Mapping of Radiation Oncology and Gynecologic Oncology Services Available to Treat the Growing Burden of Cervical Cancer in Africa.

PURPOSE: To meet the demand for cervical cancer care in Africa, access to surgical and radiation therapy services needs to be understood. We thus mapped the availability of gynecologic and radiation therapy equipment and staffing for treating cervical cancer. METHODS AND MATERIALS: We collected data on gynecologic and radiation oncology staffing, equipment, and infrastructure capacities across Africa. Data was obtained from February to July 2021 through collaboration with international partners using Research Electronic Data Capture. Cancer incidence was taken from the International Agency for Research on Cancer's GLOBOCAN 2020 database. Treatment capacity, including the numbers of radiation oncologists, radiation therapists, physicists, gynecologic oncologists, and hospitals performing gynecologic surgeries, was calculated per 1000 cervical cancer cases. Adequate capacity was defined as 2 radiation oncologists and 2 gynecologic oncologists per 1000 cervical cancer cases. RESULTS: Forty-three of 54 African countries (79.6%) responded, and data were not reported for 11 countries (20.4%). Respondents from 31 countries (57.4%) reported access to specialist gynecologic oncology services, but staffing was adequate in only 11 countries (20.4%). Six countries (11%) reported that generalist obstetrician-gynecologists perform radical hysterectomies. Radiation oncologist access was available in 39 countries (72.2%), but staffing was adequate in only 16 countries (29.6%). Six countries (11%) had adequate staffing for both gynecologic and radiation oncology; 7 countries (13%) had no radiation or gynecologic oncologists. Access to external beam radiation therapy was available in 31 countries (57.4%), and access to brachytherapy was available in 25 countries (46.3%). The number of countries with training programs in gynecologic oncology, radiation oncology, medical physics, and radiation therapy were 14 (26%), 16 (30%), 11 (20%), and 17 (31%), respectively. CONCLUSIONS: We identified areas needing comprehensive cervical cancer care infrastructure, human resources, and training programs. There are major gaps in access to radiation oncologists and trained gynecologic oncologists in Africa.

Swallowing sparing intensity modulated radiotherapy versus standard parotid sparing intensity-modulated radiotherapy for treatment of head and neck cancer: a randomized clinical trial.

BACKGROUND: Dysphagia is a distressing symptom during and after radiotherapy treatment in head and neck cancer (HNC) patients. The objective of this prospective study was to investigate whether swallowing sparing intensity modulated radiotherapy (SW-IMRT) reduces the occurrence of swallowing dysfunction compared to the standard IMRT (ST-IMRT). METHODS: We randomized, planned, and treated patients with HNC who needed whole neck irradiation using the simultaneous integrated boost (SIB) IMRT technique. Doses of 70, 60, and 54 Gy (over 33 daily fractions) were prescribed to the primary tumor, high-risk and low-risk regions, respectively. The postoperative cases received 60 and 54 Gy (over 30 daily fractions) to the high-risk planning target volume (PTV) and low-risk PTV. We contoured organs at risk related to swallowing dysfunction (SWOARs) in all cases. In the ST-IMRT group, parotids only were spared. In the SW-IMRT group, parotids and SWOARs outside the high-risk PTV were spared. Assessment of dysphagia included clinical and instrumental evaluation. RESULTS: One hundred forty-six patients ended their radiotherapy treatment. Dose distribution showed comparable PTV coverage and no difference in parotid glands sparing between the two groups. SWOARs dose reduction with SW-IMRT differs according to tumor location and its overlap with SWOARs. Using different assessment methods, SW-IMRT was associated with a lower occurrence of dysphagia up to one year after treatment. There was no difference between the two groups regarding acute dysphagia (p = 0.262), overall survival (p = 0.811), and disease-free survival (p = 0.876). CONCLUSION: SW-IMRT is significantly better than ST-IMRT regarding a physician-rated and objective assessment of swallowing dysfunction at short- and long-term post-treatment follow-up.

Effect of Transplantation of Bone Marrow Derived Mesenchymal Stem Cells and Platelets Rich Plasma on Experimental Model of Radiation Induced Oral Mucosal Injury in Albino Rats.

