Pan Arab Journal of Oncology - Arab Medical Association Against ...

Pan Arab Journal of Oncology 

ISSN: 2070-254X 

Official Publication of the Arab Medical Association Against Cancer | www.amaac.org | vol 5; issue 2 | September 2012 

Original Articles 

• 3D Conformal RT vs. Conventional 

2D RT in Bladder cancer 

• Male Breast cancer in Tunisia 

• 3D Conformal RT for Parotid Gland cancer 

• Boosting the tumor bed in ESBC

New 

Æ 

vinflunine 

The 1 st and only registered chemotherapy 

after failure of a platinum-containing regimen 

in advanced or metastatic TCCU 

Pierre Fabre Oncology Middle East - Riad El Solh - P.O.Box 11 - 2131 Beirut - Lebanon Fax : 00 961 1 98 98 42 

Full Prescribing information is available upon request

editorial board < contents < 

º Editor-in-Chief 

Marwan Ghosn, MD, MHHM 

> mghosn.hdf@usj.edu.lb 

> marwan.ghosn@cmc.com.lb 

Lebanon 

º Deputy Editor 

Sami Khatib, MD 

> amaac.pajo@gmail.com 

Jordan 

º Associate Editors 

Khaled Al-Saleh, MD 

> gffccku@yahoo.com 

Kuwait 

Mostaf Elserafi, MD 

> melserafi@link.net 

Egypt 

Sana Al Sukhun, MD 

salsukhun@yahoo.com 

Jordan 

Mohamad Jaloudi, MD 

> mjaloudi@tawamhospital.ae 

UAE 

º Design & Layout 

Zéna Khairallah 

> design@zenak.me 

º PAJO Editorial Board 

> editorinchief.pajo@yahoo.com 

AMAAC Introduction > 2 

International Advisory Board > 3 

Special Thanks > 4 - 5 


º “The reverse” Latissimus Dorsi flap for large lower lumbar defect 

Olfa Jaidane et al. > 6 - 10 

º A comparative dosimetric study of 3D conformal radical radiotherapy 

for bladder cancer patients versus conventional 2D radical radiotherapy 

in NCI-Cairo 

Hesham A. El-Hossieny et al. > 10 - 12 

º Male breast cancer in central Tunisia: A retrospective case-series 

Ghassen Marrekchi et al. > 14 - 17 

º Dosimetric study comparing photon and electron Beams for boosting 

the tumor bed in early-stage breast cancer 

Mohamed Mahmoud et al. > 18 - 24 

º Three Dimensional Conformal Radiotherapy (3DCRT) for parotid 

gland cancer: Dose to cochlea, oral cavity and contralateral parotid 

Azza Helal et al. > 26 - 30 

º Breast cancer with bone metastasis in south of Tunisia: retrospective 

review of 225 cases > 32 - 35 

Ghassen Marrekchi et al. 

News from the Arab World > 36 - 42 

º UAE Cancer Congress 2012 

º Emirates Oncology Conference 

º Near East and mid-Asia Association of Medical Oncology Societies 

º 5th Post Graduate Course on Hepatology and Gastroenterology 

º 14th International Workshop on Therapeutic GI Endoscopy 

º v2nd Clinical Research Training Program 

º 13th Pan Arab Cancer Congress 

Cancer Awareness Calendar > 44 

Instructions for Authors > 45 - 48 

ISSN: 2070-254X 

www.amaac.org 

www.amaac.org Pan Arab Journal of Oncology | vol 5; issue 3 | September 2012 < 1

amaac < 

AMAAC Introduction 

The Arab Medical Association Against Cancer (AMAAC) is a medical body that was established in 2001 as part of the Arab Medical 

Association where its main office is located in Cairo - Egypt, and it is also a continuation of the Arab Council Against Cancer that 

was founded in 1995. The Executive Committee of (AMAAC) is represented by two members who are named officially by the 

Oncology Society of each Arab Country. 

The Arab Medical Association Against Cancer aims at strengthening relationships between members in different Arab Countries to 

raise the level of cooperation in the field of oncology on both scientific and practical aspects. Exchanging information and researches 

between members through Regional and Arab Conferences and Publications. Holding Public Awareness Campaigns in the field of 

oncology that are organized by Arab Countries. Participating in scientific activities with International Oncology Societies. Finally, 

encouraging researchers and doctors to meet and exchange experiences together with finding training opportunities in the field of 

oncology inside and outside the Arab World. 

The Executive Board of AMAAC 

Sami Khatib, MD Jordan Secretary General 

Said Al-Natour, MD Jordan Associate Secretary General for financial affairs 

Khaled Al-Saleh, MD Kuwait Associate Secretary General for Prevention, Screening and awareness affairs 

Adda Bounedjar, MD Algeria Associate Secretary General for Communication Affairs 

Mostafa El Serafi, MD Egypt Associate Secretary General for Scientific Affairs 

Aqeel Shakir Mahmood, MD Iraq Associate Secretary General for JAMAAC Affairs 

Marwan Ghosn, MD Lebanon Editor in Chief for PAJO 

Atef Badran, MD Egypt Director of AMAAC Office 

The officially nominated members of AMAAC by the Oncology Societies of each country 

Algeria 

Adda Bounedjar, MD 

Kamel Bouzid, MD 

Morocco 

Hassan Errihani, MD 

Faouzi Habib, MD 

Bahrain 

Abdulla Ajami, MD 

Oman 

Bassim Bahrani, MD 

Egypt 

Mostafa El Serafi, MD 

Mohamed Saad Zaghloul, MD 

Palestine 

Fuad Sabatin, MD 

Abdel Razaq Salhab, MD 

Iraq 

Aqeel Shakir Mahmood, MD 

Khudair Jassim Sabeeh, MD 

Saudi Arabia 

Om Al Kheir Abu Al Kheir, MD 

Shawki Bazarbashi, MD 

Jordan 


Said Al-Natour, MD 

Sudan 

Hatim Abshora, MD 

Kamal Eldein Hamad Mohamed, MD 

Kuwait 

Khaled Al Khalidi, MD 

Khaled Al Saleh, MD 

Syria 

Zahera Fahed, MD 

Maha Manachi, MD 

Lebanon 

Marwan Ghosn, MD 

Nagi El-Saghir, MD 

Tunisia 

Hamouda Boussen, MD 

Khalid Rahhal, MD 

Libya 

Eramah Eramih, MD 

Hussein Al Hadi Al Hashemi, MD 

UAE 

Mohamad Abbas Alali, MD 

Mauritania 

Jiddou Abdou, MD 

Al Issawi Salem Sidi Mohamed, MD 

Yemen 

Arwa Awn, MD 

Afif Nabhi, MD 

2 > Pan Arab Journal of Oncology | vol 5; issue 3 | September 2012 

www.amaac.org

international advisory board < 

Matti AAPRO, MD 

Director, Multidisciplinary Oncology Institute, Genolier, Switzerland 

Consultant to the Scientific Director, European Institute of Oncology, Milano, Italy 

