Abstract Despite its scarcity, malignant tumor extending to the heart is a lethal condition. Cardiac metastases are considered to occur rarely. In the present paper, we represented a single-center experience in cardiac metastases diagnosis in addition to different treatment modalities for improving the patients’ quality of life and survival. We could claim that this is the largest report of this kind to date. We retrospectively reviewed the patients’ files in our hospital, from 2009 to 2022. These patients presented with radiological/ intraoperative evidence of intracardiac extension of malignant tumor. Seven patients with transvenous intracardiac tumor extension were referred to our center. There was primary tumor in the lung in four cases (57.14%), two with synovial sarcoma (14.3%), one with renal cell carcinoma with inferior vena cava extension to the right atrium, and one with osteosarcoma. Moreover, there was one case of thymic origin (14.3%). Four patients underwent urgent surgery upon diagnosis, in order to have higher quality of life, and R0 resection which was not possible in any of them (two patients had R1 and two had R2). Among them, one received palliative chemotherapy followed by chemoradiation after debulking surgery, one received concurrent chemoradiotherapy, one received palliative chemotherapy only, and one refused to get any treatment. Survival was better in the patients who received concurrent chemoradiotherapy. According to our results, urgent/unplanned surgery could not be a good candidate for intracardiac extension of malignant tumors and does not improve survival. Combined multidisciplinary approach, on the other hand, was found to be a better option for disease control. Keywords: Heart atria, Lung, Quality of life, Cytoreductive surgical procedures

Background

Colorectal cancer (CRC) ranks as the third most common cancer and the third most killing cancer worldwide [1]. The addition of oxaliplatin to fluorouracil (FOLFOX) or capecitabine (CAPOX) has become a fundamental component of chemotherapeutic regimens and chemoradiation in adjuvant treatment of CRC cancer. Excision repair cross-complementation group 1 (ERCC1) encodes an enzyme that is essential for the efficient repair of DNA damage induced by platinum compounds including Oxaliplatin.

Purpose

This study aims to investigate the role of ERCC1 as a predictive and prognostic marker in colorectal patients receiving oxaliplatin based chemotherapy and chemoradiation.

Patients and Methods

100 annotated stage III CRC patients were prepared as immunohistochemical (IHC) analysis of ERCC1 protein expression. All of the patients received oxaliplatin based chemotherapy.

Results

Analysis of data showed that high ERCC1 expression was significantly associated with early treatment failure and disease free survival among patient with stage III CRC.

Conclusion

High ERCC1 expression was an independent predictor factor of early treatment failure (P < 0.018) and associated with lower disease free survival (P = 0.004).

Background: Based on the special pattern of recurrence in the excision cavity, secondary computed tomography (CT) can be introduced after hypofractionated whole breast radiotherapy with early breast cancer, aiming for accurate delineation of tumor bed boost and reduced toxicity. This study aimed to assess the volumetric changes in the lumpectomy cavity before and after hypofractionated whole breast radiation therapy (WBRT) and related clinical factors.

Method:  This prospective study was designed and CT simulation was done for 45 patients from September 2019 to April 2020, two radiotherapy treatment planning were generated for each patient before and after hypofractionated WBRT. The tumor bed is defined using surgical clips, seroma, and postoperative alterations. Based on the original CT and tumor bed boost CT, statistically significant decrease was examined. The relationship between various factors and the volume decrease in the excision cavity was examined. 

Results: The median value of reduction in the excision cavity was 15.4 cm³ with the statistical significance (P < 0.001). In multivariate linear regression, the significant variable which predict the volume reduction was the presence of seroma (B = 24.48, confidence interval, 13.09 to 35.87, P < 0.001). 

Conclusion: our results suggested significant benefit from re-simulation before boost planning especially for patients with clinical evident seroma.

