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Background Small cell carcinoma (SCC) is a neuroendocrine tumor that usually originates in the lungs but can also arise from extrapulmonary sites. Extrapulmonary small cell carcinomas (EPSCCs) are aggressive and rare, with limited data guiding their management. This case report contributes to the literature by presenting the diagnosis and treatment of primary peritoneal SCC. Case presentation This case describes a 69-year-old man who presented with abdominal distension and pain, raising concerns for metastasis. He had a history of prostate cancer treated with radical prostatectomy and pelvic lymph node dissection. Biopsy and imaging revealed metastatic SCC involving the peritoneum and omentum. A diagnosis of primary peritoneal SCC or SCC of unknown primary origin was made due to the absence of a detectable primary tumor in typical sites. The patient underwent three separate courses of carboplatin/etoposide chemotherapy (6 cycles each), with each course resulting in significant disease regression and symptom relief. Recurrence was managed effectively with repeated chemotherapy cycles, but long-term follow-up showed the need for continued treatment to maintain disease control and quality of life. Conclusion This case underscores the importance of a multidisciplinary approach and patient-centered care in managing rare cancers like primary peritoneal SCC. Further research is essential to clarify its molecular characteristics and improve therapeutic options. Graphical abstract

Adjuvant trastuzumab significantly improves outcomes for patients with HER2-positive early breast cancer. The standard treatment duration is 12 months but shorter treatment could provide similar efficacy while reducing toxicities and cost. We aimed to investigate whether 6-month adjuvant trastuzumab treatment is non-inferior to the standard 12-month treatment regarding disease-free survival. This study is an open-label, randomised phase 3 non-inferiority trial. Patients were recruited from 152 centres in the UK. We randomly assigned patients with HER2-positive early breast cancer, aged 18 years or older, and with a clear indication for chemotherapy, by a computerised minimisation process (1:1), to receive either 6-month or 12-month trastuzumab delivered every 3 weeks intravenously (loading dose of 8 mg/kg followed by maintenance doses of 6 mg/kg) or subcutaneously (600 mg), given in combination with chemotherapy (concurrently or sequentially). The primary endpoint was disease-free survival, analysed by intention to treat, with a non-inferiority margin of 3% for 4-year disease-free survival. Safety was analysed in all patients who received trastuzumab. This trial is registered with EudraCT (number 2006–007018–39), ISRCTN (number 52968807), and ClinicalTrials.gov (number NCT00712140). Between Oct 4, 2007, and July 31, 2015, 2045 patients were assigned to 12-month trastuzumab treatment and 2044 to 6-month treatment (one patient was excluded because they were double randomised). Median follow-up was 5·4 years (IQR 3·6–6·7) for both treatment groups, during which a disease-free survival event occurred in 265 (13%) of 2043 patients in the 6-month group and 247 (12%) of 2045 patients in the 12-month group. 4-year disease-free survival was 89·4% (95% CI 87·9–90·7) in the 6-month group and 89·8% (88·3–91·1) in the 12-month group (hazard ratio 1·07 [90% CI 0·93–1·24], non-inferiority p=0·011), showing non-inferiority of the 6-month treatment. 6-month trastuzumab treatment resulted in fewer patients reporting severe adverse events (373 [19%] of 1939 patients vs 459 [24%] of 1894 patients, p=0·0002) or stopping early because of cardiotoxicity (61 [3%] of 1939 patients vs 146 [8%] of 1894 patients, p<0·0001). We have shown that 6-month trastuzumab treatment is non-inferior to 12-month treatment in patients with HER2-positive early breast cancer, with less cardiotoxicity and fewer severe adverse events. These results support consideration of reduced duration trastuzumab for women at similar risk of recurrence as to those included in the trial. UK National Institute for Health Research, Health Technology Assessment Programme.