Consultant, Division of Oncology, Geneva University Hospital 

Geneva - Switzerland 

Hoda ANTON-CULVER, PhD 

Professor & Chair 

Department of Epidemiology 

Professor, Department of Microbiology and molecular Genetics, 

School of Medicine 

Director, Genetic Epidemiology Research Institute 

University of California 

Irvine – USA 

Jean-Pierre ARMAND, MD 

Professor & General Director 

Centre de Lutte contre le Cancer 

Institut Claudius Regaud 

Toulouse – France 

Ahmad AWADA, MD 

Head of Medical Oncology Clinic 

Jules Bordet Cancer Institute 

Brussels - Belgium 

Patrice CARDE, MD 

Chairman Lymphoma Committee 

Gustave Roussy Institute 

Paris - France 

Franco CAVALLI, MD 

Professor & President UICC 

Director 

Oncology Institute of Southern Switzerland 

Bellinzona - Switzerland 

Joe CHANG, MD 

Assistant Professor of Radiation Oncology 

Clinical Service Chief, Thoracic Radiation Oncology 

MD Anderson Cancer Center 

Houston - USA 

William DALTON, MD 

President and Chief Executive Officer 

H.Lee Moffitt Cancer Center and Research Institute 

University of South Florida 

Florida - USA 

Jean-Pierre DROZ, MD 

Professor & Former Head of Oncology Department 

Centre de Lutte contre le Cancer Leon Berard 

Lyon - France 

Alexander EGGERMONT, MD, PhD 

Professor of Surgical Oncology 

Head of Department of Surgical Oncology 

Erasmus University Medical Center 

Daniel den Hoed Cancer Center 

Rotterdam - The Netherlands 

Jean-Pierre GERARD, MD 

Professor of Radiation Oncology 

General Director of Antoine-Lacassagne Cancer Center 

Lyon - France 

Joe HARFORD, MD 

Director of the Office of International Affairs 

National Institute of Health 

United States Department of Health and Human Services 

Bethesda - USA 

Alan HORWICH, MD 

Professor of Radiotherapy 

Section of Academic Radiotherapy and 

Department of Radiotherapy 

The Institute of Cancer Research 

London – United Kingdom 

Fritz JANICKE, MD 

Director Clinic & Polyclinic of Gynecology 

University Medical Center Hamburg-Eppendorf 

Hamburg – Germany 

Sima JEHA, MD 

Director of the Leukemia / Lymphoma Developmental Therapeutics 

Saint-Jude Children’s Research Hospital 

Memphis - USA 

Hagop KANTARJIAN, MD 

Professor of Medicine 

Chair of the Department of Leukemia 

The University of Texas - MD Anderson Cancer Center 

Houston - USA 

Fadlo R. Khuri, MD 

Professor and Chair, Department of Hematology and Medical Oncology 

Roberto C. Goizueta Distinguished Chair in Cancer Research 

Deputy Director, Clinical and Translational Research - Winship Cancer Institute 

Emory University School of Medicine 

Atlanta - USA 

Jean-Francois MORERE, MD 

Professor at University Paris XIII 

Head of the Department of Oncology 

Assistance Publique – Hôpitaux de Paris 

Paris - France 

Mack ROACH, MD 

Professor & Chairman 

Radiation Oncology & Professor of Urology 

University of California, Irvine 

California - USA 

Philippe ROUGIER, MD 

Professor of Medical Oncology 

Gastrointestinal Cancer 

Liver and Pancreas Tumors 

Ambroise-Pare Hospital 

Boulogne - France 

Youcef RUSTUM, PhD 

Chairman of the Department of Cancer Biology 

Roswell Park Cancer Institute 

Academic Research Professor 

Associate Vice Provost 

University at Buffalo 

New York - USA 

Sandra M. SWAIN, MD 

Medical Director, Washington Cancer Institute 

Washington Hospital Center 

Washington – USA 


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but don’t wait to catch it from others.Be a carrier. 

Official Publication of the Arab Medical Association Against Cancer | www.amaac.info | vol 1; issue 2 | June 08 

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Hope begins in the dark, the stubborn hope that if you just show 

up and try to do the right thing, the dawn will come. You wait and 

watch and work: You don’t give up. 

Anne Lamott 

ISSN: 2070-254X 

Official Publication of the Arab Medical Association Against Cancer | www.amaac.org | vol 4; issue 4 | December 2011 

special thanks < 





Original Article 

Special Report 

Health Economics Review Articles 

A cost-minimization analysis Present & Future of Radiation Oncology 

of 1st line polyCT regimens in Review of the Current Management of 

advanced NSCLC 

advanced prostate cancer 

new publication 

Review 

Meeting Highlights 

Treatment of Acute Lymphoblastic Leukemia ASCO 2008 

UICC 2008 

Targeted Therapy Development 

Angiogenesis review 


Breast Cancer in Tunisia 

Highlights on the Speech and Language 

Pathologist’s role in Head and Neck Cancer 

Review 

Soft Tissue Sarcoma in Young Individuals MENA 2008 

BLOM Beirut Marathon 08 


Special Issue Including the Proceedings of PACC 2009 

9 TH PAN ARAB CANCER CONGRESS 

7 - 9 May 2009 - Cairo, Egypt 







CANCER 

SURVIVOR 

MONTH 

While there’s 

there’s 

life, 

hope. 

(Cicero, 106 - 43 BC) 


Low dose Gemcitabine and Cisplatin 

in Advanced NSCLC 

PRAME and WT1 Genes expression 

in CML Patients 

Meeting Highlights 

9th Pan Arab Oncology Congress 

Best of ASCO 2009 


Special Report: COMO 8 | Nov 2009 | Beirut, Lebanon 


Effect of radiotherapy on malignant 

Proteomic approach for the detection of pleural mesothelioma in adjuvant, 

breast cancer biomarkers. 

radical or palliative basis. 


INITIATIVE TO IMPROVE CANCER CARE IN THE ARAB WORLD 

Proceedings of the Symposium 

March 23 - 25, 2010 | Riyadh, KSA 


• L’ approche immuno-ptoteomique 

SEPRA et Cancer du Sein (in French) 

• Receptor for hyaluronic acid-mediated 

motility (RHAMM/CD 168) in AML patients 

• Egyptian experience of modified 

medical thoracoscopy 


• Infiltrating Ductal Carcinomas of the • Locally Advanced HNC: Cisplatin and 

Breast: Proteomic Analysis of Human Docetaxel plus Radiation Therapy 

plasma protein 

• Triple negative MBC: BRCA1 and EGFR 

• Gastric carcinoma: DCF vs ECF 

as prognostic biomarkers 






Screening and Early Detection Awareness 

No winter lasts forever; no spring skips its turn. 

Know, then, whatever 

cheerful and serene 

Supports the mind 

supports the body too. 

~John Armstrong 

~Hal Borland 


• Report of preliminary experience of the 

prone table stereotactic breast core biopsy 

at the King Fahad National Guard Hospital 

• C/EBPα Expression in Egyptian patients with 

Acute Myeloid Leukemia 

• Treatment results of Stereotactic Radiosurgery 

for cerebral arteriovenous malformations 


• Pathologist’s role in Modern Oncology 

Practice 

• Chroidal Metastases from Breast 

carcinoma 

• Hypofractionated vs. Conventional 

RT in Glioblastoma Multiforme 


• Colon Cancer during pregnancy 

• Comparison between the 

• Chemoradiotherapy in anaplastic thyroid radiosenstizing effect of Cisplatin 

Cancer 

& Gemcitabine in Bladder Cancer 


• Breast Cancer Characteristics in a 

multiethnic population 

• 3D vs. 2D Radiotherapy in rectal cancer 

• EC followed by PC in Endometrial cancer 

• Intracystic papillary carcinoma of the 

breast: case report 

Genito-Urinary 

Special Publications 

3 rd Africa and Middle-East 

Oncology Forum 


• Isocentre Shift during Radiotherapy in overweight 

& obese Prostate Cancer 

• Dosimetric Comparison of IMRT vs. 3D-CRT in 

Operable Breast Cancer 

• CD38 as prognostic factor in CLL 




A healthy attitude is contagious, 

Tom Stoppard 

CANCER 

SURVIVOR 

MONTH 


• Pegylated liposomal doxorubicin versus • IMRT breast sparing in post-operative 

Gemcitabine in ovarian Cancer. 

breast cancer radiation therapy. 

