Intensity-modulated radiotherapy with simultaneous modulated accelerated boost technique and chemotherapy in patients with nasopharyngeal carcinoma.

BACKGROUND: To present our experience of intensity-modulated radiotherapy (IMRT) with simultaneous modulated accelerated radiotherapy (SMART) boost technique in patients with nasopharyngeal carcinoma (NPC). METHODS: Sixty eight patients of NPC were treated between April 2006 and December 2011 including 45 males and 23 females with mean age of 46 (range 15-78). Stage distribution was; stage I 3, stage II 7, stage III 26 and stage IV 32. Among 45 (66.2%) evaluated patients for presence of Epstein-Barr virus (EBV), 40 (88.8%) were positive for EBV. Median radiation doses delivered to gross tumor volume (GTV) and positive neck nodes were 66-70 Gy, 63 Gy to clinical target volume (CTV) and 50.4 Gy to clinically negative neck. In addition 56 (82.4%) patients with bulky tumors (T4/N2+) received neoadjuvant chemotherapy 2-3 cycles (Cisplatin/Docetaxel or Cisplatin/Epirubicin or Cisplatin/5 Flourouracil). Concurrent chemotherapy with radiation was weekly Cisplatin 40 mg/m2 (40 patients) or Cisplatin 100 mg/m2 (28 patients). RESULTS: With a median follow up of 20 months (range 3-43), one patient developed local recurrence, two experienced regional recurrences and distant failure was seen in 3 patients. Estimated 3 year disease free survival (DFS) was 94%. Three year DFS for patients with EBV was 100% as compared to 60% without EBV (p = 0.0009). Three year DFS for patients with undifferentiated histology was 98% as compared to 82% with other histologies (p = 0.02). Acute grade 3 toxicity was seen as 21 (30.9%) having G-III mucositis and 6 (8.8%) with G-III skin reactions. Late toxicity was minimal and loss of taste was seen in 3 patients (7.5%) at time of analysis. CONCLUSIONS: IMRT with SMART in combination with chemotherapy is feasible and effective in terms of both the clinical response and safety profile. EBV, histopathology and nodal involvement were found important prognostic factors for locoregional recurrence.

Factors Affecting Isocenter Displacement and Planning Target Volume Margin for Patients With Rectal Cancer Receiving Radiation Therapy.

Purpose: Setup errors are inherent in the process of daily radiation therapy (RT) delivery. Pelvic RT for rectal cancer is one of the body sites associated with the largest shift among other body sites. This study aimed to evaluate interfraction random and systematic errors and hence propose the optimum planning target volume (PTV) in patients with rectal cancer. Methods and Materials: Translational and angular isocenter displacements were retrospectively collected for 189 patients. Random and systematic errors were determined, and then the PTV margin was computed. Effect of positioning, body mass index (BMI), and type of immobilization were studied. Portal images before and after online correction were used to define PTV for no-daily image-guided radiotherapy (IGRT) and daily IGRT respectively. Results: Before the online correction, the systematic errors were 2.5, 2.8, and 3.0 mm for superior-inferior (SI), right-left (RL), and anterior-posterior (AP) directions, respectively, compared with 2.1, 1.7, and 1.8 mm after online correction. The random errors were 6.2, 7.4, and 8.2 mm in SI, RL, and AP, respectively, before online correction, compared with 4, 4.2, and 4.5 mm after online correction. The recommended PTV margin was 0.7 and 1.0 cm for daily IGRT and no-daily IGRT, respectively. The prone position and BMI >30 kg/m2 warrant higher margins in no-daily IGRT cases, 1.2 and 1.4 cm, respectively. Conclusions: The prone position, BMI >30 kg/m2, and belly board device are associated with larger daily setup errors warranting higher PTV margins for no-daily IGRT; however, that can be avoided by using daily IGRT.

Skin Metastasis Occurring 30 Years After Thyroidectomy for Papillary Thyroid Carcinoma.

