The first BGICC consensus and recommendations for breast cancer awareness, early detection and risk reduction in low- and middle-income countries and the MENA region.

In low-middle income countries (LMICs) and the Middle East and North Africa (MENA) region, there is an unmet need to establish and improve breast cancer (BC) awareness, early diagnosis and risk reduction programs. During the 12th Breast, Gynecological & Immuno-oncology International Cancer Conference - Egypt 2020, 26 experts from 7 countries worldwide voted to establish the first consensus for BC awareness, early detection and risk reduction in LMICs/MENA region. The panel advised that there is an extreme necessity for a well-developed BC data registries and prospective clinical studies that address alternative modalities/modified BC screening programs in areas of limited resources. The most important recommendations of the panel were: (a) BC awareness campaigns should be promoted to public and all adult age groups; (b) early detection programs should combine geographically distributed mammographic facilities with clinical breast examination (CBE); (c) breast awareness should be encouraged; and (d) intensive surveillance and chemoprevention strategies should be fostered for high-risk women. The panel defined some areas for future clinical research, which included the role of CBE and breast self-examination as an alternative to radiological screening in areas of limited resources, the interval and methodology of BC surveillance in women with increased risk of BC and the use of low dose tamoxifen in BC risk reduction. In LMICs/MENA region, BC awareness and early detection campaigns should take into consideration the specific disease criteria and the socioeconomic status of the target population. The statements with no consensus reached should serve as potential catalyst for future clinical research.

Whole lung irradiation for completely responding pulmonary metastases in pediatric Ewing sarcoma.

Aim: Scarce data assessing the real value of whole lung irradiation (WLI) in Ewing's sarcoma (ES) with lung-only metastasis, with published conflicting results. We studied the impact of WLI in a homogenous pediatric population. Materials & methods: Retrospective study evaluating the survival outcomes of WLI in these patients. Results: Out of 163 metastatic ES; 41 patients were eligible for WLI. 30 patients (73.1%) received WLI (+ve) while 11 patients (26.8%) did not receive WLI (-ve). Five-year event-free survival was statistically significant in WLI (+ve). Five-year pulmonary relapse-free survival showed trend for improvement with WLI (+ve), while 5-year overall survival was not statistically significant between the two arms. Conclusion: WLI added significantly to the long term clinical outcome of metastatic ES patients, with no irreversible toxicity.

Stage I seminoma: Outcome of different treatment modalities and changes in patterns of care. A single institution experience.

BACKGROUND: The mainstay for management of stage I seminoma is high inguinal orchiectomy with post-orchiectomy therapeutic options including active surveillance, chemotherapy or radiation therapy. OBJECTIVES: To analyze different post-orchiectomy treatment modalities outcomes of stage I seminoma patients presented to NCI, Cairo University in the period from 2005-2019. PATIENTS AND METHODS: A retrospective review of all patients' records with clinical stage I seminoma who presented to our institute in the period from 2005-2019 was done. Adjuvant treatment details were extracted and we compared overall survival (OS) and disease free survival (DFS) for different modalities and changes in patterns of care over this period. RESULTS: Thirty five patients were identified with thirty three patients eligible for analysis. Median age was 35 years (range, 19-52). Fourteen patients were kept under active surveillance, eleven patients received adjuvant carboplatin and eight patients received adjuvant radiation to para-aortic chain. Five-year OS was 100% for all patients regardless post-operative approach. Five-year DFS was 100% for patients who received adjuvant chemotherapy or radiotherapy versus 93% for patients who were kept under active surveillance (p=0.03). CONCLUSION: Clinical stage I seminoma is a favorable disease entity with favorable disease related outcomes regardless post-operative approach. Active surveillance is reasonable and safe given equal survival to active treatment.

Nephrectomy for Pediatric Renal Tumors: A Modified Surgical Approach to Minimize Post-operative Intestinal Obstruction.