• Quality of life among breast cancer patients. • Impact of chemotherapy induced 


• XELOX vs. FOLFOX in Colon Cancer 

• Conformal vs. Intensity modulated RT in 

• Cost effectiveness study in Colon cancer nasopharyngeal cancer 

• TNBC: Neoadjuvant platinum regimen 


• 3D Conformal RT vs. Conventional 

2D RT in Bladder cancer 

• Male Breast cancer in Tunisia 

• 3D Conformal RT for Parotid Gland cancer 

• Boosting the tumor bed in ESBC 

• Male Breast Cancer in Sudan. 

amenorrhea on the prognosis of early BC. 


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Thank you for all contributors, authors and reviewers of PAJO 

Gerard Abadjian, MD 

Hamdi Abdel Azim, MD 

Wafaa Abdel-Hadi, MD 

A. Abdelkefi, MD 

Abdel Rahman M., MD 

Fatma Aboulkasem, MD 

Omalkhair Abulkhair, MD 

Mohsen Abdel Mohsen, MD 

Arabi Abdessamad, MD 

Noha Abdou, MD 

Miguel Aboud, MD 

Philippe Aftimos, MD 

Salim Adib, MD 

B. Allani, MD 

Bekadja Mohamed Amine, MD 

Elie Attieh, MD 

Fadwa Attiga, MD 

Ahmad Awada, MD 

Amal Baccar, MD 

Jean-Marc Bachaud, MD 

Thouraya Baroudi, MD 

Ali Bazerbachi, MD 

Amel Ben Ammar Elgaaied, MD 

Khaled Ben Rhomdhane, MD 

Alain Bernard, MD 

Ghislaine Bernard, MD 

Nizar Bitar, MD 

H. Boussen, MD 

Karim Chahed, MD 

Georges Chahine, MD 

Anouar Chaieb, MD 

Nicolas Chemali, MD 

Lotfi Cherni, MD 

Lotfi Chouchane, MD 

Elizabeth Cohen, MD 

Michel Daher, MD 

Géraldine Dalmasso, MD 

Kamal El-Dein Hamed Mohamed, MD 

Dalia Darwish, MD 

Jean-Pierre Droz, MD 

Tayssir Eyada, MD 

Ahmad El-Ezzawy, MD 

Fadi Farhat, MD 

Nivine Gado, MD 

Marwan Ghosn, MD 

Heba Gouda, MD 

E. Gouider, MD 

Amin Haddad, MD 

Mohammad El-Hajj, MD 

Khaled Halahlah, MD 

Bechr Hamrita, MD 

Gregory Hangard, MD 

Colette Hanna, MD 

Mohamed A Hassan, MD 

Hassan A. Hatoum, MD 

Johan Hoebeke, MD 

Hesham El Hossieny, MD 

Ahmad Husari, MD 

Noha Ibrahim, MD 

Elias Jabbour, MD 

Sima Jeha, MD 

Maria Kabbage, MD 

Fadi El Karak, MD 

Joseph Kattan, MD 

M. Kefi, MD 

Jamal Khader, MD 

Hussein Khaled, MD 


Anne Laprie, MD 

Robert Launois, MD 

Katell Le Lay, MD 

Christelle Lemaitre-Guillier, MD 

Rami Mahfouz, MD 

Nazar Makki, MD 

Carole Massabeau, MD 

Andre Megarbane, MD 

Brahimi Mohamed, MD 

Mohsen Mokhtar, MD 

Walid Moukaddem, MD 

Jonathan Moyal, MD 

Elie Nasr, MD 

Fadi Nasr, MD 

Ghazi Nsouli, MD 

Ben Othman, MD 

Zaher Otrock, MD 

Martine Piccart, MD 

Shadi Qasem, MD 

Silvia Al Rabadi, MD 

Karim Rashid, MD 

Sami Remadi, MD 

Kamel Rouissi, MD 

Raya Saab, MD 

Ebtessam Saad El Deen, MD 

Laurence Ehret-Sabatier, MD 

Gamal Saied, MD 

Nagi El-Saghir, MD 

Ibrahim Saikali, MD 

Khaled El-Saleh, MD 

Ziad Salem, MD 

Lobna Sedky, MD 

Ali Shamseddine, MD 

Ahmad Shehadeh, MD 

Sana Al-Sukhun, MD 

Iyad Sultan, MD 

Ali Taher, MD 

Paul-Henri Torbey, MD 

Wafa Troudi, MD 

Virginie Vandenberghe, MD 

Alain Vergnenegre, MD 

Laure Vieillevigne, MD 

Besma Yacoubi-Loueslati, MD 

Mahmoud Yassein, MD 

Riad Younes, MD 


original article < 

“The reverse” Latissimus Dorsi flap for large lower lumbar defect 

Jaidane O, MD; Bouraoui K, MD; Ben Hassouna J, MD; Rahal Khaled, MD 

Department of Surgical Oncology, Salah Azaiez Institute, Tunis, Tunisia. 

Corresponding Author: Dr Olfa Jaidane, MD 

Departement of Surgical Oncology 

Salah Azaiez Institute, Tunis 

E-mail: olfa_jaidane@yahoo.fr 

Key words: Latissimus dorsi, Reverse Latissimus dorsi, Flap, Lumbar defect, Secondary pedicles, Kidney tumor. 

ISSN: 2070-254X 

Abstract 

The latissimus dorsi (LD) flap is one of the most common flaps used in plastic 

surgery based on its dominant thoracodorsal pedicle as well as free tissue 

transfer. The “distally based “or “reverse” fashion design has been used to repair 

myelomeningoceles, congenital diaphragmatic agenesis or thoraco-lumbar 

defects. 

We present a case of a large lumbar defect after cancer resection covered by 

a combined tegument solution starring the “reverse” LD flap in its muscular 

version with a cutaneous gluteal flap. This flap is a safe and reliable way to cover 

large distal lumbar defect 

Introduction 

Covering the lumbar region was always a challenge for plastic surgeons. Although 

different pedicled muscular and musculocutaneous flaps were described around 

this area, the repair of large defects is still a difficult matter [1, 2] We present a 

case in which a “reverse” latissimus dorsi muscle flap was successfully used for 

repairing an important defect remaining after resection of a malignant recurrent 

tumor located in the lower lumbar region. 

Case Report 

A 69-year-old man was referred for treatment of a massive infected tumor 

situated in the left lumbar region, 12 months after left nephrectomy for squamous 

cell carcinoma of the kidney. 

On clinical examination the mass was located on the lombotomy scar and 

measured 15 cm (Fig.1). 

