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Objective: We aim to quantify the magnitude of setup errors in intensity-modulated radiotherapy (IMRT) treated Head and Neck cancer patients and recommend appropriate PTV margin. Methods: 60 patients with head and neck cancer required bilateral neck irradiation were planned and treated by simultaneous integrated boost IMRT technique either treated radically or postoperative. Patients undergoing image-guided radiotherapy (IGRT) each with once weekly scheduled cone beam computed tomography (CBCT). The 3D displacements, systematic and random errors were calculated. The appropriate PTV expansion was determined using Van Herk’s formula. Results: Mean 3D displacement was 0.16 cm in the vertical direction, 0.14 cm in the horizontal direction and 0.16 cm in the longitudinal direction. Conclusion: Use of weekly CBCT allows the planning target volume (PTV) expansion to be reduced according to our setup. The appropriate clinical target volume (CTV)-PTV margin for our institute is 0.30 cm, 0.38 cm, and 0.33 cm in the horizontal, vertical, and longitudinal directions, respectively.

Aim: To keep the cervical canal dilated after the fi rst high dose rate (HDR) brachytherapy fraction to avoid general anesthesia during subsequent applications.

Aim This study evaluated the survival outcome, pattern of failure and prognostic factors in cervix uteri cancer patients. Methods We reviewed the data of 60 patients with stages IB-IVA cancer who were treated between January 2004 and December 2010. Results Most patients (n = 50; 83%) had squamous cell carcinoma. Stage IIB was the most common presentation (n = 41; 68%). Forty-seven patients (78%) received Cisplatin concurrent with radiotherapy (CRT). The 2- and 4-year overall survival (OS) was 82% and 79%, respectively. Prolongation of the overall treatment time (OAT) for greater than 56 days, advanced stage and pretreatment hemoglobin (Hb) levels (

Purpose: To retrospectively compare the potential dosimetric advantages of a multichannel vaginal applicator vs. a single channel one in intracavitary vaginal high-dose-rate (HDR) brachytherapy after hysterectomy, and evaluate the dosimetric advantage of fractional re-planning. Material and methods: We randomly selected 12 patients with endometrial carcinoma, who received adjuvant vaginal cuff HDR brachytherapy using a multichannel applicator. For each brachytherapy fraction, two inverse treatment plans (for central channel and multichannel loadings) were performed and compared. The advantage of fractional re-planning was also investigated. Results: Dose-volume-histogram (DVH) analysis showed limited, but statistically significant difference (p = 0.007) regarding clinical-target-volume dose coverage between single and multichannel approaches. For the organs-at-risk rectum and bladder, the use of multichannel applicator demonstrated a noticeable dose reduction, when compared to single channel, but statistically significant for rectum only (p = 0.0001). For D 2cc of rectum, an average fractional dose of 6.1 ± 0.7 Gy resulted for single channel vs. 5.1 ± 0.6 Gy for multichannel. For D 2cc of bladder, an average fractional dose of 5 ± 0.9 Gy occurred for single channel vs. 4.9 ± 0.8 Gy for multichannel. The dosimetric benefit of fractional re-planning was demonstrated: DVH analysis showed large, but not statistically significant differences between first fraction plan and fractional re-planning, due to large inter-fraction variations for rectum and bladder positioning and filling. Conclusions: Vaginal HDR brachytherapy using a multichannel vaginal applicator and inverse planning provides dosimetric advantages over single channel cylinder, by reducing the dose to organs at risk without compromising the target volume coverage, but at the expense of an increased vaginal mucosa dose. Due to large inter-fraction dose variations, we recommend individual fraction treatment plan optimization. J Contemp Brachytherapy 2014; 6, 4: 362–370 DOI: 10.5114/jcb.2014.47816

Synovial sarcoma accounts for 5 to 10% of soft tissue sarcoma. It occurs mainly in young adults, where 90% of cases occur before 50 years. Over 80% of cases arise in deep soft tissue of extremities, especially around the joints [1]. Unusual sites (about 15%) have been reported, including head, neck and trunk where differential diagnosis is difficult and surgical treatment is complex due to proximity to vital structures. Here, we report a case of synovial sarcoma in an unusual site which is thyroid gland with special clinical, histopathological, immunohistochemical and molecular features.

