Primary therapy of early breast cancer: Egyptian view of 2021 St. Gallen consensus.

PURPOSE: The theme of the St. Gallen International Breast Cancer Conference 2021 held virtually for the first time, due to the COVID-19 pandemic, was on tailoring therapies for patients with early breast cancer. A monkey survey that included an Egyptian Panel voted on most of the questions of the original St. Gallen consensus, and some added new questions most relevant to oncology practice in the country, to be able to compare voting results that reflect differences in breast cancer management and decision making. METHODS: The panel included 74 Egyptian scientists from different oncology specialties. Management issues including controversial diagnostic and therapeutic interventions were prepared by a small committee and then projected using the online monkey survey website: https://www.surveymonkey.com . The survey included 130 questions. Results were then analyzed, tabulated, and compared to the voting results of the original St. Gallen consensus. RESULTS AND CONCLUSIONS: Voting questions and resulting percentages of answers from the Egyptian panel were summarized. There was no consensus between the Egyptian and the original St. Gallen panels on 28/130 statements. They mostly included genetic and pathologic aspects, specifically the routine use of gene signature assays and a few queries involving surgical, radiotherapeutic, and systemic interventions. Probably, available resources and healthcare system differences in Egypt compared to European and the USA were the cause of these differences. This would also be applicable to other low- and low-middle-income healthcare scenarios present in many countries, especially with the present constraints of the COVID-19 pandemic.

The St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017: Egyptian view.

PURPOSE: The theme of the 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria was about seeking where appropriate to escalate or de-escalate therapies for early breast cancer based on the up-to-date information of loco-regional and systemic therapies. Along with this line, a group of Egyptian experts decided to arrange for a consensus session to elicit the differences and similarities in therapy recommendations for early breast cancer in Egypt compared to the original Saint Gallen voting and recommendations. METHODS: During the Egyptian National Cancer Institute's Annual Congress held in November 2017, 30 Egyptian scientists and clinicians from different specialties gathered in a special session and voted on the same questions of the original 15th St. Gallen consensus. Therapies were discussed from different aspects including their intensity, duration, and side effects, and were correlated with tumor stage and tumor biology. RESULTS AND CONCLUSIONS: This report summarizes the voting questions and resulting percentages of answers of the Egyptian scientists. Interestingly the differences were minimal between the Cairo and original Saint Gallen Consensus denoting a more global view of breast cancer management all over the world.

Role of radiotherapy fractionation in head and neck cancers (MARCH): an updated meta-analysis.

BACKGROUND: The Meta-Analysis of Radiotherapy in squamous cell Carcinomas of Head and neck (MARCH) showed that altered fractionation radiotherapy is associated with improved overall and progression-free survival compared with conventional radiotherapy, with hyperfractionated radiotherapy showing the greatest benefit. This update aims to confirm and explain the superiority of hyperfractionated radiotherapy over other altered fractionation radiotherapy regimens and to assess the benefit of altered fractionation within the context of concomitant chemotherapy with the inclusion of new trials. METHODS: For this updated meta-analysis, we searched bibliography databases, trials registries, and meeting proceedings for published or unpublished randomised trials done between Jan 1, 2009, and July 15, 2015, comparing primary or postoperative conventional fractionation radiotherapy versus altered fractionation radiotherapy (comparison 1) or conventional fractionation radiotherapy plus concomitant chemotherapy versus altered fractionation radiotherapy alone (comparison 2). Eligible trials had to start randomisation on or after Jan 1, 1970, and completed accrual before Dec 31, 2010; had to have been randomised in a way that precluded prior knowledge of treatment assignment; and had to include patients with non-metastatic squamous cell carcinoma of the oral cavity, oropharynx, hypopharynx, or larynx undergoing first-line curative treatment. Trials including a non-conventional radiotherapy control group, investigating hypofractionated radiotherapy, or including mostly nasopharyngeal carcinomas were excluded. Trials were grouped in three types of altered fractionation: hyperfractionated, moderately accelerated, and very accelerated. Individual patient data were collected and combined with a fixed-effects model based on the intention-to-treat principle. The primary endpoint was overall survival. FINDINGS: Comparison 1 (conventional fractionation radiotherapy vs altered fractionation radiotherapy) included 33 trials and 11 423 patients. Altered fractionation radiotherapy was associated with a significant benefit on overall survival (hazard ratio [HR] 0·94, 95% CI 0·90-0·98; p=0·0033), with an absolute difference at 5 years of 3·1% (95% CI 1·3-4·9) and at 10 years of 1·2% (-0·8 to 3·2). We found a significant interaction (p=0·051) between type of fractionation and treatment effect, the overall survival benefit being restricted to the hyperfractionated group (HR 0·83, 0·74-0·92), with absolute differences at 5 years of 8·1% (3·4 to 12·8) and at 10 years of 3·9% (-0·6 to 8·4). Comparison 2 (conventional fractionation radiotherapy plus concomitant chemotherapy versus altered fractionation radiotherapy alone) included five trials and 986 patients. Overall survival was significantly worse with altered fractionation radiotherapy compared with concomitant chemoradiotherapy (HR 1·22, 1·05-1·42; p=0·0098), with absolute differences at 5 years of -5·8% (-11·9 to 0·3) and at 10 years of -5·1% (-13·0 to 2·8). INTERPRETATION: This update confirms, with more patients and a longer follow-up than the first version of MARCH, that hyperfractionated radiotherapy is, along with concomitant chemoradiotherapy, a standard of care for the treatment of locally advanced head and neck squamous cell cancers. The comparison between hyperfractionated radiotherapy and concomitant chemoradiotherapy remains to be specifically tested. FUNDING: Institut National du Cancer; and Ligue Nationale Contre le Cancer.