The abdomino-pelvic CT-scan showed a mass in the left lumbar region, 

measuring 95x75x65 mm and invading the 11th rib. This mass extends to the 

ipsilateral Latissimus Dorsi muscle which seems to be invaded in the lower part 

and to the iliopsoas muscle (Fig. 2). 

The biopsy revealed a squamous cell carcinoma. Recurrence of the renal tumor 

was excluded and surgery was indicated. The tumor was removed through a 

circular incision, section of the lower insertion of the latissimusdorsi, the 

quadrates lumborum, the iliopsoas and the two obliquus muscles. The peritoneal 


cavity was opened. The distal part of the 11th rib was removed with a pleural 

wound which was repaired. The excised tissues included also a nodule located 

at the superior part of lombotomy scar and a second one was situated in the left 

retro-colic area (Fig. 3 and 4). 

The Technique 

The LD outline was marked as well as its upper limit. The paraspinal perforators 

were outlined about 5 cm from the midline and the penetration of the perforators 

through the muscle was estimated about 9 cm from the vertebral column (Fig.1). 

No Doppler ultra sound or arteriography was performed. (not available in the 

center). All the benchmarks were taken based on the literature. 

An oblique incision was made from 10 cm down to the axilla to the defect. 

The LD was identified (Fig 5). The thoracodorsal artery, vein, and nerve were 

exposed, tied off and then detached (Fig 6). After section of its humerus insertion, 

the LD was harvested carefully in order to preserve the segmental pedicles. 

We found three large perforators originating from the ninth, tenth, and eleventh 

intercostal pedicles, located 5 cm from the midline of the back and penetrating 

the muscle after 3 to 4 cm (Fig 7). 

The sacrifice of the ninth pedicle was necessary to allow the LD muscle to reach 

the defect satisfactorily. The muscular flap was tacked with some absorbable 

sutures after covering the peritoneal cavity using a mersilene mesh (Fig 8). The 

dead space was filled up by the muscle and a simple cutaneous rotated gluteal 

flap was performed to protect the sutures and strengthen the set up. 

Fifteen days later a good granulation tissue was obtained and a skin graft was 

made (Fig9). 

Histological Findings 

On gross examination, the surgical specimen weighed 1200 g and measured 

25x15x10 cm. It contained a white-mostly-necrotic nodule measuring 12x10x10 

cm. On histological examination, the tumor presented a malignant squamous 

cell proliferation with atypia. Lateral limits of resection were not infiltrated. The 

posterior limit was exiguous. 

The histological examination concluded to well-differentiated squamous cell 

carcinoma. 

www.amaac.org

Follow up 

The postoperative course was complicated by a superficial infection treated with 

antibiotics and wound care and some seroma spontaneously evacuated with 

dressing. The coverage of this important defect was a success and the patient 

was completely recovered from his wound after 6 weeks. The multidisciplinary 

comity took the decision to follow up the patient without any adjuvant treatment. 

No recurrence was observed after 8 months but a back wall weakness was noted 

(Fig 10). One year later, a tumoral recurrence was diagnosed. 

Discussion 

We believe that the “reverse” LD flap is a good option to cover this particular 

region. It’s simple, safe and reliable. It also provides a backup plan like the 

microsurgery in case of failure. 

Conclusion 

We present a case of large lumbar defect covered using the LatissimusDorsi flap 

in its reverse fashion with a satisfactory result. This pedicled flap has a good 

trophicity and offers an amplified rotation vector allow reaching lower trunk 

areas. It is a reliable solution to solve difficult plastic tegument problems and 

cover large surface defects. 

Management of massive soft-tissue defects in the lumbar region is still a major 

challenge for plastic surgeons. This anatomical region is like a “no man’s land” 

for us. The local solutions are rare and the standard free tissue transfer is not an 

easy job, especially if the recipient vessels for microsurgical reconstruction like 

the gluteal arteries are far or sometimes not available. 

Reverse LatissimusDorsi (LD) flap has been described mainly for closure of 

congenital diaphragmatic agenesis, myelomeningocele and spinal cord syndrome 

or some thoracolumbar defects [3,4, 5, 6, 7]. But some cases for the coverage 

of the lower back soft-tissue loss using this flap were reported in the literature, 

proving by the way the possibility to reach this “no man’s land” region and the 

reliability of the Reverse LD flap to do it [2, 8, 9]. 

We will not discuss the oncological aspect of the treatment but we will focus 

ont our method to cover this massive lumbar defect. The LD has a double 

vascularization as described by Mathes&Nahai [10] and if it remains one of 

the most used flaps in plastic surgery, its “reverse” version is not so common. 

Described in the early eighties [3], this flap was used basically for central 

posterior trunk defects. Increasingly, its use was described for lower lumbar 

and gluteal regions [11]. Detailed anatomical studies were reported by different 

authors and sometimes the results diverge even if some similarities were found. 

In fact McCraw et al. [12] reported that segmental perforators usually arose at 

the levels of the seventh, ninth and eleventh thoracic vertebrae, approximately 8 

cm from the midline. 

Whereas Stevenson et al. [13] observed the presence of three large vascular 

pedicles originating from the ninth, tenth and eleventh intercostal vessels, 5 cm 

from the midline. 

Grinfeder et al. [14] observed the same result for 50% of their flap dissections. 

The locations in our case were almost the same as described by Stevenson 

and Grinfeder. Although we found our perforators 5 cm from the spine, their 

penetration through the muscle were detected 3 to 4 cm after. This length in 

this cleavage plan allows some translation to the lower part but the pivot point 

can be considerably increased after the sacrifice of one perforator pedicle. This 

sacrifice was described in different cases [2, 12, 14] and allows a rotation vector 

facilitating the migration for more than 5 cm in our case without altering the 

blood supply for the lower part of the muscle which is the most important one. 

The upper limit of our flap was situated 10 cm from the axilla in order to avoid 

distal suffering. 

The exact vascular territory of each segmental pedicle is unknown [2, 14] and 

the skin paddle required for this big defect (25/15 cm) is too large for the reverse 

LD flap that we cannot avoid tampering the donor site or risking a skin necrosis. 

Opting for a muscle reverse LD flap with a gluteal skin flap was for us the 

simplest solution that can fill the dead space and cover the defect. The muscle 

was bleeding well even after the sacrifice of the ninth pedicle and the granulation 

tissue is also a proof of viability. 

Conflict of interest None 

Funding None 

Figures 

Fig 1: An infected recurrence on the lombotomy scar 

Fig 2: left lumbar mass invading the iliopsoas muscle 



Fig 3: The specimen with the distal 11th rib (arrow) 

Fig 6: Identification of the thoracosorsal pedicle 

Fig 4: The defect showing the colonic flexure (arrow) 

Fig7: Dissection of the perforators 

Fig 5: Exposure of the LD muscle 

Fig 8: Mersilene mesh being placed 


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References 

Fig 9: (a) Granulating wound (b) skin graft 

1. Kato, H., Hasegawa, M., Takada, T., and Torii, S. The lumbar artery 

perforator based island flap: Anatomical study and case reports. Br. J. Plast. 

Surg. 52: 541, 1999. 

2. Yamamoto, N., Igota, S., Izaki, H., and Arai, K. “Reverse turnover” transfer 

of a latissimusdorsi muscle flap to a large lumbar defect. Plast.Reconstr. 

Surg. 2000;107: 1496, 2001. 

