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Purpose : To determine the feasibility and safety of outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia. Material and methods : We included patients diagnosed with non-metastatic cervix cancer and have completed brachytherapy between December 2015 and December 2016. Moderate to deep sedation was achieved using intravenous midazolam, propofol, fentanyl, and oxycodone. Local anesthesia was achieved with 2% lignocaine gel and a paracervical block containing a mixture of 1% ropivacaine, 2% lignocaine, and 1 : 1,000 adrenaline. Ceftriaxone and ondansetron were given prophylactically. Physiologic monitoring was performed throughout and pain scores were recorded using the Numeric Rating Scale. Follow-up was conducted at 8 weeks from the last fraction of brachytherapy. The feasibility and safety endpoints were a post-anesthesia discharge score (PADS) of 9 or above, and no grade 3 or above adverse events, respectively. Results : A total of thirty-five brachytherapy insertions were carried out on nine patients. The median age of the patients was 56 years (range, 40-65). Eight patients had American Society of Anesthesiologists’ physical status of I or II, and one had a status of III. The mean duration of the insertion was 39 minutes (standard deviation [SD] = 14), during which no adverse events occurred. There was no significant nausea or vomiting post-sedation. The median pain scores post-insertion and during recovery were 0 (range, 0-6) and 0 (range, 0-7), respectively. At discharge, all patients had pain scores of 0 and maximum PADS of 10. The mean time to discharge was 4.1 hours (SD = 0.95). There were no brachytherapy-related admissions or complications. Conclusions : Outpatient combined intracavitary and interstitial brachytherapy for cervix cancer with sedation and local anesthesia is feasible and safe. This could potentially lead to significant cost savings.

In December 2019, pneumonia of unknown cause was reported by China to WHO. The outbreak was found to be caused by a coronavirus which was officially named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2), and the disease caused by it was named 'COVID-19'. The first case in Singapore was confirmed on 23rd January 2020. With lessons learnt from the SARS epidemic in 2003 and the H1N1 flu pandemic in 2009, Singapore was much better prepared to deal with the virus outbreak. The government has taken swift measures to contain and break the chain of transmission. Healthcare workers face the challenge of keeping patients and staff safe from the disease. There is a higher risk of mortality of COVID-19 in cancer patients and hence unique considerations for a radiation oncology department operating in an infectious disease outbreak. This article is the recommendations and adapted workflow from the two National Cancer Centres in Singapore with the endorsement by the working committee of the Chapter of Radiation Oncology, Academy of Medicine, Singapore. It highlights the challenges that radiation oncology departments in Singapore face and the appropriate recommended responses. This includes interventions, business continuity plans and workflow in managing a COVID-19 positive patient on radiotherapy.

42 Background: Cervical cancer is the 4th most common cancer in females. Treatment recommendation for locally advanced cervical cancer includes concurrent chemo-radiotherapy (RT) followed by brachytherapy. However, primary treatment failure is not uncommon and is attributed to RT resistance. In view of RT-associated complications, identification of RT-resistant groups at diagnosis will help to minimize exposure to unnecessary toxicities. Methods: Our initial studies analyzing the genetic profile of RT-sensitive and RT-resistant tumours from xenograft models have identified the GAGE-family protein as a genetic marker that is selectively upregulated in RT-resistant xenograft tumours in vitro & in animal studies and is associated with more aggressive phenotypes of these tumors. To clinically validate these findings, we carried out a pilot study on 8 patients and also analyzed GAGE-family protein levels in retrospective study samples obtained from initial biopsy samples from from patients who have completed chemoRT and brachytherapy for cervical cancer to correlate their initial GAGE-family protein levels with treatment response. Results: Immuno-histological staining of pathology samples from 8 patients in our pilot study have shown that those with a higher expression of GAGE-family protein at mRNA and protein levels are more resistant to standard RT. Our retrospective analysis of 43 cervical cancer biopsy samples showed significantly elevated levels of GAGE-family protein mRNA ( P= 0.0028) and GAGE-family protein intensity score ( P= 0.026) in the 20 patients who were found to be resistant to standard definitive RT on subsequent follow-up compared to 23 patients who responded well. Median follow-up was 42 months. Conclusions: GAGE-family protein mRNA and protein expressions are elevated in patients resistant to standard definitive RT. We aim to develop a classification system to stratify patients into responders versus poor responders based on their GAGE-family protein levels at initial diagnosis in order to personalize treatment regimen whereby good responders can be treated with reduced RT dose and poor responders can receive escalated RT dose and further therapies in order to improve outcome.