BACKGROUND: The authors present a modified surgical technique during tumor nephrectomy in children with a conservative approach towards small bowel manipulation and cutting of the peritoneal reflections. We aimed to evaluate this modified surgical approach regarding the incidence of post-operative small bowel obstruction (SBO), and its technical utility. METHODS: The study includes all children with unilateral renal tumors who underwent radical nephrectomy and lymph nodes sampling at our tertiary center from 2010 to 2022. The modified technique was performed via the usual transverse incision. We cut the peritoneal reflections short of the cecum or short of the sigmoid colon. The colon is reflected over SB packing it, proceeding to nephrectomy and lymph nodes sampling. Data included demographics, clinical characteristics, treatment strategy, operative details, post-operative SBO, and overall outcomes. RESULTS: The study included 890 patients with a median age of 3.2 years. The median tumor largest diameter was 13 cm (range: 9-18 cm). The modified surgical technique was adopted in 287 patients (32.3 %). Forty-three patients (43/890, 4.8 %) had post-operative SBO. Out of them, only 4 cases were operated on using the modified surgical technique (p-value<0.001). There were no significant differences between both techniques regarding timing of surgery, tumor rupture, lymph nodes sampling, and tumor size (p-value = 0.775, 0.328, 0.216, and 0.563, respectively). CONCLUSIONS: The modified surgical approach is significantly correlated with lower incidence of post-operative SBO with no increased risk of tumor rupture or incomplete lymph nodes sampling. The timing of surgery or tumor characteristics had no significant impact on the technical utility of the modified surgical approach. LEVEL OF EVIDENCE: Level IV.

Hypofractionated Radiation Therapy For Diffuse Intrinsic Pontine Glioma: A Noninferiority Randomized Study Including 253 Children.

PURPOSE: Pediatric diffuse intrinsic pontine glioma is an orphen disease. This study aimed to confirm the noninferiority of hypofractionated (HF) radiation therapy. Identification of the prognostic factors that determine the overall survival (OS) and progression-free survival (PFS) was the secondary objective. METHODS AND MATERIALS: We randomized 253 patients into 3 arms of radiation therapy regimens: HF1, receiving 39 Gy in 13 fractions; HF2, receiving 45 Gy in 15 fractions; and conventional fractionation (CF), receiving 54 Gy in 30 fractions. The OS and PFS were calculated using Kaplan-Meier methods, and the noninferiority was estimated against the CF arm. RESULTS: The median OS for the HF1, HF2, and CF were 9.6, 8.2, and 8.7 months, respectively. The 1-, 1.5-, and 2-year OS were 34.6%, 17.9%, and 10.7% for HF1; 26.2%, 13.1%, and 4.8% for HF2; and 25.3%, 12.1%, and 8.4% for CF, respectively (P = .3). The hazard ratio was 0.776 and 1.124 for HF1 and HF2, respectively. Considering the noninferiority margin (Δ) of 15% and a power of 90%, the lower inferiority confidence interval for HF1 was -14.34% and for HF2 it was 11.37% (both below Δ), confirming its noninferiority at 18-months OS. Younger patients (2-5 years of age) had better median OS in the whole cohort (11.6 months), HF1 (13.5), and CF (12.1) but not HF2 (6.2) (P = .003). Furthermore, the OS rates at 1, 1.5, and 2 years for children 2 to 5 years of age in the HF2 arm were lower than those in the HF1 and CF arms. However, similar acute and late side effects were reported in the 3 arms. CONCLUSIONS: Two hypofractionated radiation therapy proved to be noninferior to conventional fractionation. Young age (2-5 years) is the only prognostic factor determining both OS and PFS. The young age superiority was lost with a higher hypofractionated radiation therapy dose, necessitating more caution in applying 45 Gy in 15 fractions in younger children (2-5 years of age).

Outcome of cervix uteri cancer patients: Clinical treatment results and toxicity profile in a retrospective study from Saudi Arabia.

AIM: This study evaluated the survival outcome, pattern of failure and prognostic factors in cervix uteri cancer patients. METHODS: We reviewed the data of 60 patients with stages IB-IVA cancer who were treated between January 2004 and December 2010. RESULTS: Most patients (n = 50; 83%) had squamous cell carcinoma. Stage IIB was the most common presentation (n = 41; 68%). Forty-seven patients (78%) received Cisplatin concurrent with radiotherapy (CRT). The 2- and 4-year overall survival (OS) was 82% and 79%, respectively. Prolongation of the overall treatment time (OAT) for greater than 56 days, advanced stage and pretreatment hemoglobin (Hb) levels (<10 g/dL) negatively predicted OS (P = 0.039, P = 0.044 and P = 0.008, respectively). The 2- and 4-year disease-free survival (DFS) rates were 80% and 69%, respectively. Vaginal infiltration and brachytherapy (orthogonal versus CT-based planning) were significant factors for the prediction of relapse (P = 0.048 and P = 0.049, respectively). The 2- and 4-year loco-regional control (LRC) rates were 78% and 70%, respectively, and the distant metastasis-free survival (DMFS) rates were 82% and 79%, respectively. Vaginal infiltration was the only negative predictive factor for LRC (P = 0.045), and pathological tumor grade was the only factor indicative of distant metastases (P = 0.037). Grade 3 or 4 late rectal reactions were reported in two patients (3%), and no patients developed grade 3 or 4 urinary reactions. CONCLUSION: The treatment results in our cervix uteri cancer patients and the prognostic factors are comparable to those of previous reports. Orthogonal brachytherapy planning and vaginal infiltration negatively predicted relapse.