3. Bostwick 3rd J, Scheflan M, Nahai F, et al. The “reverse” latissmusdorsi 

muscle and musculocutaneous flap: anatomical and clinical considerations. 

PlastReconstrSurg 1980;65:395-9. 

4. VanderKolk CA, Adson MH, Stevenson TR. The reverse latissimusdorsi 

muscle flap for closure of meningomyelocele. PlastReconstrSurg 

1988;81(3):454–6.. [5] Wallace CA, 

5. Roden J. Reverse, innervated latissimusdorsi flap reconstruction of 

congenital diaphragmatic absence. PlastReconstrSurg 1995;96(4):761–9. 

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Flap for Closure of Complex Back Wounds in Patients With Spinal Cord 

Injury. Spine 2003;28 (16):1893–1898. 

8. Zambacos, G. J., and Mandrekas, A. D. The reverse latissimusdorsi flap for 

lumbar defects. Plast.Reconstr. Surg. 111: 1576,2003. 

9. Keiichi M, KoichiroI.,andRitsuko O. Experiences with the “Reverse” 

LatissimusDorsi Myocutaneous Flap. Plast.Reconstr. Surg. 2006 ;117 : 

2456-2459. 

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experimental and clinical correlation. PlastReconstrSurg 1981;67(2):177– 

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11. Mathes D.W, J.F Thornton, and R J Rohrich.Management of Posterior 

Trunk Defects. Plast.Reconstr. Surg. 2006;118:73e-83. 

12. McCraw JB, Penix JO, Baker JW. Repair of major defects of the chest wall 

and spine with the latissimusdorsimyocutaneous flap. PlastReconstrSurg 

1978;62(2):197–206. 

13. Stevenson TR, Rohrich RJ, Pollock RA, et al. More experience with the 

“reverse” latissmusdorsimusculocutaneous flap: precise location of blood 

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14. C. Grinfeder, V. Pinsolle, P. Pelissier. Le lambeau musculocutané de 

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Annales de chirurgie plastique esthétique.2005 ;50 : 270–274 

Fig 10 : Local result after 8 months 



A comparative dosimetric study of 3D conformal radical radiotherapy for bladder 

cancer patients versus conventional 2D radical radiotherapy in NCI-Cairo 

Mohamed Mahmoud, MD 1 ; Hesham A. El-Hossieny, MD 1 ; Nashaat A. Diab, Ph.D 2 ; Marwa A. El Razek, B.Sc 2 

(1) The Department of Radiation Oncology, National Cancer Institute, Cairo University 

(2) The Departement of Radiation Physics, National Cancer Institute, Cairo University 

Corresponding Author: Dr. Hesham A. El-Hossieny, MD 

The Department of Radiation Oncology 

National Cancer Institute, Cairo University 

E-mail: hishamelhossieny@yahoo.com 

Key words: Dosimetric study in cancer bladder. 

ISSN: 2070-254X 

Abstract 

Purpose: This study was to compare this multiple-field conformal technique to 

the 2D conventional technique with respect to target volume coverage and dose 

to normal tissues. 

Materials and methods: We conducted a single institutional prospective 

comparative dosemetric analysis of 15 patients who recieved radical radiation 

therapy for bladder cancer presented to radiotherapy department in National 

Cancer Institute, Cairo in period between November 2011 to July 2011 using 

3D conformal radiotherapy technique for each patient, a second 2D conventional 

radiotherapy treatment plan was done, the two techniques were then compared 

using dose volume histogram (DVH) analysis. 

Results: Comparing different DVHs, it was found that the planning target 

volume (PTV) was adequately covered in both ( 3D & 2D ) plans while it was 

demonstrates that this multiple field conformal technique produces superior 

distribution compared to 2D technique, with considerable sparing of rectum and 

to lesser extent for the head of both femora. 

Conclusions: From the present study, it is recommended to use 3D planning 

for cases of cancer bladder especially in elderly patients as it produces good 

coverage of the target volume as well as good sparing of the surrounding critical 

organs. 

Introduction 

Bladder cancer represents a significant worldwide health problem with an 

estimated 356,370 new cases and 146,000 deaths reported globally for the year 

2002 (1). Although the majority of bladder cancers, present with disease confined 

to the superficial layers of the bladder wall, approximately 20-40% of the patients 

will present with or subsequently develop invasive cancer. Transitional cell 

carcinomas (TCC; also known as urothelial carcinoma) represented more than 

90% of cystectomy specimens worldwide (2). In areas where schistosomiasis is 

endemic, urothelial cancer represents approximately 50% of bladder cancers, 

while the other subtypes represents the remaining percentage (3). 

Since the late 1980s, many centers investigated the bladder preservation 

strategy as an alternative to radical cystectomy. The rationale of this strategy 

depends on 3 goals: first, eradication of the local disease, second, elimination 

of potential micrometastasis and third, maintenance of the best possible quality 


of life (QoL) through organ preservation (4). Several treatment protocols were 

carried out by different investigators. However, they all characterized 3 main 

and essential procedures with varying timing and varying minute details. The 

first main procedure is maximal TURBT. This is to be followed by neoadjuvant 

chemotherapy or radiochemotherapy (second procedure) and then after 

cystoscopic assessment, followed by either radical radiotherapy or consolidation 

radiochemotherapy for the complete responders (third procedure). The 5-year 

OS rates ranged between 39% and 58% and the 5-year survival with native 

bladder preservation ranged from 36% to 43% (5-9) 

Patients and Methods 

The aim of the present study is to compare between the 2D and 3D conformal 

planning for bladder cancer cases treated by trimodality approach regarding the 

dose distribution to the target as well as the organs at risk. 

We conducted a single institutional prospective comparative dosimetric 

analysis of 15 male patients with muscle-invasive (Stage T2-T4a) transitional 

cell carcinoma of the bladder that presented to radiotherapy department in 

National Cancer Institute, Cairo in period between November 2011 to July 

2012. Maximum Transuretheral resection (TUR) was done for all patients then 

followed by concurrent chemoradiotherapy. Patients were simulated in the 

supine position and should have an empty bladder. 

In 2D planning, the treatment field typically extends craniocaually from the L5- 

S1 disc space to the lower pole of the obturator foramen and laterally to 1-2 

cm beyond the margin of the bony pelvis at its widest part. For the lateral field 

anteriorly, the field extends 1.5-2 cm beyond the bladder and posteriorly to the 

level of the third sacral vertebra. 

The CTV for irradiating the whole bladder should encompass the entire 

outer circumference of the bladder, any extra vesical disease spread and any 

microscopic disease spread. 

In 3D planning, an initial planning pelvic CT scan was performed with the 

patient in a supine position strictly within 10 mm of bladder empty. The planning 

gross target volume (GTV) is determined by including the bladder with any 

extravesical extension. It is widely accepted that the CTV is created with 2- to 

2.5-cm margins. However, these margins are still debatable and not universally 

accepted. The CTV included the bladder, prostate and prostatic urethra in males 

or the upper vagina in females. The pelvic nodal CTVs extend around external 

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and internal iliac vessels. The external iliac CTV extends anteriorly along the 

iliopsoas muscle to include the lateral external iliac nodes. The internal iliac 

CTV extends laterally to pelvic side wall. The contours around the external and 

internal iliac vessels were joined 

to create a single volume on each side of the pelvis, ensuring that it included the 

obturator nodes. The pre-sacral CTV extends over the anterior sacral prominence 

guided with Tayler et al atlas (10). The planning target volume (PTV) margins 

are 5-10 mm according to the institutional policy of creating CTV-PTV margins. 

