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Background: Internal mammary lymph nodes (IMNs) are a potential site of metastasis for breast cancer. Targeting IMNs as part of a comprehensive regional nodal irradiation comes at the cost of higher unwanted doses to critical nearby organs at risk. Thus, the efficacy and safety of different radiotherapy techniques for the coverage of this area remain elusive. Objectives: We present a dosimetric comparison between partially wide tangents (PWT) and direct photon/electron (P/E) portals in terms of target volume coverage and normal tissue sparing. Methods: Patients with left-sided breast cancer, who were referred to our clinic for post-lumpectomy or post-mastectomy radio-therapy, underwent computed tomography (CT) simulation. The left breast and IMNs, heart, lung, right breast, and esophagus were contoured. Dosimetric comparisons were based on dose-volume histograms (DVHs) generated for all of the aforementioned organs. A subgroup analysis was also performed based on patients' type of surgical treatment. Results: A total of 30 patients (10 with breast conserving surgery and 20 with modified radical mastectomy) were included. The P/E plan provided a higher coverage of the left breast (P-value of CTV V105%: < 0.001) and IMNs with a P-value of 0.087 regarding the mean dose received by IMNs, and also less volume of the heart (P-value of Heart V30Gy: 0.021), and lungs (P-value of Lung V20Gy: 0.003) were irradiated. However, these advantages came at the cost of a higher dose to the esophagus and right breast and more hotspots compared to the PWT technique. Conclusions: The P/E technique had advantages regarding target volume coverage and toxicity regardless of the type of surgery. Based on the results of this study, overall, the P/E portal is superior to the PWT for radiotherapy of breast cancer with internal mammary node inclusion. However, the appropriate treatment plan should be decided on a case-by-case basis. [ABSTRACT FROM AUTHOR]

Purpose: Peripheral neuropathy is a dose-limiting adverse effect of oxaliplatin. The aim of this study was to evaluate the efficacy and safety of duloxetine in the prevention of oxaliplatin-induced peripheral neuropathy (OIPN). Method: Cancer patients receiving oxaliplatin based chemotherapy were randomized into two arms. Duloxetine 60 mg capsule was given in the first 14 days of each chemotherapy cycle to one arm and placebo was similarly given to another. We compared the two arms based on the incidence of neuropathy and the results of the nerve conduction study (NCS). Grade of complained neuropathy was recorded according to Common Terminology Criteria for Adverse Events (CTCAE). Results: Thirty-two patients mostly rectal cancer (90.6%) were randomized to duloxetine and placebo arms. Highest grade of neuropathy in each cycle was not significantly different between the two groups. Six weeks after treatment incidence of neuropathy of any grade was 52.9 in duloxetine arm compared to 76.9% in placebo arm (P: 0.26). Patients in the duloxetine arm had a lower percentage of chemotherapy cycles (mean) in which they reported distal paresthesia (51% vs. 84%, P = 0.01) and throat discomfort (37% vs. 69%, P = 0.01). Results of NCS were mostly comparable between the two arms except for the velocity in two of the examined nerve which was significantly higher in duloxetine group. Duloxetine was safe and well-tolerated. Conclusion: Although a definite conclusion might be difficult to draw but administering duloxetine for 14 days in each chemotherapy cycle could not decrease the incidence of acute OIPN based on CTCAE grading system. [ABSTRACT FROM AUTHOR]

Background and Objectives: The non-surgical treatment outcome of gastroesophageal junction (GEJ) adenocarcinoma remains to be defined. We aimed to assess the outcomes of definitive chemoradiation (CRT) of GEJ tumors. Methods: This retrospective cohort study was entirely carried out in the radiation oncology ward of Cancer Institute of Iran. We included patients with adenocarcinoma histology whose tumors had involved the gastro-esophageal junction and underwent chemoradiotherapy without surgery. In the final analysis, we evaluated 50 patients with non-metastatic adenocarcinoma of GEJ (Siewert's type I and II) from 2008 to 2017. The primary outcome was overall survival; secondary outcomes were progression-free survival and local and distal metastasis. Results: The reasons for not undergoing surgery in order of frequency from highest to lowest were patient refusal or medical unfitness for surgery, tumor unresectability or progress at the time of operation and incident metastasis in pre-op restaging, and. The 1-year, 2-year, and 3-year overall survival rates were 53%, 26%, and 12%, respectively. The 1-year, 2-year, and 3-year progression-free survival rates were 44%, 18%, and 10%, respectively. In the multivariate analysis, the only independent predictor of survival was a distant failure (P=0.031). Conclusion: Although the outcomes of non-surgical treatments are disappointing in GEJ adenocarcinomas, a few patients may experience long-term survival using definitive CRT. This option should be discussed with all patients who are not candidates for surgery. [ABSTRACT FROM AUTHOR]

