Technological Improvements in Low- and Middle-Income Countries (LMICs): A Review of the Literature and the "Sociedad de Lucha Contra el Cáncer" (SOLCA) Institutional Experience in Neuro-Radiosurgery During the Coronavirus Disease 2019 (COVID-19) Pandemic.

OBJECTIVE: Neurosurgery is a medical field that requires specialized professionals and equipment, 2 important but scarce resources in low- and middle-income countries. Our goal was to report our experience with the replacement and implementation of linear accelerators with radiosurgery capabilities at "Sociedad de Lucha Contra el Cáncer" (SOLCA) Hospital in Quito, Ecuador, and give some recommendations for future technological replacements (TRs). METHODS: Two surveys were performed in SOLCA's radiosurgery department, one before the TR was finalized and one after, consisting of an open and multiple-choice questionnaire. Questions focused on the performance of the new equipment, perceptions regarding the training, and the influence of the pandemic on the whole process. In addition, we share our experience regarding the difficulties and benefits of TR at SOLCA. RESULTS: The most-reported limitation was lack of training (48%). By the time of the second survey, 95.2% of the staff had already treated patients or planned a radiosurgical procedure; 42.9% considered training to have been adequate, and 76.2% felt that the pandemic hindered the training process. Currently, 33 radiosurgeries have been done (26 for the central nervous system and 7 stereotactic radiation body therapies). CONCLUSIONS: The TR in SOLCA had similarities with other experiences in low- and middle-income countries, but the pandemic brought additional limitations, mainly complicating the staff training. Nevertheless, those limitations can be resolved with a structured training program and international collaboration. Overall, the benefits obtained from a TR result in exponentially better medical care and accessibility to novel treatments.

Management of an Unusual Metastasis of Cervical Cancer in the Adrenal Bed With Stereotactic Ablative Body Radiation Therapy.

Uterine cervical carcinoma is an important type of cancer among Ecuadorian women, especially in adult women. Survival rates have improved with the development of radiotherapy, surgical techniques, and chemotherapy. However, recurrence and/or metastasis are not unusual phenomena. Frequent sites of metastasis are the lungs, regional lymph nodes, and bones. Atypical locations can also occur on solid organs, such as adrenal glands. Treatment for the rare complication that is adrenal metastasis is individualized, it can include surgical resection, chemotherapy, local ablation, or different types of radiotherapy. We aimed to report a case of an Ecuadorian woman from Quito city with a diagnosis of cervical carcinoma diagnosed in 2009, treated surgically and with adjuvant chemotherapy. Her progression was monitored with medical controls with no recurrence until 2018, when she relapsed with a metastatic invasion of the pelvic ganglia and the surroundings of the abdominal aorta, with a histopathologic diagnosis of adenocarcinoma. She was then treated with chemotherapy and radiotherapy until June 2019. In 2020, she went through a splenectomy and left adrenalectomy to treat vascular thrombosis. In 2021, 37 x 15 mm mass was discovered in the surgical bed of the previously removed adrenal gland. It was treated as an oligometastatic carcinoma with stereotactic body radiotherapy (SBRT) by a linear accelerator.

Management of an Unusual Central Nervous System Metastasis With Linear Accelerator Radiosurgery in a Low-Middle Income Country.

Large cell neuroendocrine carcinoma, a type of non-small cell lung cancer, is quite rare and has been associated with brain metastasis, mainly to the cerebral hemispheres. However, the rate of cerebellar metastasis is underreported in the literature and appears to be quite rare. Despite the rarity of this metastasis, treatment guidelines for both supratentorial and cerebellar lesions have been established by using either radiosurgery or whole-brain radiation therapy. The choice of modality must take into consideration the vicinity of relevant structures such as the brainstem and its multiple nuclei. Here we report the case of a 68-year-old male, resident of a rural community in the Andean region of Ecuador, a low-middle income country; with the diagnosis of a large cell neuroendocrine carcinoma of the lung with dual central nervous system metastasis treated with linear particle accelerator radio-surgery due to its versatility and cost-effectiveness in a resource-limited setting. We showcase the rarity of the metastatic lesions as well as the utility of linear accelerators and their versatility to perform precise radiosurgical procedures in two simultaneous locations.

[Reducing the impact of COVID-19 on radiation oncology units of developing countries: A rapid review and expert consensus]. / Reduciendo el impacto de COVID-19 sobre la radioterapia oncológica en países en desarrollo: revisión rápida y consenso de expertos.