The dose delivered was 50 Gy to the bladder and lymph nodes followed by boost 

to the bladder only 16 Gy giving total dose 66 Gy. 

Results 

For each of the 15 patients 2 DVHs were constructed for the PTV, rectum, 

head of both femurs, one for the conformal technique and the other for the 2D 

technique, they were then exported for the precise treatment planning computer 

system and averaged using Microsoft Excel to “a mean” DVH for each organ 

or volume. The percentage volume receiving different doses was calculated and 

then averaged over the 15 patients to obtain a mean value. These values were 

then plotted to produce a mean DVH for each OARs and PTV. 

Radiation dose to the rectum is much lower in the 3D conformal radiotherapy 

planning compared to the 2D plan as showed in Fig. 1, it was found that the V50 

in the 3D plan is 39% while in the 2D plan is 90%, the V60 for 3D plan is 35% 

while it is 87% in 2D plan, the V70 is 32% for the 3D plan while it is 82% in 

the 2D plan. 

Fig 2: Mean DVH for right femur using 2D technique and 3D technique. 

Fig 3: Mean DVH for left femur using 2D technique and 3D technique. 

Regarding the coverage of the PTV as shown in fig. 4 no difference was found 

between the 3D and 2D techniques where the average dose for the 50 % PTV 

was about 69 Gy, also it was found that the V99 was nearly the same that it was 

102 % for 3D plane and 104 % for 2D plane. 

Fig 1: Mean DVH for rectum using 2D technique and 3D technique. 

Figure 2 showed that the average maximum dose received for the head of right 

femur is in favor for the 3D conformal planning which is 52 Gy compared to 72 

Gy for the 2D planning. The mean average dose for the 3D planning was 43 Gy 

versus 39 Gy for the 2D plan, while for the head of left femur Fig. 3 the mean 

average dose is in favor for 3D conformal planning 57 Gy compared to 69 Gy 

for the 2D technique, it was found that the V50 in both the 2D and 3D plans are 

nearly the same and they are about 44 Gy for both. 

Fig 4: Mean DVH for PTV using 2D technique and 3D technique. 

Discussion 

This preliminary study showed that 3DCRT for bladder cancer produces lower 

dose to OAR including the rectum and head of femur. This supports the use of 

this modality in elderly patients. 



Radiation dose to the rectum is much lower in the 3D conformal radiotherapy 

planning compared to the 2D plan, the V70 is 32% for the 3D plan, while it was 

28% for the study reported by Wojciech et al. 2009 (11), this difference may 

be attributed to the difference in the degree of bladder filling in the patients in 

both studies. 

In the present study, it was found that the V50 for the rectum is 39% in the 3D 

plan while in the 2D plan is 90%, this is similar also to what was reported by 

Chen-Hsi Hsieh et al (12) where the V55 in the rectum was 4.7% for the IMRT 

compared to 46.1% for the 2D planning. 

The average maximum dose received by the head of right femur is in favor 

for the 3D conformal planning which is 52 Gy compared to 72 Gy for the 

2D planning while for the head of left femur it was 57 Gy compared for 3D 

conformal planning to 69 Gy for the 2D technique, this is similar to what was 

reported by Chen-Hsi Hsieh et al (12) who compared 2D planning versus IMRT 

for planning of cancer bladder where the dose received by the IMRT technique 

for the head of right femur was 35% versus 73.7% for the 2D planning and the 

dose received by the head of left femur was 26.5% for IMRT planning versus 

71.1% for the 2D planning much less than that by 2D planning. 

Regarding the coverage of the PTV, no difference was found between the 3D and 

2D techniques, this is different from what was reported by Chen-Hsi Hsieh et al 

(12), where better coverage was found for the IMRT technique than for the 2D 

planning, this difference in attributed to the use of inverse planning of the IMRT 

that allows better intensification of the dose to the target. 

8. Sauer R, Birkenhake S, Kühn R, Wittekind C, Schrott KM, Martus P. Efficacy 

of radiochemotherapy with platin derivatives compared to radiotherapy 

alone in organ-sparing treatment of bladder cancer. Int. J. Radiat. Oncol. 

Biol. Phys. 40(1), 121-127 (1998). 

9. Arias F, Domínguez MA, Martínez E et al. Chemoradiotherapy for muscle 

invading bladder carcinoma. Final report of a single institutional organsparing 

program. Int. J. Radiat. Oncol. Biol. Phys. 47(2), 373-378 (2000). 

10. Taylor A, R0ckall AG, Powel ME: An atlas of the pelvic lymph node regions 

to aid radiotherapy target volume definition. Clin. Oncol. 19, 542-550 

(2007). 

11. Wojciech majewski, m.d. ph. D., iwona wesolowska, m.sc., hubert 

urbanczyk, m.d., ph. D. Et al. Dose distribution in bladder and surrounding 

normal tissue in relation to bladder volume in conformal radiotherapy for 

bladder cancer. Int. J. Radiat oncol biol phys., vol 75, no. 5, pp.1371-1378, 

2009. 

12. Chen-Hsi Hsieh1, Shiu-Dong Chung, Pei-Hui Chan, Siu-Kai Lai, Hsiao- 

Chun Chang, Chi-Huang Hsiao, Le-Jung Wu1, Ngot-Swan Chong1, Yu- 

Jen Chen, Li-Ying Wang, Yen-Ping Hsieh and Pei-Wei Shueng, Intensity 

modulated radiotherapy for elderly bladder cancer patients. Radiat Oncol. 

2011; 6: 75. Published online 2011 June 16. doi: 10.1186/1748-717X-6-75. 

Conclusions and Recommendations 

From the present study, it is recommended to use 3D planning for radical 

radiotherapy for cases of cancer bladder especially in elderly patients as it 

produces good coverage of the target volume as well as good sparing of the 

surrounding critical organs when compared to conventional 2D plan. 

References 

1. Parkin DM, Bray F, Ferlay J et al.: Global cancer statistics, 2002. CA 

Cancer. J Clin. 55, 74-108 (2005). 

2. Stein JP, Lieskovsky G, Cote R et al.: Radical cystectomy in treatment of 

invasive bladder cancer: long term results in 1054 patients. J. Clin. Oncol. 

19, 666-675 (2001). 

3. Zaghloul MS, Nouh A, Moneer M et al.: Time-trend in epidemiological 

and pathological features of schistosomaassociated bladder cancer. J. Egypt. 

Natl Canc. Inst. 20(2), 168-174 (2008). 

4. Rödel C. Current status of radiation therapy and combined-modality 

treatment for bladder cancer. Strahlenther. Onkol. 180(11), 701-709 (2004). 

5. Tester W, Porter A, Asbell S et al. Combined modality program with possible 

organ preservation for invasive bladder carcinoma: results of RTOG protocol 

85-12. Int. J. Radiat. Oncol. Biol. Phys. 25(5), 783-790 (1993). 

6. Kachnic LA, Kaufman DS, Heney NM et al. Bladder preservation by 

combined modality therapy for invasive bladder cancer. J. Clin. Oncol. 

15(3), 1022-1029 (1997). 