Keywords: Breast neoplasms, Radiation dose hypofractionation, Lumpectomy cavity, Radiotherapy

Abstract

Background: Repopulation of tumor cells during radiotherapy of transitional cell bladder carcinoma is believed to be a significant cause for treatment failure, and it was reported from clinical observations that the local control rate decreased with a prolonged treatment time, so accelerated hypofractionated radiotherapy with concurrent capecitabine may provide good local control in elderly patients unfit for surgery. The study aimed to evaluate the tolerability and efficacy of hypofractionated radiotherapy with capecitabine in elderly patients with urothelial carcinoma. Methods: Between October 2019 and September 2021, 30 patients with muscle-invasive bladder cancer staged T2-4aN0M0, underwent transurethral resection of bladder tumor followed by capecitabine (825 mg/m² orally, 2 times a day) and radiation therapy (55 Gy in 2.2 Gy per fraction). Results: Thirty patients with a median age of 73.5 years (range, 65-85) were included in our study. Most patients had T2N0, and T3N0 (28 patients), furthermore 73.3% had an intermediategrade tumor, Transurethral resection of bladder tumor was incomplete in 43.3. No grade 4 toxicity was documented. Grade 3 urinary toxicities occurred in two patients requiring hospitalization and temporal radiation cessation. Regarding late toxicities, no grade 3 or 4 toxicity was reported. A complete response was obtained in 56.7% of  patients. After a median follow-up of 16 months, the locoregional control rate was 63%. Overall survival, local failure-free survival, and event-free survival were 100%, 93.3%, 80% and 43.3%, 33.3%, 30% at one and two years respectively. Conclusion: Hypofractionated chemoradiation with capecitabine, appears to be an effective and well-tolerated curative treatment strategy in the selected elderly population with urothelial carcinoma.

Keywords: Bladder cancer- elderly- hypofractionation radiotherapy- capecitabine

Abstract:

Background: The current gold standard for adjuvant radiotherapy for breast cancer nowadays is hypofractionated radiotherapy. Measures for balancing both infectious and oncologic risk among patients and healthcare professionals must be carefully considered in the context of expected resource shortages and worldwide widespread community SARS-CoV-2 infection during the COVID- 19 pandemic. Here, we document the early and late skin toxicity and efficacy outcome of a prospective institutional phase III trial comparing a 1-week course of adjuvant breast radiotherapy to a 3-week regimen after surgical treatment for early breast cancer.

Methods: A phase III, randomized controlled trial is described here. Patients who underwent breast conserving surgery or a mastectomy and had invasive ductal or lobular breast cancer (pathological stagingT1-3, pN0-1, M0) were eligible if they were at least 18 years old. Sequential tumor bed boost radiotherapy (dose of 10 Gy/ 4 fractions and 5.2 Gy/ 1 fractions, respectively) is permitted in patients who have undergone breast conservative surgery and are younger than 50 years old and those of older age with high grade tumor or lymphovascular invasion. Patients were randomly assigned to receive 40 Gy/15 fractions (F)/3 weeks or 26 Gy/5 fractions (1 week). First endpoint evaluation of immediate and delayed effects on normal tissue and cosmetic results, Clinicians evaluated the impact on normal tissue using pictures, secondary endpoint estimation of two years LRR free survival, and two years disease free survival Results: At six weeks after the end of treatment, 65 patients in the control arm and 63 patients in the test arm were assessed for the most severe acute breast skin reactions. Grade 2 reactions, which were graded using CTCAE criteria (V4.03), were present in 47.7% of the control arm patients and 27% of the test arm patients, respectively.