OBJECTIVE: To generate recommendations on the management of radiotherapeutic treatments during the pandemic, adapted to a country with limited health resources. METHODS: We did a rapid review of the literature, searching for papers that describe any measures to reduce the risk of COVID-19 infection, as well as management guidelines to reduce the workload, in radiotherapy units. The following conditions were included in the scope of this review: gynecological tumors, breast cancer, gastrointestinal tumors, genitourinary tumors, head and neck tumors, skin cancer, tumors of the central nervous system, and lymphomas. An expert group discussed online the extracted data and drafted the recommendations. Using a modified Delphi method, the consensus was reached among 14 certificated radio-oncologists. The quality of the evidence that supported the recommendations on treatment schedules was assessed. RESULTS: A total of 57 documents were included. Of these, 25 provided strategies to reduce the risk of infection. Recommendations for each condiction were extracted from the remaining documents. The recommendations aim to establish specific parameters where treatments can be omitted, deferred, prioritized, and shortened. Treatment schemes are recommended for each condition, prioritizing hypo-fractionated schemes whenever possible. CONCLUSIONS: We propose strategies for the management of radiotherapy services to guarantee the continuity of high-quality treatments despite the health crisis caused by COVID-19.

OBJETIVO: Establecer recomendaciones para la toma de decisiones de manejo en radioterapia durante la pandemia de COVID-19, adaptadas a un país con recursos de salud limitados. MÉTODOS: A través de una revisión rápida de la literatura se buscaron publicaciones que describieran medidas para reducir el riesgo de infección por COVID-19, así como también pautas de manejo para reducir la carga de trabajo en las unidades de radioterapia. Se incluyeron en el alcance de esta revisión las siguientes patologías: tumores ginecológicos, cáncer de mama, tumores gastrointestinales, tumores genitourinarios, tumores de cabeza y cuello, cáncer de piel, tumores del sistema nervioso central y linfomas. Un grupo de expertos discutió en línea los datos extraídos y redactó las recomendaciones. Mediante un método Delphi modificado, se evaluó el consenso entre 14 radio-oncólogos certificados. Se evaluó la calidad de la evidencia que sustentó las recomendaciones sobre esquemas de tratamiento. RESULTADOS: Se incluyeron un total de 57 documentos. De 25 trabajos se extrajeron las estrategias para reducir el riesgo de infección. De los restantes, se obtuvieron las recomendaciones para cada patología. Las recomendaciones están orientadas a establecer escenarios específicos donde se pueden omitir, diferir, priorizar y acortar los tratamientos. En el ítem de acortar se recomiendan esquemas de tratamiento para cada patología, priorizando los esquemas hipofraccionados cuando fue posible. CONCLUSIÓN: Se plantean estrategias para la gestión de los servicios de radioterapia con el objetivo de garantizar que los tratamientos de alta calidad para pacientes oncológicos sigan entregándose, pese a la crisis sanitaria ocasionada por COVID-19.

Reduciendo el impacto de COVID-19 sobre la radioterapia oncológica en países en desarrollo: revisión rápida y consenso de expertos / Reducing the impact of COVID-19 on radiation oncology units of developing countries: a rapid review and expert consensus

OBJETIVO: Establecer recomendaciones para la toma de decisiones de manejo en radioterapia durante la pandemia de COVID-19, adaptadas a un país con recursos de salud limitados. MÉTODOS: A través de una revisión rápida de la literatura se buscaron publicaciones que describieran medidas para reducir el riesgo de infección por COVID-19, así como también pautas de manejo para reducir la carga de trabajo en las unidades de radioterapia. Se incluyeron en el alcance de esta revisión las siguientes patologías: tumores ginecológicos, cáncer de mama, tumores gastrointestinales, tumores genitourinarios, tumores de cabeza y cuello, cáncer de piel, tumores del sistema nervioso central y linfomas. Un grupo de expertos discutió en línea los datos extraídos y redactó las recomendaciones. Mediante un método Delphi modificado, se evaluó el consenso entre 14 radio-oncólogos certificados. Se evaluó la calidad de la evidencia que sustentó las recomendaciones sobre esquemas de tratamiento. RESULTADOS: Se incluyeron un total de 57 documentos. De 25 trabajos se extrajeron las estrategias para reducir el riesgo de infección. De los restantes, se obtuvieron las recomendaciones para cada patología. Las recomendaciones están orientadas a establecer escenarios específicos donde se pueden omitir, diferir, priorizar y acortar los tratamientos. En el ítem de acortar se recomiendan esquemas de tratamiento para cada patología, priorizando los esquemas hipofraccionados cuando fue posible. CONCLUSIÓN: Se plantean estrategias para la gestión de los servicios de radioterapia con el objetivo de garantizar que los tratamientos de alta calidad para pacientes oncológicos sigan entregándose, pese a la crisis sanitaria ocasionada por COVID-19.