The skin is an extremely rare site of metastasis from papillary thyroid carcinoma (PTC) and is linked to underlying disseminated malignancy, which reflects a dismal prognosis. We present the case of a 70-years-old Saudi female who presented at our clinic with an eight-month history of two painful and itchy skin nodules over the scalp and the medial aspect of the right arm. She had a history of total thyroidectomy for PTC 30 years prior. Computed tomography-positron emission tomography showed multiple fluorodeoxyglucose avid lung and skeletal metastases. This case highlights the fact that skin nodules in a patient with a history of PTC should be assessed carefully with a high suspicion of skin metastasis to avoid any delay in treatment.

National approaches to managing cancer care: responses of countries in the MENA region to the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic presents serious challenges to cancer care because of the associated risks from the infection itself and the disruption of care delivery. Therefore, many professional societies have published recommendations to help manage patients with cancer during the current pandemic. The objective of our study is to assess the national responses of Middle East North Africa (MENA) countries in terms of publishing relevant guidelines and analyse various components of these guidelines. METHODS: A survey based on the preliminary review of the literature regarding cancer care adaptations has been developed and then completed by a group of oncologists from the following Arab countries affected by the pandemic: Algeria, Egypt, Iraq, Jordan, Kuwait, Lebanon, Morocco, Oman, Saudi Arabia, Syria, Tunisia, United Arab Emirates and Yemen. The survey inquired about COVID-19 cases, national recommendations regarding general measures of COVID-19 prevention and patient care in oncology as well as their implementation about cancer care adaptations during the pandemic. RESULTS: Analysis of the COVID-19 pandemic-related guidelines revealed at least 30 specific recommendations that we categorised into seven essential components. All included countries had national guidelines except one country. Estimated full compliances with all specific category recommendations ranged from 30% to 69% and partial compliance ranged from 23% to 61%. CONCLUSION: There is a very good response and preparedness in the Arab Middle East and North Africa region surveyed. However, there are inconsistencies in the various components of the guidelines across the region, which reflects the evolving status of the pandemic in each country as well as the lack of clear evidence-based guidelines for many of the issues in question. There is a need for a clear framework on essential components that should be included in these guidelines to assure providing the best guidance to the oncology community.

Scholarly Activity of Radiation Oncologists in High-Income Developing Countries: Saudi Arabia as an Example.

PURPOSE: To examine the trends and quality metrics of publications by radiation oncologists in Saudi Arabia. METHODS: PubMed was searched using names of all Saudi radiation oncologists to retrieve published articles between January 2010 and December 2019. International collaboration, journal impact factor and country of origin, and number of citations were collected. Each article was assessed for epidemiologic type and independently assigned a level of evidence (LOE) by two authors. The trend in publications was examined and compared in the first and second 5-year periods (2010-2014 and 2015-2019) using relevant parameters. RESULTS: A total of 186 publications were found and included. The most common type of research was cohort studies followed by case reports and case series in 24%, 14%, and 13% of all publications, respectively. Dosimetry, clinical, and preclinical studies formed 7%, 8.6%, and 7.5% of the total publications, respectively. The LOE was I, II, III, IV, and not applicable in 8.6%, 22%, 25.8%, 29%, and 14.5% of the included publications, respectively. Comparing the first and second 5-year periods, there was an increase in international collaboration (P < .001) in the second period. The number of citations (P < .001) and journal impact factor (P = .028) were lower in the second period. LOE and publications in international journals were not statistically different between the two periods. CONCLUSION: Although radiation oncology research activity in Saudi Arabia has gained momentum in terms of volume and international collaboration over time, the LOE has not improved. This calls for a national effort to make the contribution to the literature a priority, allocate adequate resources, and apply appropriate measures to enhance research productivity and quality.

Defining Clinical Indications of Proton Beam Therapy at National Level in the Kingdom of Saudi Arabia.