7. Shipley WU, Winter KA, Kaufman DS et al. Phase III trial of neoadjuvant 

chemotherapy in patients with invasive bladder cancer treated with selective 

bladder preservation by combined radiation therapy and chemotherapy: 

initial results of Radiation Therapy Oncology Group 89-03. J. Clin. Oncol. 

16(11), 3576-3583 (1998). 


www.amaac.org

notes < 



Male breast cancer in central Tunisia: A retrospective case-series 

M. Hochlef, MD 1 ; G. Marrekchi, MD 1 ; A. Doufaai, MD 1 ; L. Ben Fatma, MD 1 ; O. Gharbi, MD 1 ; I. Chabchoub, MD 1 ; 

F. Zairi, MD 1 ; H. Khairi, MD 2 ; R. Bel Haj Hmida, MD 3 ; R. Ltaif, MD 4 ; M. Mokni, MD 5 ; S. Ben Ahmed, MD 1 . 

(1) Medical oncology department, Farhat Hached Hospital, Sousse 

(2) Gynecology and obstetrics department, Farhat Hached Hospital, Sousse 

(3) General surgery department, Sahloul Hospital, Sousse 

(4) General surgery department, Farhat Hached Hospital, Sousse 

(5) Pathology and cytology department, Farhat Hached, Sousse 

Corresponding Author: Dr Ghassen Marrekchi, MD 

Medical Oncology Department 

Farhat Hached Hospital, Sousse, Tunis 

E-mail: ghassenmarrekchi@yahoo.fr 

Key words: Mastectomy, Chemotherapy, Radiotherapy, Men, Arab. 

ISSN: 2070-254X 

Background 

Male breast cancer (Mbc) represents worldwide less than 1% of malignancies 

in men and 1% of breast carcinomas. Its incidence has increased over the last 

four decades, but remains still very low compared to breast cancer in women (2). 

Mbc has a poor prognosis compared to female breast cancer. This is due to the 

higher rate of advanced stages at presentation and to the lack of clear therapeutic 

strategies. Because of the disease rarity, treatment recommendations for Mbc 

have been extrapolated from results of trials in female patients. 

Our objective was to study the clinical, para clinical, histopathological and 

therapeutic characteristics of patients with Mbc and to assess the survival 

prognostic factors in a 15-year case series treated in central Tunisia. 

Patients and Methods 

We conducted a retrospective review of Mbc cases collected in the oncology 

department of Farhat Hached public hospital in Sousse (Tunisia) over a period of 

fifteen years (January 1996 to December 2010). The diagnosis of breast cancer 

was confirmed by histopathological study for each patient. Results of Scraff- 

Bloom-Richardson grading (SBR) and hormonal receptor status results were 

obtained when available. 

The data analysis including survival curves were conducted with the SPSS 

software. 

Results 

From January 1996 to December 2010, 36 cases of male breast cancer (Mbc) 

were diagnosed in our institution. The mean age at diagnosis was 64 years (range 

34-89 years), with 66% of patients aged between 50 and 80 years. Personal 

medical history of our patients is presented in table 1. 

Five patients had a familial cancer history: two cases of female breast cancer, 

two cases of lung cancer and one case of squamous cell skin carcinoma. No 

patient had a history of another cancer, especially any history of breast cancer. 

Breast tumefaction was the presenting sign common to all patients, followed by 


breast pain in 15 cases (41.7%) and enlarged axillary lymph nodes in 14 cases 

(39%). The right breast was more frequently affected than the left one (58%) 

with no case of bilateral cancer. The retro nipple localization was most frequent 

(66.7%). The tumor size, as noted in the first examination, ranged from 1 to 10 

cm with a mean of 4 cm. Eleven percent of cases had a tumor measuring less 

than 2 cm. 

Radiological diagnosis was made by mammography and/or breast ultrasounds in 

nineteen patients who had a solitary nodular opacity and two who had multifocal 

lesions. Patients’ characteristics are summarized in table 2. TNM staging was 

made using X rays, abdominal ultrasounds and bone scintigraphy. Fifty-five 

percent of patients had a T4 tumor at initial examination. Sixty-eight percent 

had not axillary lymph node involvement (N0), 20% had movable axillary nodes 

(N1) and 12% had fixed nodes (N2). Eight patients (22%) had metastatic disease 

(stage IV): 7 cases of metastases to bone, 3 to lung, 2 to liver and 1 to skin. 

Thirty-five patients had a ductal carcinoma (97%) and 1 patient a mucinous type. 

SBR grading was performed in 35 patients; 8% had SBR I tumor, 67% had SBR 

II tumor and 22% had SBR III tumor. 

A total of 32 patients underwent surgery (89%): 25 had a primary surgery (78%) 

and 7 had a secondary surgery after neoadjuvant chemotherapy. The majority 

(31 patients) had a radical mastectomy with axillary node clearance (ANC); one 

patient had a conservative surgery with ANC. 

Chemotherapy was given in 31 cases: in adjuvant settings for 19 patients 

and in neo adjuvant settings for 7 patients. Five patients received palliative 

chemotherapy. The chemotherapy was mainly based on anthracyclines. 

Seventeen patients received FAC schedules, 11 received FEC schedules and 3 

received CMF schedules (11,12). Twenty-four patients (67%) received adjuvant 

radiotherapy following chemotherapy in all cases. Hormonal therapy was given 

to 27 patients, all with tamoxifen. 

Overall survival (OS) was on average 54 months with a median survival of 60 

months. Two-year and five-year survival rates were respectively 70% and 44 

%.(Fig 1: overall survival curve). Disease free survival (DFS) was on average 

70.5 months with a median survival of 72 months. Two-year and six-year 

DFS rates were respectively 73.6% and 37% (Fig2: DFS curve). Survival was 

significantly better in patients with smaller tumor size (< 2 cm) compared to 

patients with tumors measuring more than 2 cm (p=0.003), this was also true 

for patients with lower stage tumors (stage T1 and T2) compared to patients 

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with higher stage tumors (p=0.006) (Fig 3). Hormone receptor positivity was 

significantly associated with a better survival (p=0.03) (Fig 4). Initially non 

metastatic patients had a significantly better survival compared to those with 

metastases (p=0.03). Patients aged less than 65 years had a better survival 

than older ones (p=0.005). Patients with no clinical axillary lymph nodes (N0) 

had better survival than patients with clinical identifiable lymph nodes (N1 

and N2) but without reaching strict statistical significance (p=0.08). There 

was no statistical difference in survival between patients having histological 

confirmed axillary lymph node metastasis (pN1) and patients with negative 

nodes (pN0) (p=0.8). Similarly, the histopathological characteristics had no 

impact on survival. 

Discussion 

Male breast cancer is rare. According to the Tunisian Center Cancer Registry, 

Mbc incidence between 1998 and 2007 has remained about 0.7 cases per 100.000 

per year. In Tunisia, Mbc represents 1% of malignancies in men and 1.6% of all 

breast cancers, which is concordant with Mbc situation worldwide in general, 

and in the Maghreb countries such as Morocco (0.97%). The relative proportion 

of Mbc among cancers in men is much more important in some sub Saharan 

countries such as Uganda and Zambia (5% and 15% respectively), where 

cervical cancers ranked in the leading position for women. This uncommon 

association led some researchers to hypothesize that since cervical cancer is for 

most a consequence of a sexually transmitted disease, then possibly a STD may 

be at the origin of Mbc in the same region (13). 

