Introduction: Classical Hodgkin Lymphoma in the elderly (ecHL) is a rare disease with dismal prognosis and no standard treatment. In elderly lymphoma patients (pts) functional status evaluation helps define different prognostic subgroups and may be useful to design appropriate treatments. Sarcopenia has been associated with worse survival in various solid tumors, but its impact in ecHL is unknown. The aim of this retrospective multicenter study was to investigate the prognostic role of sarcopenia in ecHL. Methods: We retrospectively analyzed ≥65 years old ecHL pts treated at 4 participating centers, who performed a baseline comprehensive geriatric assessment (CGA) and high-dose computed tomography (CT) or positron emission tomography/CT (PET/CT) before any treatment. Sarcopenia was measured as skeletal muscle index (SMI, cm2/m2) by the analysis of high dose CT or low-dose PET/CT images at the L3 level. The specific cut-offs for the SMI were determined by receiver operator curve (ROC) analysis and compared with those studied in Diffuse Large B Cell Lymphoma (DLBCL) pts (Lanic et al, Leuk Lymphoma 2014; Nakamura et al, Ann Hematol 2015). Survival functions (Progression Free Survival, PFS; Overall Survival, OS) were calculated for the whole population and for different subgroups defined as per different sarcopenia cut-off levels. Results: One hundred and fifty-four pts (median age 71y, 76 females) were included in the study. The median L3-SMI was 42 cm2/m2. The specific cut-off derived in our male population was 45 cm2/m2; using this cut-off, 27 male pts (35%) were defined as sarcopenic. After a median follow-up of 5.9 years, the overall 5-year PFS and OS rates were 53% and 65%, respectively, and were significantly shorter in sarcopenic males compared to non-sarcopenic (PFS 31% vs 61%, p = 0.008; OS 51% vs 74%, p = 0.042) [Figure 1]. Applying DLBCL-derived sarcopenic thresholds, there were no significant differences between sarcopenic and non-sarcopenic pts for both PFS and OS, with a sole exception of a significant reduced PFS in sarcopenic male pts using Namakura-cut off. The CGA-determined frail functional status was an independent adverse prognostic factor for both female and male pts. Conclusions: Baseline evaluation of sarcopenia through radiological examinations performed for ecHL staging may help define a proportion of male pts with unfavorable outcome with current treatment strategies. Also the functional status evaluation could allow to identify a frail subgroup of pts with worse outcome. Prospective studies are warranted to better define the effective role and utility of this approach in the setting of ecHL. OS and PFS according to sarcopenic status defined by our specific population cut-off [<45 cm2/m2] in male patients Keywords: Hodgkin lymphoma No conflicts of interest pertinent to the abstract.

Radiomics hypothesize that imaging features of disease and normal tissues may be useful for predicting prognosis and toxicity for various conditions, thus providing valuable information for personalized therapy. Aim of this monocentric study is to explore radiomics based on staging positron emission tomography/computed tomography (PET/CT) as a toxicity biomarker in early stage non-small cell lung cancer (NSCLC) patients treated with stereotactic body radiation therapy (SBRT). PET/CT images, medical records and radiation plans of 25 stage I-II primary NSCLC patients treated with SBRT were retrospectively analyzed on an IEC-approved protocol. Clinical variables (age, gender, smoking history, performance status, pulmonary function tests PFTs, CT-defined emphysema presence, comorbidities, concurrent drugs, previous lung surgery, tumor size, tumor location, planning target volume PTV), dosimetric lung and heart indices and 42 radiomic features were extracted. Radiomic features were calculated from ipsilateral and contralateral lung of CT images of PET/CTs. Univariate analysis was done to evaluate the association of clinical-dosimetric variables and imaging features with toxicity outcomes using Wilcoxon and Fisher test. The clinical outcomes considered were Pneumonitis-free probability (PFP) and lung toxicity-free probability (LTFP) which were defined respectively as the absence of radiation pneumonitis ≥ grade 2 and of any radiation-related lung toxicity ≥ grade 2, according to CTCAE v. 5.0. All patients received SBRT with a median biologically effective dose of 113 Gy. Median follow-up was 23 months. According to Kaplan-Meier estimate, 2-year OS was 51% and 2-year PFS was 47%. PFP was 56% and LTFP was 40%. Dose to 5% and 10% of ipsilateral lung and all cardiac dosimetric indices were correlated with PFP (P-value < 0.05). PTV volume, several ipsilateral lung dosimetric indices and several ipsilateral and contralateral lung radiomic features were significantly associated with LFTP. Neither PFTs nor radiologic evidence of lung emphysema nor other clinical variables were associated with any toxicity endpoint. This study demonstrated the clinical relevance of radiomics as a toxicity biomarker in patients with early stage NSCLC treated with SBRT. Unlike PFTs or radiological evidence of lung emphysema, lung radiomic features may be a useful tool to quantify full range of variation within lungs volume and heterogeneity between patients.

