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Abstract Background Radiotherapy (RT) is effective for cervical cancer but causes late side effects (SE) to nearby organs. These late SE occur more than 3 months after RT and are rated by clinical findings to determine their severity. While imaging studies describe late gastrointestinal (GI) SE, none demonstrate the correlation between the findings and the toxicity grading. In this study, we demonstrated the late GI toxicity prevalence, CT findings, and their correlation. Methods We retrospectively studied uterine cervical cancer patients treated with RT between 2015 and 2018. Patient characteristics and treatment(s) were obtained from the hospital’s databases. Late RTOG/EORTC GI SE and CT images were obtained during the follow-up. Post-RT GI changes were reviewed from CT images using pre-defined criteria. Risk ratios (RR) were calculated for CT findings, and multivariable log binomial regression determined adjusted RRs. Results This study included 153 patients, with a median age of 57 years (IQR 49–65). The prevalence of ≥ grade 2 RTOG/EORTC late GI SE was 33 (27.5%). CT findings showed 91 patients (59.48%) with enhanced bowel wall (BW) thickening, 3 (1.96%) with bowel obstruction, 7 (4.58%) with bowel perforation, 6 (3.92%) with fistula, 0 (0%) with bowel ischemia, and 0 (0%) with GI bleeding. Adjusted RRs showed that enhanced BW thickening (RR 9.77, 95% CI 2.64–36.07, p = 0.001), bowel obstruction (RR 5.05, 95% CI 2.30–11.09, p

PURPOSETo report the patterns of care for brain metastases (BMs) in the Federation of Asian Organizations for Radiation Oncology (FARO).METHODSOverall, 37 questions were prepared. The survey was conducted online using Google Forms, and the URL was distributed to members of the FARO research committee. Radiation oncologists associated with FARO responded to the questionnaire between May 2023 and June 2023, and their answers were analyzed.RESULTSResponses were received from 32 radiation oncologists in 13 countries participating in FARO. Twenty-six physicians (81.3%) were affiliated with academic centers, and 22 (68.8%) were able to perform stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (fSRT) for BMs at their institution. The most typically used prognostic index for BM was the recursive partitioning analysis classification (17 physicians, 53.1%). The maximum number of BMs indicated for SRT/SRS was ≤three (11 physicians, 34.4%), whereas eight (25.0%) physicians answered for 6-10 BMs. The maximum size of BMs considered for SRS/fSRT was ≤3 cm (14 physicians, 43.8%), whereas nine (28.1%) answered that SRS/fSRT was preferred if the maximum size was >4 cm. When whole-brain radiotherapy (RT) was indicated, hippocampal avoidance and memantine usage were limited to 50.0% and 25.0% of patients, respectively. The most typical RT modality after BM resection was SRS/fSRT alone, regardless of whether the margin was positive (19 physicians, 59.4%) or negative (13 physicians, 40.6%).CONCLUSIONWe report the survey results of the patterns of care for BMs in the FARO. This survey was conducted only among a limited number of FARO members. Since many respondents were affiliated with relatively large-scale academic centers, large-scale surveys, including community hospitals, are warranted for future initiatives.

IntroductionNorthern Thailand experiences high levels of air pollution in the dry season due to agricultural waste burning and forest fires. Some air pollutants can enter the bloodstream, and the liver has the role of detoxifying these along with other harmful substances. In this study, we assessed the effects of long-term exposure to air pollutants on liver cancer mortality in this area.MethodsA cohort of 10,859 primary liver cancer patients diagnosed between 2003 and 2018 and followed up to the end of 2020 were included in the study. Extended time-varying covariates of the annually averaged pollutant concentrations updated each year were utilized. The associations between air pollutants and mortality risk were examined by using a Cox proportional hazard model.ResultsMetastatic cancer stage had the highest adjusted hazard ratio (aHR) of 3.57 (95% confidence interval (CI):3.23–3.95). Being male (aHR = 1.10; 95% CI: 1.04–1.15), over 60 years old (aHR = 1.16; 95% CI: 1.11–1.21), having a history of smoking (aHR = 1.16; 95%CI: 1.11–1.22), and being exposed to a time-updated local concentration of PM2.5 of 40 μg/m3 (aHR = 1.10; 95% CI: 1.05–1.15) increased the mortality risk.ConclusionWe found that air pollution is one of several detrimental factors on the mortality risk of liver cancer.

Abstract Early diagnosis of breast cancer is crucial for reducing mortality rates. The purpose of this study is to determine the impact of demographics/social determinants of health on beliefs about the practice of self-breast examination, using mammogram and ultrasound in the context of breast cancer screening among Thai women in a hospital-based setting for implying program planning and future research. A cross-sectional study was conducted in two health centers in Chiang Mai Province from August 2021 to December 2021, involving 130 Thai women ages 40 to 70 years. Data were collected by a survey using a questionnaire to gather sociodemographic information, and health beliefs about breast cancer and screening behavior utilizing the modified Thai version of Champion's Health Belief Model Scale (MT-CHBMS). Descriptive statistics, t-tests, ANOVA, and linear regression models were employed for examining association between sociodemographic factors and health beliefs about the practice of self-breast examination (BSE), using mammogram (MG) and ultrasound (UTS). Health insurance schemes were associated with Benefit-MG, Barrier-BSE, Barrier-MG and Barrier-UTS subscales. Additionally, monthly income was associated with Barrier-MG and Barrier-UTS subscales. The most common barriers reported were “embarrassment”, “worry”, and “takes too much time”. To enhance breast cancer screening in Thailand, program planning and future research should focus on health insurance schemes, especially women with social security schemes, as they may be the most appropriate target group for intervention.

