Intimate partner violence after cancer diagnosis: an SOS call.

PURPOSE: The aim of the present study was to measure the frequency and types of IPV among patients with cancer and evaluate risk factors. METHODS: The study was a cross-sectional, questionnaire-based study, conducted between January and April 2022, including 141 patients treated with cancer regardless of gender, site, or stage. We developed the study questionnaire by adapting items from the "WHO multi-country questionnaire on violence against women" and "The Women's Experiences with Battering Scale." Odds ratio (OR) and spearman tests were performed to assess the impact of several factors associated with the reported IPV. RESULTS: Median age was 50 years old, 38.3% were male cancer patients. IPV prevalence was 24.8%, we observed 5 cases of torture (3%). The most common forms of violence were placing severe restriction on certain types of food and clothing in 21%, psychological violence in 20%, exposing intimate information about the patient health status to others in 17%, ignoration in 13.5%, putting restrictions on visiting friends or families in 9.2%, verbal assault in 9.2%, physical violence in 7.9%, and 7.1% racist conducts. Financial violence was rare in 4.3%. There was no difference in the incidence of IPV between man and women. We observed a significant correlation between IPV prevalence and disease stage (19.1% M0 vs 34.6% M1, p=0.04, OR=2.2 [1-4.8]), patient's educational level (48.5% vs 17.6%, p=0.01, OR= 4.4 [1.8-10.2]), and being under ongoing cancer therapy (11.4% vs 30.9%, p=0.013, OR=3.4 [1.2-9.7]) CONCLUSION: Patients were shown to be victims of several forms of IPV regardless of gender.

Hypofractionated radiotherapy after breast-conserving surgery: Clinical and dosimetric factors predictive of acute skin toxicity.

PURPOSE: The purpose of this study was to evaluate acute skin toxicity in early breast cancer patients treated with hypofractionated radiotherapy (HFRT) after breast-conserving surgery and to identify factors predictive for grade ≥ 2 acute skin toxicity. MATERIALS AND METHODS: A monocentric retrospective study was carried out using cases treated between December 2017 and November 2020. We analyzed data from 202 patients with early breast cancer treated with 3D hypofractionated RT (40.05 Gy in 15 fractions) to the whole breast with or without regional lymph nodes, followed by 13.35 Gy in 5 fractions to the tumor bed. Acute skin toxicity was monitored during RT according to CTCAE (common toxicity criteria for adverse events) scale. Univariate and multivariate analyses were performed to assess predictive factors of acute skin toxicity. RESULTS: Overall, there was no erythema in 9%, grade 1 erythema in 64.5%, grade 2 in 24%, and grade 3 in 2.5%. No grade 4 erythema was seen. Median delay between RT initiating and maximum skin reaction was 22 days (range 4-44 days). No patient interrupted treatment. In univariate analysis, the rate of acute skin toxicity grade 2---3 (G2-3) was significantly higher for patients with larger tumor size (p = 0.02), body mass index > 27 (p = 0.04), and time between chemotherapy (CT) and RT less than 20 days (p = 0.01). Dosimetric risk factors for acute skin toxicity G2­3 were breast volume > 800 cc (p = 0.000), boost volume > 18 cc (p = 0.002), V105% > 40 cc (p = 0.03), and Dmax > 56 Gy (p = 0.007). CT, trastuzumab, regional lymph node radiation, and age were not correlated with increased skin toxicity. In multivariate analysis, acute skin toxicity correlated with T stage (p = 0.032), breast volume > 800 cc (p = 0.012), boost volume > 18 cc (p = 0.04), and Dmax > 56 Gy (p = 0.035). CONCLUSION: Our results confirm that whole breast with or without lymph nodes hypofractionated RT is safe and well tolerated. The factors strongly associated with a decreased risk of G2­3 skin toxicity are T1, breast volume < 800 c, boost volume < 18 cc, and Dmax < 56 Gy. Long-term follow-up is needed to evaluate late toxicity.

Concurrent Chemoradiotherapy as an Adjuvant Treatment of Primary Central Nervous System Neuroblastoma.