Background: Minimizing the overall treatment time is an issue of great importance in cancer management. Concomitant boost is a way of decreasing the overall treatment time in breast cancer. The present prospective randomized study aimed to evaluate the feasibility and toxicity and cosmetic outcome of concomitant weekly boost in patients with breast cancer. Method: Patients with breast cancer who underwent breast conservation surgery and were referred to our Radiation Oncology department from 2018 to 2019 were included in this randomized clinical trial. They were randomized to two groups both of which received conventional (50 Gy in 25 fraction, 5 days a week) whole breast irradiation (WBI) with 10 Gy boost dose to lumpectomy cavity. The boost dose in one group (n = 40) was delivered concomitantly on the 6th day of each week. The other group (n = 42) received the boost dose sequentially after completion of conventional WBI. Skin toxicity and cosmetic outcome was compared between the two groups according to CTCAE-4 skin complications and Harvard criteria. Results: We did not observe any significant differences between the sequential and concomitant groups in terms of acute skin reaction within and one month after completion of radiotherapy. After one year of follow-up, no significant differences were seen concerning the cosmetic outcome between the two groups. No local recurrence was observed after 22 months of follow-up. Conclusion: Accelerated radiotherapy with weekly concomitant boost in breast cancer patients was found to be feasible with an acceptable toxicity profile and cosmetic outcome during one year of follow-up. [ABSTRACT FROM AUTHOR]

Background: Adenoid cystic carcinomas is a rare tumor occurring in major salivary glands. Despite definitive treatment, these aggressive cancers often recur and metastasize with no known effective chemotherapy regimen. The present study aimed to evaluate the recurrence and survival rates of head-and-neck adenoid cystic carcinoma and assess the prognostic factors related to the patients' local recurrence and survival. Method: A retrospective study was conducted on 54 patients with adenoid cystic carcinoma. Demographic data, operative factors of patients before, during, and after surgery were reviewed and finally calculated using the Kaplan-Meier method. Results: Among the 54 patients, 61.1% were female, and 38.9% were male with an average age of46.00 ± 14.52 years. The survival rate at 12, 24, 36, 60, 84, 100 and 120 months post-surgery were 100, 93.3, 84.4, 48.9, 24.4, 20.0 and 13.3%, respectively. Both the marital status (P = 0.002) and the type of surgery (P = 0.045) were significantly related to the overall survival of the patients, and the local recurrence significantly correlated with overall survival (P = 0.027). Conclusion: According to the findings, marital status, type of surgery, metastases, histological staging, and local recurrence rate were related to the overall survival of the patients. Hence, it is of utmost importance to pay attention to these factors in health centers. It is recommended to opt for case-control and prospective studies with more samples for further investigation in the future. [ABSTRACT FROM AUTHOR]