Normal tissue damage following radiotherapy is still a major problem in cancer treatment. Therefore, the current work aimed at exploring the possible role of systemically injected bone marrow derived mesenchymal stem cells (BM-MSCs) and/or locally injected platelet rich plasma (PRP) in ameliorating the side effects of ionizing radiation on the rat's tongue. Twelve rats served as control group (N) and 48 rats received a single radiation dose of 13 Gy to the head and neck region; then, they were equally divided into 4 experimental groups: irradiated only (C), irradiated + MSCs (S), irradiated + (PRP) (P), and combined group (PS). Animal scarification occurred in 3 and 7 days after radiation. Then, tongues were dissected and examined histologically and for expression of bcl-2 by RT-PCR. Histological examination of the treated groups (S), (P), and (PS) revealed an obvious improvement in the histological structure of the tongue, compared to group (C), in addition to upregulated expression of bcl-2, indicating decreased apoptotic activity. Conclusion. BM-MSCs and PRP have shown positive effect in minimizing the epithelial atrophy of normal oral mucosa after regional radiotherapy, which was emphasized by decreasing apoptotic activity in these tissues. Nevertheless, combined use of BM-MSCs and PRP did not reveal the assumed synergetic effect in oral tissue protection.

IAEA-HypoX. A randomized multicenter study of the hypoxic radiosensitizer nimorazole concomitant with accelerated radiotherapy in head and neck squamous cell carcinoma.

PURPOSE: To test the hypothesis that radiotherapy (RT) of head and neck squamous cell carcinoma (HNSCC) can be improved by hypoxic modification using nimorazole (NIM) in association with accelerated fractionation. MATERIALS AND METHODS: The protocol was activated in March 2012 as an international multicenter randomized trial in patients with HNSCC. Tumors were treated to a dose of 66-70Gy, 33-35 fractions, 6 fractions per week. NIM was administered in a dose of 1.2gperm(2), 90min before the first daily RT fraction. The primary endpoint was loco-regional failure. The trial was closed prematurely by June 2014 due to poor recruitment. An associated quality assurance program was performed to ensure the consistency of RT with the protocol guidelines. RESULTS: The trial was dimensioned to include 600 patients in 3years, but only 104 patients were randomized between March 2012 and May 2014 due to the inability to involve three major centers and the insufficient recruitment rate from the other participating centers. Twenty patients from two centers had to be excluded from the analysis due to the unavailability of the follow-up data. Among the remaining 84 patients, 82 patients were evaluable (39 and 43 patients in the RT+NIM and the RT-alone arms, respectively). The treatment compliance was good with only six patients not completing the full planned RT course, and 31 patients (79%) out of 39 allocated for NIM, achieving at least 90% of the prescribed drug dose. At the time of evaluation, 40 patients had failed to achieve persistent loco-regional tumor control, and a total of 45 patients had died. The use of NIM improved the loco-regional tumor control with an 18month post-randomization cumulative failure rate of 33% versus 51% in the control arm, yielding a risk difference of 18% (CI -3% to 39%; P=0.10). The corresponding values for overall death was 43% versus 62%, yielding a risk difference of 19% (CI -3% to 42%; P=0.10). Sixteen patients, out of 55 patients analyzed for hypoxic gene expression, were classified as having more hypoxic tumors. Such patients, if treated with RT alone, had a higher loco-regional tumor failure rate as compared to the rest of the patients with known hypoxic status (P=0.05). CONCLUSION: Although the trial was incomplete and suffered from a small number of patients, the results suggested an improvement in loco-regional tumor control and overall survival in patients with advanced HNSCC given the hypoxic modifier NIM in addition to accelerated fractionation RT. However, the trial also revealed that conducting multicenter and multinational study combining drug and RT in developing countries may suffer from uncontrolled and unsolvable problems.

Rhabdomyosarcoma in childhood: a retrospective analysis of 190 patients treated at a single institution.