// Jeremy Tey 1 , Yu Yang Soon 1 , Wee Yao Koh 1 , Cheng Nang Leong 1 , Bok Ai Choo 1 , Francis Ho 1 , Balamurugan Vellayappan 1 , Keith Lim 1 and Ivan W.K. Tham 1 1 Department of Radiation Oncology, National University Hospital, National Cancer Institute of Singapore, Singapore Correspondence to: Jeremy Tey, email: // Keywords : radiotherapy, gastric cancer, palliation, bleeding, pain Received : December 01, 2016 Accepted : February 07, 2017 Published : February 20, 2017 Abstract Background/Purpose: To review the efficacy and toxicity of palliative radiotherapy (RT) for symptomatic locally advanced gastric cancer (GC) and to determine the optimal RT schedule for symptom palliation. Methods: We searched MEDLINE and CENTRAL for eligible studies published from 1995 to 2015. Outcomes of interest were relief of bleeding, pain and obstruction. Results: Seven non-comparative observational studies were included. There were large variations in RT dose and fractionation. The pooled overall response rates for bleeding, pain and obstruction symptoms were 74%, 67% and 68% respectively. There was no difference in response rate of bleeding between regimens with high biological equivalent dose (BED) of ≥ 39Gy versus regimens with low BED

Recent reports have suggested that women undergoing mastectomy, instead of wide local excision (WLE) for Stage I and II breast cancers have poorer overall survival. This is particularly important in our setting where mastectomy rates are high. In this study, we evaluated the trends in mastectomy and WLE over a 10-year period at a single institute, identified factors more common among women who underwent mastectomy and specifically examined the effect of surgery on outcome. Retrospective review was performed of 2244 women who underwent curative surgery for non-metastatic breast cancer at our institute from 1st January 2001 to 31st December 2010. Mastectomy rates remained high over the 10 years, ranging from 43 to 59 %. Older women, those with symptoms, larger tumours and clinical nodal involvement were more likely to receive mastectomy (P

RATIONALE FOR CASE REPORT Cutaneous Squamous Cell Carcinoma (cSCC) of the hand is uncommon and tends to have poorer outcomes. Surgical resection with wide margins around the tumor is recommended as the treatment of choice, and radiotherapy is considered second-line treatment. Nodal evaluation involves dissection necessitating some morbidity. The role of less invasive modalities of nodal evaluation is not well established. CASE PRESENTATION We report a case of locally advanced case of hand cSCC. Positron emission tomography-computed tomography (PET-CT) showed disease involving full thickness of the hand as well as the ipsilateral axillary node. To achieve adequate surgical margins would have necessitated amputation at the wrist, which the patient did not consent to. Instead, he was given a two-and-a-half week course radiotherapy to the hand without axillary radiation. With the radiotherapy treatment, he managed to achieve complete remission of disease while retaining full function of the hand, which was maintained at 22 months post-treatment. MAIN LESSONS CSCC of the hand is uncommon and challenging to treat. Radiotherapy is a highly effective treatment modality which is able to achieve functional preservation. Care should be taken when evaluating nodal status using PET-CT.

Vicky Koh,1 Johann I Tang,1 Bok Ai Choo,1 Chek Wee Tan,1 Boon Keat Lim,2 Liang Shen,3 Jiade Jay Lu1 1Department of Radiation Oncology, National University Cancer Institute, Singapore; 2Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore; 3Department of Biostatistics, National University of Singapore, Singapore Background: Irradiation of the supraclavicular fossa is commonly used as part of adjuvant breast radiotherapy. Intensity-modulated radiotherapy (IMRT) may be used to target this region accurately, and there are subgroups of patients that may benefit more from IMRT than others. We identify the benefit of IMRT over fixed-depth dose prescription to the supraclavicular fossa in patients of different builds in a clinical setting. Methods: Fifteen patients who received radiotherapy to the left breast and supraclavicular fossa were selected. Computed tomographic planning was used to generate plans for supraclavicular fossa coverage. Dose prescription to 1.5 cm and 3.0 cm depths was compared with IMRT plans. Coverage of the planning target volume and dose to the organs at risk were compared and correlated with patient body mass index (BMI) and computed tomography measurements. Results: Within the IMRT group, increasing depth of the supraclavicular fossa produced significantly better coverage of the planning target volume with IMRT. IMRT resulted in lower mean doses to the brachial plexus (P = 0.00) when compared with 1.5 cm and 3 cm depth dose prescriptions, but higher maximum brachial plexus doses. IMRT was more beneficial in patients with lower BMI because this resulted in a decreased maximum brachial plexus dose (P-values of 0.03 and 0.001 when compared with 1.5 cm and 3.0 cm depth dose prescriptions, respectively). Higher patient BMI resulted in a lower dose contribution of IMRT to the cord (P-values 0.066 and 0.034 when compared with 1.5 cm and 3.0 cm depth dose prescriptions respectively). Conclusion: IMRT of the supraclavicular fossa results in lower brachial plexus doses for patients with low BMI while patients with higher BMI benefit from lower mean cord doses. IMRT provides superior coverage of the planning target volume, especially in patients with a deeper supraclavicular fossa. Keywords: intensity-modulated radiotherapy, radiotherapy, breast cancer, supraclavicular fossa