Purpose or ObjectiveElderly people represent more than 50% of sarcoma patients and they often present many differences compared to younger patients.In fact, older patients experience increased cancer-related morbidity and mortality compared to younger patients: this is shown in several studies pointing out that older age is associated to poorer outcomes.Nowadays, there are no data regarding the management of advanced soft-tissue sarcoma (STS) in elderly patients.The aim of this study is to analyze clinical outcome and treatment related toxicity of elderly STS patients in a single Institution. Material and MethodsWe retrospectively collected data of patients ≥65 years old diagnosed with localized advanced STS between 1998 and 2017 in a single institution. ResultsThe study included 111 patients.Mean Charlson Index was 7.5 (2-12).One hundred five (94.6%) patients underwent surgery, ninety-one patients (82%) received radiotherapy, 23 (20.7%) patients received concurrent radiochemotherapy and 20 (18.1%) patients received chemotherapy alone.Grade >3 acute skin toxicity was recorded in 38 (52.8%) patients out of 72 patients who received postoperative radiotherapy, age > 80 years correlated with higher incidence of toxicity compared to younger patients (63.6% vs 33.3%, p=0.02).Late fibrosis, late edema and joint stiffness occurred in 10.4%, 11.8% and 4% of patients, respectively.Age did not correlate to late toxicity incidence.At a mean follow up of 4.1 years (0.1-17.7) twenty-four (22%) patients recurred, 3-and 5year local recurrence free survival was 80.3% and 75.7%, respectively.At statistical analysis no treatments and patients characteristics affected local recurrence.Fiftyfive (52.9%) patients developed distant metastasis, 3-and 5-year distant metastasis free survival (DMFS) was 59.6% and 44.6%, respectively.At univariate analysis no delivered of adjuvant radiotherapy and no surgery correlated with higher local recurrence (p=0.043 and p=0.002).On multivariate analysis, undifferentiated pleomorphic sarcoma histology was the only independent factors associated with DMFS (p=0.026).Overall survival (OS) was 62% and 46.6% at 3 and 5 years, respectively.On multivariate analysis, surgery was the only independent factor associated with OS (p=0.006). ConclusionOlder patients have worse outcomes because they tend to present with worse tumors and are treated less aggressively.In this study elderly STS patients were treated with a tailored treatment comprising surgery, radiotherapy and/or chemotherapy resulted in a good efficacy and safe.