Pelvic exenteration and composite sacral resection in the surgical treatment of locally recurrent rectal cancer.

BACKGROUND: The incidence of rectal cancer recurrence after surgery is 5-45%. Extended pelvic resection which entails En-bloc resection of the tumor and adjacent involved organs provides the only true possible curative option for patients with locally recurrent rectal cancer. AIM: To evaluate the surgical and oncological outcome of such treatment. PATIENTS AND METHODS: Between 2006 and 2012 a consecutive series of 40 patients with locally recurrent rectal cancer underwent abdominosacral resection (ASR) in 18 patients, total pelvic exenteration with sacral resection in 10 patients and extended pelvic exenteration in 12 patients. Patients with sacral resection were 28, with the level of sacral division at S2-3 interface in 10 patients, at S3-4 in 15 patients and S4-5 in 3 patients. RESULTS: Forty patients, male to female ratio 1.7:1, median age 45 years (range 25-65 years) underwent extended pelvic resection in the form of pelvic exenteration and abdominosacral resection. Morbidity, re-admission and mortality rates were 55%, 37.5%, and 5%, respectively. Mortality occurred in 2 patients due to perineal flap sepsis and massive myocardial infarction. A R0 and R1 sacral resection were achieved in 62.5% and 37.5%, respectively. The 5-year overall survival rate was 22.6% and the 4-year recurrence free survival was 31.8%. CONCLUSION: Extended pelvic resection as pelvic exenteration and sacral resection for locally recurrent rectal cancer are effective procedures with tolerable mortality rate and acceptable outcome. The associated morbidity remains high and deserves vigilant follow up.

Epidemiology of mesothelioma in Egypt. A ten-year (1998-2007) multicentre study.

INTRODUCTION: Mesothelioma is a cancer strongly linked to exposure to carcinogenic minerals, especially asbestos. The aim of the study was to detect the incidence of malignant pleural mesothelioma (MPM) in Egypt, to clarify the impact of occupational and environmental risk factors, and to characterise its demographic features. MATERIAL AND METHODS: They were 584 cases diagnosed as MPM detected in Cairo University Hospitals and National Cancer Institute from 1998 to 2007. Unfortunately, full epidemiological data were only available for 165 cases due to absence of a reliable registration system. RESULTS: A steady increase in the number of cases was detected, from 24 in 1998, peaking at 82 cases in 2005, followed by a gradual decline (though still high) with 68 cases in 2006 and 51 cases in 2007. Male/female ratio was 1.35/1 (p > 0.05). The occupational exposure to asbestos was 13.9%. Residential exposure plays a major role in two regions, Helwan and Shoubra (27.3% and 20.6% respectively), while in Upper and Lower Egypt the level was 12.7% and 17.5% respectively. Kaplan-Meier survival for sex, residence and the pathological types epithelioid, biphasic and sarcomatoid was insignificant. The median survival for different grades and treatment modalities was significant (P < 0.001). CONCLUSIONS: There was a steady increase in the incidence of MPM from 1998 to 2005 followed by a decline during 2006-2007. Mesothelioma in Egypt is mainly concentrated in areas of high environmental pollution. The decline within the last 2 years may be attributed to recent strict industrial preventive measures. However, a better environmental control programme would benefit Egypt.

Role of pectoralis major myocutanuos flap in salvage laryngeal surgery for prophylaxis of pharyngocutaneuos fistula and reconstruction of skin defect.