Primary central nervous system neuroblastoma is a rare malignant embryonal tumor. With only few cases reported in the literature, data on regardingthe diagnosis and management of these tumors are limited. We reported a case of primary cerebral neuroblastoma in a 20-year-old woman complaining of progressive headaches. The patient underwent subtotal tumor resection and adjuvant concurrent chemoradiotherapy. The prescription dose was 54 Gy. She remained free of recurrence for 14 months after the end of radiotherapy treatment.

Understanding COVID-19 vaccine hesitancy and resistance: another challenge in cancer patients.

INTRODUCTION: We aimed to measure the acceptability towards the COVID-19 vaccination in cancer patients and to investigate determinant factors associated with the patient's choice. METHODS: We conducted a cross-sectional survey with a self-administered questionnaire delivered to 329 cancer patients in 3 oncology cancer centers in Tunisia between February-May 2021. Logistic regression was used to evaluate odds ratio predicting patient's intentions toward the vaccine. RESULTS: Acceptance rate was 50.5%, 28.3% (n = 93) reported to definitely refuse the vaccine and 21.2% (n = 70) did not make their decision yet. High educational level, history of comorbidities, history of influenza vaccination in the current season, and patient's opinion about the severity of COVID-19 did not predict vaccine resistance. However, patients who think that the vaccine may interfere with treatment efficacy (OR = 7.28, 95%CI [2.5-12.32]), or may impact cancer outcome (OR = 6.14, 95%CI [2.27-16.7]), were significantly more likely to refuse the vaccine. Patients who disagree that the vaccine is a major weapon against the pandemic (OR = 6.07, 95%CI [2.34-9.52]) or that it could reduce the virus transmission (OR = 7.34, 95%CI [4.22-11.81]) were also significantly more likely to reject the vaccination. Safety concerns were also significant predictive factors (OR = 7.9, 95%CI [4.10-11.27]. Confidence level in the authorities played a significant role in patient's acceptance of the vaccine, indeed patients who are not registered (OR = 5.9, 95%CI [1.58-8.7]) or not informed about the Tunisian national vaccination platform EVAX (OR = 5.51, 95%CI [2.1-7.9]) were more likely to be against the vaccine. CONCLUSION: Cancer patient's education about the impact of the vaccine on their disease and on the COVID-19 is needed. Governments should build strategies to gain more population confidence.

Survival and prognostic factors in adult medulloblastoma: the Salah Azaiz Institute experience.

BACKGROUND: Medulloblastoma is the most common malignant brain tumor in children. This entity in adulthood is rare. The aim of our study is to evaluate therapeutic results and prognostic factors of adult medulloblastoma treated at our institute with post-operative radiotherapy. METHODS: We retrospectively reviewed a cohort of 55 patients with medulloblastoma who underwent radiation in the department of radiation oncology of institute Salah Azaiz (Tunis) over a 18-year period (1994-2012). RESULTS: The surgery was total or subtotal resection in 73% of cases. Forty-eight patients received radiotherapy to the entire craniospinal axis as part of the curative treatment. The median interval from surgery to the initiation of radiotherapy was 83 days. Etoposide-cisplatin chemotherapy was only performed in metastatic patients (n = 4). The 5-years and 10-years overall survival rates were respectively 53 and 34%. The dose of radiotherapy to the craniospinal axis was a prognostic factor. The 5-years and 10-years event-free-survival rates were 64 and 41%. Reduction in the dose of radiotherapy to the craniospinal axis and fourth ventricular floor involvement were correlated with a worse event-free survival. CONCLUSION: Our results, compared to those of the literature, conclude that the reduction in the dose of radiotherapy to the craniospinal axis (<34 Gy) in the standard risk group of adult medulloblastoma could not be done without chemotherapy. In the high-risk group of adult medulloblastoma, radiotherapy to the cerebrospinal axis at the dose of 36 Gy with chemotherapy, is required for disease control.

Management of patients with cardiac implantable electronic devices (CIED) undergoing radiotherapy: A consensus document from the Tunisian Society of Oncology Radiotherapy and the Tunisian Society of Cardiology and Cardiovascular Surgery.

In patients with cardiac implantable electronic devices CIEDs, including cardiac pacemakers (PM) and implantable cardioverter-defibrillators (ICD), radiotherapy (RT) could compromise CIED function. Managing radiotherapy patients with CIED, has been a great practical and procedural challenge in radiotherapy and requires a structured multidisciplinary approach. A consensus document is presented as a result of a multidisciplinary working group involving cardiac electrophysiologists, Radiation Oncologists and Medical physicists. It aims to propose recommendations on risk stratification, management approach before, during and after radiation treatment/course of patients with CIED.