Introduction/BackgroundStereotactic Ablative Body Radiotherapy (SABR) is emerging as a treatment option for patients with oligometastatic solid tumours. The primary aim of this approach is to prolong disease free survival and delay the initiation of systemic therapies. We report a single institution clinical outcomes.Methodology71 lesions from 51 patients with relapsed oligometastatic (1 -3 lesions) gynaecological cancers (endometrium = 23, ovary = 16, cervical = 10, vulva = 1 and Vagina = 1) were treated with SABR, delivered using both cyberknife and VMAT. Treatment was delivered using a median of 4 fractions to a median dose of 45 Gy. Response was assessed with repeat imaging 10 – 12 weeks post-SABR. CTCAE system version 5.0 was used to assess acute and late toxicity.ResultsMean age was 67 years. Target lesions were pelvic node = 22, para-aortic node = 18, lung = 16, liver = 4, brain = 3, peritoneal mass = 2, porta-hepatis node = 2, bone =2, right adnexa = 1, vaginal vault = 1. After a median follow-up of 17 months, 48% of the lesions had a partial response (PR), 12% had a complete response (CR), 26.5% were stable (SD), and 13.5% has progressive disease. Lesions greater than 30 mm had unfavourable outcome. Median progression free survival (PFS) was 11.2 months. Median survival (OS) has not been reached. Treatment was generally well tolerated, 2 patients experienced grade 3 toxicity.ConclusionSABR for patients with relapsed oligometastatic gynaecological cancers is a safe treatment with promising results in terms of local control and PFS. As distant progression remains the primary mode of failure in these patients, the combination of SABR and systemic therapies requires evaluation in randomized controlled trials.

Background:During the SARS-CoV-2 virus pandemic, University Hospital Birmingham NHS Trust Oncology Department incorporated the ultrahypofractionated regime of 26Gy/5 fractions alongside the moderate hypofractionated regime of 40Gy/15 fractions as part of local adjuvant breast radiotherapy treatment (RT) for eligible patients. We conducted a local study to assess the real-life experience of patients undergoing ultrahypofractionated schedule to compare feasibility and toxicity to the fast-forward trial during the COVID − 19 pandemic.Methods:A single institution, retrospective, qualitative study. Patients included had early-stage breast cancer and received adjuvant radiotherapy between 23 March 2020 and 31 May 2020, a total of 211 patients. Inclusion was irrespective of any other neoadjuvant/adjuvant treatments. Data were collected retrospectively for treatment dose, boost dose and toxicity.Results:Of the total 211 patients, 85 were treated with 26Gy in 5# and 19 patients received a boost as per the fast-forward protocol. Of these 85 patients, 15·9% did not report any skin toxicity post-treatment. 63·5% of patients reported RTOG Grade 1, 15·9% had RTOG Grade 2, and 1·6% reported RTOG Grade 3 skin toxicity. 3·2% of the patients could not be contacted for follow-up. Of the 19 patients who received a breast boost, 10·53% reported no skin changes. 78·9% reported Grade 1 skin toxicity. Both Grades 2a and 2b skin toxicity were reported by 5·26% each. The patient demographics and tumour characteristics in our study cohort were comparable to those within the fast-forward trial. In terms of post-RT skin toxicity, fewer patients reported any toxicity in the UHB patient cohort versus those in the trial, and the number of Grade 2/3 toxicities reported was also low. A delay in toxicity reporting from 2 weeks for 40Gy/15 to 3 weeks for 26Gy/5 was observed.Conclusion:Our study concluded that offering ultrahypofractionation was convenient for patients; reducing the number of hospital visits during the SARS-CoV-2 virus pandemic appeared safe in terms of acute post-RT-related skin toxicity. The reduced hospital visits limited exposure of patients and staff to the SARS-CoV-2 virus while also ensuring efficient use of Radiotherapy Department resources. Local follow-up protocols have been amended to ensure review at 3 weeks for the 26Gy/5 schedule to acknowledge the delay in acute toxicity development. To date, there is only 5-year toxicity and relapse data available from the fast-forward trial; therefore, hypofractionation schedules should be offered to patients as long as they fulfil the criteria and understand the limitations of the study as well as accelerated peer review processes in the face of the pandemic.

