[en] Purpose: A retrospective study was performed to investigate the relationship between spontaneous apoptosis and angiogenesis uterine cervix squamous cell carcinoma patients. The prognostic value of each (and both) of these biologic parameters was also tested. Methods and Materials: The pathologic materials of 40 cervical uteri squamous cell carcinoma patients were examined and immunohistochemically stained to determine the tumor angiogenesis (tumor microvascular score), using factor VIII-related antigen, and their tumor apoptotic index (AI), using the TdT-mediated dUTP nick end-labeling (TUNEL) method. Three patients were Stage I, 18 were Stage II, 15 were Stage III, and 4 were Stage IV (FIGO classification). All patients were treated with radical radiotherapy and all had follow-up for more than 2 years. Results: The mean AI was 15.1 ± 12.8, with a median of 8.3. The mean tumor microvascular score was 3 9.7 ± 14.4, with a median of 3 8. The patients' age and tumor grade did not seem to significantly affect the prognosis. On the other hand, AI and angiogenesis (tumor microvascular score) were of high prognostic significance. The 3-year disease-free survival (DFS) rate for the patients having AI above the median was 78% (confidence interval [CI] 69-87%), compared to 32% (CI 22-42%) for those having AI below the median. The DFS was 18% (CI 9-27%) for patients having an angiogenesis score above the median, while it was 86% (CI 78-94%) for those patients having a score below the median. Conclusion: Determination of both tumor microvascular score and AI can identify patients with the best prognosis of 100% DFS (with low angiogenesis score and high AI). Women with a high score and low AI had the worst prognosis (DFS = 3%, CI 1-5%). Moreover, high AI can compensate partially for the aggressive behavior of tumors showing a high rate of angiogenesis.

[en] The improvement in conformal radiotherapy techniques enables us to achieve steep dose gradients around the target which allows the delivery of higher doses to a tumor volume while maintaining the sparing of surrounding normal tissue. One of the reasons for this improvement was the implementation of intensity-modulated radio therapy (IMRT) by using linear accelerators fitted with multi-leaf collimator (MLC), Tomo therapy and Rapid arc. In this situation, verification of patient set-up and evaluation of internal organ motion just prior to radiation delivery become important. To this end, several volumetric image-guided techniques have been developed for patient localization, such as Siemens OPTIVUE/MVCB and MVision megavoltage cone beam CT (MV-CBCT) system. Quality assurance for MV-CBCT is important to insure that the performance of the Electronic portal image device (EPID) and MV-CBCT is suitable for the required treatment accuracy. In this work, the commissioning and clinical implementation of the OPTIVUE/MVCB system was presented. The geometry and gain calibration procedures for the system were described. The image quality characteristics of the OPTIVUE/MVCB system were measured and assessed qualitatively and quantitatively, including the image noise and uniformity, low-contrast resolution, and spatial resolution. The image reconstruction and registration software were evaluated. Dose at isocenter from CBCT and the EPID were evaluated using ionization chamber and thermo-luminescent dosimeters; then compared with that calculated by the treatment planning system (TPS- XiO 4.4). The results showed that there are no offsets greater than 1 mm in the flat panel alignment in the lateral and longitudinal direction over 18 months of the study. The image quality tests showed that the image noise and uniformity were within the acceptable range, and that a 2 cm large object with 1% electron density contrast can be detected with the OPTIVUE/MVCB system with 5 monitor units (MU) protocol. The registration software was accurate within 2 mm in the anterior-posterior, left-right, and superior-inferior directions. The additional dose to the patient from MV-CBCT study set with 5 MU at the isocenter of the treatment plan was 5 cGy. For Electronic portal image device (EPID) verification using two orthogonal images with 2 MU per image the additional dose to the patient was 3.8 cGy. These measured dose values were matched with that calculated by the TPS-XiO, where the calculated doses were 5.2 cGy and 3.9 cGy for MVCT and EPID respectively. (author)

[en] Access to radiation facilities in low- and middle-income countries (LMIC) is far from optimal. Latin America and Africa represent 55% of LMIC, and radiation therapy facilities are available in only 70% and 46% of the countries, respectively. Only 3 countries in both regions meet the International Atomic Energy Agency's recommendation of 250,000 population per megavoltage machine (MVM). In Africa, the mean population served by 1 MVM is 3.56 million, compared with 0.65 million in Latin America. The distribution of radiation facilities in both regions varies according to income group. In Latin America, lower-middle-income countries have a distribution of 1.64 million inhabitants per MVM, as opposed to 0.64 and 0.49 million inhabitants per MVM in upper-middle- and high-income countries, respectively. In Africa, a distribution of 39.8, 2.47, and 0.8 million people per MVM is present in low-, lower-middle-, and upper-middle-income countries, respectively. Significant correlations were clearly demonstrated between population per MVM and gross domestic product (GDP) per capita (r = −0.3, P = .014), percentage of current health expenditure from GDP (r = −0.4, P = .014), life expectancy (r = −0.5, P = .0007), and cancer mortality incidence ratio (r = 0.4, P = .003). Stepwise multivariate regression showed that life expectancy was the only statistically significant factor (P = .001). These findings may indicate the detrimental impact of low radiation therapy coverage on life expectancy and cancer mortality incidence ratio in LMIC. It is noteworthy that in Latin America, a significant negative correlation was noted between population per MVM and GDP per capita (r = −0.6, P = .0004), as opposed to Africa (r = −0.4, P = .075). This indicates that African countries face challenges other than income level in addressing radiation therapy needs. More international efforts are urgently required to address the crisis of unmet radiation therapy needs in LMIC.

[en] Highlights: • One-third of pediatric tumor patients require radiotherapy. • High pediatric radiotherapy utilization rate in a middle-income country. • Pediatric soft tissue sarcoma requires the highest radiotherapy utilization rate. • Palliative radiotherapy is frequently used for brainstem glioma patients. • Palliative radiotherapy is underutilized in childhood cancers. Although the radiotherapy utilization rate (RUR) is determined for most adult cancers, it is seldom reported in childhood tumors, particularly in low- and middle-income countries (LMIC) where the majority of pediatric cancer patients reside. This study aims to investigate the real-life RUR for pediatric tumors in a large LMIC center.

[en] Background: The pediatric diffuse intrinsic pontine glioma (DIPG) outcome remains dismal despite multiple therapeutic attempts. Purpose: To compare the results of treatment of pediatric diffuse intrinsic pontine glioma (DIPG) using hypofractionated versus conventional radiotherapy. Patients and methods: Seventy-one newly diagnosed DIPG children were randomized into hypofractionated (HF) (39 Gy/13 fractions in 2.6 weeks) and conventional (CF) arm (54 Gy/30 fractions in 6 weeks). Results: The median and one-year overall survival (OS) was 7.8 months and 36.4 ± 8.2% for the hypofractionated arm, and 9.5 and 26.2 ± 7.4% for the conventional arm respectively. The 18-month OS difference was 2.2%. The OS hazard ratio (HR) was 1.14 (95% CI: 0.70–1.89) (p = 0.59). The hypofractionated arm had a median and one-year progression-free survival (PFS) of 6.6 months and 22.5 ± 7.1%, compared to 7.3 and 17.9 ± 7.1% for the conventional arm. The PFS HR was 1.10 (95% CI: 0.67–1.90) (p = 0.71). The 18-month PFS difference was 1.1%. These differences exceed the non-inferiority margin. The immediate and delayed side effects were not different in the 2 arms. Conclusions: Hypofractionated radiotherapy offers lesser burden on the patients, their families and the treating departments, with nearly comparable results to conventional fractionation, though not fulfilling the non-inferiority assumption