Background: Hypopharyngeal carcinoma (HPC) is a rare head and neck cancer which poses many therapeutic challenges. There is limited evidence regarding the outcomes of HPC treatment in Iran. Method: In this retrospective cohort study, we evaluated patients treated with chemoradiation or radiation alone, between 2007 and 2016 in the radiation oncology ward of the cancer institute affiliated to Tehran University of Medical Sciences. The design of the study was reviewed and approved by the local institutional review board (code: 86100142). All patients underwent definitive radiotherapy with or without concurrent or sequential chemotherapy. We assessed the two-year overall survival (OS) as the primary outcome. The progression-free survival (PFS) was our secondary outcome. Results: We studied 40 patients whose median age was 58 years. 37 patients were stage 3 or 4, while the most common stage was T3N1-2, observed in 35% of the cases. The most common site of involvement was pyriform sinus (47.5%). The twoyear OS rate was 29%. The two-year PFS was 22%. In the univariate analysis, N0-1 vs. N 2-3 and stage 2 vs. stage 3-4 were significant predictors of OS. In addition, distant metastasis had almost a significant association with lower OS. Conclusion: The outcome of locally advanced HPC was not promising using 3DCRT alone. It is necessary to implement dramatic changes in the management of these patients to achieve better outcomes. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to test the in vitro sensitivity of lymphocytes of patients with head and neck cancer against gamma irradiation and also to find out if the frequencies of chromosomal aberrations correlate with side effects of radiotherapy. Methods: Peripheral blood of 101 patients with head and neck cancer was collected before the onset of radiotherapy, cultured and irradiated in the G-2 or the G-0 phase of the cell cycle. Lymphocytes of 40 healthy donors were treated in the same way. Chromosomal aberrations such as chromosome and chromatid breakages, chromosome and chromatid gaps, chromatid exchanges and micronuclei were scored in metaphase cells of the patient and control groups. Results: The frequency of radiation- induced G2 aberrations in lymphocytes of patients were on average higher than that of healthy donors (P=0.001 for chromosomal breaks). The frequency of radiation-induced micronuclei in the G0 assay were also higher in patients than that in controls (P=0.05). The results also indicate that there is no correlation between the two assays. No significant correlation was observed between aberration frequencies in lymphocytes and the degree of both early and late normal tissue reactions. Conclusion: The induced chromosomal aberration frequencies in lymphocytes of patients with head and neck cancer are higher than those in healthy individuals, however, it does not appear to have a predictive value for the risk of developing side effects to radiotherapy. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the morbidity and mortality in patients with operable stage II and III rectal cancers within one or two months after surgery, who has been treated pre-operatively with short course radiotherapy. Twenty-eight patients with rectal adenocarcinoma, consecutively referred to the Cancer Institute of Imam Khomeini Hospital from March 2009 to March 2010, were selected for the study after staging by endorectal ultrasound and CT of abdomen, pelvis, and chest; and if they had inclusion criteria for short course schedule, they were treated with radiotherapy alone at 2500 cGy for 5 sessions, and then they were referred to the surgical service for operation one week later. They were visited there by a surgeon unaware of the research who completed a questionnaire about pre-operative, operative, and post-operative complications. Of 28 patients, 25 patients underwent either APR or LAR surgery with TME. One patient developed transient anal pain grade I and one patient had dysuria grade I; they were improved in subsequent follow-up. Short course schedule can be performed carefully in patients with staged rectal cancer without concerning about serious complications. This shorter treatment schedule is cost-effective and would be more convenient for patients due to fewer trips to the hospital and the main treatment, i.e. operating the patient, will be done with the shortest time the following diagnosis. [ABSTRACT FROM AUTHOR]

Background: Colorectal carcinoma is a common malignancy, in treatment of which pelvic radiotherapy plays an important role. But this may lead to azospermia. We designed a study to determine the delivered dose to the testis with thermoluminescence dosimetry (TLD) and compare it to the dose calculated by the Three-dimensional planning software. Methods: We measured the testicular doses by TLD; the TLDs were fixed to the scrotum in six points anteriorly and posteriorly in two random fractions of the radiation course. All patients received a 50-50.4 Gy radiation dose to the pelvis in a prone position with standard fractionation and 3-dimensional planning, through three or four fields. The average dose of the TLD measurements was compared to the average of 6 relevant point doses calculated by the planning software. Results: In 33 patients with a mean age of 56 years, the mean testis dose of radiation measured by TLD was 3.77 Gy, equal to 7.5% of the total prescribed dose. The mean of point doses calculated by the 3-dimensional planning software was 4.11 Gy, equal to 8.1% of the total prescribed dose. A significant relationship was seen between the position of the inferior edge of the fields and the mean testis dose (P= 0.04). Also body mass index (BMI) was inversely related with the testicular dose (P= 0.049). Conclusion: In this study, the mean testis dose of radiation was 3.77 Gy, similar to the dose calculated by the planning software (4.11 Gy). This dose could be significantly harmful for spermatogenesis, though low doses of scattered radiation to the testis in fractionated radiotherapy might be followed with better recovery. Based on above findings, careful attention to testicular dose in radiotherapy of rectal cancer for the males desiring continued fertility seems to be required. [ABSTRACT FROM AUTHOR]