Dosimetric prospective study comparing 2D and 3D planning for irradiation of supraclavicular and infraclavicular regions in breast cancer patients.

PURPOSE: The purpose of this study is to compare 2D plan and 3D plan regarding coverage of the target (supraclavicular and infraclavicular regions) and dose reaching the risk organs (using mean DVH). Depending on the results of this study, modifications can be made to the 2D conventional planning of supraclavicular and infraclavicular regions in order to achieve better coverage of the target tissues. MATERIALS AND METHODS: This is a dosimetric study carried out at the radiation oncology department in NCI-Cairo University in the period from January 2012 to October 2012, on 15 patients with breast cancer who are eligible for supraclavicular and infraclavicular irradiation. For All patients, a 2D and a 3D plan were done. RESULTS: We found that the coverage of the supraclavicular and infraclavicular regions and the chest wall or breast together with levels I and II axilla (PTV) were significantly better with the 3D technique with less over dose than the 2D technique. That difference was highly significant and was most evident in MRM cases. Also we found that organs at risk received a dose in the 3D technique that was more than that received in the 2D technique, again that difference was highly significant and was also most evident in MRM cases but all doses were still within tolerance. CONCLUSIONS: From the present study we concluded that the coverage of the supraclavicular and infraclavicular PTV is significantly worse with the 2D technique using a single oblique field at a fixed depth of 3 cm for all patients despite their different builts.

Dosimetric analytic comparison of inverse and forward planned IMRT techniques in the treatment of head and neck cancer.

PURPOSE: Our aim was to investigate if, and to what degree, improvements of IMRT treatment plans generated by forward planning can be achieved with an inverse planning strategy for treatments of head and neck cancer. METHODS: Between June 2007 and April 2008, 19 patients with head-and-neck cancers were treated at KAAH and Oncology Center Jeddah, using forward planning intensity modulated radiation therapy (FP-IMRT). They received thirty fractions over six weeks, to simultaneously deliver 66 Gy to the gross tumor (CTV1), 60 Gy to the soft tissue and nodes adjacent to the previous volume (CTV2), and 54 Gy to elective nodes (CTV3). These are biologically equivalent to 70, 60, and 50 Gy, if given 2 Gy per fraction. These were retrospectively re-planned with an inverse planning algorithm (IP-IMRT). The main objective of the optimization process was sparing of the parotid glands, spinal cord, and brainstem beside adequate treatment of the planning target volume. RESULTS: Having 95% and 98% of CTV1 to receive at least 95% and 90% of prescribed dose respectively was fulfilled in all cases in both groups with higher figures in group B (IP-IMRT) than in group A (FR-IMRT), more obvious in CTV2 and CTV3. The average maximum dose to the spinal cord was 45.1 Gy in group A, and 41.6 Gy in group B. The mean dose of both parotid glands was kept below 26 Gy in four patients in group A, but in all cases in group B. CONCLUSION: IP-IMRT selectively spared critical organs to greater degree with better target coverage and should be considered the standard of treatment in head and neck tumors.

Locally advanced rectal carcinoma: preoperative radiotherapy versus postoperative chemoradiation, 10-year follow-up results of a randomized clinical study.