AIM OF WORK: This study was carried out to minimize the incidence of pharyngocutaneous fistula (PCF) following salvage laryngeal surgery using vascularized pedicle pectoralis major myocutaneous flap (PMMC) for enhancing wound healing, rapid intake of oral feeding, reconstruction of desqauamated irradiated skin, achieving short hospital stay and protection against catastrophic blow out mortality. PATIENTS AND METHODS: This case series study of sixteen patients carried out from May 2005 to July 2009, at the National Cancer Institute, Cairo University where we applied PMMC flap in salvage laryngeal surgery for those with high risk to develop complications: Patients of poor general conditions (anemia, hypoproteinemia, diabetics) and/or poor local conditions for healing (irradiated neck, extensive local or nodal recurrence with skin desquamation, infiltration or tumor fungation which need extensive resection). Five cases had been treated with primary cobalt radiotherapy laryngeal field only and 4 cases laryngeal field with draining neck nodes, while photon therapy was given in 4 cases as laryngeal field only and 3 cases laryngeal field with draining neck nodes. All cases were squamous cell carcinoma (13 cases grade 2, 2 cases grade 3 and one case grade 1) proved before radiotherapy. Supraglottic recurrence was detected in 7 cases (43.75%) and glottis in 9 cases (56.25%). Following salvage surgery, 11 cases were staged T3 N0, N1 and N2, 3 cases were T2 N0 or N1 and 2 cases were T4 N2 with skin infiltration. Tracheostomy was there in 4 cases. RESULTS: The study included fifteen males (93.75%) and one female (6.25%), age was between 38-73 years (mean=55.5 years). Five cases were operated on as total laryngectomy with excision of skin flaps + PMMC flap, 4 cases as total laryngectomy with skin flap excision + functional block neck dissection + PMMC flap and 7 cases as total laryngectomy + block neck dissection with skin excision (modified radical in 4 cases &radical in 3 cases) + PMMC flap reconstruction. Flaps survived in all cases, PCF developed in 2 cases (12.5%) with wound infection but healed conservatively within 2 weeks. Dropped shoulder occurred in 3 cases (18.75%) treated by physiotherapy. Mild postoperative chest infection developed in 7 cases (36.84%) improved by broad spectrum antibiotics and chest physiotherapy. CONCLUSION: Routine use of pectoralis major myocutaneous flap in salvage laryngeal surgery is of great help in such high risk patients to minimize incidence of pharyngocutaneous fistula and to allow primary skin wound healing. This flap will give the patient the advantage of early oral feeding, good tracheostomy care, short hospital stay and protection against catastrophic vascular blow out mortality. KEY WORDS: Pectoralis major myocutaneous flap - Prevention of pharyngocutaneous fistula - Salvage laryngectomy.

Overdose problem associated with treatment planning software for high energy photons in response of Panama's accident.

BACKGROUND AND PURPOSE: The purpose of this study was to quantify dose distribution errors by comparing actual dose measurements with the calculated values done by the software. To evaluate the outcome of radiation overexposure related to Panama's accident and in response to ensure that the treatment planning systems (T.P.S.) are being operated in accordance with the appropriate quality assurance programme, we studied the central axis and pripheral depth dose data using complex field shaped with blocks to quantify dose distribution errors. MATERIAL AND METHODS: Multidata T.P.S. software versions 2.35 and 2.40 and Helax T.P.S. software version 5.1 B were assesed. The calculated data of the software treatment planning systems were verified by comparing these data with the actual dose measurements for open and blocked high energy photon fields (Co-60, 6MV & 18MV photons). RESULTS: Close calculated and measured results were obtained for the 2-D (Multidata) and 3-D treatment planning (TMS Helax). These results were correct within 1 to 2% for open fields and 0.5 to 2.5% for peripheral blocked fields. Discrepancies between calculated and measured data ranged between 13. to 36% along the central axis of complex blocked fields when normalisation point was selected at the Dmax, when the normalisation point was selected near or under the blocks, the variation between the calculated and the measured data was up to 500% difference. CONCLUSIONS: The present results emphasize the importance of the proper selection of the normalization point in the radiation field, as this facilitates detection of aberrant dose distribution (over exposure or under exposure).

Shielding for scattered radiation to the testis during pelvic radiotherapy: is it worth?