The Saudi Particle Therapy Centre (SPTC) is establishing proton beam therapy (PBT) services within Kingdom of Saudi Arabia (KSA). Thus, national guidelines for the pertinent draft, and recommendations of PBT for cancer patients are utmost important. Saudi Particle Therapy Centre invited a panel of expert radiation oncologists practicing within KSA to formulate national clinical practice guidelines for the referral, absolute and relative indications and dose/fractionation for PBT. After identifying the key clinical questions, ample search through PubMed, EMBASE, and various search drives was accomplished for appropriate meta-analyses, clinical trials, case-control, and case series studies, and case reports. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach was incorporated to formulate various recommendations. Saudi Particle Therapy Centre expert panel recommended PBT as utter modality for ocular tumors, base of skull/spine tumors, hepatocellular carcinoma, all pediatric central nervous system (CNS) malignancies, para-nasal sinuses/nasal cavity tumors and for re-irradiation of all sites aimed for cure. However, PBT may be contemplated, as a relative indication if no other parallel option is available, or when photon therapy plans exceed the dose constraints for critical structures.  Further, panel did not recommend routine PBT for other sites beyond clinical trials. However, individual oncology patients can be considered for PBT after a multidisciplinary approach and expert's opinion.

Efficacy of 8 Gy Single Fraction Palliative Radiation Therapy in Painful Bone Metastases: A Single Institution Experience.

Introduction Bone metastasis (BM) is a major complication of many solid tumors like breast, prostate, lung and renal cancers. BM leads to serious sequelae of pain, fractures, spinal cord compression and hypercalcemia. Radiotherapy has an established role in relieving pain caused by BM. Worldwide different radiotherapy schedules are being used for BM. The aim of this study is to determine the efficacy of single fraction palliative radiotherapy for painful bone metastases. Methods Between April 2014 and April 2017, single fraction radiotherapy was used to treat 73 patients in our institution. They had pathologically proven breast, prostate, lung or renal cancer with radiological evidence of bone metastases. There were 39 males (53%) and 34 females (47%). The median age was 58 years (range 33-87 years). 39% patients (n = 28) had breast cancer, 35% had prostate cancer (n = 26), 23% had lung cancer (n = 17), and 3% had renal cancer (n = 2). On presentation, all the patients had a pain score of more than five on Brief Pain Inventory (BPI). Results Response assessment to pain after three months from single fraction radiotherapy was found to be complete response (CR) in 23% patients (n = 17), partial response (PR) in 38% patients (n = 28), stable disease (SD) in 26% patients (n = 19) and progressive disease (PD) in 12% patients (n = 9). The overall efficacy of treatment was 62%, with CR 23% and PR 38%. Pre-treatment mean pain score was 8.15 compared to 4.68 post-treatment (p < 0.001). Conclusions Single fraction palliative radiotherapy of 8 Gy showed significant efficacy in painful bone metastases in our setting and merits further investigation in our population.

The Effect of Satellite Laboratory Installation on Chemotherapy Waiting Time in an Oncology Treatment Unit.

Background Timely treatment is a patient's right. Increasing the efficiency of laboratory testing could potentially improve hospital operations, provide quicker access to health services, and have a positive impact on patient experience. Installation of a satellite laboratory may shorten laboratory turnaround time (TAT) and chemotherapy waiting time. Method The laboratory TAT and chemotherapy waiting time were analyzed and compared before and three years after the establishment of the satellite laboratory. Result The mean laboratory TAT decreased from one hour and 30 minutes at baseline in 2012 to 43, 43, and 37 minutes in 2013, 2014, and 2015, respectively; a reduction rate of 59%. Mean chemotherapy waiting time also reduced, from a 2012 baseline of 252 minutes to 170, 157, and 146 minutes in 2013, 2014, and 2015, respectively; a reduction rate of 42%. Conclusion The reduced chemotherapy waiting time after the installation of a satellite laboratory had a positive impact on patient care. It also reduced employee workload and maximized the utilization of hospital resources.

Bleeding in Locally Invasive Pelvic Malignancies: Is Hypofractionated Radiation Therapy a Safe and Effective Non-Invasive Option for Securing Hemostasis? A Single Institution Perspective.