Objective: This retrospective study evaluated the preliminary outcomes of image-guided vaginal brachytherapy (IG-VBT) in the adjuvant treatment of high intermediate risk endometrial cancer. Materials and Methods: Data were collected from 48 patients who underwent adjuvant IG-VBT between 2019 and 2022 at the Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Chiang Mai University. The vaginal cuff clinical target volume (CTV-VC) is composed of a 4-mm-thick band around vaginal cylinder at the upper 3 cm of the vaginal cuff. A total dose of 21 Gy in three fractions was delivered to the CTV-VC, and the dose to the bladder and rectum were evaluated. Treatment details, patient characteristics, and outcomes were analyzed. Descriptive statistics were used for analysis, and Kaplan-Meier method was employed for survival analysis. Results: The mean age was 62 years, with mainly endometrioid carcinoma pathology (96 %). All patients were at stage I, with 87.5 % receiving complete surgical staging. Mean total treatment time was 10 days with mean D90 of CTV-VC was 29.7 Gy, and D2cc of bladder, rectum, and sigmoid were 24.6 Gy, 21.0 Gy, and 7.7 Gy, respectively. At a median follow-up of 37 months, 3-year local control, disease-free survival, and overall survival rates were 100 %, 100 %, and 97.9 %. respectively. Two patients (4.2 %) experienced grade 1–2 gastrointestinal toxicity, while no genitourinary toxicity or serious adverse events were observed. Conclusions: The preliminary results of IG-VBT in endometrial cancer demonstrated favorable outcomes in terms of vaginal control and toxicity. Further studies with larger cohorts and longer follow-up durations are warranted.

IntroductionRadiation-induced brachial plexopathy (RIBP) is one of the most concerning late radiation effects after hypofractionated postmastectomy radiotherapy (HF-PMRT) to the chest wall and regional lymph nodes. The purpose of this study was to investigate the RIBP events occurring in breast cancer patients after HF-PMRT using intensity-modulated radiation therapy (IMRT) by helical tomotherapy. Furthermore, the dosimetric parameters of the ipsilateral brachial plexus were reported.Materials and methodsBreast cancer patients who underwent HF-PMRT using the IMRT via HT at our institute were included. In the first cohort, subjective RIBP symptoms were measured using a QuickDASH questionnaire, whereas objective RIBP events were assessed using a comprehensive physical evaluation in the second cohort. The ipsilateral brachial plexus from all eligible patients’ treatment plans was contoured, and the dosimetric parameters were explored.ResultsFrom March 2014 to December 2022, 229 patients were enrolled; 107 and 72 individuals were in the first and second cohorts, respectively. The first cohort’s median follow-up period was 27 months, and the second cohort was 31 months. In the first cohort, 80 patients (74.77%) had a normal function, 21 (19.63%) had a mild grade, and 6 (5.61%) had a moderate grade; no severe or very severe RIBP was observed. However, the comprehensive physical evaluation of the second cohort indicated no RIBP events. Dosimetric analysis revealed that the median maximum dose was 44.52, 44.52, and 44.60 Gy; the median mean dose was 33.00, 32.23, and 32.33 Gy; and the median dose at 0.03 cc was 44.33, 44.36, and 44.39 Gy for all patients, patients in the first and second cohort, respectively. Each dosimetric parameter was evaluated, and no statistically significant differences were detected.ConclusionThe absence of RIBP events supports the safety of employing HF-PMRT by HT for the chest wall and all regional lymph nodes. We propose that applying the ICRU Report 83 criteria for IMRT planning, which limit the maximum dose (107% of the prescribed dose) to less than 2% of the planning target volume and exclude the brachial plexus region from the maximal dose area, is a practical way to minimize the risk of RIBP from HF-PMRT.

Abstract Background To evaluate survival rates of hepatocellular carcinoma (HCC), the Chiang Mai Cancer Registry provided characteristics data of 6276 HCC patients diagnosed between 1998-2020 based on evolution of imaging diagnosis. Evolution can be separated into four cohorts, namely, cohort 1 (1990-2005) when we had ultrasound (US) and single-phase computed tomography (CT), cohort 2 (2006-2009) when one multi-phase CT and one magnetic resonance imaging (MRI) were added, cohort 3 (2010-2015) when MRI with LI-RADS was added, and finally, cohort 4 (2016-2020) when two upgraded MRIs with LI-RADS were added. Methods Cox proportional hazard models were used to determine the relation between death and risk factors including methods of imagining diagnosis, gender, age of diagnosis, tumor stages, history of smoking and alcohol-use, while Kaplan-Meier curves were used to calculate survival rates. Results The median age of diagnosis was 57.0 years (IQR: 50.0-65.0) and the median survival time was 5.8 months (IQR: 1.9-26.8) during the follow-up period. In the univariable analysis, all factors were all associated with a higher risk of death in HCC patients except age of diagnosis. In a multivariable analysis, elderly age at diagnosis, regional and metastatic stages and advanced methods of imagining diagnosis during cohorts 2 and 3 were independently associated with the risk of death in HCC patients. The survival rate of patients diagnosed during cohort 4 was significantly higher than the other cohorts. Conclusion As a significantly increasing survival rate of HCC patients in cohort 4, advanced methods of diagnostic imaging can be a part of the recommendation to diagnose HCC.

Chiang Mai province of Thailand is known for having the highest natural background radiation in the country, as well as being recognized as one of the world’s most polluted cities for air quality. This represents the major contributor to the development of lung cancer. This research aims to estimate the comprehensive dose of both internal and external exposure due to natural background radiation and related health perspectives in the highly polluted area of Chiang Mai. The average values of indoor radon and thoron concentrations in 99 houses over 6 months were 40.8 ± 22.6 and 17.8 ± 16.3 Bq/m3, respectively. These results exceed the worldwide value for indoor radon and thoron (40 and 10 Bq/m3), respectively. During burning season, the average values of indoor radon (56.7 ± 20 Bq/m3) and thoron (20.8 ± 20.4 Bq/m3) concentrations were higher than the world-wide averages. The radon concentration in drinking water (56 samples) varied from 0.1 to 91.9 Bq/L, with an average value of 9.1 ± 22.8 Bq/L. Most of the drinking water samples (87%) fell below the recommended maximum contamination limit of 11.1 Bq/L. The average values of natural radionuclide (226Ra, 232Th and 40K) in 48 soil samples were 47 ± 20.9, 77.9 ± 29.7 and 700.1 ± 233 Bq/kg, respectively. All values were higher than the worldwide average of 35, 30 and 400 Bq/kg, respectively. The average value of outdoor absorbed gamma dose rate (98 ± 32.5 nGy/h) exceeded the worldwide average of 59 nGy/h. Meanwhile, the average activity concentrations of 226Ra, 232Th and 40K in 25 plant food samples were 2.7 ± 0.1, 3.2 ± 1.6 and 1000.7 ± 1.9 Bq/kg, respectively. The 40K concentration was the most predominant in plant foods. The highest concentrations of 226Ra, 232Th and 40K were found in Chinese cabbage, celery and cilantro, respectively. The total annual effective dose for residents in the study area varied from 0.6 to 4.3 mSv, with an average value of 1.4 mSv. This indicates a significant long-term public health hazard due to natural background radiation and suggests a heightened radiation risk for the residents. The excess lifetime cancer risk value (5.4) associated with natural background radiation was found to be higher than the recommended value. Moreover, the number of lung cancer cases per year per million average of 25.2 per million persons per year was in the limit range 170–230 per million people. Overall, our results will be used for future decision making in the prevention of lung cancer risk associated with natural background radiation.