OBJECTIVES: The study goal was to retrospectively review the treatment results of childhood rhabdomyosarcoma and identify prognostic factors that affect treatment outcome. PATIENTS AND METHODS: The records of 190 patients with childhood rhabdomyosarcoma treated between January 1991 and December 1999 were reviewed. The data were analyzed for clinico-epidemiological factors and the impact of potential prognostic factors on failure-free survival. Factors evaluated were age, gender, histology type, primary site, tumor size, Intergroup Rhabdomyosarcoma Study (IRS) group, surgical procedure, and the use of radiation treatment. RESULTS: The 5-year actuarial FFS and OS were 40% and 50%, respectively. The only significant prognostic factors as estimated by univariate analysis were histology type (p=0.01), primary site (p=0.002), tumor size (p=0.049), IRS-group (p=0.003), surgical procedure (p=0.002), and radiation treatment (p=0.001). Multivariate analysis showed that histology type (p=0.02), primary site, and IRS-group (p=0.02) were the only independent prognostic factors. CONCLUSIONS: This analysis demonstrates that failure-free survival for rhabdomyosarcoma is dependent on several factors at the time of initial diagnosis, including histologic subtype, primary site and disease group. Our treatment results were inferior compared to IRS-studies as the patients during this period were treated on individual bases and not standardized protocol.

Computerized treatment planning in radiation therapy of intact breast: influence of number of CT-cuts.

PURPOSE: To compare the accuracy of 2D algorithm with an established 3D algorithm, and to define the number of CT-slices needed for treatment planning of intact breast irradiation. MATERIAL AND METHODS: Twenty patients with breast cancer treated with conservative surgery were included in this study, ten of them had right breast cancer and the other 10 patients had cancer of the left breast. For each patient, 3-D calculations (HeLax-TMS) were performed using one CT-slice (central), 3 CT-slices (central, caudal, and cephalic) and full set CT-slices in addition to 2D calculations (Multidata System) on the digitized central cut. All calculations were done using 6MV-photon. RESULTS: When using 2D planning with lung correction, a large hot area of 105% was found at the medial and lateral subcutaneous (SC) regions. Comparison of 2D-treatment planning using Multidata System (2D-physics) and 2D-planning using HeLax System (3D-physics) showed that the 2D planning using Multidata System gave a large hot area of 105% compared with HeLax-2D at the subcutaneous region. The central axis dose distributions obtained from 2D and 3D calculations using HeLax system were compared. No differences were found in the two planes (central cut plane) and this was because the two planes were based on the same algorithm. The only difference was that the hot area (110%) was found at the superior or the inferior border of the field. Also, a comparison using the 3D-system for the central slice and the multiple slices showed a difference in calculating the maximum dose to the target of 2.19%, which was Statistically significant (p=0.001). For all left sided patients, the maximum dose to the heart was significantly different from one to full CT-cuts. It was 12.0+/-6.0% when using one CT-cut versus 6.6+/-1.3% when using full CT-cuts (p<0.03). We compared isodose distributions using three and full CT-cuts for both small and large breasts. For the large breast patients, larger differences in isodose distributions were observed in the cephalic and the caudal planes than for small breast patients. CONCLUSION: Dose distributions based on a single CT cut through the central axis using 2D or even 3D treatment planning system will lead, quite often, to hot volumes in 76 excess of 105%. For patients whose breast contours vary slowly within the tangential fields, a three-slice CT scan appears to be adequate for clinical decision. However, for patients with large variation of contours within the tangential fields, a full CT scan gives more accurate dose distributions than the three-slice model.

A randomized study of accelerated fractionation radiotherapy with and without mitomycin C in the treatment of locally advanced head and neck cancer.

