A Prospective Study on the Impact of Waiting Times for Radiotherapy for Cervical Cancer at Charlotte Maxeke Johannesburg Academic Hospital

Background. Radiotherapy plays a vital role in the management of cervical cancer. However; due to high patient load and limited resources; waiting lists are unacceptably long. This is a highly curable malignancy that often occurs in economically active; relatively young women. Thus; the impact of treatment delays on society is disproportionately large when compared to many other malignancies. Delays also impact negatively on the health care system and places further stress on an already burdened department. This prospective study aimed to evaluate the potential impact of radiotherapy delays Patients and methods. Eighty-one patients requiring radical radiotherapy for cervical cancer were selected. Patients were re-evaluated every four weeks while waiting; and again at simulation.Results. Median delay from first consultation to simulation was 55 days. Longer delays were not statistically correlated to tumour progression. Most of the upstaging occurred around 40 to 65 days. One in four patients received blood transfusions and required hospital admission. Four patients needed haemostatic brachytherapy for bleeding. Conclusion. A relationship between time waited and disease progression could not be proven. However; numbers were small and statistical tests were likely underpowered. The study does; however; highlight unacceptably long delays for radiotherapy and a wait of less than 40 days is recommended

Management of undifferentiated embryonal sarcoma of the liver in children: a case series and management review.

BACKGROUND: Undifferentiated embryonal sarcoma of the liver (UESL) is a rare neoplasm, and the third-most common paediatric hepatic malignancy. However, no treatment guidelines exist. No randomised, controlled trials support specific combinations of therapy. OBJECTIVE: To compare presentation and management of UESL with other series, review the literature, and formulate treatment guidelines. METHODS: A retrospective chart review of all hepatic malignancies was conducted from 1996 to 2007 and 5 children with UESL were identified. Management and outcomes were documented. The literature regarding treatment modalities up to September 2012 was reviewed. RESULTS: Over a period of 11 years, 5 patients presented. All underwent surgery and 4 received chemotherapy. One received radiotherapy at relapse. Three are disease-free with follow-up of 58 - 184 months. One died after relapse, as did the patient whose family declined chemotherapy. CONCLUSION: The improved outcomes are consistent with the international experience and are probably related to combined treatment modalities and advances in supportive care. Pre-operative percutaneous biopsy provides no benefit if the lesion is resectable because it may not prove to be diagnostic, and may cause recurrence in the biopsy tract. If resectable, the recommended treatment is primary excision and adjuvant chemotherapy, with radiotherapy in selected cases. If unresectable, open biopsy is necessary to document histology, and neo- adjuvant chemotherapy is given prior to resection. If deemed unresectable, liver transplantation is considered.

Use of Ir192 interstitial brachytherapy for an equine malignant dermal schwannoma.

A 10-year-old Hanoverian mare was evaluated for a right buccal swelling that recurred 3 months following surgical resection. Ultrasonographic examination showed a broadly pedunculated subcutaneous mass at the level of 106-109 and 406-409 cheek teeth associated with an erosive mucosal lesion on the inside of the cheek. Histological examination of a biopsy specimen revealed a well-demarcated, malignant, dermal schwannoma. Following subcutaneous placement of platinum coated Ir192 wires under general anaesthesia, low-dose radiation of 5 gray per day was delivered for 14 days. Short-term complications included loss of patency of the right nasolacrimal duct, erythema, dermatitis, leukotrichia and left-sided deviation of the muzzle. Ten months later, there has been no tumour recurrence. Findings suggest that the use of interstitial brachytherapy should be considered for a malignant, dermal schwannoma that has recurred or is not amenable to surgery.

A phase I study of concurrent cisplatin chemotherapy in patients with carcinoma of the cervix receiving pelvic radiotherapy.