Cancer care and COVID-19: tailoring recommendations for the African radiation oncology context.

Africa is the second most populous continent after Asia comprising 54 countries. Given the healthcare system deficiencies in Africa, the impact of the COVID-19 pandemic was expected to be disastrous. The first case of COVID-19 on the continent was reported in Egypt on 14 February 2020. By 13 May, cases had been reported in all 54 countries. Several practice guidelines specific to radiation oncology departments have been published, including prioritisation criteria for postponing radiotherapy, continuation of treatment, hypofractionation or even omitting radiotherapy. The oncology community in Africa has suddenly needed to protect both patients and caregivers and to ensure continuity of essential clinical services despite several challenges. Considering equipment unavailability, lack of human resources and poor infrastructure, tailoring COVID-19 pandemic management to the African context seems mandatory and a unified approach to guideline development in this context is encouraged. In this article, we discuss contextual issues coming into play, highlighting steps to be taken by radiotherapy centres in Africa to mitigate fallouts from the current pandemic to ensure the safety of our patients and staff as well as the impact on future care.

Once-a-day fractionated total-body irradiation: A regimen tailored to local logistics in allogeneic stem cell transplantation for acute lymphoblastic leukemia.

AIM: The objective of the study was to estimate the cumulative incidence (CI) of relapse, relapse-free survival (RFS) and overall survival (OS) in ALL patients after a once-a-day fractionated TBI (F-TBI) regimen with 9.9 Gy. The secondary objectives were evaluation of short and long-term toxicity and non-relapse mortality (NRM). BACKGROUND: Total body irradiation (TBI), as a part of the conditioning regimen before allogeneic stem cell transplantation (ASCT) for acute lymphoblastic leukemia (ALL), allows disease control by eradicating residual blast cells in the transplant recipient. MATERIALS AND METHODS: Retrospective study conducted in patients with ALL who received between March 2003 and December 2013 a conditioning regimen with F-TBI and chemotherapy. Irradiation was delivered with 3.3 Gy once-a-day for three consecutive days. RESULTS: Eighty-seven patients were included. The median age was 19 years (range: 5-49 years). The 3-year CI of relapse was 30%. The estimated 3-year RFS and OS were 54% and 58%, respectively. Cumulative incidence of acute graft-versus-host disease (aGVHD) grade II-IV and chronic GVHD (cGVHD) was 31% and 40%, respectively. Interstitial pneumonitis was observed in 2 patients. The 3-year CI of NRM was 16%. In multivariate analysis, cGVHD was associated with a lower CI of relapse (RR = 0.26, 95% CI: 0.07-0.95, p = 0.04). High-risk cytogenetics was associated with a lower RFS (RR = 2, 95 CI: 1.04-3.84, p = 0.03). Grade II-IV aGVHD was an independent predictor of higher CI of NRM (RR = 6.7, 95% CI: 1.4-31.7, p = 0.02). CONCLUSIONS: Once-a-day F-TBI regimen is effective, safe and practical in patients who underwent ASCT for ALL.

Synergistic Effect and Tolerance of Concurrent Radiotherapy and Lenalidomide Use in Relapsing Mantle Cell Lymphoma: A Case Report.

INTRODUCTION: Mantle cell lymphoma is an aggressive disease. Limited treatment options are available for refractory or relapsing presentation. We report the first case, to the best of our knowledge, of concurrent radiotherapy and lenalidomide use in this setting, focusing on its possible synergy and tolerance. CASE PRESENTATION: A 76-year-old man with a history of mantle cell lymphoma presented with ptosis of the left eyelid, eyelid swelling, and nasal obstruction. Results of positron emission tomography-computed tomography revealed a pathologic fluorodeoxyglucose uptake at the pharynx and left eyelid. He received treatment with ibrutinib, which was stopped 3 months later because of digestive toxic effects. Radiotherapy for the eyelid and pharynx was performed at a dose of 18 Gy, with concurrent lenalidomide administration. Evaluation 3 months later revealed complete disappearance of the 2 relapse sites. DISCUSSION: This case highlights the role of concomitant lenalidomide treatment and low-dose radiotherapy in patients with relapsing mantle cell lymphoma. Use of this combination treatment has achieved a complete local control with a safe toxicity profile. The case also illustrates the possible lenalidomide-induced radio sensitization.