Purpose: To retrospectively assess the incidence and magnitude of air pockets around vaginal cylinders and its impact on dose distribution in vaginal cuff image-guided high-dose-rate (HDR) brachytherapy. Material and methods: Fifty endometrial carcinoma patients treated by postoperative HDR vaginal cuff brachytherapy were included in the study. The average age of patients was 58.3 ± 11.8 years (range: 31-87 years). Brachytherapy was performed using cylindrical applicators, and the dose prescribed to 0.5 cm from the applicator’s surface, over a length of 5 cm from the applicator’s tip. Computed tomography (CT) simulation was used for each brachytherapy fraction. The incidence, vaginal mucosa displacement, volume, and dosimetric effect of air pockets around the vaginal cylinder were evaluated. Results: A total of 78 air pockets were found in 29/50 patients (58%) and 45/135 (33%) brachytherapy plans. They were located at the apex: 16/78 (20%) and lateral to the applicator: 62/78 (80%). The volume of air pockets ranged between 0.01 and 2.1 cm 3 (mean: 0.15 cm 3 ± 0.36 cm 3 ), and the maximum displacement of vaginal mucosa from cylinder surface was between 0.1 and 1.09 cm (mean: 0.34 cm ± 0.2 cm). The dose reduction to the vaginal mucosa generated by the air pockets ranged from 0.5 to 66% (mean: 26.4% ± 13.9%). Conclusions: The presence of air pockets around vaginal cylinder applicators is frequently noticed in post-operative vaginal cuff brachytherapy. The dose to the vaginal mucosa is reduced, as a result of displacement generated by air pockets. The effect on the clinical outcome of this dose reduction is yet to be determined. J Contemp Brachytherapy 2014; 6, 3: 271–275 DOI: 10.5114/jcb.2014.45436

Synovial sarcoma accounts for 5 to 10% of soft tissue sarcoma. It occurs mainly in young adults, where 90% of cases occur before 50 years.

Purpose To investigate the correlation between the dose predicted by the treatment planning system using digitally reconstructed radiographs or three-dimensional (3D)–reconstructed CT images and the dose measured by semiconductor detectors, under clinical conditions of high-dose-rate brachytherapy of the cervix uteri. Patients and methods Thirty-two intracavitary brachytherapy applications were performed for 12 patients with cancer of the cervix uteri. The prescribed dose to Point A was 7 Gy. Dose was calculated for both International Commissioning on Radiation Units and Measurements (ICRU) bladder and rectal points based on digitally reconstructed radiographs and for 3D CT images–based volumetric calculation of the bladder and rectum. In vivo diode dosimetry was performed for the bladder and rectum. Results The ICRU reference point and the volumes of 1, 2, and 5 cm3 received 3.6 ± 0.9, 5.6 ± 2.0, 5.1 ± 1.7, 4.3 ± 1.4 and 5.0 ± 1.2, 5.3 ± 1.3, 4.9 ± 1.1, and 4.2 ± 0.9 Gy for the bladder and rectum, respectively. The ratio of the 1 cm3 and the ICRU reference point dose to the diode dose was 1.8 ± 0.7 and 1.2 ± 0.5 for the bladder and 1.9 ± 0.6 and 1.7 ± 0.5 for the rectum, respectively. Conclusions 3D image–based dose calculation is the most accurate and reliable method to evaluate the dose given to critical organs. In vivo diode dosimetry is an important method of quality assurance, but clinical decisions should be made based on 3D-reconstructed CT image calculations.

AIM: Women in Saudi Arabia develop breast cancer at a young age with high prevalence of poor prognostic features. Because of such features, it is necessary to examine prognostic factors in this population. One such factor is the prognostic role of lymph node ratio (LNR). METHODS: We performed retrospective analyses of patients with invasive non-metastatic breast cancer who underwent axillary lymph node dissection and had one or more positive axillary lymph nodes. RESULTS: Two hundred and seventeen patients were considered eligible for the analysis. The median age was 46 years. At a median follow-up of 39.8 months, the median disease-free survival (DFS) was 67.3 months (95% CI, 50.4 to 84.3 months). Neither the classification of patients based on positive lymph node (pN) staging system, nor the absolute number of pN prognosticated DFS. Conversely, age 0.20 to 0.65) LNR categories were the only variables that were independently associated with adverse DFS. Using these variables in a prognostic model allowed the classification of patients into three distinctive risk strata. The overall survival (OS) in this series was 92.5 months (95% CI, 92.1-92.6). Only ER negative tumor adversely influenced OS. CONCLUSION: Analysis of survival outcome of mostly young patients with early breast cancer identified adverse prognostic variables affecting DFS. If the utility of the derived model including LNR is proven in a larger patient population, it may replace the use of absolute number of positive axillary lymph nodes