INTRODUCTION:  Control of bleeding due to locally invasive disease is of paramount importance in the management of cancer patients. This study was undertaken to explore the outcomes of palliative intent hypofractionated radiation therapy (HRT) in advanced stage pelvic malignancies that presented with bleeding. METHODS:  This study enrolled patients treated with palliative intent hypofractionated radiation therapy from July 2015 to November 2017. In the inclusion criteria, all these patients had the common presenting complaint of bleeding from the tumor. These patients were not treated with radiation therapy before for the same indication. Patients with known bleeding disorders and those undergoing parallel interventions for bleeding control were excluded from the study. Bleeding was categorized based on the World Health Organization (WHO) scale for the classification of bleeding. Response assessment was classified into a complete response, partial response and no response. A comparison was made for the bleeding scale before and after HRT using the Wilcoxon signed rank test. The comparison of mean hemoglobin levels before and after the HRT was calculated by paired t-test. RESULTS:  Forty-two patients with advanced pelvic malignancies qualified for inclusion in the study after applying the inclusion/exclusion criteria. Among those analyzed, the median age was 67 years (range 37 - 95 years). The male and female proportion was 38% and 62% respectively. Different cancers included uterine cancer 31%, cervical cancer 24%, bladder cancer 21%, rectal cancer 17% and vulvar cancer in 7%. The baseline bleeding scale in these cases was found to be grade 1 in 12%, grade 2 in 55% and grade 3 in 33% cases. The median dose in our cohort was 20 Gy in five fractions over one week (range was 8 Gy to 40 Gy). Following HRT, the WHO bleeding score at one month was recorded as grade 0 in 57%, grade 1 in 31%, grade 2 in 7%, grade 3 in 5% and grade 4 in none. Toxicity profile did not show any grade 3 or above acute toxicity in the study. Response rates were 57% complete response, 36% partial response and 7% no response. The mean hemoglobin level post-treatment versus pre-treatment was found to be 9.6 g/dL versus 7.3 g/dL. CONCLUSIONS:  Hypofractionated radiotherapy was found to be a safe and effective non-invasive palliative treatment modality for securing hemostasis in advanced pelvic malignancies that presented with bleeding.

Impact of body mass index on survival outcome in patients with differentiated thyroid cancer.

INTRODUCTION: Increased body mass index is known to be associated with the high prevalence of differentiated thyroid cancers; however data on its impact on survival outcome after thyroidectomy and adjuvant therapy is scanty. OBJECTIVE: We aimed to evaluate the impact of body mass index on overall survival and disease free survival rates in patients with differentiated thyroid cancers. METHODS: Between 2000 and 2011, 209 patients with differentiated thyroid cancers (papillary, follicular, hurthle cell) were treated with thyroidectomy followed by adjuvant radioactive iodine-131 therapy and thyroid-stimulating hormone suppression. Based on body mass index, patients were divided into five groups; (a) <18.5kg/m2 (underweight); (b) 18.5-25kg/m2 (normal weight); (c) 26-30kg/m2 (overweight); (d) 31-40kg/m2 (obese) and (e) >40kg/m2 (morbid obese). Various demographic, clinical and treatment characteristics and related toxicity and outcomes (overall survival, and disease free survival) were analyzed and compared. RESULTS: Median follow up period was 5.2years (0.6-10). Mean body mass index was 31.3kg/m2 (17-72); body mass index 31-40kg/m2 was predominant (89 patients, 42.6%) followed by 26-30kg/m2 seen in 58 patients (27.8%). A total of 18 locoregional recurrences (8.6%) and 12 distant metastasis (5.7%) were seen. The 10 year disease free survival and overall survival rates were 83.1% and 58.0% respectively. No significant impact of body mass index on overall survival or disease free survival rates was found (p=0.081). Similarly, multivariate analysis showed that body mass index was not an independent prognostic factor for overall survival and disease free survival. CONCLUSION: Although body mass index can increase the risk of thyroid cancer, it has no impact on treatment outcome; however, further trials are warranted.

Is radiation-induced ovarian ablation in breast cancer an obsolete procedure? Results of a meta-analysis.