Abstract Intracranial hemorrhage (ICH) from traumatic brain injury (TBI) requires prompt radiological investigation and recognition by physicians. Computed tomography (CT) scanning is the investigation of choice for TBI and has become increasingly utilized under the shortage of trained radiology personnel. It is anticipated that deep learning models will be a promising solution for the generation of timely and accurate radiology reports. Our study examines the diagnostic performance of a deep learning model and compares the performance of that with detection, localization and classification of traumatic ICHs involving radiology, emergency medicine, and neurosurgery residents. Our results demonstrate that the high level of accuracy achieved by the deep learning model, (0.89), outperforms the residents with regard to sensitivity (0.82) but still lacks behind in specificity (0.90). Overall, our study suggests that the deep learning model may serve as a potential screening tool aiding the interpretation of head CT scans among traumatic brain injury patients.

Purpose: The dose expansion methods as the skin flash and virtual bolus were used to solve intrafraction movement for breast planning due to breathing motion. We investigated the skin dose in each planning method by using optically stimulated luminescence on an in-house moving phantom for breast cancer treatment in tomotherapy. The impact of respiratory motion on skin dose between static and dynamic phantom's conditions was evaluated. Methods: A phantom was developed with movement controlled by the respirator for generating the respiratory waveforms to simulate respiratory motion. Five optically stimulated luminescence dosimeters were placed on the phantom surface to investigate the skin dose for the TomoDirect and TomoHelical under static and dynamic conditions. Eight treatment plans were generated with and without skin flash or virtual bolus by varying the thickness. The difference in skin dose between the two phantom conditions for each plan was explored. Results: All plans demonstrated a skin dose of more than 87% of the prescription dose under static conditions. However, the skin dose was reduced to 84.1% (TomoDirect) and 78.9% (TomoHelical) for dynamic conditions. The treatment plans without skin flash or virtual bolus showed significant skin dose differences under static and dynamic conditions by 4.83% (TomoDirect) and 9.43% (TomoHelical), whereas the skin flash with two leaves (TomoDirect 2L) or virtual bolus of at least 1.0 cm thickness (VB1.0) application compensated the skin dose in case of intrafraction movements by presenting a skin dose difference of less than 2% between the static and dynamic conditions. Conclusion: The skin dose was reduced under dynamic conditions due to breathing motion. The skin flash method with TomoDirect 2L or virtual bolus application with 1.0 cm thickness was useful for maintaining skin dose following the prescription by compensating for intrafraction movement due to respiratory motion for breast cancer in tomotherapy.

Abstract Background: The incidence of breast cancer (BC) in Thailand has been rising at an alarming rate. The annual incidence of BC in Thailand has doubled over a span of 15 years. A retrospective study was conducted with the primary objective of assessing and comparing survival rates of patients with BC, stratified by subtype of BC. Methods: A retrospective study was implemented for a cohort of women receiving a diagnosis of invasive BC with the objective of assessing and comparing their overall survival, stratified by BC subtype. Thai women receiving a diagnosis of their first primary invasive BC between January 2006 and December 2015 at Chiang Mai University Hospital were studied with 3,150 cases meeting the eligible criteria. Results: The median follow-up time was 4.9 years (Inter Quartile Range: 2.8–7.7). The most common diagnosed subtype was luminal B-like (n = 1,147, 36.4%). It was still the most prevalent subtype (35.8%) in women younger than 40 years and the 40–60 age-group, The proportion of patients with TNBC is the highest in women aged less than 40 years with 19.3% compared to the other age categories. Finally, among women older than 60 years, the proportion of each subtype was relatively uniform. Most women received a diagnosis of stage II disease. Triple negative subtype increased overall mortality in advanced staging (stages III and IV) (aHR:1.42, 95% CI: 0.96–2.11). The 5-year overall survival rate was found in luminal A-like at 82.8%, luminal B-like at 77.6%, HER-2 enriched at 66.4% and triple negative subtype at 64.2%. Conclusion: The histologic subtype, correlated with age and staging influenced the OS. Our results confirmed the association of triple negative BC with poor prognosis especially in advanced stage. The adjuvant medical treatment in our country could not be accessible in some group of patients, so the results of treatment and survival especially HER-2 enriched are lower than other countries without treatment barrier.

Summary: Sex disparities in cancer exist along the cancer spectrum, ranging from genomic predisposition and behavioral risk factors to access to screening, diagnostics, treatment, and survivorship care. A growing body of research is studying the biological underpinnings of these differences, from cancer risk to tumor biology to treatment response. It is well known, however, that the social determinants of health play a large role across the cancer disease continuum, which encompasses risk, prevention, diagnosis, treatment, survivorship, rehabilitation, and palliative care. Less literature focuses on the gendered disparities that are epidemiologic in nature, especially in Southeast Asia (SEA), a diverse region that is home to nearly 670 million people, where most are lower middle income countries, and where socioeconomic and cultural factors increase cancer risk for women. In this review, we highlight the social drivers of gendered disparities, namely the geographic, environmental, sociocultural, economic, and political forces that contribute to the increased mortality and poorer health outcomes in the region.