Our study's assessment of the late effects on normal tissue after a median follow-up of 25 months, a range of 21 to 30 months, revealed that radiotherapy- related fibrosis, Telangiectasia, and hyperpigmentation were similar between the two groups (p>0.05), with fibrosis within the tumour bed being the most prevalent moderate or marked effect at 2 years, as occurred in 2 patients (3.1%) of 65 patients who received 40 Gy and 4 patients (6.3%) of 63 patients. Ultrahypofractionation resulted in incidence    of excellent or good cosmesis over fair or poor cosmesis of 87.3% versus 12.7%, and the control arm resulted in a rate of 87.7% versus 12.3%, which is statistically insignificant (p=0.9). Two-year LRR-free survival was 96.9% in the control group and 98.4% in the ultrahypofractionation group, both of which were statistically insignificant. Of the two patients with LRR (3.1%) in the control arm and one (1.6%) patient in the ultrahypofractioation group, respectively, the disease-free survival rate was 95.3% in the control arm and 95.2% in the ultrahypofractioation arm.

Conclusion: 26 Gy in 5.2 Gy per fraction daily over 1 week is equal to 40.05 Gy in 2.67 Gy per fraction daily over 3 weeks for patients received adjuvant radiotherapy after surgical resection for early-stage breast cancer as regard normal tissue effects up to 2 years and for local tumor control and to confirm study result need longer follow up.

Keywords: Breast cancer, Ultrahypofractionation, Radiotherapy.

Abstract :

Background: For endometrial carcinoma, the main surgical treatment is total hysterectomy and bilateral salpingo -oophorectomy. Women with high-risk endometrial cancer have a relatively higher recurrence rates and poor prognosis  following  hysterectomy alone. Therefore, pelvic external beam radiotherapy has bee n the standard adjuvant treatment for these patients. This is a prospective study on patients with high-risk endometrial cancer evaluating the benefit of adding concurrent weekly paclitaxel with adjuvant radiotherapy, versus radiotherapy alone. 

Methods: Eligible patients were randomized to Arm A; Concurrent chemotherapy with radiotherapy [CCRT], and Arm B; External beam pelvic radiotherapy alone [RTH]. Pelvic radiotherapy was 50.4Gy over 28 fractions, and chemotherapy course was weekly paclitaxel (50mg/m2) for 5 weeks. Patients were evaluated for treatment related toxicities, disease failures and survival.  

Results: Seventy-one patients met the eligibility criteria of study protocol; 34 patients received CCRT; and 37 patients received RTH alone. The median age at time of diagnosis is 66 years. Regarding to tumor staging; 47% were Stage Ib, and other patients were stage II or III. Grade 3 toxicity were more in CCRT arm, and no grade 4 toxicity were recorded. The most common events were diarrhea and hematological affection. No significant difference in acute toxicities between treatment groups; except for hematological affection with concurrent paclitaxel [p=0.025]. Ten patients [14%] had a treatment failure; treatment failures are more in RTH group, but without statistical significance [p-value =0.51]. Estimated 2-years OS was around 86% with no statistical significance between both treatment arms [p-value = 0.83], and estimated 2-years DFS was; 83.2% for CCRT arm and 77.1% for RTH arm, with no statistical significance [p-value = 0.48]. 

Conclusion: Adding concurrent paclitaxel to pelvic radiotherapy in high-risk endometrial cancer patient is safe and tolerable, and tends to decrease treatment failures, even though this not translated to OS nor DFS improvement.

Keyword: Endometrial Carcinoma; Radiotherapy; Concurrent Chemotherapy

Background: Post-operative chest wall irradiation improves local control &  survival with higher techniques (conformal & intensity modulated) are  recommended in left side. These techniques involve mastectomy bed Clinical  Target Volume (CTV) delineation which varied clearly among guidelines especially for the lateral margin with subsequent possible effects on dose  received by lung & heart (in left sided cases). Aim of work: Comparison  between American & European guidelines to a more anatomical (from our point of view) method using wire following anatomical lines regarding post left mastectomy chest wall CTV volume & doses received by the heart & left lung. Methodology: One oncologist had delineated 10 cases referred for radiation therapy of the chest wall & peripheral lymphatics following left modified radical mastectomy. He delineated every case according to Radiation Therapy Oncology Group (RTOG), European Society of Therapeutic Radiology and Oncology (ESTRO) & according to an anatomically set wire during scanning. Plans were set for each delineation by an expert radiation physicist. Results of the 3 plans were compared regarding coverage, homogeneity of CTV & doses to risk organs.