Gastrointestinal (GI) cancers are a significant source of morbidity and mortality in Iran, with stomach adenocarcinoma as the most common cancer in men and the second common cancer in women. Also, some parts of Northern Iran have one of the highest incidences of esophageal cancer in the world. Multi-disciplinary organ-based joint clinics and tumor boards are a well-recognized necessity for modern treatment of cancer and are routinely utilized in developed countries, especially in major academic centres. But this concept is relatively new in developing countries, where cancer treatment centres are burdened by huge loads of patients and have to cope with a suboptimum availability of resources and facilities. Cancer Institute of Tehran University of Medical Sciences is the oldest and the only comprehensive cancer treatment centre in Iran, with a long tradition of a general tumor board for all cancers. But with the requirements of modern oncology, there has been a very welcome attention to sub-specialized organ-based tumor boards and joint clinics here in the past few years. Considering this, we started a multi-disciplinary tumor board for GI cancers in our institute in early 2010 as the first such endeavor here. We hereby review this 2-year evolving experience. The process of establishment of a GI tumor board, participations from different oncology disciplines and related specialties, the cancers presented and discussed in the 2 years of this tumor board, the general intents of treatment for the decisions made and the development of interest in this tumor board among the Tehran oncology community will be reviewed. The GI tumor board of Tehran Cancer Institute started its work in January 2010, with routine weekly sessions. A core group of 2 physicians from each surgical, radiation and medical oncology departments plus one gastroenterologist, GI pathologist and radiologist was formed, but participation from all interested physicians was encouraged. An electronic database was kept from the beginning. The number of patients presented in the tumor board increased from 4 in January 2010 to 16 in December 2011. Most patients were presented by radiation oncology department (38%) and then surgical (36%) and medical oncology (20%) departments. Physicians' participation also grew from an average of 8 each session to 12 in the same months, with a number of cancer specialists taking part from other university hospitals in Tehran. A total number of 225 patients were presented with a treatment decision made in this 2-year period. The majority of cases were colorectal (32%), stomach (23%), and esophageal (17%) cancers. The number of pancreatic (7%) and hepatobiliary (6%) cancers were much smaller. Most decisions were for a primary treatment (surgery or radiochemotherapy) and then a neoadjuvant approach. Tehran Cancer Institute's GI tumor board is one of the first multi-disciplinary organ-based tumor boards in Iran, and as such has made a successful start, establishing itself as a recognized body for clinical decisions and consultations in GI oncology. This experience is growing and evolving, with newer presentation and discussion formats and adapted guidelines for treatment of GI cancers in Iran sought. [ABSTRACT FROM AUTHOR]

BACKGROUND: One of the most important selection criteria for spinal metastases surgery is life expectancy and the most important system for this prediction has been proposed by Tokuhashi. The aim of this study was to evaluate predictive value of the Tokuhashi score for life expectancy in Iranian patients with spinal metastases one year after diagnosis. METHODS: From February 2007 to March 2009, of 180 patients suffering spinal metastatic tumors, 71 patients were excluded. This left a study population of 109 patients with known malignant metastases to spine (56 females and 53 males; mean age, 57 ± 12 years). Tokuhashi revised evaluation system for the prognosis of metastatic spinal tumors was used for all patients. The survival period predicted by this system for the prognosis and the actual survival period after 1 year follow up were evaluated. RESULTS: The predicted survival according to Tokuhashi prognostic scoring system was less than 6 months in 38(34.9%) patients, 6-12 months in 39(35.8%) patients and 1 year or more in 32(29.4%) patients. 39 (35.8%) patients died at first six-month of the follow up, 28(25.7%) patients at the second six-month period and 42(38.5%) patients were alive at the end of the year. There was no significant difference between predicted and actual survival time (p = 0.116). CONCLUSIONS: Present study showed that the Tokuhashi revised scoring system may be practicable and highly predictive preoperative scoring system for patients with spinal metastases in Iran. [ABSTRACT FROM AUTHOR]