PurposeWe prospectively investigated the acute toxicities focusing on skin and hematologic function in breast cancer patients who received hypofractionated whole breast irradiation with simultaneous integrated boost (HF-WBI-SIB) with helical tomotherapy (HT), with or without regional nodal irradiation (RNI).MethodsThe dose of WBI and RNI was 42.4 Gy in 16 fractions. Tumor bed was prescribed to 49.6 Gy in 16 fractions simultaneously. The association between the worst grade of acute toxicities during treatment and receiving RNI was analyzed. The integral dose to the whole body between the two groups was also compared.ResultsBetween May 2021 and May 2022, 85 patients were enrolled; 61 patients received HF-WBI-SIB only (71.8%) and 24 patients (28.2%) received HF-WBI-SIB with RNI. Grade 2 acute skin toxicity was found in 1.2%. The most frequent grade 2 or more hematologic toxicity was leukopenia, which occurred in 4.8% and 11% in the 2nd and 3rd week, respectively. Mean whole body integral dose was significantly higher in patients treated with RNI compared to patients treated without RNI: 162.8 ± 32.8 vs. 120.3 ± 34.7 Gy-L (p-value < 0.001). There was no statistically significant difference in acute grade 2 or more skin and hematologic toxicities between the two groups.ConclusionsHF-WBI-SIB with or without RNI is feasible with acceptable acute skin and hematologic toxicities. RNI and whole body integral dose were not associated with these acute toxicities.

Abstract Background Breast cancer incidence in Northern Thailand has shown a continuous increase since records began in 1983. In 2002 the urgency of the situation prompted Maharaj Nakorn Chiang Mai Hospital to initiate the Suandok Breast Cancer Network (SBCN). Methods The SBCN is a not-for-profit organization in the university hospital which serves as a training and education center and provides highly specialized medical care for patients in Chiang Mai and in 5 provinces of northern Thailand, with the key mission of improving breast cancer care. The short-term goal was to overcome the barriers to engagement with breast cancer and its treatment and the long-term goal was to increase the overall survival rate of breast cancer patients in our region. Results We enrolled breast cancer patients treated at Maharaj Nakorn Chiang Mai Hospital between January 2006 and December 2015 and divided into 2 cohorts: 1485 patients who were diagnosed from 2006 to 2009 (cohort 1: early implementation of SBCN) and 2383 patients who were diagnosed from 2010 to 2015 (cohort 2: full implementation of SBCN). Criteria to measure improved cancer waiting time (CWT) would include: time to diagnosis, time to surgery, and time to radiotherapy. The 5-year overall survival (OS) of the cohort 2 was higher than that in cohort 1, at 73.8 (72.0–75.5) compared to 71.5 (69.2–73.7) (p-value = 0.03). Conclusions Reasons behind the success of project include the uniformity of care encouragement, service network development and timely access to each step of breast cancer management. The model used in SBCN could be adopted as a learning guide to improve healthcare access and outcome for breast cancer patients in low- to middle-income countries.

ObjectiveWe study factors affecting neutrophil-to-lymphocyte ratio (NLR) and its changes throughout the treatment (ΔNLR) of nasopharyngeal carcinoma (NPC) underwent chemoradiotherapy (CCRT) followed by adjuvant chemotherapy (AC) and oncological outcomes including overall survival (OS) and disease-free survival (DFS).MethodsData from 81 NPC patients was retrospectively evaluated. NLRs were obtained from first week of CCRT (pre-CCRT), last week of CCRT (end-CCRT), and at last cycle of AC (end-AC). Pre-CCRT NLR was categorized into "low" and "high". End-CCRT and end-AC ΔNLRs were divided into "increased" and "decreased" based on NLR at these two timepoints relative to the value at pre-CCRT. Associations between sex, age, cancer stage and NLR, ΔNLRs were investigated. OS and DFS were reported.ResultsMedian NLR at pre-CCRT (2.47) was lower than NLR at end-CCRT (6.29) and end-AC (3.77) (P-value = 0.043). Advanced cancer stage associated with high pre-CCRT NLR (P-value = 0.047). Male gender was associated with "increased" end-CCRT ΔNLR, whereas male gender and age ≤51 were associated with "increased" end-AC ΔNLR. Three-year OS and DFS rates were 85.25% and 76.39%, respectively. There were no statistically significant differences observed in OS and DFS among groups categorized by pre-CCRT NLR, ΔNLRs, gender, age, and cancer stage.ConclusionsNLR increases during NPC treatment. Advanced staging is associated with higher baseline NLR. Increased ΔNLR is associated with male gender at end-CCRT and male gender with age ≤51 years at end-AC. No relation between NLR and its dynamic change with either OS or DFS was demonstrated.

Intracranial hematoma (ICH) volume is considered a predictor of clinical outcome and mortality rate in ICH patients with traumatic brain injury (TBI). The ABC/2 method for ICH volume is the standard method used to date, however, its level of accuracy has been questioned in some studies. This study compared the performance of the ABC/2 method with planimetry and truncated pyramidal methods to highlight the potential of the planimetry method applied with automatic segmentation for evaluation of epidural hematoma (EDH) and intraparenchymal hematoma (IPH) volume. Six different phantoms were designed to evaluate the accuracy of volume estimation methods. 221 hematoma regions extracted from CT scans of 125 patients with head injury were also used to analyze the efficiency. The roundness index was utilized for the quantification of the ellipsoid-like shape. Regions of EDH and IPH on the CT scans were annotated by radiologists. The estimation errors for each method were statistically analyzed and compared. In addition, the relationship between the errors and roundness index was examined. The planimetry method showed the lowest relative error on phantom data. In the case of the CT scan data, the truncated pyramidal method resulted in the underestimation of the volumes of EDH and IPH. Meanwhile, the ABC/2, through principal component analysis (PCA) in the two-dimensional and PCA in the three-dimensional methods, resulted in a significant overestimation. In addition, both these approaches produced relative errors that showed a correlation with the roundness indexes for IPH. In comparison to other methods, the planimetry method had the lowest level of error with regards to calculation of the volume and it was also independent of the hematoma shape. The planimetry method, therefore, has the potential to serve as a useful tool for the assessment of ICH volume in TBI patients by using a deep learning system.