Purpose or ObjectiveDeep inspiration breath-hold (DIBH) has been routinely applied in left breast radiotherapy to reduce cardiac exposure.The purpose of this study was to compare deep inspiration breath hold and free breathing techniques (FB) in terms of heart and left-lung doses and to determine possible predictors of the dose reduction achieved with DIBH (ΔDBH-FB). Material and MethodsTen patients with left breast cancer have been treated with postoperative radiotherapy in Parma Hospital.For each patient both the FB and the DIBH planning CT were acquired.3DCRT treatment plans using tangential fieldin-field beams were developed for both FB and DIBH.FB and DIBH dose distributions were compared in terms of Dmean, V5Gy, V20Gy, V30Gy of the heart and V5Gy, V20Gy of the left-lung.Many geometric/anatomical parameters were measured in the FB condition: heart and left-lung volumes (Vheart, Vlung-L), maximum thickness of the same organs inside the tangential fields (dheart, dlung-L), axial and para-sagittal cardiac contact distances (CCDax, CCDps), maximum tangential distance between beam-entrance and beam-exit (dentrance-exit), maximum anteroposterior diameter of the chest. ResultsDIBH plans showed a significant reduction of Dmean (-60.9%),V5Gy (-82.5%),V20Gy (-93.6%) and V30Gy (-95.8%) of the heart (p<0.01,Wilcoxon signed-rank test), while no significant difference in target coverage and left-lung V5Gy, V20Gy.The parameters which significantly correlated with ΔDBH-FB were: Vheart (0.041≤p≤0.049,0.63≤R≤0.65),dheart (p<0.001,0.96≤R≤0.97),CCDps (0.036≤p≤0.045,0.64≤R≤0.66)and dentrance-exit (0.036≤p≤0.048,0.64≤R≤0.67). ConclusionThis study confirmed how DIBH for left breast cancer treatment can decrease cardiac dose.The benefit of DIBH over FB strictly depends on chest shape, heart size and heart position.However, most of the parameters showed a weak correlation with ΔDBH-FB, so they can't be used to effectively predict ΔDBH-FB.Only dheart seems to be a good predictor of ΔDBH-FB, but more cases must be included to confirm/reject these findings.

Purpose Deep inspiration breath-hold (DIBH) has been routinely applied in left breast radiotherapy to reduce cardiac exposure. The purpose of this study was to compare deep inspiration breath hold and free breathing techniques (FB) in terms of heart and left-lung doses and to determine possible predictors of the dose reduction achieved with DIBH ( Δ DBH-FB). Methods Ten patients with left breast cancer have been treated with postoperative radiotherapy in Parma Hospital. For each patient both the FB and the DIBH planning CT were acquired. 3DCRT treatment plans using tangential field-in-field beams were developed for both FB and DIBH. FB and DIBH dose distributions were compared in terms of Dmean, V5Gy, V20Gy, V30Gy of the heart and V5Gy, V20Gy of the left-lung. Many geometric/anatomical parameters were measured in the FB condition: heart and left-lung volumes (Vheart, Vlung-L), maximum thickness of the same organs inside the tangential fields (dheart, dlung-L), axial and para-sagittal cardiac contact distances (CCDax, CCDps), maximum tangential distance between beam-entrance and beam-exit (dentrance-exit), maximum anteroposterior diameter of the chest. Results DIBH plans showed a significant reduction of Dmean (−60.9%), V5Gy (−82.5%), V20Gy (−93.6%) and (−95.8%) of the heart (p < 0.01, Wilcoxon signed-rank test), while no significant difference in target coverage and left-lung V5Gy, V20Gy. The parameters that significantly correlated with Δ DBH-FB were: Vheart (0.041 < p < 0.049, 0.63 < R < 0.65), dheart (p < 0.001, 0.96 < R < 0.97), CCDps (0.036 < p < 0.045, 0.64 < R < 0.66) and dentrance-exit (0.036 < p < 0.048, 0.64 < R < 0.67). Conclusions This study confirmed how DIBH for left breast cancer treatment can decrease cardiac dose. The benefit of DIBH over FB strictly depends on chest shape, heart size and heart position. However, most of the parameters showed a weak correlation with Δ DBH-FB, so they cannot be used to effectively predict Δ DBH-FB. Only dheart seems to be a good predictor of Δ DBH-FB, but more cases must be included to confirm/reject these findings.