BACKGROUND: A meta-analysis was conducted to assess the impact of radiation-induced ovarian ablation (RT-OA) on amenorrhea cessation rates, progression-free survival, and overall survival in pre/perimenopausal women with breast cancer. MATERIALS AND METHODS: The Medline, CANCERLIT, and Cochrane Library databases and search engines were searched to identify randomized controlled studies comparing RT-OA with control for early or metastatic breast cancer. Further, radiotherapy doses, techniques, and associated side effects were evaluated. RESULTS: Six controlled trials with a total patient population of 3,317 were identified. Pooled results from these trials showed significant amenorrhea rates (P<0.00001) and increase in progression-free survival in patients treated with RT-OA (P<0.00001). However, there was no difference in overall survival (P=0.37). The majority of patients were treated with larger field sizes with parallel-opposed anteroposterior and posteroanterior pelvic fields. RT-OA was generally well tolerated. Radiotherapy doses of 1,500 cGy in five fractions, 1,500 cGy in four fractions, 1,600 cGy in four fractions, and 2,000 cGy in ten fractions were associated with excellent amenorrhea rates. The resultant funnel plot showed no publication bias (Egger test P=0.16). CONCLUSION: RT-OA is cost-effective and can safely be used in pre/perimenopausal women with metastatic breast cancer, or if luteinizing hormone-releasing hormone analogs are contraindicated, or in patients in whom fertility preservation is not an issue. Radiation dose of 1,500 cGy in five fractions, 1,500 cGy in four fractions, 1,600 cGy in four fractions, and 2,000 cGy in ten fractions showed more efficacies. However, further studies incorporating three-dimensional conformal radiotherapy and intensity-modulated radiotherapy are warranted.

Tall Cell Variant Papillary Thyroid Carcinoma in Saudi Patients: A clinicopathological and Outcomes Analysis.

OBJECTIVES: To evaluate the clinicopathological features and treatment outcomes of papillary thyroid carcinoma tall cell variant (PTC-TCV) in Saudi population. Methods: This retrospective study were medical records of 776 treated PTC patients between December 2007 and 2015, at King Fahad Medical City and King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia was probed for PTC-TCV. Total 42 (5.4%) patients were found to have PTC-TCV, which were investigated for demographic, symptoms, histopathological features, and treatment outcomes locoregional control (LRC), distant metastasis control (DMC), disease free survival (DFS), and overall survival (OS) rates. Results: Mean age of cohort was 52.3 years (range: 46-80), with female predominance (73.8%). Mean tumor size was 3.62 cm (range: 0.4-10). Rates of LVSI (59.5%), positive pathological lymph nodes (66.7%), multifocality (42.9%) and extrathyroidal extension, (45.3%). Median follow-up was 37.4 months (range: 6-60). Local recurrence rate were seen in 6/42 (14.2%) patients and 8/42 (19%) developed distant metastasis. The 5 year rates of LRC (82.3%), DMC (77.8%), DFS (69.2%), and OS (86.7%) multivariate analysis showed PTC-TVC as an important independent prognosticator (odds ratio: 4.2; 95% confidence interval: 1.79-7.3; p=0.03)  Conclusion: Papillary thyroid carcinoma tall cell variant is associated with aggressive biological behavior.

Comparative clinicopathological and outcome analysis of differentiated thyroid cancer in Saudi patients aged below 60 years and above 60 years.

INTRODUCTION: The aim of this study was to evaluate the treatment outcomes of differentiated thyroid cancer in Saudi patients aged above 60 years. MATERIALS AND METHODS: Comparative analysis was performed in 252 patients aged 46-60 years (Group A) and 118 patients aged above 60 years (Group B), who had thyroidectomy, radioactive iodine-131, and thyroid-stimulating hormone suppression therapy between July 2000 and December 2012. Different clinicopathological features, treatment, complications, disease-free survival, and overall survival rates were compared. RESULTS: Mean age of patients in Group A was 51.9 years (range: 46-60), and mean age of those in Group B was 68.6 years (range: 62-97). Group B patients had higher positive lymph nodes (43.2%), P=0.011. The frequency of extrathyroidal extension, multifocality, and lymphovascular space invasion was seen more in Group B than in Group A. Postsurgical complications (permanent hypoparathyroidism, bleeding, and wound infections) were also seen more in Group B (P=0.043, P=0.011, and P=0.021, respectively). Group B patients experienced more locoregional recurrences (11.0%, P=0.025); similarly, more distant metastases were observed in Group B (15.3%, P=0.003). The 10-year disease-free survival rates were 87.6% in Group A and 70.8% in Group B (P<0.0001). CONCLUSION: Differentiated thyroid cancer in patients aged above 60 years are more aggressive biologically and associated with a worse prognosis, and the morbidity is significantly high as compared to patients aged below 60 years.