Abstract Background Oral candidiasis is a common problem associated with head and neck radiation therapy (RT) consequences being pain, burning sensation, taste change, and systemic infection. There are difficulties in differentiating between oral candidiasis and radiation induced oral mucositis. We conducted a prospective study to explore the incidence of clinical oral candidiasis and evaluate the accuracy of diagnosis among head and neck cancer (HNC) patients receiving RT or concurrent chemoradiotherapy (CCRT). Methods This study included 86 HNC patients who had no clinical signs or symptoms of oral candidiasis. Oral mucosa and tongue swabs were carried out and analyzed three times by fungal cultures at the following time points: (1) before RT, (2) at the time of clinically diagnosed candidiasis or during RT at between the 15th–17th fraction (whichever occurred first), and (3) at the end of RT. The accuracy of clinical oral candidiasis was explored and confirmed by fungal colonization techniques. The incidence and risk factors associated with fungal colonization before and throughout the treatment were analyzed. Results The overall incidence of clinical oral candidiasis was 53.5% throughout the course of RT. Confirmation of fungal colonization was found in 39.5%, 65.9%, and 57.7% of cases before RT, during RT, and end of RT, respectively. The accuracy of the diagnosis using only clinical presentation was demonstrated in 60%, 50%, and 52% before RT, during RT, and end of RT, respectively. Logistic regression analysis showed that age, CCRT, and using 2% viscous lidocaine solution were independent risk factors for fungal colonization. Conclusions The results of this study demonstrated an underestimation of clinical oral candidiasis before and throughout the course of radiotherapy from using only clinical sign and symptoms. Crucial attention to detail and testing in the oral examination could improve decision making for detection of oral candidiasis in HNC patients receiving RT or CCRT.

Abstract Background The Ministry of Public Health of Thailand established universal health coverage (UHC) in 2002, which also included national-level screening for cervical cancer in 2005. This study examined the changes in mortality of cervical cancer in rural and urban areas in Chiang Mai Province of northern Thailand during the era of UHC and the immediately preceding period. Methods Data of cervical cancer patients in Chiang Mai in northern Thailand, who died from 1998 through 2012, were used to calculate the change in age-standardized rates of mortality (ASMR) using a joinpoint regression model and to calculate estimated annual percent changes (APC). The change in mortality rate by age groups along with changes by geographic area of residence were determined. Results Among the 1177 patients who died from cervical cancer, 13(1%), 713 (61%) and 451 (38%) were in the young age group (aged

BackgroundThe burden of HPV-related cancers in different regions worldwide varies according to several factors. This study aims to measure inequality in the risk of incidence of HPV-related cancers in term of geographical risk patterns in northern Thailand using a population-based cancer registry data.MethodsTrends in age-standardized HPV-related cancer incidence were calculated for the 2008-2017 time period. The Besag-York-Molli´e model was used to explore the spatial distribution of the relative risk (RR) of HPV-related cancers at the district level. A higher RR reflects a larger disparity. The geographical risk pattern of the diseases in two periods, 2008-2012 and 2013-2017 were described and compared.ResultsFrom 2008 to 2017, the incidence of oropharyngeal and anal cancers showed a slightly increased trend in males but remained stable in females, the incidence of vulvar, vaginal and penile cancers were stable while the incidence of cervical cancer decreased. The RR range was closer to 1 in the second period compared to the first period. This suggests a decrease in the disparities of incidence of cervical cancer. However, in some areas near the Thai-Myanmar border, the RR values remained high.ConclusionThe incidence rate of most HPV-related cancers remained low and stable over the study period in northern Thailand. For the most common HPV-related malignancy, cervical cancer, the incidence rate steadily decreased but with marked geographic disparities, possibly reflecting health inequity especially in the border areas.

Abstract Objective We evaluated the long-term outcomes and late toxicity of conventional fractionated (CF) and hypofractionated (HF) postmastectomy radiotherapy (PMRT) in terms of locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), overall survival (OS), and late toxicity. Methods A cohort of 1640 of breast cancer patients receiving PMRT between January 2004 and December 2014 were enrolled. Nine hundred eighty patients were treated with HF-PMRT: 2.65 Gy/fraction to a total of 42.4–53 Gy and 660 patients were treated with CF-PMRT: 2 Gy/fraction to a total of 50–60 Gy. Results The median follow-up time was 71.8 months (range 41.5–115.9 months). No significant difference was found in the rates of 5-year LRRFS, DFS, and OS of HF-PMRT vs CF-PMRT; 96% vs. 94% (p = 0.373), 70% vs. 72% (p = 0.849), and 73% vs. 74% (p = 0.463), respectively. We identified a cohort of 937 eligible breast cancer patients who could receive late toxicities assessment. With a median follow-up time of this patient cohort of 106.3 months (range 76–134 months), there was a significant higher incidence of grade 2 or more late skin (4% vs 1%) and subcutaneous (7% vs 2%) toxicity in patients treated with HF-PMRT vs CF-PMRT. Patients who received additional radiation boost were significantly higher in the HF-PMRT group. Grade 2 or more late RTOG/EORTC lung toxicity was significant lesser in HF-PMRT vs CF-PMRT (9% vs 16%). Grade 1 brachial plexopathy was also significant lesser in HF-PMRT vs CF-PMRT (2% vs 8%). Heart toxicity and lymphedema were similar in both groups. Conclusions HF-PMRT is feasible to deliver with comparable long-term efficacy to CF-PMRT. HF-PMRT had higher grade 2 or more skin and subcutaneous toxicity but less lung and brachial plexus toxicity.

