Simultaneous Multiple Liver Metastasis Treated with Pencil Beam Proton Stereotactic Body Radiotherapy (SBRT)

Compared with photon stereotactic body radiotherapy (SBRT) plans that may have to use many more penetrating x-ray beams for each isocenter, proton SBRT with ultrahypofractionated doses use fewer beam angles and offer significantly reduced low-dose radiation bath to normal liver tissue. We demonstrate techniques to deliver safe and effective proton SBRT, where planning and organ motion complexity further increased with multiple liver lesions. For treatment planning, we recommend robust and logical beam angles, avoiding devices and encouraging entry perpendicular to the dominant motion, as well as volumetric repainting to mitigate the interplay effect to clinically acceptable levels. This report highlights the significant technical challenges with ultrahypofractionated proton pencil beam scanning liver therapy, how they are managed, and the effectiveness of this treatment.

BRAF Mutated Metastatic Colorectal Carcinoma (mCRC): A case report

Colorectal cancer (CRC) is the third and second most frequent cancer in men and women respectively. Although histologically similar, CRCs are diverse with respect to the underlying molecular mechanism which could be explored for planning treatment strategies. Chromosomal instability, microsatellite instability, and errors in the DNA repair mechanism are the most frequent molecular aberrations involved in various sub groups of CRCs. BRAF (v-Raf murine sarcoma viral oncogene homolog B) mutation is seen in 5-15 % of CRC, with a higher mutation rate in right sided colon cancer. Patients with BRAF V 600E mutation tends to have a poor prognosis with a median survival rate of less than 12 months. In terms of treatment these patients do not benefit from therapeutics targeting the EGFR so it is important for clinicians to be aware. Treatment options beyond standard chemotherapy are crucial to achieve better outcomes and the role of anti-EGFR therapy alone remains controversial. Current trials assessing combinations of molecular targeted agents have shown some promise. We report a case of a 32 year old female who presented with features of intestinal obstruction and pallor of skin and mucous membranes. Her blood test showed low Hb and a high serum CEA value and CT Abdomen revealed a large hepatic flexure growth with multiple liver metastasis. Colonoscopic biopsy showed moderately differentiated adenocarcinoma and molecular assay confirmed wild type K RAS and mutated BRAF. To the best of our knowledge there are no reported cases of BRAF mutated metastatic carcinoma colon from Nepal.

Complete Response of Synchronous Liver Metastasis in a Pancreatic Ductal Adenocarcinoma: Could Surgery Represent a Therapeutic Option?

Metastatic pancreatic ductal adenocarcinoma pancreatic (PDAC) is characterized by poor prognosis and short survival. Today, the use of new polytherapeutic regimens increases clinical outcome of these patients opening new clinical scenario. A crucial issue related to the actual improvement achieved with these new regimens is represented by the occasional possibility to observe a radiological complete response of metastatic lesions in patients with synchronous primary tumor. What could be the best therapeutic management of these patients? Could surgery represent an indication? Herein we reported a case of a patient with a PDAC of the head with multiple liver metastasis, who underwent first line chemotherapy with mFOLFIRINOX. After 10 cycles, he achieved a complete radiological response of liver metastases and a partial response of pancreatic lesion. A, duodenocephalopancreasectomy was performed. Due to liver a lung metastases after 8 months from surgery, a second line therapy was started with a disease free survival and overall survival of 8 months and 45 months, respectively. Improvement in the molecular characterization of PDAC could help in the selection of patients suitable for multimodal treatments.