OBJECTIVE: To generate recommendations on the management of radiotherapeutic treatments during the pandemic, adapted to a country with limited health resources. METHODS: We did a rapid review of the literature, searching for papers that describe any measures to reduce the risk of COVID-19 infection, as well as management guidelines to reduce the workload, in radiotherapy units. The following conditions were included in the scope of this review: gynecological tumors, breast cancer, gastrointestinal tumors, genitourinary tumors, head and neck tumors, skin cancer, tumors of the central nervous system, and lymphomas. An expert group discussed online the extracted data and drafted the recommendations. Using a modified Delphi method, the consensus was reached among 14 certificated radio-oncologists. The quality of the evidence that supported the recommendations on treatment schedules was assessed. RESULTS: A total of 57 documents were included. Of these, 25 provided strategies to reduce the risk of infection. Recommendations for each condiction were extracted from the remaining documents. The recommendations aim to establish specific parameters where treatments can be omitted, deferred, prioritized, and shortened. Treatment schemes are recommended for each condition, prioritizing hypo-fractionated schemes whenever possible. CONCLUSIONS: We propose strategies for the management of radiotherapy services to guarantee the continuity of high-quality treatments despite the health crisis caused by COVID-19.

Comparación de la dosis estimada en Recto y Vejiga con planificación de Braquiterapia 3D vs 2D / Comparison of the estimated dose in the Rectum and Bladder with 3D versus 2D brachytherapy planning

Introducción: En el tratamiento del Cáncer Cervico Uterino la braquiterapia (BQT) con planificación tridimensional (3D) está altamente extendida, aunque por su costo otros centros utilizan BQT con planificación bidimensional (2D). Es importante establecer si el beneficio que se obtiene con BQT en 3 D, en la protección a los órganos de riesgo, es un factor determinante para el cambio hacia esta nueva tecnología. El objetivo del estudio es comparar las dosis en ambos tipos de BQT en los órganos adyacentes al útero como el colon y vejiga. Métodos: El presente estudio descriptivo, incluye pacientes con diagnóstico de cáncer de cuello uterino que recibieron BQT en el período comprendido de enero 2015 a diciembre 2018, en el servicio Radioterapia del Hospital Solón Espinosa Ayala, Quito-Ecuador. Las variables fueron la dosis recibida con planificaciones en 2D y 3D. Se obtuvo histogramas dosis volumen de los órganos de riesgo: recto y vejiga. Se comparan los promedios con T de Student. Resultados: Participaron 44 casos, de 50.6 ±13.8 años de edad. En estadío clínico IIB 24 casos (55 %). La dosis prescrita de BQT en el grupo fue de 683.6 ±27 cGY. El tipo de aplicador usado fue en la gran mayoría AyT de 5 mm en 34 casos (77 %). La mayoría de los tratamientos consistieron en terapias de 4 sesiones 32 casos (73 %), con 117 implantes para BQT. La dosis planificada en vejiga en 2D fue 5.5 Gy, versus 5.1 Gy en 3D, P= 0.01. La dosis planificada en recto en 2D fue 2.8 Gy; versus 3.0 Gy en 3D P= 0.06. Conclusión: La planificación en 3D reduce significativamente 0.4 Gy la dosis irradiada a vejiga. En el caso del recto la dosis la dosis no produce cambios estadísticos respecto a planificación en 2D.

Introduction: In the treatment of Uterine Cervical Cancer brachytherapy (BQT) with three-dimensional planning (3D) is highly widespread, although for its cost other centers use BQT with two-dimensional planning (2D). It is important to establish if the benefit obtained with BQT in 3 D, in the protection of risk organs, is a determining factor for the change towards this new technology. The aim of the study is to compare the doses in both types of BQT in the organs adjacent to the uterus such as the colon and bladder. Methods: The present descriptive study includes patients diagnosed with cervical cancer who received BQT in the period from January 2015 to December 2018, in the Radiotherapy service of the Hospital Solón Espinosa Ayala, Quito-Ecuador. The variables were the dose received with 2D and 3D plans. Histograms were obtained volume volume of the organs at risk: rectum and bladder. The averages are compared with Student's T. Results: There were 44 cases, of 50.6 ± 13.8 years of age. In clinical stage IIB 24 cases (55%). The prescribed dose of BQT in the group was 683.6 ± 27 cGY. The type of applicator used was in the great majority AyT of 5 mm in 34 cases (77%). The majority of treatments consisted of therapies of 4 sessions 32 cases (73%), with 117 implants for BQT. The planned dose in 2D bladder was 5.5 Gy, versus 5.1 Gy in 3D, P = 0.01. The planned dose in rectum in 2D was 2.8 Gy; versus 3.0 Gy in 3D P = 0.06). Conclusion: 3D planning significantly reduces 0.4 Gy the dose irradiated to the bladder. In the case of the rectum, the dose does not produce statistical changes with respect to 2D planning.