PURPOSE: Head and neck cancer is the sixth most common cancer in the world, and the largest burden occurs in developing countries. Although the primary risk factors have been well characterized, little is known about temporal trends in head and neck cancer across Thailand. METHODS: Head and neck squamous cell carcinoma (HNSCC) occurrences diagnosed between 1990 and 2014 were selected by International Classification of Diseases (10th revision; ICD10) code from the Songkhla, Lampang, Chiang Mai, and Khon Kaen cancer registries and the US SEER program for oral cavity (ICD10 codes 00, 03-06), tongue (ICD10 codes 01-02), pharynx (ICD10 codes 09-10, 12-14), and larynx (ICD10 code 32). The data were analyzed using R and Joinpoint regression software to determine age-standardized incidence rates and trends of annual percent change (APC). Incidence rates were standardized using the Segi (1960) population. Stratified linear regression models were conducted to assess temporal trends in early-onset HNSCC across 20-year age groups. RESULTS: Although overall HNSCC rates are decreasing across all registries, subsite analyses demonstrate consistent decreases in both larynx and oral cavity cancers but suggest increases in tongue cancers among both sexes in the United States (APCmen, 2.36; APCwomen, 0.77) and in pharyngeal cancer in Khon Kaen and US men (APC, 2.1 and 2.23, respectively). Age-stratified APC analyses to assess young-onset (< 60 years old) trends demonstrated increased incidence in tongue cancer in Thailand and the United States as well as in pharyngeal cancers in Khon Kaen men age 40 to 59 years and US men age 50 to 59 years. CONCLUSION: Although overall trends in HNSCC are decreasing across both Thailand and the United States, there is reason to believe that the etiologic shift to oropharyngeal cancers in the United States may be occurring in Thailand.

Although cisplatin is a first-line chemotherapy drug for head and neck squamous cell carcinoma (HNSCC), its therapeutic efficacy is limited owing to serious side effects and acquired drug resistance. This study determined whether combining pentagalloyl glucose (PGG) and cisplatin enhanced their anti-tumor activities on HNSCC cell lines. We investigated the anticancer effect of PGG combined with cisplatin in 2D and 3D multicellular spheroid cell culture. The results revealed that PGG combined with cisplatin inhibited cell viability and produced synergistic effects. PGG potentiates the anticancer effect of cisplatin by promoting apoptosis and inhibiting cell migration. The western blot and molecular docking analysis revealed that the synergistic effect of the combination treatment may be related to the PGG-mediated reduced expression of phosphorylated STAT3 and phosphorylated Akt. Furthermore, we found that the combined treatment of PGG and cisplatin’s effect on 3D multicellular spheroid size was more potent than the monotherapies. Our findings indicated that the combination therapy of PGG and cisplatin synergistically inhibited HNSCC cancer cell viability and induced apoptosis in 2D and 3D models. The present results suggested that PGG may be a promising adjunct drug used with cisplatin for a practical therapeutic approach to head and neck cancer.

This paper presents the first measurement of the investigation of the health impacts of indoor radon exposure and external dose from terrestrial radiation in Chiang Mai province during the dry season burning between 2018 and 2020. Indoor radon activity concentrations were carried out using a total of 220 RADUET detectors in 45 dwellings of Chiang Mai (7 districts) during burning and non-burning seasons. Results show that indoor radon activity concentration during the burning season (63 ± 33 Bq/m3) was significantly higher (p < 0.001) compared to the non-burning season (46 ± 19 Bq/m3), with an average annual value of 55 ± 28 Bq/m3. All values of indoor radon activity concentration were greater than the national (16 Bq/m3) and worldwide (39 Bq/m3) average values. In addition, the external dose from terrestrial radiation was measured using a car-borne survey during the burning season in 2018. The average absorbed rate in the air was 66 nGy/h, which is higher than the worldwide average value of 59 nGy/h. This might be due to the high activity concentrations of 238U and 323Th in the study area. With regards to the health risk assessment, the effective dose due to indoor radon exposure, external (outdoor) effective dose, and total annual effective dose were 1.6, 0.08, and 1.68 mSv/y, respectively. The total annual effective dose is higher than the worldwide average of 1.15 mSv/y. The excess lifetime cancer risk and radon-induced lung cancer risk during the burning season were 0.67% and 28.44 per million persons per year, respectively. Our results substantiate that indoor radon and natural radioactive elements in the air during the burning season are important contributors to the development of lung cancer.

BackgroundLeft-sided post-mastectomy radiotherapy (PMRT) certainly precedes some radiation dose to the cardiopulmonary organs causing many side effects. To reduce the cardiopulmonary dose, we created a new option of the breathing adapted technique by using abdominal compression applied with a patient in deep inspiration phase utilizing shallow breathing. This study aimed to compare the use of abdominal compression with shallow breathing (ACSB) with the free breathing (FB) technique in the left-sided PMRT.Materials and methodsTwenty left-sided breast cancer patients scheduled for PMRT were enrolled. CT simulation was performed with ACSB and FB technique in each patient. All treatment plans were created on a TomoTherapy planning station. The target volume and dose, cardiopulmonary organ volume and dose were analyzed. A linear correlation between cardiopulmonary organ volumes and doses were also tested.ResultsRegarding the target volumes and dose coverage, there were no significant differences between ACSB and FB technique. For organs at risk, using ACSB resulted in a significant decrease in mean (9.17 vs 9.81 Gy, pConclusionsThe ACSB technique significantly reduced the cardiac dose compared with the FB technique in left-sided PMRT treated by Helical TomoTherapy. Our technique is uncomplicated, well-tolerated, and can be applied in limited resource center.

Abstract Background Over the past decade, lung cancers have exhibited a disproportionately high mortality and increasing mortality trend in Thailand, especially in the northern region, and prevention strategies have consequently become more important in this region. Spatial analysis studies may be helpful in guiding any strategy put in place to respond to the risk of lung cancer mortality in specific areas. The aim of our study was to identify risk patterns for lung cancer mortality within the northern region of Thailand. Methods In the spatial analysis, the relative risk (RR) was used as a measure of the risk of lung cancer mortality in 81 districts of northern Thailand between 2008 and 2017. The RR was estimated according to the Besag-York-Mollié autoregressive spatial model performed using the OpenBUGS routine in the R statistical software package. We presented the overall and gender specific lung cancer mortality risk patterns of the region using the Quantum Geographic Information System. Results The overall risk of lung cancer mortality was the highest in the west of northern Thailand, especially in the Hang Dong, Doi Lo, and San Pa Tong districts. For both genders, the risk patterns of lung cancer mortality indicated a high risk in the west of northern Thailand, with females being at a higher risk than males. Conclusions There was distinct geographical variation in risk patterns of lung cancer mortality in Thailand. Differences could be related to differences in risk factors such as ground-based radon and air pollution. This study provides a starting point for estimating the spatial pattern of the risk of lung cancer mortality and for examining associations between geographic risk factors and lung mortality for further studies.