OBJECTIVES: To assess the value of external shielding of the testis during pelvic radiotherapy. MATERIAL AND METHODS: Nineteen patients, receiving radiotherapy to the pelvis with the lower border of the field at the obturator foramen, were randomly selected. A 5 half value layer cerrobent shield was positioned at the inferior border of the field. The dose to the testis was measured with and without the shield. Observations were made regarding the reflex cremaster contraction and phantom measurements were done at different distances from the perineum. RESULTS: The mean radiation dose to the testis for patients receiving treatment with no shield was 7.4cGy (1.3) and it was 5.7cGy (-/+2.5) for patients with external shield, this difference was statistically significant by the paired t test p<0.0001. This accounted for a 22 % decrease in the dose received by the testis. The position of the testis with the contraction of the cremaster muscle and the dartos fascia after manipulation of the testis during diodes placement changed up to 3.5 cm (mean 1.5). Phantom measurements showed 37% increase in the dose with 2cm change in the position of the testis to the pelvic direction. CONCLUSION: External shield at the inferior border of the pelvic field is a simple, easy reproducible, convenient shielding method. Clam-shell scrotal shield is not free of drawbacks, but still its benefits overweigh its harms and should be used with caution.

Ipsilateral in-breast tumor relapse after breast conservation therapy: true recurrence versus new primary tumor.

BACKGROUND AND PURPOSE: Ipsilateral breast tumor relapse (IBTR) occurs in approximately 8-20% of women 10 years after breast conservation therapy (BCT). The aim of this study is to classify ipsilateral breast tumor relapses in patients treated with conservative surgery and radiation therapy as true recurrences or new primary and to show the clinical significance of classification into these two types of recurrences. PATIENTS AND METHODS: Out of 267 patients treated at National Cancer Institute, Cairo University in the period extending from 1993 to 2000, 29 patients have experienced ipsilateral tumor relapse as the first site of recurrence. These relapses were classified as true recurrence if it was located within 3cm of the primary tumor bed and was of the same histologic subtype. All other ipsilateral breast tumor relapses were considered as new primary. The patients were followed-up until January 2005. RESULTS: After a mean follow-up period of 7.9 +/- 2.6 years following the original diagnosis, the overall ipsilateral breast tumor relapse rate was 9.6% (29/267). Relapses were classified as TR in 21 patients (72.4%) and were considered as a new primary in 8 cases (27.6%). Patients diagnosed with a new primary had a longer mean time to breast relapse (6.09 years for NP Vs 3.09 years for TR, p < 0.001) and were significantly younger than true recurrence patients (38.38 years Vs 47.54 years, p=0.006). Patients with a new primary had a 10- year overall survival of 87.5%; whereas, it was 61.90% for TR cases (p=0.13). CONCLUSIONS: It appears that a significant portion of patients who experience ipsilateral breast tumor relapse following conservative surgery and radiation therapy have new primary tumors as opposed to true recurrences. Patients with a new primary had better survival rates than those with true recurrence. Distinguishing new primary breast carcinoma from local disease recurrence may have importance in therapeutic decisions and chemoprevention strategies.

Ru106 brachytherapy for management of choroidal melanoma: do we need to adjust total dose according to the new NIST calibration measurement?

PURPOSE: To detect the need of adjusting the apical total dose according to the new NIST calibration measurement introduced by BEBIG Isotopen und Medizintechnik GmbH for the treatment of choroidal melanoma. As the total radiation dose should not be individualized depending on errors pf previous calibration but can be applicable if based on a radiosensitivity test that was able to predict the final response of tumor to radiation for each particular patient. PATIENTS AND METHODS: Twenty patients with choroidal melanomas were treated between November 2002 and July 2004 at "Suzanne Mubarak Eye Tumor Centre", National Eye centre Rod-EL Farag, Cairo, Egypt. The prescribed dose was calculated according to the new NISTcalibrated dosimetry introduced by BEBIG, but without dose modification by using a conversion factor F(type,z) from the ASMW calibrated measurement to the NIST calibrated measurement that have been calculated depending on the plaque type and the distance z from the inner concave plaque surface along the central axis. For the treatment of choroidal melanoma in this study the apical dose ranged from 9000-10400cGy with a mean of 9855 +/- 385. RESULTS: After a follow up period from 12-28 months (median of 19 months) there was a local control rate of 100 % and the three years actuarial disease specific survival was 95% as only one patient died of liver metastases. Fourteen patients had a best corrected pre-treatment visual acuity of better than 6/60 in the affected eye. At the last follow up available, useful visual acuity of>0.5 was preserved in 7 of the patients. CONCLUSION: Recalculation of the apical total dose (mostly increasing of the total dose) according to the conversion factor F(type,z), suggested by BEBIG after the new NIST calibration measurement, does not seem to have an effect on both local control and survival, in this study.