Purpose Although the relationship between pulmonary emphysema (PE) and pneumonitis after radiotherapy has been investigated in recent years, it remain controversial [ 1 Ishijima M et al. Patients with severe emphysema have a low risk of radiation pneumonitis following stereotactic body radiotherapy. Br J Radiol 2015;88(1046):20140596. Google Scholar , 2 Zhou Z et al. Pulmonary emphysema is a risk factor for radiation pneumonitis in NSCLC patients with squamous cell carcinoma after thoracic radiation therapy. Sci Rep 2017;7:2748. Google Scholar ]. The aim of this study was to retrospectively examine the role of PE on radiation-induced lung toxicity (RILT). The feasibility of a "functional treatment plan (FTP)", designed to spare the functional volumes of the lungs (FLV), was also investigated. Methods 34 patients with NSCLC who underwent radiotherapy has been selected for this study. An expert radiologist analysed the first CT after-treatment and subdivided patients in two categories: RILT-1, 13 patients with no/low RILT; RILT-2, 21 patients with high RILT. Thresholds were applied on planning CT (before-treatment) to define PE (below −900 U) and FLV (between −899 and −500 HU). Through the Mann-Whitney test, RILT-1 and RILT-2 were compared in terms of PE volumes and of dosimetric parameters V5Gy and V20Gy of both total (DPTL) and functional lungs (DPFL). For patients who had considerable PE volumes, FTPs were developed based on VMAT technique. To selectively spare the FLV, arc sectors that involved parts of FLV were avoided and high-weight constraints for FLV were applied in the VMAT Optimizer. Results PE volume was significantly higher in RILT-1 than in RILT-2 (p < 0.05). RILT-1 was characterised by significantly lower DPTL than RILT-2 and the difference become stronger when considering DPFL. The 66.7% of FTPs were not feasible because PE was irregularly distributed over the whole lungs volume. Regarding the remaining 33.3% of the FTPs, FLV Dmean averagely decreased by 0.67 Gy (0.25 < ΔDmean < 1.52 Gy). Conclusions This study suggested that patients with emphysema were less subject to RILT. In addition, RILT was better associated with FLV exposure than total lung exposure. Therefore, a FTP would be desirable, but it's limited to a small number of cases depending on PE amount and distribution. Although the relationship between pulmonary emphysema (PE) and pneumonitis after radiotherapy has been investigated in recent years, it remain controversial [ 1 Ishijima M et al. Patients with severe emphysema have a low risk of radiation pneumonitis following stereotactic body radiotherapy. Br J Radiol 2015;88(1046):20140596. Google Scholar , 2 Zhou Z et al. Pulmonary emphysema is a risk factor for radiation pneumonitis in NSCLC patients with squamous cell carcinoma after thoracic radiation therapy. Sci Rep 2017;7:2748. Google Scholar ]. The aim of this study was to retrospectively examine the role of PE on radiation-induced lung toxicity (RILT). The feasibility of a "functional treatment plan (FTP)", designed to spare the functional volumes of the lungs (FLV), was also investigated. 34 patients with NSCLC who underwent radiotherapy has been selected for this study. An expert radiologist analysed the first CT after-treatment and subdivided patients in two categories: RILT-1, 13 patients with no/low RILT; RILT-2, 21 patients with high RILT. Thresholds were applied on planning CT (before-treatment) to define PE (below −900 U) and FLV (between −899 and −500 HU). Through the Mann-Whitney test, RILT-1 and RILT-2 were compared in terms of PE volumes and of dosimetric parameters V5Gy and V20Gy of both total (DPTL) and functional lungs (DPFL). For patients who had considerable PE volumes, FTPs were developed based on VMAT technique. To selectively spare the FLV, arc sectors that involved parts of FLV were avoided and high-weight constraints for FLV were applied in the VMAT Optimizer. PE volume was significantly higher in RILT-1 than in RILT-2 (p < 0.05). RILT-1 was characterised by significantly lower DPTL than RILT-2 and the difference become stronger when considering DPFL. The 66.7% of FTPs were not feasible because PE was irregularly distributed over the whole lungs volume. Regarding the remaining 33.3% of the FTPs, FLV Dmean averagely decreased by 0.67 Gy (0.25 < ΔDmean < 1.52 Gy). This study suggested that patients with emphysema were less subject to RILT. In addition, RILT was better associated with FLV exposure than total lung exposure. Therefore, a FTP would be desirable, but it's limited to a small number of cases depending on PE amount and distribution.