Radon is a major cause of lung cancer (LC) deaths among non-smokers worldwide. However, no serum biomarker for screening of LC risk in high residential radon (HRR) areas is available. Therefore, the aim of this study was to determine diagnostic values of serum carcinoembryonic antigen (CEA), cytokeratin 19 fragment (Cyfra21-1), human epididymis protein 4 (HE4), interleukin 8 (IL-8), migration inhibitory factor (MIF), tumor nuclear factor-alpha (TNF-α) and vascular endothelial growth factors (VEGF) occurring in high radon areas. Seventy-five LC non-smoker patients and seventy-five healthy controls (HC) were enrolled in this study. Among the HC groups, twenty-five HC were low residential radon (LRR) and fifty HC were HRR. Significantly higher (p < 0.0004) serum levels of CEA, Cyfra21-1, IL-8 and VEGF were found in the LC compared with the LRR and HRR groups. More importantly, significantly higher levels (p < 0.009) of serum CEA, Cyfra21-1 and IL-8 were observed in HRR compared with the LRR group. Likewise, a ROC curve demonstrated that serum CEA and Cyfra21-1 could better distinguish LC risk from HRR groups than IL-8. These results indicated that serum CEA and Cyfra21-1 were significantly increased in the HRR group and may be considered as potential biomarkers for individuals at high-risk to develop LC.

Cancer stem cells (CSCs) play a critical role in radiation resistance and recurrence. Thus, drugs targeting CSCs can be combined with radiotherapy to improve its antitumor efficacy. Here, we investigated whether a gallotannin extract from Bouea macrophylla seed (MPSE) and its main bioactive compound, pentagalloyl glucose (PGG), could suppress the stemness trait and further confer the radiosensitivity of head and neck squamous cell carcinoma (HNSCC) cell lines. In this study, we evaluate the effect of MPSE or PGG to suppress CSC-like phenotypes and radiosensitization of HNSCC cell lines using a series of in vitro experiments, tumorsphere formation assay, colony formation assay, apoptosis assay, and Western blotting analysis. We demonstrate that MPSE or PGG is able to suppress tumorsphere formation and decrease protein expression of cancer stem cell markers. MPSE or PGG also enhanced the radiosensitivity in HNSCC cells. Pretreatment of cells with MPSE or PGG increased IR-induced DNA damage (γ-H2Ax) and enhanced radiation-induced cell death. Notably, we observed that pretreatment with MPSE or PGG attenuated the IR-induced stemness-like properties characterized by tumorsphere formation and the CD44 CSC marker. Our findings describe a novel strategy for increasing therapeutic efficacy for head and neck cancer patients using the natural products MPSE and PGG.

We present a single center's experience of treatment outcomes and dosimetric parameters for breast cancer patients treated with hypofractionated Helical TomoTherapy (HT). This is a retrospective study of one hundred and thirty-six patients with invasive breast cancer treated between March 2012 and October 2016. Dosimetric parameters and 3-year loco-regional failure free survival (LRFFS) were analyzed. Dose to ipsilateral lung, heart and contralateral breast as well as acute and late toxicities were recorded. The median follow-up time is 45 months (range: 5-83). Two patients had loco-regional failure. The 3-year LRFFS was 99%. Acute grade 1 and 2 skin toxicities occurred in 95% and 1%, respectively. Coverage of the target volumes was achieved with the mean ± standard deviation (SD) of homogeneity and conformity index being 0.1 ± 0.04, and 0.8 ± 0.07, respectively. Dose to ipsilateral lung, contralateral breast, and heart was also within the limited constraints regardless of the complexity of target volumes. Only two percent of patients experienced late grade 2 skin toxicity. No late grade 2 subcutaneous tissue toxicity was found. Nine percent of patients developed late grade 1 lung toxicity. Hypofractionated radiotherapy using Helical TomoTherapy in breast irradiation provides excellent 3-year LRFFS and minimal acute and late toxicities. A careful, longer follow-up of healthy tissue effects to lung, heart, and contralateral breast is warranted.

Background: Overexpression of excision repair cross-complementing Group 1 (ERCC-1) is related to cisplatin resistance and defective repair of radiation damage. The purpose of this study was to evaluate the clinical significance of excision (ERCC-1) expression in nasopharyngeal cancer (NPC). Materials and Methods: We conducted a retrospective review of patients diagnosed with NPC between 2000 and 2013. The archived tissues were analyzed using immunohistochemistry to determine ERCC-1 expression. The ERCC-1 expression level along with other clinical factors and overall survival (OS) were analyzed. Hazard ratio (HR) with a 95% confidence interval was calculated to assess the risk. Results: The analysis of ERCC-1 expression was available in 262 NPC patients who had medical records at our hospital. Among those patients, 221 (84%) were treated with curative radiotherapy (RT)/concurrent chemoradiotherapy, 22 (7%) were treated with palliative RT alone, and 19 (9%) were given best supportive care. There was no correlation between ERCC-1 expression and stage of cancer or OS. No difference in 5-year OS was found between patients with low ERCC-1 expression and high ERCC-1 expression (38% vs. 36%; P = 0.981). The adjusted HR (aHR) of cancer death increased with cancer stage (aHR = 2.93 for advanced Stages III–IV; P = 0.001) and age (aHR = 2.11 for age >55; P ≤ 0.001). ERCC-1 expression exhibited no prognostic significance in our study (aHR = 1). Conclusion: In this study, ERCC-1 expression has no statistical significance to be considered a prognostic factor for OS among NPC patients. On the other hand, cancer stage, age, and types of treatment can be prognostic factors in NPC patients.