To determine the addition of value of neoadjuvant, concurrent and adjuvant chemotherapy to radiation in the treatment of nasopharyngeal carcinoma with regard to the overall survival (OS) and disease free survival (DFS) within a six year period in Tehran cancer institute. Files of all patients with nasopharyngeal carcinoma treated by radiotherapy with or without concurrent chemotherapy in a curative setting in Tehran cancer institute during the period of 1999-2005 were retrospectively reviewed.. A total of 103 patients with nasopharyngeal carcinoma had been treated during the study period with radiotherapy or chemoradiotherapy in our institute. There were 29 (28.2%) females and 74 (71.8%) males. The median age at the time of radiotherapy was 47 years old (range 9-75 years). The patients were followed 2 to 76 months with a median follow-up of 14 months. Time of first recurrence after treatment was 3-44 months with a median of 10 months.. Survival in 2 groups of patients treated with radiotherapy alone or chemoradiation did not have a significant difference (P>0.1). Two-year survival in patients treated with or without adjuvant chemotherapy and had local recurrence after treatment did not have significant difference (P>0.1). Two-year survival in patients with or without local recurrence after treatment did not have significant difference (P>0.1). A beneficial affect or a survival benefit of adjuvant/neoadjuvant chemotherapy and concurrent chemoradiation was not observed in Iranian patients. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer is the third common cancer world wide and the forth in Iran. Neoadjuvant chemoradiotherapy is the standard treatment for locally advanced rectal cancer. In this study we evaluate the efficacy a cox-2 inhibitor on pathologic response, sphincter preservation and acute toxicity during neoadjuvant chemoradiation. Methods: Thirty-six patients that have adenocarcinoma of rectum was enrolled (up to 15 cm of anal verge). The patients were undergone Endometrial Ultrasound (EUS), abdomino-pelvic and chest CT for staging. Then received neoadjuvant concurrent chemo radiation (xeloda 825 mg/m2 bid in combination with celecoxib 100 mg qid and 50-50.4Gy/25-28f). Surgery was done 4-8 weeks after chemoradiation. During the chemoradiation the patients was observed for the probable complication one year. Tumor regression grade was reported. Results: From 36 surgery patients, Total Mesorectal Excision (TME) was done in 30 patients. Pathologic complete response was seen in eight of 30 patients (26.7%). Tumor regression grade was calculated in three and five grade system: in three grade system 17 patients had grade 1 (60.7%), eight patients had grade 2 (28.6%) and three patients had grade 3 (10.7%). In five grade system of tumor regression eight patients had grade 1 (28.6%), nine patients had grade 2 (32.1%), eight patients grade 3 (28.6%), three patients had grade 4 (10.7%). T down staging was 43.3%. N downstaging was 30.8%. No patient had skin reaction or cardio-vascular complication. Conclusion: Based on our study results, Celecoxib in combination with neoadjuvant chemoradiation is safe and is associated with low complications. This combination can promote pathologic complete response, TRG and T and N downstaging in Rectal adenocarcinoma. [ABSTRACT FROM AUTHOR]

Objectives: Radiation-induced proctitis is a common complication of radiotherapy, which sometimes leads to treatment discontinuation. Currently, no specific preventive or treatment strategies have been proposed. In this study, the effects of mallow products on the prevention of proctitis were evaluated in patients with prostate cancer receiving hip radiotherapy. Materials and Methods: In this doubleblinded clinical trial, 80 patients with prostate cancer were divided into two equal groups. The subjects received 4 g sachets containing mallow products (mixed in warm water) three times a day since the first day of radiotherapy until two weeks following the procedure. The incidence and grading of proctitis were evaluated based on the criteria by the Radiation Therapy Oncology Group (RTOG).Also, the severity of symptoms such as diarrhea, anal irritation, cramps, bleeding and mucous discharge were measured by a visual analogue scale. Results: Finally, 65 patients were enrolled in the study. In 23% of the test group and 10% of the placebo group, no symptoms were reported. Grade II proctitis (based on RTOG scale) was reported in 26.6% of subjects in the placebo group and 11% of cases in the test group; however, this difference was not statistically significant (p=0.059). The most common complaint of patients in both groups was anal irritation; however, its intensity was significantly lower in the test group, compared to the placebo group (p<0.05). Moreover, the placebo group required adjuvant drugs earlier than the test group. Conclusion: Mallow as an anti-inflammatory and wound healing agent could clearly decrease anal irritation, which is a disturbing complication of radiation-induced proctitis. [ABSTRACT FROM AUTHOR]

