of life, of carboplatin AUC10 chemotherapy in patients with metastatic seminoma. Forty-four patients with metastatic seminoma treated at Mount Vernon Cancer Centre with carboplatin AUC10 were included in this study. Response to treatment was determined by radiological imaging (Response Evaluation Criteria in Solid Tumors v 1.1) and serum tumour markers. Toxicities were evaluated using the Common Terminology Criteria for Adverse Events Version 4.0. Quality of life treatment-related toxicities were assessed during treatment at pre-chemotherapy assessments. After treatment, toxicity was assessed using a defined telephone questionnaire consisting of four questions relating to hair loss, hearing impairment, days absent from work, and neuropathy. At a median follow-up of 27.5 (range=4-84) months, no patient had experienced relapse. Grade 3/4 neutropenia was seen in 15 (35%) patients, nine (21%) required prophylactic granulocyte colony-stimulating factor, 13 (30%) patients had grade 3/4 thrombocytopenia. Commonest non-haematological toxicities were fatigue in 28 (65%) and nausea 14 (33%) patients. They were grade 1 in 82% and 92% of cases, respectively. Six out of 44 (14%) had residual tinnitus. One patient had residual grade 1 peripheral neuropathy. Ten patients continued to work throughout treatment and two patients were retired. Of the remaining patients, 16 (37%), took fewer than 5 days off work. Carboplatin AUC10 is a safe and effective treatment for stage II/III seminoma with better health-related quality of life than experienced with combination cisplatin-based chemotherapy.

Bone is the most common site of metastatic disease in advanced prostate cancer. Radium-223 ( Ra) is a calcium-mimetic alpha-particle emitter, which has been shown to have activity in prostate cancer with clinical benefit in patients with symptomatic bone metastasis. The recommended schedule is six cycles of Ra, 5 kBq/kg, at 4-weekly intervals. Although previous studies have assessed clinical outcomes in patients who received six cycles of Ra , there is very little information about outcomes of patients receiving fewer courses of treatment. Patients with hormone-refractory metastatic prostate cancer treated from May 2014 to August 2016 were included in this retrospective study. A total of 113 patients were identified with a median age of 76 (range=52-92) years. The median number of cycles administered was 5 (range=1-6) with 54 (48%) completing six cycles of treatment. Eighty-five patients (75%) received Ra prior to docetaxel chemotherapy and 28 (25%) received it after receiving docetaxel. Eleven patients developed grade 2/3 thrombocytopenia, and none of these received further Ra. Only 25% of patients who had a haemoglobin level of 10 g/dl or below at the start of the treatment were able to complete six courses of Ra. Of the patients who completed fewer than six cycles of Ra (1-5 cycles), the survival was 121 days, compared to 398 days in men who received six cycles (odds ratio(OR)=4.767, 95% confidence internal(CI)=1.07-21.25; p=0.0005). Careful selection of patients is essential to obtain good clinical outcomes from Ra therapy. When fewer than six cycles were delivered then a beneficial survival effect was not seen.

Introduction/BackgroundMalignant ovarian germ cell tumours (MOGCTs) are rare and aggressive malignancies mainly affecting young women. Unlike testicular GCTs, prognostic factors are poorly understood, but small series have most consistently suggested that advanced stage best predicts worse outcomes. Here, we examine a large, international patient series to identify new adverse prognostic factors.MethodologyWe evaluated 254 patients treated in Charing Cross Hospital and Mount Vernon Cancer Centre, UK and in Multi-centre Italian Trials in Ovarian Cancer (MITO) group between 1971 and 2018. Descriptive statistical, survival and Cox regression techniques were performed using STATA (StataCorp, v.16, Texas, USA).ResultsMedian age was 26 years (IQR, 20–32). There were 22.4% dysgerminomas, 18.5% immature teratomas, 33.5% yolk sac, 17.7% mixed, 1.2% embryonal, 2.4% choriocarcinoma and 4.3% unclassified. FIGO stage distribution was 31.5% (IC/M), 12.6% (II), 40.5% (III) and 15.4% (IV). First line chemotherapy consisted of BEP, POMB/ACE or other regimens for 48.0%, 42.5% and 9.5% of patients, respectively. Recurrences received high dose chemotherapy (HDCT), conventional chemotherapy ± surgery, and surgery alone in 24.4%, 65.9% and 7.3% of cases.At multivariable analysis, age ≥35 at presentation [HR 2.3, 95%CI (1.0–5.0), p=0.04], stage [HR 1.5, 95%CI (1.0–2.1), p=0.032], and non-dysgerminoma versus dysgerminoma [HR 12.7, 95%CI (1.7–94.0), p=0.013] were significantly associated with worse cancer-specific survival (CSS). Twenty-year CSS for stage IC/M, II, III, and IV were 94.8%, 82.3%, 83.2% and 84.3%, respectively. In patients relapsing or failing to achieve a complete response, HDCT showed a trend for improved 5-year CSS compared to conventional treatments [HR 0.5, 95%CI (0.2–1.5), p=0.241].ConclusionThis study demonstrated that in addition to advanced stage, age ≥35 years, and non-dysgerminoma, but not immature teratomas, are independent adverse prognostic factors for CSS. Strikingly, stage IV disease can still achieve >80% long-term survival rates. HDCT may improve outcomes for relapsing/incomplete responding patients.