¿Dosis menores de Radioterapia generan mayor riesgo de Fístulas Vaginales en pacientes con Cáncer de Cuello Uterino? / Do lower doses of Radiotherapy generate higher risk of Vaginal Fistulas in patients with Cervical Cancer?

Introducción: El tratamiento del cáncer de cuello uterino con radiaciones ionizantes y quimioterapia radiosensibilizadora puede tener como complicación la generación de fístulas vaginales. El objetivo del presente estudio fue establecer la prevalencia de fístulas vaginales en un grupo de pacientes que recibieron radioterapia convencional versus radioterapia 3D. Métodos: El presente estudio retrospectivo fue realizado en el Hospital de Solón Espinosa Ayala, SOLCA- Quito. Se registraron las pacientes que recibieron radioterapia externa ya sea en modalidad 2D o 3D más braquiterapia o refuerzo externo de dosis, con quimioterapia concurrente o sin esta última en el período de estudio Enero 2008 a Diciembre 2012. Para el análisis se compararon los tipos de radioterapia y se reporta Odds Ratio. Resultados: Se registraron 315 casos en el grupo de Radioterapia Convencional 2D (R2D) y 299 casos en el grupo de radioterapia Conformacional 3D (R3D). La prevalencia de fístulas en el grupo R2D fue de 10 casos (1.62 %) y en el grupo R3D fue de 8 casos (1.31 %), Odds ratio de 1.19 (IC95 % 0.46 a 3.06) P =0.71. De los 18 casos de fístulas, 9 casos (50 %) fueron con refuerzo externo, 6 casos (33 %) por braquiterapia y 3 casos (17 %) sin refuerzo. El refuerzo externo vs braquiterapia mostro un OR=4.77 IC 95 % (1.66 ­ 13.65) P =0.04. La dosis de radioterapia usada en el tratamiento de Braquiterapia fue de 87.5 ±2.5 Gy vs Refuerzo 68 ±2.5 Gy P <0.001. Conclusión: No existe diferencia entre la prevalencia en los grupos de Radioterapia convencional versus Radioterapia 3D. La radioterapia de refuerzo es un factor de riesgo para fístulas vaginales comparado con la braquiterapia, aun cuando la dosis de radioterapia fue menor en este grupo.

Introduction: The treatment of cervical cancer with ionizing radiation and radiosensitizing chemotherapy can have as a complication the generation of vaginal fistulas. The aim of the present study was to establish the prevalence of vaginal fistulas in a group of patients who received conventional radiotherapy versus 3D radiotherapy. Methods: The present retrospective study was carried out at the Solón Espinosa Ayala Hospital, SOLCA-Quito. The patients who received external radiotherapy either in 2D or 3D modality plus brachytherapy or external dose reinforcement, with concurrent chemotherapy or without the latter in the study period January 2008 to December 2012, were registered. For the analysis, radiotherapy types were compared and Odds Ratio is reported. Results: 315 cases were registered in the 2D Conventional Radiotherapy group (R2D) and 299 cases in the Conformacional 3D radiotherapy group (R3D). The prevalence of fistulas in the R2D group was 10 cases (1.62 %) and in the R3D group it was 8 cases (1.31%), Odds ratio 1.19 (95 % CI 0.46 to 3.06) P = 0.71. Of the 18 cases of fistulas, 9 cases (50 %) were externally reinforced, 6 cases (33 %) by brachytherapy and 3 cases (17%) without reinforcement. The external reinforcement vs. brachytherapy showed an OR = 4.77 IC 95 % (1.66 - 13.65) P = 0.04. The dose of radiotherapy used in the Brachytherapy treatment was 87.5 ± 2.5 Gy vs Reinforcement 68 ± 2.5 Gy, P <0.001. Conclusion: There is no difference between the prevalence in the groups of conventional radiotherapy versus 3D radiotherapy. Booster radiotherapy is a risk factor for vaginal fistulas compared to brachytherapy, even when the dose of radiotherapy was lower in this group.