Objectives: Malva sylvestris and Althea officinalis are genus Malvaceae species used in the Iranian traditional medicine (ITM) for the treatment of dysuria. Preventive effects of these species are attributed to high quantities of mucilage, antioxidant properties and wound healing agents, which are beneficial in the treatment of urinary toxicity during radiotherapy. This study aimed to evaluate the prophylactic effects of a bi-ingredient formulation (BIF) of these herbs in reducing urinary symptoms in patients with prostate adenocarcinoma. Materials and Methods: This double-blind, placebo-controlled, randomized clinical trial was conducted on patients undergoing external beam radiotherapy (EBRT) for prostate adenocarcinoma, comparing BIF versus placebo. Patients were randomly assigned to BIF (3.5 g of mixed powder of M. sylvestris and A. officinalis, 3 times daily) and matching placebo groups. All patients started medication therapy one day before radiotherapy and continued for 45 days. Afterwards, symptoms were evaluated on a 0-10 scale, and visual prostate symptom score (VPSS) was calculated before radiotherapy and every 2 weeks for 6 weeks after radiotherapy. In case of urinary retention, intolerable urinary symptoms, or willingness to discontinue the trial, subjects were excluded from the study. Results: In total, 85 patients were enrolled in this study during April 2013-August 2014, and 60 subjects completed the study (medication therapy: 3, placebo: 27). Dysuria was detected in 21 patients (77.7%) of the control group and 23 patients (69.6%) of the BIF group (odds ratio: 1.52). Moreover, mean scale of dysuria and VPSS was significantly higher in the placebo group compared to the BIF group at two, four and six weeks after radiotherapy (p<0.05). Conclusion: According to the results of this study, prophylactic BIF could significantly reduce the severity of dysuria and VPSS within the first 6 weeks of EBRT. [ABSTRACT FROM AUTHOR]

Background: For patients receiving external beam radiation therapy (EBRT) after radical prostatectomy as adjuvant treatment or patients receiving EBRT as definitive treatment, partial irradiation of the urinary bladder is common. Many of such patients experience some degree of radiation-induced cystitis during or after EBRT. There is currently no efficient treatment for preventing radiation cystitis. Objective: The aim of this study was to evaluate the effectiveness of one of the safe mucilaginous herbs (Malva) in preventing radiation-induced dysuria in patients who are undergoing EBRT for prostate cancer. Methods: From April 2013 to August 2014, 68 patients were randomized into two groups using four block randomization, 34 to the drug (Malva) group and 34 to the placebo group. Of the 68 patients who began the study, 60 completed it. They were instructed to use the medication, i.e., Malva or the placebo, three times a day for six weeks. They were followed by a physician every two weeks for eight weeks, and urinary function was assessed in each visit by asking questions based on the Visual Prostate Symptom Score (VPSS) and a dysuria severity score. The changes in the VPSS and dysuria severity score between baseline and each follow-up visit were compared between the two groups in the study using repeated measures analysis of variance (ANOVA) and t-tests. Results: The median age of the 68 patients was 66. Twenty-one of 27 patients in the control group (77.7%) suffered from dysuria, while dysuria was detected in 23 of 33 patients (69.6%) who received Malva (odds ratio=2.70 for dysuria). After two weeks, four weeks, and six weeks of treatment with Malva, dysuria due to EBRT was milder in the treatment group than in the control group, and the differences were statistically significant (p = 0.005, p = 0.004, p = 0.001, respectively). Conclusion: To the best of our knowledge, our study is the first study to assess the protective effect of a mucilaginous herb (Malva) against urinary toxicity induced by EBRT. The positive results of this study warrant further studies in this field. [ABSTRACT FROM AUTHOR]