Comparative efficacy, tolerability, and survival outcomes of various radiopharmaceuticals in castration-resistant prostate cancer with bone metastasis: a meta-analysis of randomized controlled trials.

BACKGROUND: A meta-analysis was conducted to assess the impact of radiopharmaceuticals (RPs) in castration-resistant prostate cancer (CRPC) on pain control, symptomatic skeletal events (SSEs), toxicity profile, quality of life (QoL), and overall survival (OS). MATERIALS AND METHODS: The PubMed/MEDLINE, CANCERLIT, EMBASE, Cochrane Library database, and other search engines were searched to identify randomized controlled trials (RCTs) comparing RPs with control (placebo or radiation therapy) in metastatic CRPC. Data were extracted and assessed for the risk of bias (Cochrane's risk of bias tool). Pooled data were expressed as odds ratio (OR), with 95% confidence intervals (CIs; Mantel-Haenszel fixed-effects model). RESULTS: Eight RCTs with a total patient population of 1,877 patients were identified. The use of RP was associated with significant reduction in pain intensity and SSE (OR: 0.63, 95% CI: 0.51-0.78, I(2)=27%, P,0.0001), improved QoL (OR: 0.71, 95% CI: 0.55-0.91, I(2)=65%, three trials, 1,178 patients, P=0.006), and a minimal improved OS (OR: 0.84, 95% CI: 0.64-1.04, I(2)=47%, seven trials, 1,845 patients, P=0.11). A subgroup analysis suggested an improved OS with radium-223 (OR: 0.68, 95% CI: 0.51-0.90, one trial, 921 patients) and strontium-89 (OR: 0.21, 95% CI: 0.05-0.91, one trial, 49 patients). Strontium-89 (five trials) was associated with increased rates of grade 3 and 4 thrombocytopenia (OR: 4.26, 95% CI: 2.22-8.18, P=0.01), leucopenia (OR: 7.98, 95% CI: 1.82-34.95, P=0.02), pain flare (OR: 6.82, 95% CI: 3.42-13.55, P=0.04), and emesis (OR: 3.61, 95% CI: 1.76-7.40, P=0.02). CONCLUSION: The use of RPs was associated with significant reduction in SSEs and improved QoL, while the radium-223-related OS benefit warrants further large, RCTs in docetaxel naive metastatic CRPC patients.

Calvarium and dura mater as delayed sites of distant metastasis from papillary thyroid carcinoma.

BACKGROUND: Skull calvarium and dura mater are rare sites of distant metastasis, and mostly have been reported in lung, breast, and prostate malignancies. However, the calvarial and dural metastases from papillary thyroid cancer (PTC) are rare entities and pose diagnostic and therapeutic challenges. To date, only seven cases of calvarial metastasis with intracranial extension from PTC have been reported in literature. However, true dural metastasis from PTC has not yet been reported. CASE PRESENTATION: A 65-year-old Saudi woman presented with 6 months history of painful posterior scalp lump, 7 years after initial diagnosis of PTC. Computed tomography and magnetic resonance imaging showed occipitoparietal calvarial lesion with massive intracranial extension. Another para-sagittal lesion was found at the top of corpus callosum mimicking a meningioma. Histopathology of para-sagittal lesion and the biopsy of calvarial mass confirmed the diagnosis of metastatic PTC. After surgical resection, residual tumors were treated with postoperative intensity-modulated radiation therapy. At 13 months of follow-up, patient was alive and without any signs of recurrence. CONCLUSION: Calvarial and dural metastases from PTC are extremely rare clinical entities. Surgical resection followed by postoperative radiotherapy is the treatment of choice. However, for such cases, multidisciplinary approach can prolong the treatment outcome and survival.