HPV16 E2 variants correlated with radiotherapy treatment and biological significance in cervical cell carcinoma.

Specific genetic mutations in human papillomavirus type 16 (HPV16) DNA are considered important in cervical lesion progression. This study analyzes to what extent radiotherapy treatment contributes to viral DNA mutation in cervical cell carcinomas, and the biological significance of these mutations. Serial tumor tissue, including 44 cervical cancer samples, collected before and after radiotherapy, and 52 biopsies with benign cervices, were tested and analyzed for the presence of HPV16, and for the integrity of the E2 gene. Analysis was performed with polymerase chain reaction (PCR), and a bidirectional sequencing assay was performed to find HPV16 E2 gene variants. HPV16 E2 accounted for 81.8% and 37.5% among tumor and benign cervices respectively (p = 0.02). The incremental number of DNA mutations was associated with radiotherapy treatment. Most E2 gene mutations involved regions encoding the amino-terminal and carboxy-terminal regions of E2 in the tumor irradiated samples. Amino acid changes T135 K, A143T, N203D and P208A in the amino-terminal region were the most common mutations across the irradiated samples. Rather, the mutations in the carboxy-terminal region (T3694A and T3805G) were synonymous changes. Specific nucleotide deletions were detected in the hinge domain, at positions 3455A > -, 3466 T > -, and 3501A > -. The mutation degree is influenced by the irradiation modalities, interestingly E2 sequence mutation being found widely after radiotherapy treatment with a total fractioned dose of 50 Gy (p = 0.004). E2 mutation has predictive and biological significance in cervical cancer patients receiving curative radiation therapy. Possibly, E2 mutation could influence viral genome intactness and could serve as an intrinsic marker for cervical cancer.

Radiotherapy utilization in developing countries: An IAEA study.

BACKGROUND: The planning of national radiotherapy (RT) services requires a thorough knowledge of the country's cancer epidemiology profile, the radiotherapy utilization (RTU) rates and a future projection of these data. Previous studies have established RTU rates in high-income countries. METHODS: Optimal RTU (oRTU) rates were determined for nine middle-income countries, following the epidemiological evidence-based method. The actual RTU (aRTU) rates were calculated dividing the total number of new notifiable cancer patients treated with radiotherapy in 2012 by the total number of cancer patients diagnosed in the same year in each country. An analysis of the characteristics of patients and treatments in a series of 300 consecutive radiotherapy patients shed light on the particular patient and treatments profile in the participating countries. RESULTS: The median oRTU rate for the group of nine countries was 52% (47-56%). The median aRTU rate for the nine countries was 28% (9-46%). These results show that the real proportion of cancer patients receiving RT is lower than the optimal RTU with a rate difference between 10-42.7%. The median percent-unmet need was 47% (18-82.3%). CONCLUSIONS: The optimal RTU rate in middle-income countries did not differ significantly from that previously found in high-income countries. The actual RTU rates were consistently lower than the optimal, in particular in countries with limited resources and a large population.

Rare Case of a Well-Differentiated Paratesticular Sarcoma of the Spermatic Cord in a 60-Year-Old Patient.

Introduction. Liposarcomas are tumors that occur mostly in the retroperitoneum. Of all liposarcomas only 3 to 7% are found in the paratesticular region. The spermatic cord is the main site of origin in these cases. The patients ages range from 50 to 60 years. This malignant disease can result in a loss of fertility aside from life-threatening sequelae. Case. We present a case of a liposarcoma of the paratesticular region. A 60-year-old man was referred with a painless mass in the scrotum and the right inguinal region. The patient underwent surgery and the mass was removed along with the right testis, the spermatic cord, and the soft tissues to the internal inguinal ring. Histopathological examination found a well-differentiated liposarcoma of 80⁎80 mm. The surgical margins were negative. The adjuvant treatment consisted in radiation therapy of the right inguinoscrotal area to the dose of 54 Gray, 2 Gy per session, 5 times a week. Conclusion. Paratesticular liposarcomas are rare tumors. Surgery with large margin resections was the main treatment in all reported cases. The adjuvant treatment is still unclear especially when the surgical margins are negative. The main factor that indicated this adjuvant treatment was the size of the tumor and the histologic subtype.