Purpose: Lung cancer is one of the most common cancers worldwide and in Thailand. We characterize and forecast region-specific patterns of lung cancer incidence by histology and sex. Methods: We analyzed lung cancer incidence trends in Thailand by histology (adenocarcinoma [AdC]; squamous cell carcinoma [SCC]; and large-cell, small-cell, and other carcinomas) from 1990 to 2014 in four cancer registries in three regions (north, Chiang Mai Province and Lampang Province; northeast: Khon Kaen Province; south: Songkhla Province). Annual percent change (APC) was calculated to quantify the incidence rate trends using joinpoint regression. Age-period-cohort models were used to examine the temporal trends of AdC and SCC by age, calendar year, and birth cohort. We projected the incidence of AdC and SCC up to 2030 using three independent approaches: joinpoint, age-period-cohort, and Nordpred models. Results: AdC incidence significantly increased from 1990 to 2012 in Chiang Mai males (APC, 1.3%), Songkhla males from 2004 to 2014 (APC, 2.5%), Songkhla females from 1990 to 2014 (APC, 5.9%), and Khon Kaen females from 2005 to 2014 (APC, 3.1%). Conversely, SCC incidence significantly decreased from 1990 to 2012 in Chiang Mai males and females (APC, −1.2% and −4.8%, respectively), Lampang males and females from 1993 to 2014 (APC, −5.4% and −5.2%, respectively), and Songkhla females from 1990 to 2014 (APC, −2.1%). In general, trends of AdC and SCC correlated more with birth cohort than with calendar year. Three projection models suggested that incidence rates of AdC in Songkhla may continue to increase until 2030. Conclusion: Temporal trends of lung cancer by histology varied among regions in Thailand. Reduction of lung cancer incidence in Thailand likely will require prevention strategies tailored to each specific region.

Background. Uterine malignancy coexistent with pelvic organ prolapse (POP) is uncommon and standardized treatment is not established. The objective of this case study was to highlight the management of endometrial cancer in association with pelvic organ prolapse. Case Report. An 87-year-old woman presented with POP Stage IV combined with endometrioid adenocarcinoma of the uterus: clinical Stage IV B. She had multiple medical conditions including stroke, deep vein thrombosis, and pulmonary embolism. She was treated with radiotherapy and pessary was placed. Conclusion. Genital prolapse with abnormal uterine bleeding requires proper evaluation and management. Concurrent adenocarcinoma and POP can be a difficult clinical situation to treat, and optimum management is controversial.

Inflammatory breast cancer (IBC) is a rare, aggressive form of breast cancer associated with HER2 amplification, with high risk of metastasis and an estimated median survival of 2.9 y. We performed an open-label, single-arm phase II clinical trial (ClinicalTrials.gov NCT01325428) to investigate the efficacy and safety of afatinib, an irreversible ErbB family inhibitor, alone and in combination with vinorelbine in patients with HER2-positive IBC. This trial included prospectively planned exome analysis before and after afatinib monotherapy.HER2-positive IBC patients received afatinib 40 mg daily until progression, and thereafter afatinib 40 mg daily and intravenous vinorelbine 25 mg/m2 weekly. The primary endpoint was clinical benefit; secondary endpoints were objective response (OR), duration of OR, and progression-free survival (PFS). Of 26 patients treated with afatinib monotherapy, clinical benefit was achieved in 9 patients (35%), 0 of 7 trastuzumab-treated patients and 9 of 19 trastuzumab-naïve patients. Following disease progression, 10 patients received afatinib plus vinorelbine, and clinical benefit was achieved in 2 of 4 trastuzumab-treated and 0 of 6 trastuzumab-naïve patients. All patients had treatment-related adverse events (AEs). Whole-exome sequencing of tumour biopsies taken before treatment and following disease progression on afatinib monotherapy was performed to assess the mutational landscape of IBC and evolutionary trajectories during therapy. Compared to a cohort of The Cancer Genome Atlas (TCGA) patients with HER2-positive non-IBC, HER2-positive IBC patients had significantly higher mutational and neoantigenic burden, more frequent gain-of-function TP53 mutations and a recurrent 11q13.5 amplification overlapping PAK1. Planned exploratory analysis revealed that trastuzumab-naïve patients with tumours harbouring somatic activation of PI3K/Akt signalling had significantly shorter PFS compared to those without (p = 0.03). High genomic concordance between biopsies taken before and following afatinib resistance was observed with stable clonal structures in non-responding tumours, and evidence of branched evolution in 8 of 9 tumours analysed. Recruitment to the trial was terminated early following the LUX-Breast 1 trial, which showed that afatinib combined with vinorelbine had similar PFS and OR rates to trastuzumab plus vinorelbine but shorter overall survival (OS), and was less tolerable. The main limitations of this study are that the results should be interpreted with caution given the relatively small patient cohort and the potential for tumour sampling bias between pre- and post-treatment tumour biopsies.Afatinib, with or without vinorelbine, showed activity in trastuzumab-naïve HER2-positive IBC patients in a planned subgroup analysis. HER2-positive IBC is characterized by frequent TP53 gain-of-function mutations and a high mutational burden. The high mutational load associated with HER2-positive IBC suggests a potential role for checkpoint inhibitor therapy in this disease.ClinicalTrials.gov NCT01325428.

Background: Changing anatomic and volumetric occur in nasopharyngeal cancer (NPC) patients during fractioned radiotherapy cause the delivered dose considerably different from the original plan. Objectives: The study purpose was to evaluate dose difference between original plan and planned adaptive software calculation during the course of radiotherapy in NPC patients treated with Tomotherapy HiArtTM system. Materials and methods: Three NPC patients treated with helical tomotherapy underwent daily positional correction using megavoltage CT imaging. Both parotid glands and spinal cord of patients were recontoured on daily MVCT images. MVCT images were used to recalculate dose distribution for all 33 fractions by planned adaptive software. The original plan dose and recalculate dose were compared. Results: Percent dose difference between original plan and planned adaptive dose of PTV70 (D95%), left and right parotid glands (D50%) were 1.74%±0.32%, 35.19%±12.67% and 24.60%±15.21%, respectively. The structure dose difference were statistically significant (p