Skull base metastasis from papillary thyroid carcinoma: a report of three cases.

Skull base metastasis from differentiated thyroid carcinoma, including papillary and follicular thyroid carcinoma, is a rare manifestation. Herein, we present three cases of skull base metastasis of papillary thyroid carcinoma. The mean age of the patients was 68.6 (65-74) years, and the mean interval between initial diagnosis and skull base metastasis was 56.3 (28-89) months. Cranial nerve palsies were seen in all patients. Intensity modulated radiation therapy to deliver 6,000-6,600 cGy to the skull base metastasis was given to all patients, in addition to partial resection in one patient. At the time of last follow-up, all skull base metastases were well controlled.

Cerebellum as Initial Site of Distant Metastasis from Papillary Carcinoma of Thyroid: Review of Three Cases.

Background. The cerebellum as initial site of distant metastasis from differentiated thyroid carcinoma (DTC) including papillary (PTC) and follicular thyroid carcinoma (FTC) is rare manifestation. Case Presentations. Herein, we present three cases of cerebellar metastasis (CBM) of PTC. Mean age of patients was 67 years (range: 64-72), and mean duration between initial diagnosis and CBM was 49.6 months (range: 37-61). Frequent location was left cerebellar hemisphere and was associated with hydrocephalus. All patients underwent suboccipital craniectomy, and in two patients postoperative intensity modulated radiation therapy (IMRT) was given to deliver 5000 cGy in 25 fractions to residual lesions. Patient without postoperative IMRT had cerebellar recurrence along with lung and bone metastasis after 38 months. However, two patients were found alive and free of disease at the time of last follow-up. Conclusion. CBM from PTC is a rare clinical entity and is often associated with hydrocephalus. Histopathological diagnosis is important to initiate effective treatment, which relies on multidisciplinary approach to prolong the disease-free and overall survival rates.

Adjuvant Radioactive iodine 131 ablation in papillary microcarcinoma of thyroid: Saudi Arabian experience [corrected].

BACKGROUND: Papillary Microcarcinoma (PMC) of thyroid is a rare type of differentiated thyroid cancer (DTC), which according to the World Health Organization measures 1.0 cm or less. The gold standard of treatment of PMC is still controversy. Our aim was to contribute in resolving the debate on the therapeutic choices of the surgical and adjuvant I-131 (RAI) treatment in PMC. METHODS: From 2000 to 2012, 326 patients were found to have PMC and were retrospectively reviewed for clinicopathological characteristics, treatment outcomes and prognostic factors. RESULTS: Mean age of cohort was 42.6 years (range: 18-76) and the mean tumor size was 0.61 cm ± 0.24; lymph node involvement was seen in 12.9 % of cases. Median follow up period was 8.05 years (1.62-11.4). Total 23 all site recurrences (7.13 %) were observed; more observed in patients without I-131 ablation (p <0.0001). Ten year DFS rates were 89.6 %. Cox regression Model analysis revealed size, histopathologic variants, multifocality, extrathyroidal extension, lymphovascular space invasion, nodal status, and adjuvant RAI ablation the important prognostic factors affecting DFS. DISCUSSION: Despite excellent DFS rates, a small proportion of patients with PMC develop recurrences after treatment. Adjuvant RAI therapy improves DFS in PMC patients with aggressive histopathologic variants, multifocality, ETE, LVSI, tumor size (> 0.5 cm) and lymph node involvement. Failure of RAI ablation to decrease risk in N1a/b supports prophylactic central neck dissection during thyroidectomy, however more trials are warranted. CONCLUSION: Adjuvant I-131 ablation following thyroidectomy in PMC patients, particularly with poor prognostic factors improves DFS rates.

"Clinicopathological features and treatment outcomes of differentiated thyroid cancer in Saudi children and adults".