Brachytherapy of Uveal Melanomas with Ruthenium-106 Plaques

Background: Brachytherapy is the most commonly used conservative treatment for the uveal melanoma. The aim of this study was to evaluate therapeutic results of Ruthenium-106 plaque brachytherapy in the management of localized uveal melanoma cases. Methods: We reviewed retrospectively the clinical records of all patients treated in our department for an uveal melanoma, undergoing Ruthenium-106 plaque brachytherapy, from January 1996 to December 2015. We focused on clinical features, therapeutic characteristics, local and distant tumor control and side effects. Results: Nineteen patients were enrolled in our study. Mean age was 56.2 years (28-79) and the sex ratio was 1.37:1 males to females. Diagnosis was made on the basis of ophthalmological clinical examination, angiography, ultrasound and/or magnetic resonance. Median tumor diameter was 9.7 mm (6-13) and median thickness 4.4 mm (2.5- 8). The dose of Ruthenium-106 plaque brachytherapy prescribed to the apex of each tumor was 70 Gy in all cases. The median radiation dose to the sclera surface was 226.4 Gy (range: 179.6­342.3) and the median total application time 115.2 hours (range: 27 to 237). After a median follow-up of 61.5 months, local control was achieved in 17 patients (89%): 16 demonstrated a partial tumor response and 1 tumor stabilization. Two patients suffered local progression leading to enucleation, one dying of hepatic metastasis. Radiation-induced complications were cataracts in 3 cases and vitreal hemorrhage in 2. Conclusion: Ruthenium-106 plaque brachytherapy is an efficient treatment for localized uveal melanoma, offering good local control with low toxicity.

Molecular detection of human papillomavirus and viral DNA load after radiotherapy for cervical carcinomas.

AIMS AND BACKGROUND: Infection with high-risk types of human papillomavirus (HPV) is a necessary cause for cervical carcinoma. Radiation therapy together with surgery is the most effective treatment. The purpose of this study was to investigate the molecular basis of the response to radiotherapy in cervical cancer cells. METHODS AND STUDY DESIGN: Tumor cells were obtained from biopsies of 44 cervical cancers, collected before and after radiotherapy. The presence of HPV was analyzed by polymerase chain reaction (PCR) using primers specific for the L1 region. RESULTS: The prevalence of HPV was 70.4%, with HPV16 being the most common (54.5%) and HPV18 the second (15.9%). Our analyses show that ionizing radiation does not influence HPV detection, as the percentage of HPV-positive biopsies was similar in patients before and after radiotherapy (HPV16 60% vs. 51.7% and HPV18 20% vs. 13.7%, respectively). However, the detection of HPV did vary by tumor stage, with the highest proportion observed in late-stage tumors (HPV16 and HPV18 in 80% and 60% of stage III tumors, respectively). We also found that HPV viral load is influenced by radiotherapy and tumor stage, with the highest viral loads in late-stage tumors (stage III) after 1 day since radiotherapy (p<0.05). According to Kaplan-Meier curves, higher HPV viral load was associated with significantly shortened progression-free survival (p = 0.04). CONCLUSIONS: Our data provide prospective evidence that ionizing radiation can affect the HPV viral load and this might offer the best strategies for assessment of therapeutic efficacy.

IAEA randomised trial of optimal single dose radiotherapy in the treatment of painful bone metastases.

BACKGROUND: To determine the optimal single-dose radiotherapy schedule for pain from bone metastases in a multi-centre, international, randomised trial. PATIENTS AND METHODS: 651 patients were randomised to either 8Gy (n=325) or 4Gy (n=326) radiotherapy. Pain at 4, 8, 12, 24 and 52weeks was assessed using a Categorical Scale (CS) and a Visual Analogue Scale (VAS). The primary endpoint was response at 4weeks. RESULTS: There was no significant difference in patient demographics and other co-variates. The complete response (CR) rate and ORR (complete or partial response) for all follow-up times were higher after 8Gy (p=0.02). The Kaplan-Meier actuarial rate (categorical scale) at 4weeks for ORR was 80% after 8Gy compared to 68% after 4Gy (p=0.0015). 117 re-treatments were given of which 72 were in the 4Gy group and 45 in 8Gy arm (p=0.01). CONCLUSIONS: There was a marked consistent difference in pain relief at all time points in favour of 8Gy. These data reinforce the case for single dose 8Gy radiotherapy to be recommended for metastatic bone pain in all healthcare settings.