OBJECTIVES: This single-institution study evaluates the feasibility of accelerated fractionation radiotherapy (AF) with and without mitomycin C (MMC) in the treatment of locally advanced head and neck cancer. PATIENTS AND METHODS: Between May 1998 and October 2001, sixty patients with locally advanced stage III and IV of head and neck cancer were randomized into three treatment arms: (1) conventional fractionation radiotherapy (CF) (5 fractions per week); (2) accelerated fractionation radiotherapy (AF) (6 fractions per week); and (3) AF plus Mitomycin C (MMC). RESULTS: The 2-year overall survival (OS) of the whole group was 21%. The OS according to treatment arm was 23%, 20%, and 28% in CF, AF, and AF+MMC arms respectively (p<0.19). The 2-year loco-regional control (LC) rate was 22% for the whole group of patients. The LC was 10%, 25%, and 30% for the CF, AF, and AF+MMC respectively (p=0.27). The only significant parameters for OS and LC were performance status and pre-treatment hemoglobin level. Mucositis grades 3 & 4 occurred in 70% and 90% of the patients in the AF and AF+MMC arm respectively compared to 55% of patients in the CF arm (p=0.04). However the addition of MMC did not significantly increase the incidence or severity of mucositis between AF and AF+MMC (p=0.13). Hematological toxicity grades 3 & 4 were significantly higher after MMC (occurred in 40% of patients versus 10% and 5% in CF and AF arms respectively, p=0.04). There was no statistically significant difference in the incidence of grade 3 dryness of mouth (p=0.06), fibrosis (p=0.6), or lymphoedema (p=0.39) among the three arms. CONCLUSION: There was a trend for improvement of LC and OS rates with the use of AF and the addition of MMC to AF compared to CF radiotherapy, although the difference was not statistically significant. The small number of the patients in each treatment arm and the inclusion of multiple tumor sites may contribute to these statistically insignificant results. Accordingly we advise 85 to continue the trial with inclusion of a larger number of patients and restrict tumor sites to one major site.

Management of parapharyngeal space tumors at the National Cancer Institute, Egypt.

PURPOSE: The purpose of this study is to evaluate parapharyngeal space (PPS) tumors as regards clinicopathological features, preoperative assessment, different surgical approaches, perioperative complications, patterns of recurrence and the role of non-surgical treatment. MATERIALS AND METHODS: This study included twenty-five patients with (PPS) tumors presented to NCI, Cairo University, from October 2001 to March 2003. The data of each patient included age, sex, presenting symptoms and signs, provisional diagnosis, preoperative investigations, operative data, histopathological examination, non-surgical treatment and state of follow up. All were collected and analyzed. RESULTS: This study included 12 males and 13 females. The mean age was 37.1 years. The main presenting symptom and sign was neck swelling. All patients were subjected to CT scan, while 9 patients had MRI. Nineteen patients underwent fine needle aspiration cytology (FNAC) which was conclusive in only 16 patients. Benign lesions were found in 12 patients (48%) and malignant lesions in 13 patients (52%). Parotid gland tumors (40%) and neurogenic tumors (16%) were the commonest. Surgical excision was done in 22 cases. There was no postoperative mortality and overall postoperative morbidity was 9% (2/22). Eight patients received postoperative radiotherapy. Three patients with lymphoma were treated with chemotherapy and two of them received involved field radiotherapy to the Waldyer's ring region. On follow up to 12-30 months, there were only one local and two distant recurrences in the malignant group. CONCLUSION: Surgery is the mainstay treatment for tumors of the (PPS). The addition of postoperative radiotherapy in certain indications in malignant tumors of the (PPS) will improve the local control.

Total skin electron therapy: a modified technique for small room linear accelerator.

OBJECTIVE: Development of a technique for treating whole-body skin using linear accelerator with electron beam energy of 6-MeV at a short treatment distance. MATERIAL AND METHODS: The 6 MeV high dose rate total skin electron irradiation mode on a linear accelerator was used. Beam profiles and percentage depth doses in the patient plane were measured for different beam angulations. RESULTS: At a treatment distance (SSD) of 292 cm and using acrylic scatterer-degrader 4mm thick, the beam penetration was calculated so that the 80% dose lied at 1.6 cm for the single beam and only 6 mm for the clinical beam. A uniform vertical profile was obtained by using 3 beams for each treatment position with gantry angles of 700, 900 and 1100. CONCLUSIONS: We could implement a modified stanford technique for total skin electron beam irradiation at a short treatment distance. Using an acrylic scatterer-degrader and three beam angulations we could produce a uniform beam in the treatment plane.