The purpose of this study was to evaluate the maximum tolerated dose (MTD) of weekly cisplatin in a sample population of South African patients with cervical carcinoma, when given in combination with radical pelvic irradiation. Patients with cervical carcinoma stage IB2-IIIB (without hydronephrosis) received up to six cycles of cisplatin at weekly intervals. Groups consisting of three patients each were treated at each of the three predetermined dose levels of cisplatin (20, 25, and 30 mg/m(2)). Eighteen patients were treated and evaluated for toxicity. All the patients who received 20 mg/m(2) (n = 3) and 25 mg/m(2) (n = 3) cisplatin had no dose-limiting toxicity (DLT). Four of the 12 patients who were given cisplatin 30 mg/m(2) experienced DLT with rising serum creatinine and declining creatinine clearance. The minimum creatinine clearance was 22 mL/min. The highest serum creatinine was 174 mumol/L. This study showed that a weekly dose of 25 mg/m(2) of cisplatin was the MTD when used in combination with pelvic irradiation for this sample of patients. This dose is lower than the recommended dose of cisplatin 40 mg/m(2)/week. The patients in this study may have reduced tolerance to higher doses of cisplatin, when compared to patients from Western countries.

Adenoid cystic carcinoma of the salivary glands: a review of 10 years.

A retrospective analysis was performed of 50 patients with adenoid cystic carcinoma who were seen in the Department of Radiation Oncology, University of Witwatersrand, Johannesburg, South Africa, in the past 10 years. There were 25 men and 25 women with a mean age of 52 years (age range, 21 to 88 years). Five patients had metastatic disease, and 17 had neural invasion. Thirty-four patients had surgery (11, complete; 23, microscopic residual). Sixteen patients had radiotherapy as initial management. The disease-free survival was 26%, overall survival was 29%, and local control was 30% at 10 years. Most recurrences occurred in the first 3 years. Nine patients had metastasis following treatment. The mean survival after metastasis was 15 months. Seven prognostic variables were analyzed using the log-rank test. There was no impact of age, site, type of salivary gland (major vs. minor), tumor stage, node positivity, or neural invasion on disease-free survival, overall survival, or local control. Extent of surgical resection (complete vs. microscopic residual) had a significant impact on disease-free survival and local control (P < 0.05) but no impact on overall survival (P > 0.05) because of the slow-growing nature of these tumors. Similarly, patients who had microscopic residual after surgery and were treated with radiotherapy did better than those who had biopsy and radiotherapy, although this was not significant statistically (P > 0.05). Thus, whenever possible, every attempt must be made to remove all microscopic tumor by surgery. Addition of postoperative radiotherapy with high-energy photons did not improve the locoregional control or survival in our series. There is a place for neutrons in the treatment of adenoid cystic carcinomas in advanced cases of inoperable or recurrent tumors, as a review of literature shows.

Diagnosis and management of paediatric brainstem gliomas.

A review of paediatric brainstem gliomas (BSGs) treated in the Department of Radiation Oncology of the University of the Witwatersrand teaching hospital group is presented. Eleven patients between the ages of 4 years and 9 years were seen in the period 1982-1992. Of these cases, 9 were diffuse, 1 focal and 1 exophytic; the radiological features classifying these primary brainstem tumours are described. The survival from initiation of treatment was longest for the exophytic type BSG (72 weeks), while little difference in survival between the 9 diffuse type BSGs (mean 21.5 weeks) and the single focal type BSG (21 weeks) was found. The treatment is described and the role of hyperfractionated radiotherapy is reviewed.

Intraductal hepatocellular carcinoma treated by intralumenal brachytherapy.

Hepatocellular carcinoma (HCC) rarely presents as biliary tract occlusion [1,2]. Intralumenal iridium-192 brachytherapy has been used to treat extrahepatic bile duct carcinoma and may be curative if the macroscopic tumour has been resected surgically [3]. We describe a rare event, a case of HCC presenting with biliary tract occlusion treated with intralumenal iridium-192 brachytherapy.