Myxofibrosarcoma is a common sarcoma in the extremities, but is rare in the head and neck region. Here, we report a case of 76 year old female patient in whom myxofibrosarcoma generated from the thyroid. The tumor was characterized by spindle cell proliferation with low to moderate cellular density in myxoid stroma. Immunohistochemically, the tumor cells showed positive reactivity for vimentin and actin, but negative staining for S-100, CK and desmin. Tumor cells showed low proliferative activity as demonstrates by low Ki-67 labelling index (5%). The tumor was diagnosed as a low-grade myxofibrosarcoma. Despite the suboptimal general conditions of the patient, yet, surgery was the sole treatment of her and was successfully done. Adjuvant radiotherapy was indicated due to close circumferential margin. Myxofibrosarcoma is a very rare tumor in the head and neck region, and morphology beside immunohistochemistry is powerful tools to establish the diagnosis. Surgery is the main line of treatment followed by adjuvant radiotherapy to improve patient's survival.

To report our early experience using the Intrabeam radiotherapy delivery system for intraoperative radiotherapy (IORT) in early breast cancer.This is a prospective phase 2 study carried out at the Department of Surgery and Radiology, King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia from December 2010 to November 2012. Females eligible for breast-conserving surgery with biopsy-proven invasive duct carcinoma, and with a mass of/=3.5 cm were included in this study. After wide local excision, sentinel lymph node dissection, and surgically positioning of the appropriately sized applicator on the tumor bed, a 20 Gray (Gy) single dose was prescribed using the Intrabeam x-ray generator. External beam radiotherapy (EBRT; 46 Gy/23 fractions/4.5 weeks) was given when the tumor was3 cm, with lymphovascular invasion, multifocal lesion, extensive intraductal carcinoma, and positive nodes. Early and late toxicity were recorded using the Radiation Therapy Oncology Group (RTOG) criteria.Forty-five patients were included with a median age of 54 (range: 27-79 years). Thirty-six cases (80%) had tumor3 cm in diameter, and 36 (67%) have pathologically negative axillary lymph node metastases. None of the patients developed delayed wound healing, postoperative infection requiring intravenous antibiotic, or breast seroma requiring aspiration. Sixteen (36%) received EBRT after IORT. Twelve patients developed radiologically proved fat necrosis.The IORT for early stage breast cancer patients using the Intrabeam delivery system was easily implemented in our center with an acceptable toxicity profile and cosmetic outcome.

To compare the inverse planning optimization based on total dose constraints versus conventional treatment plan (point A planning method) for cervical carcinoma, and evaluate the benefit of CT-based image-guided brachytherapy.We prospectively analyzed data of 10 consecutive patients with cervical cancer treated with external beam radiotherapy to the whole pelvis (45 Gy in 25 fractions) followed by high-dose-rate (HDR) brachytherapy (21 Gy in 3 fractions). For treatment planning of HDR brachytherapy, the basic equations of the linear-quadratic model were used to calculate the physical dose for each brachytherapy fraction needed to achieve a given total iso-effective dose for the whole treatment. Specific dosimetric parameters are evaluated for high risk (HR CTV), intermediate risk (IR CTV) clinical target volumes, and organs at risk (OARs).In conventional plans, the HR CTV was well covered in only 15/31, and the IR CTV in 7/31 of the brachytherapy implants, while dose constraints of OARs bladder and rectum were respected in 28/31 and 14/31 implants. After optimization, the HR CTV and IR CTV dose constraints were respected in all the implants, and the bladder and rectum of cases dose constraints were respected in 25/31 and 17/31 of cases.Point A is a poor surrogate of target dose. Significant differences between point doses and dose volume histogram parameters indicate the need for inverse planning in image-guided brachytherapy of cervical cancer.

To use electronic portal images (EPI) to clinically evaluate inter-fraction variations during tangential breast irradiation, using either a skin marks setup, or a bony anatomy setup, and to determine the required margins for simultaneously integrated boost (SIB) planning target volume (PTV).Ten patients undergoing radiotherapy to the entire breast with tangential fields, after breast conservation surgery were considered for this pilot prospective study in the Radiation Therapy Unit of King Abdulaziz University Hospital between February and September 2009. Patient setup was carried out either using skin marks or bony anatomy landmarks. The EPIs of the medial tangential radiation fields were performed daily; displacement of the EPI with respect to the digital reconstructed radiographs (DDRs) was quantified after manual registration with the corresponding DDRs and recorded in both antero-posterior (AP) and cranio-caudal (CC) directions. The inter-fraction variations were used to calculate required margins for SIB PTV.Considerable geometric uncertainties in patient positioning have been observed for both investigated treatment setup protocols. The margins required for a correct assessment of boost PTV were: 15.6 mm for AP and 15.4 mm for CC directions for the skin marks setup protocol, and 12 mm for AP and 12.2 mm for CC directions for the bony anatomy landmarks setup protocol.Systematic and random errors induced by inter-fraction patient setup variations are significant in tangential breast radiotherapy, and lead to a large PTV margin for SIB. Such large margins indicate the need for image-guided radiotherapy.