Aim:Stereotactic ablative body radiotherapy (SABR) for spine metastases is associated with a risk of vertebral compression fracture (VCF). The aim of this study was to determine the rate of VCF at one UK institution and evaluate the use of the Spinal Instability Neoplastic Score (SINS) to predict these.Materials and methods:A retrospective analysis of all patients who underwent SABR for spinal metastases between 2014 and 2018 at one UK institution was performed. Basic demographic data were collected, and SINS prior to SABR was calculated. The primary outcome was VCF rate. Secondary outcomes included time to VCF and need for surgical intervention following VCF.Results:A total of 48 oligometastases were treated with a median follow-up of 20·5 months. A maximum of two vertebral bodies were treated. The median baseline SINS was calculated as 3. The median dose was 26 Gy in three fractions. Two patients were reported to have VCF and both were successfully conservatively managed.Findings:SABR for spine oligometastases is being performed safely with low VCF rates which are comparable with those in international publications. This may be as a result of strict adherence to criteria for delivery of SABR with low pre-treatment SINS.

Malignant mesotheliomas (MMs) are malignancies of the mesothelium, with primary deposits originating in the pleura, peritoneum, pericardium and the tunica vaginalis (ie, testicular). Metastatic spread is commonly reported to affect the liver, adrenal glands, kidney and contralateral lung (in cases of malignant pleural mesothelioma). Metastases to distant sites are uncommon. Spread to the oral cavity in particular is very rare. A total of 23 cases of metastatic spread to the oral cavity have been reported in the literature to date; of those, 9 cases have been to the tongue. Given the rarity of the site of metastasis, the management remains challenging. This case highlights a rare site of metastasis in MM, discusses treatment options available and briefly talks about technical limitations in treating a mobile structure such as the tongue. Good palliative and supportive care is crucial in managing cases where no curative treatment is possible.

Endodontic technical errors are the foremost cause of treatment failure. A thorough understanding of root canal configuration (RCC) is essential to prevent these iatrogenic errors. This study used CBCT images to determine the association between root canal configuration, endodontic technical errors, and periapical status. CBCT images of 101 patients, including total of 212 obturated premolars (256 canals) were assessed. RCCs were classified according to the Vertucci system. The presence of endodontic errors and periapical lesions associated with each RCC was noted. Presence or absence of coronal restoration and its association with periapical radiolucency was recorded. The most frequent RCC was Type I (199 cases; 77.73%), followed by Type II (26 cases; 10.15%), Type IV (22 cases; 8.59%), Type V (4 cases; 1.56%), Type III (4 cases; 1.56%), and Type VI (1 case; 0.39%). Under-filling and non-homogeneous filling were the most common technical errors. Prevalence of periapical radiolucency was 81% in the presence of technical errors. The absence of coronal restoration caused apical lesions in 93% of cases. The frequency of endodontic technical errors increased as the root canal configurations became more complex. Periapical lesions occurred more often in teeth with endodontic errors and/or absent coronal restoration.

Background: In Saudi Arabia, major health challenges are chronic diseases like diabetes, hypertension, cardiovascular conditions. Family medicine physicians occupy a unique position in managing these conditions especially if the targets of Saudi Vision 2030 for improvement in healthcare access and quality were tallied. But effective disease management requires attendance at clinical guidelines, coping with limited resources, and implementing telemedicine.Aim: This systematic review aims to determine family medicine physicians' role in Saudi Arabia in the management of chronic diseases in line with Saudi Vision 2030 goals, and to examine challenges and opportunities for quality improvement of care delivery.Method: Ten primary studies published between 2020 and 2024 were reviewed using a systematic review. Cross-sectional surveys, cohort studies and literature reviews were all included among these studies. Finally, the data was extracted on family physicians' roles, following clinical guidelines, use of technology, and the integration of Saudi Vision 2030's modifications in healthcare. Quality and relevance were assessed in the studies.Results: The review revealed that family physicians play a central role in the management of chronic disease, providing continuity of care, education and preventive health. Despite these challenges however, teachers don’t consistently adhere to the guidelines due to time constraints, lack of resources or inadequate professional development. However, telemedicine had promised but there were technological barriers to integrating it. The studies also outlined how family medicine practices supported the realization of Saudi Vision 2030 through the alignment with the family physician for every family model, a key goal of Vision 2030 health objectives.Conclusion: Adequate family medicine physicians are critical to the management of chronic diseases in Saudi Arabia, but they need systemic reforms, increased training and improved telemedicine infrastructure to fully deliver on Saudi Vision 2030 Healthcare goals.