PURPOSE: A prospective study was designed to randomize locally advanced rectal carcinoma patients between either preoperative radiotherapy (+/- postoperative chemotherapy) or postoperative adjuvant chemoradiation. Two end points were evaluated, local recurrence and survival, aiming at defining prognostic parameters that can help in the choice of the optimum treatment modality. PATIENTS AND METHODS: This is a prospective randomized clinical study including patients with locally advanced low rectal cancer treated at the National Cancer Institute (NCI), Cairo University, during the period from December 1994 to January 1999. Fifty patients with previously untreated rectal cancer were randomized into two groups, Group I: Subjected to surgery followed by radiation therapy (50Gy/5 weeks, 2Gy/fraction, 5 days/week) plus chemotherapy and Group II, subjected to preoperative radiotherapy (46Gy/4.5 weeks, 2Gy/ fraction, 5 days/week) followed by surgery +/- postoperative chemotherapy. Chemotherapy in the concomitant setting was given in the form of Leucovorin in a dose of 300mg/m2 as a short i.v. infusion followed by 5-FU in a dose of 350mg/m2 as a 6 hour i.v. infusion, whereas adjuvant chemotherapy consisted of 5- FU as 600mg/m2 short i.v. infusion weekly for 48 weeks, in addition to levamisole tablets. RESULTS: The long-term treatment end results obtained showed that group I patients had a slightly higher 10-year overall survival (OS) rate when compared to group II patients (63% versus 60%, p=0.698). The corresponding figures for the 10-year disease-free survival (DFS) were 65% and 66%, respectively, p=0.816. Although the 10- year local failure rate (persistent/relapsed disease) was higher for the preoperative group, it was not of statistical significance, (30% Vs. 8%, p=0.057). On the other hand, the 10-year distant metastasis free survival was higher in the preoperative group (88% Vs. 72%), yet this difference did not reach statistical significance (p=0.16). The rate of acute radiation reactions was higher in the postoperative group, with no increase in the operative complications in the preoperative group. Moreover, none of the 50 patients had grade 3 or more late radiation/surgical squealae. There were no grade 3 or 4 chemotherapy related toxicities. CONCLUSIONS: This work showed equal results for DFS and OS rates between preoperative and postoperative radiation therapy with the same acceptable acute and late radiation toxicity. High dose preoperative irradiation did not cause any significant increase in acute or late radiation induced reactions, delay in wound healing or increased postoperative morbidity when compared to postoperative adjuvant radiochemotherapy. Duke' s stage and response to preoperative irradiation proved to be of significance regarding DFS, while compliance to systemic therapy was of significance regarding both OS and DFS.

The prognostic impact of additional chemotherapy to radiation therapy for postoperative management of pediatric medulloblastoma.

PURPOSE: The aim of this study is to evaluate treatment results of combined therapy; surgery, postoperative craniospinal radiotherapy with chemotherapy compared to treatment with postoperative radiotherapy only. Also to assess the effect of extent of surgical resection on prognosis. PATIENTS AND METHODS: Between 1993 and 2003, 34 children > 3 years of age with nondisseminated medulloblastoma were treated with postoperative, craniospinal radiation therapy (36 Gy in 20 fractions to the craniospinal axis, supplemented by a posterior fossa dose of 1980 cGy in 11 fractions (total dose of 56 Gy). Daily fractions of 1.8 Gy were used. Out of them, 16 children received chemotherapy in the form of vincristine, at a dose of 1.5 mg/m2, which was given weekly during radiotherapy. One month after completion of radiation therapy, chemotherapy was continued every 4 weeks with cycles of cyclophosphamide (750 mg/m2) and vincristine(2mg/m2) for a maximum dose of 2mg, alternating with vincristine and carboplatin (500 mg/m2). A total of 12 alternating cycles were administered. RESULTS: The follow-up period ranged from 14-132 months. The median overall survival (OAS) for the whole group was 49.5 months (mean of 61+/-38) while the median progression free survival (PFS) was 47.5 months (mean 59.6+/-39). Although both PFS and OAS were better among those who had total resection than subtotal resection (estimated 5-y PFS of 60% and 64% for both groups, respectively and estimated 5-y OAS of 65% for subtotal resection and 69% for those underwent total resection), however this difference was not statistically significant (p=0.1). The median PFS for the chemotherapy group was 60.5 months (Mean was 72.6+/-41.7) while that for the non-chemotherapy group was 39.5 months (mean 48+/-33.6). The difference was of borderline significance with a p-value of 0.06. The estimated 5-year progression free survival for the chemotherapy group was 70% while that of no chemotherapy group was 59% with a p-value of 025. While the estimated 5-year overall survival for chemotherapy group was 70% in comparison to 60% for non-chemotherapy group giving borderline statistical significance difference with a p-value of 08. CONCLUSION: Maximum possible surgical resection, postoperative radiotherapy and adjuvant chemotherapy are important factors in improving outcome in the management of medulloblastoma.