Women in Saudi Arabia develop breast cancer at a young age with high prevalence of poor prognostic features. Because of such features, it is necessary to examine prognostic factors in this population. One such factor is the prognostic role of lymph node ratio (LNR).We performed retrospective analyses of patients with invasive non-metastatic breast cancer who underwent axillary lymph node dissection and had one or more positive axillary lymph nodes.Two hundred and seventeen patients were considered eligible for the analysis. The median age was 46 years. At a median follow-up of 39.8 months, the median disease-free survival (DFS) was 67.3 months (95% CI, 50.4 to 84.3 months). Neither the classification of patients based on positive lymph node (pN) staging system, nor the absolute number of pN prognosticated DFS. Conversely, ageor= 35 years at diagnosis, grade 3 tumors and the intermediate (0.20 toor=0.65) and high (0.65) LNR categories were the only variables that were independently associated with adverse DFS. Using these variables in a prognostic model allowed the classification of patients into three distinctive risk strata. The overall survival (OS) in this series was 92.5 months (95% CI, 92.1-92.6). Only ER negative tumor adversely influenced OS.Analysis of survival outcome of mostly young patients with early breast cancer identified adverse prognostic variables affecting DFS. If the utility of the derived model including LNR is proven in a larger patient population, it may replace the use of absolute number of positive axillary lymph nodes.

sion, by quantitative reverse-transcription polymerase chain reaction (RT-PCR). Findings: The overall rate of MAGE-A3 expression was 41% (37% in Taiwan and 48% in Thailand, from 132 valid samples). MAGEA3 expression was lower in patients with HBV infection (33.3%) than in HCV-infected patients (63.0%). No difference in MAGEA3 expression was noted for the following factors: age, gender, liver cirrhosis, Child-Pugh class, chronic alcohol abuse, number and size of (largest) tumours. No clinical effects on survival were associated with MAGE-A3 expression in this HCC Asian population. The hazard ratio (HR) for the disease-free interval for MAGE-A3-positive versus MAGE-A3-negative patients was 1.06 (p = 0.82; HR adjusted for T stage, tumour number and size, cirrhosis, Child-Pugh score, and ECOG performance status was 1.40 [p = 0.29]). HRs for disease-free and overall survival were 1.03 (p = 0.91) and 0.97 (p = 0.94), respectively; adjusted HRs were 1.32 (p = 0.37) and 1.33 (p = 0.63). However, because of the small number of patients, no subset analysis by stage or other variables that affect disease-free and overall survival could be done. Interpretation: MAGE-A3 can be assessed by RT-PCR on surgically resected HCC. The overall expression rate is sufficient to consider MAGE-A3 a target for active immunotherapy. The relatively higher expression in HCV-infected patients has no explanation, so far. Clinical evaluation of MAGE-A3 antigen-specific cancer immunotherapeutics in early HCC after resection is being discussed. Funding: GlaxoSmithKline Biologicals. D.D., J.L., A.M., and P.T. are employed by GlaxoSmithKline.

bile tumor) and another one cholangitis complicated by sepsis (one Klatskin III tumor), so only 20 patients underwent HDR-192Ir-ILBT. One biliary brachytherapy catheter was used in 14 patients, two catheters in 6 patients. The dose delivered was 15 Gy in 3 patients, 20 Gy in 9 patients and 25 Gy in 8 patients with daily 500 cGy per fraction. During the brachytherapy procedure, cholangitis occurred in two patients. The median followup was 42 months (range 6e76 months). Two patients developed late toxicity (1 hemobilia, 1 hepatic abscess). Subsequent bouts of cholangitis occurred in 16 patients (72,7%, median 7 months) while stent occlusion (due to biliary sludge, tumor ingrown and overgrown) was observed in 12 patients (54,5%, median 13 months). Six-month and oneyear overall survival was 77% and 59%, with a median of 13 months; sixmonth and one-year local progression (tumor ingrown and overgrown) was 82% and 72% (median not reached).