Sequence variation in the E2-binding domain of HPV16 and biological function evaluation in Tunisian cervical cancers.

HPV16 E2 variants have different effects on the transcriptional activity of the LCR. In this study, we examined the nucleotide and amino acid sequence variation within the HPV16 E2 gene and to correlate with disease progression. E2 gene disruption was detected by PCR amplification of the entire E2 gene using a single set of primers. Nucleotide variations were analyzed by bidirectional sequencing. mRNA expression patterns of E6 and E7 gene transcripts were evaluated by a reverse transcriptase-PCR method (RT-PCR). The detection of intact E2 genes was significantly higher among controls than cases (81.8% versus 37.5%, resp., P < 0.05). Among the E subgroup, variation at position 3684 C>A results in the amino acid substitution T310K and was more common among the E2 undisrupted cases (7/9; 77.7%), compared to controls (2/9; 22.2%). In addition, specific sequence variations identified in the E2 ORF at positions 3684 C>A were associated with increased viral oncogenes E6-E7 production. Besides HPV16 E2 disruption, the 3684 C>A variation within undisrupted E2 genes could be involved in an alternative mechanism for deregulating the expression of the HPV16 E6 and E7 oncogenes and appears to be a major factor contributing to the development of cervical cancer in Tunisian women.

HPV-16 E2 physical status and molecular evolution in vivo in cervical carcinomas.

A key event in the development of cervical carcinoma is the deregulated expression of high-risk human papillomavirus (HR-HPV) oncogenes, most commonly due to HPV integration into host DNA. Here we explored whether HPV-16 E2 gene integrity is a biomarker of progressive disease with oncogenes expression. HPV-16 genome disruption was assessed by amplification of the entire E2 gene, while mRNA expression patterns of the E1, E2, E6, and E7 genes were evaluated by reverse transcription PCR (RT-PCR). As expected, E2 disruption was significantly higher among patients with cervical cancers than subjects with benign lesions (p=0.02). The status of the E2 gene correlated with tumorogenesis, and seemed also to correlate with the stage of the carcinomas, since integrated HPV-16 DNA was frequently detected in patients with advanced cancer stages (75% of stage III vs 60% stages I and II). In bivariate analysis, the lesions’ grade was most significantly associated with HPV-16 DNA disruption (p<0.05). In cervical carcinoma the deletion pattern involved more frequently the E2 gene rather than the E1 gene (62.5% vs 45.8%). The prevalence of the E6/E7 HPV-16 transcripts in cervical carcinoma specimens and in benign cervical lesions were detected with frequencies of, respectively, 91.6% and 45.4%. The mRNA levels of the HPV-16 E6/E7 genes were expressed at approximately the same levels in each physical state. We consistently observed that E6/E7 were absent or weakly detectable in the presence of E2. However, in the absence of E2 the levels of E6/E7 markedly increased (p<0.05). This study underscores the significance of investigating alternative mechanisms of E2 expression and oncogenes E6/E7 transcripts in vivo as biomarkers for disease severity in cervical carcinomas.

Larynx preservation: what is the best non-surgical strategy?

The concept of larynx preservation in locally advanced laryngeal or hypopharyngeal squamous cell carcinoma has evolved during the last three decades, especially with the advancement of nonsurgical strategies. These nonsurgical strategies include: (1) radiotherapy alone; (2) concomitant chemoradiotherapy (CCRT); and (3) induction chemotherapy followed by radiotherapy or CCRT and concurrent anti-epidermal growth factor receptor (EGFR). To date, the best approach for larynx preservation has yet to be defined. In this article, we review and discuss important recent randomized phase II/III trials investigating larynx preservation in order to facilitate the selection of an appropriate strategy in the clinical setting. However, the decision of larynx preservation should always be a multidisciplinary approach.