Results: The three CTVs were well covered & homogeneously treated. Statistically significant less left lung  V20Gy & V30Gy for anatomical wire based delineation (16.0 +/- 4.1% &12.75 +/- 2% respectively) compared to  ESTRO (19.1 +/- 1.73 & 15.2 +/- 5.1 respectively) & RTOG (18.22 + 1.6 & 14.52 + 5.3 respectively), p=0.001 for V20Gy & 0.01 for V30Gy. Cardiac D50% was statistically significantly lower (101.6 + 41.2cGy) vs (141 +/- 81cGy & 132 +/- 93 cGy, p= 0-00001) for ESTRO & RTOG respectively. Conclusion: Delineation of left mastectomy chest wall CTV based on anatomical landmarks guided by wire set during patient scanning may reduce cardiac & pulmonary doses compared to ESTRO & RTOG. Clinical follow up of cases treated based on this delineation is highly recommended specially to evaluate local recurrence.

Key words: Left breast cancer, Conformal radiotherapy, delineation lateral border.

Abstract

Background: measuring the extent to which the breast setup error contributed to the total delivered dose discrepancies in all patients treated with Volumetric modulated arc therapy (VMAT) both in deep inspiration breath-hold technique (DIBH) and free breathing (FB) and to compare the dosimetric stability of each technique. Methods: the dose distribution parameters of the mean of 90 cone-beam computer tomographies (CBCTs) reshaped by deformable image registration (DIR) compared to the mean of their reference plan (RP) in left (Lt) sided breast cancer (BC) patients treated with adjuvant loco-regional radiation. 50 CBCTs in the first group treated in DIBHT and 40 CBCTs in the second group treated in FB compared also to the mean of their RP. Deviations in the delivered from the planned dose distributions have been analyzed. The average of this difference has been calculated for all cases and in each group of patients.

Results: 1% reduction in PTV-total D95% caused by -4% decrease in the PTV-supraclavicular (supra). 13% and 3% increase in Dmean of heart and Lt lung, respectively. 8% and 6% increase in spinal cord Dmax and right (Rt) breast D2%, respectively. The difference between both techniques was significant in heart with its sub-volume, Rt breast and spinal cord.

Conclusions: The dosimetric impacts of breast setup errors during Lt BC loco-regional radiation by VMAT technique using DIR was significant for the heart with its sub-volume in the FB group only.

Keywords CBCT, VMAT, Breast setup error, deformable image registration

Background: CD44, a cell hyaluronic acid transmembrane glycoprotein implicated in cell growth, differentiation, survival as well as the metastatic behavior of some cancer cells. Its expression is upregulated in subpopulations of cancer cells and is identified as a molecular marker for cancer stem cells (CSC). Methodology: This retrospective study investigated CD44 immunoreactivity in 85 cancer colon patient’s specimens at diagnosis obtained from the pathology department, South Egypt Cancer Institute. All specimens were stained by Anti CD44 antibody. Patients were followed up for 3 years. Aim: The study aims at inspecting CD44 immunoreactivity in the epithelium of colorectal cancer specimens and at detecting its association with the patients’ survival function by calculating disease free survival and overall survival of patients.

Results: In our current study there was a statistically significant association between low epithelial expression of CD44 marker (H score≤ 150) and 3-year OS (p= 0.009) as well as a statistically significant association between low CD44 epithelial expression and 2-year DFS (P= 0.041). In multivariate analysis the high epithelial expression of CD44 is the only independent factor for early recurrence (HR: 9.393, P= 0.031) concluding that high epithelial expression of CD44 is a bad prognostic factor and the likelihood of death is 9 times more with CD44 overexpression.

Conclusion: CD44 positivity in non-metastatic colorectal cancer specimens at diagnosis is associated with worse overall survival of patients and more likelihood of progression or death.