INTRODUCTION: Age is an important prognostic factor in differentiated thyroid cancer (DTC). Our aim was to evaluate differences in clinicopathological features and treatment outcomes among children and adult patients with DTC. MATERIALS AND METHODS: We studied 27 children (below 18 years) with DTC treated during the period 2000-2012 and were compared with (a) 78 adults aged 19-25 years and (b) 52 adults aged 26-30 years treated during the same period in terms of their clinicopathological features and long term treatment outcomes. Locoregional recurrence (LRR), locoregional control (LRC), distant metastasis (DM), distant metastasis control (DMC), disease free survival (DFS) and overall survival (OS) rates were evaluated. RESULTS: Mean age of children was 13.5 years (range: 5-18), while mean age of adults was 24.6 years (range: 19-30). In children, female: male ratio was 2.85:1, and in adults female: male ratio was 7.1:1 (P = 0.041). No significant difference in tumor size was seen between the two groups (P = 0.653). According to American Thyroid Association (ATA) risk stratification classification, the children (85.2 %) were found to have at high risk as compared to adults P = 0.001. Post-thyroidectomy complications and RAI induced toxicities were observed more in children than adults (P = 0.043 and P = 0.041 respectively). LRR occurred in 6 (22.2 %), 9 (11.5 %) and 3 (5.8 %) in age groups of <18 years, 19-25 years and 26-30 years respectively (P = 0.032); while DM was seen in 10 (37.0 %), 9 (10.3 %) and 5 (9.6 %) in age groups of <18 years, 19-25 years and 26-30 years respectively (P = 0.002). Ten year DFS rates were 67.3 % in age group below 18 years, 82.4 % in age group of 19-25 years and 90.1 % in age group of 26-30 years (P = 0.021). CONCLUSION: At the time of diagnosis, children with DTC were found to have more aggressive clinicopathological characteristics. Comparatively lower LRC, DMC and DFS rates in children warrants further multi-institutional studies.

Is thyroid gland an organ at risk in breast cancer patients treated with locoregional radiotherapy? Results of a pilot study.

BACKGROUND: Aim was to evaluate the dose distribution within the thyroid gland its association with hypothyroidism in breast cancer (BC) patients receiving supraclavicular (SC) radiation therapy (RT). MATERIALS AND METHODS: Consecutive 40 BC patients with baseline normal thyroid function tests (TFTs), were randomized into two groups: (a) Adjuvant chest wall/breast with SC-RT (20 patients) and (b) control group (adjuvant chest wall/breast RT only); 20 patients. The thyroid gland was contoured for each patient. Each patient's dose volume histogram (DVH), mean thyroid volume, the volume percentages of the thyroid absorbing respectively 5, 10, 20, 30, 40, and 50 Gy (V5, V10, V20, V30, V40, and V50), and Dmean (average dose in whole volume of thyroid) were then estimated. TFTs were performed at the time of the last follow-up and compared. RESULTS: Mean thyroid volume of cohort was 19.6 cm(3) (4.02-93.52) and Dmean of thyroid gland in SC-RT and control group was 25.8 Gy (16.4-52.2) and 5.6 Gy (0.7-12.8), respectively. Median values of V5, V10, V20, V30, V40, and V50 were 54%, 51%, 42.8%, 30.8%, 27.8%, and 7.64%, respectively, in SC-RT as compared to control group (V5;4.9%, V10;2.4%, V20;1.75%, V301%, V40;0%, and V50;0%, respectively) with P < 0.0001. At 52 months, a majority of patients (90%) had a normal thyroid function whereas four patients (10%) had hypothyroidism; 3/20 (15%) patients in SC-RT and 1/20 (5%) in control group with P < 0.001. Significant prognostic factors were; SC-RT (P = 0.001), V30 above 50% (P = 0.001), and smaller thyroid volume (P = 0.03). CONCLUSION: The risk of hypothyroidism in BC patients after SC-RT depends on the thyroid gland volume and V30 >50% and the risk can be minimized by thyroid gland shielding during RT.