Mbc has increased worldwide by 26% in the last three decades, in parallel to 

52% increase in women breast cancer in the same period (1). This is mainly 

explained by the elongation of the average age worldwide, although Mbc is 

considered as cancer of the elderly. A familial history of breast cancer, like in 

female breast cancer, increases the risk of developing a breast neoplasm with 

a relative risk of 2.5 (3,4). Twenty percent of men with breast cancer have a 

familial Mbc history in a first degree parent (3). A personal history of breast 

cancer in one side multiplies by 20 the risk of developing a cancer in the 

opposite breast (4). Some genetic syndromes are associated in 5% of cases with 

breast cancer such as Klinefelter syndrome, Cowden syndrome and BRCA1 or 

BRCA2 mutations. None of these syndromes were found in our patients. Some 

endocrine anomalies have been suggested as risk factors for Mbc. They include: 

cryptorchidism, testicular ectopia, orchidectomy and congenital inguinal hernia. 

In our series, only one case had been operated for inguinal hernia. Gynecomastia 

has been suggested as Mbc risk factor. In some series, the gynecomastia-Mbc 

association reaches 60%. 

Breast tumefaction is the most frequent clinical sign at diagnosis, occurring 

in 93.5% of Mbc (5). It is generally noticed by the patient himself. The breast 

tumefaction is rarely painful (less than 5% of cases) and inflammatory signs 

are generally absent (less than 2%). Other less frequent clinical signs can be 

seen in Mbc such as mammary ulceration (6-17%), mammary retraction (9%) 

and nipple bloody discharge (4-20%) which is correlated with a malign breast 

disease in 75% of cases (5,6). 

The utility of mammography in Mbc is debated because it does not provide, 

generally, supplementary information relative to clinical findings. The main 

advantage of breast ultrasounds is to allow the performance of fine needle 

aspiration cytology and core biopsies, which remain the final diagnostic tests. 

More than 85–90% of Mbc are of the invasive ductal type because the male 

breast normally contains only ducts (6). Thus, lobular type is extremely rare. 

Other histological subtypes can be seen (tubular, mucinous and papillary). 

Ductal carcinoma in situ (DCIS) is relatively rare in breast tumors in men (1- 

10% of cases) compared to women. In a previous Tunisian study about 123 

cases of Mbc, 92% of patients had ductal carcinoma. In our series, almost all 

patients had a ductal carcinoma. The tumor histopathological grade according 

to the SBR grading system is a predictive factor of chemo sensitivity and tumor 

aggressiveness. The distribution of Mbc on SBR grades (grades I, II and III) is 

comparable to female cancers. Aldhiab et al. found SBR II and III tumors in 

81.5% of Mbc. 

In Mbc, tumor size was identified as an independent survival prognostic factor: 

the 5-year survival is 94% in tumors less than 1 cm, 80% in tumors 1-4 cm 

80% and 40% in tumors more than 4 cm 40% (5). In our series, survival was 

significantly better in patients having a tumor size less than 2 cm. Axillary lymph 

node involvement is a very important prognostic factor of survival and replase 

and is decisive for adjuvant treatment modalities (6). In previous series, the rate 

of axillary lymph node metastases ranges from 35 to 75%. This rate is dependent 

on tumor size: about 35% for tumors measuring less than 2 cm and reaching 75% 

for those measuring more than 2 cm. In the Tunisian series of Aldhiab et al. the 

rate of axillary positive lymph nodes was 65%. As in breast cancer in women, 

lymph node involvement is a very important prognostic factor (5). The overall 

5-year survival is estimated to be 85% when there is no lymph node involvement 

and 57% when lymph nodes are involved. 

Mbc is more hormone dependent than in women (7). When comparing hormonal 

receptors in breast cancer between two sexes, breast cancer in men expresses 

estrogen receptors (ER) in 65-93% of cases and progesterone receptors (PR) in 

73-92% of cases; while breast cancer in women expresses ER in 77% and PR 

in 69%. The tumor hormone receptors positivity is not influenced by age like in 

woman breast tumors (5,7). In most Mbc reports, the hormone receptors status 

does not seem to influence survival. This can be due to wide HR positivity in 

Mbc so that it cannot emerge as a survival factor. In our series, HR positivity was 

significantly associated with better survival. This is probably explained by the 

relative balance between positive and negative HR tumors. 

The C-Erb-B2 status is less studied in men compared to woman and the effect of 

trastuzumab therapy is not known. The largest study, reported by Rudlowski et 

al. showed a C-Erb-B2 positivity in 15 of 99 (15). 

In staging Mbc, T4 stage is more frequently found than in female breast cancers. 

This is due to the small volume of male breast, so that the tumor quickly expands 

to the chest wall or the breast upper skin with, in some cases, inflammatory signs. 

A T4 stage tumor or an N2 node status can indicate neoadjuvant chemotherapy 

before surgical resection. 

Most frequent breast cancer metastases are to bone, lung, pleural tissue, liver, 

peripheral lymph nodes and skin (4). The 5-year survival is significantly better 

in non metastatic patients compared to metastatic ones, in this series as in other 

reports (3,4). As Mbc is very rare, its management is of Mbc is guided by 

breast cancer therapeutic approaches in women, in which surgery remains the 

backbone, especially in absence of metastases (4,5). Axillary node dissection 

is an important component of therapy; men who do not receive it tend to have 

poorer outcomes with 10 times more risk of loco regional relapse (5). Radiation 

therapy is an important component in local treatment of breast cancer, generally 

indicated after conservative surgery, positive resection margins or high risk 

breast carcinomas (high SBR grade, positive axillary lymph nodes, capsular 

rupture, lymph vascular invasion…) (8,9). Adjuvant radiation therapy improves 

the relapse free-survival, mainly in high risk tumors (10), but its impact on 

survival is still not proved. Anuradha et al. had demonstrated in a retrospective 

study of 44 Mbc cases that post-mastectomy radiation therapy is useless in small 

and early stage Mbc while it is associated with an improved replase-free survival 

in high risk tumors (10). Men tend to be treated more often with radiation therapy 



than women due to the frequent tumor extension to skin and/or the chest wall. 

Mbc is sensitive to chemotherapy and indications are again guided by woman 

breast cancer guidelines and recommendations. One prospective study conducted 

by Bagley et al. in the National Cancer Institute showed a 5-year survival rate of 

more than 80% in patients with stage II breast cancer treated with adjuvant CMF 

chemotherapy. In many other retrospective studies, adjuvant chemotherapy was 

associated with a reduced risk of relapse and death related to disease. Sharon 

et al. founded that adjuvant chemotherapy was correlated to 43% decreased 

risk of death (7). In metastatic and neoadjuvant settings and in the absence of 

response to hormone therapy, a 13% objective response rate can be achieved 

with fluorouracil mono chemotherapy, whereas 67% objective response can be 

reached with an anthracycline-based chemotherapy (FAC and FEC protocols). 

As Mbc is often HR positive, there is clear evidence that men may benefit from 

the use of hormone therapy. The efficacy of tamoxifen as a treatment of Mbc is 

proven in patients with locally advanced and metastatic disease with 25 to 80% 

of objective response rate (5). Tamoxifen was also associated with an overall 

survival gain (5-year survival with tamoxifen: 44-61%). Hormone therapy with 

tamoxifen can be considered actually as a standard treatment for stage IV male 

breast cancers (7). One series reported that men had some difficulties tolerating 

tamoxifen. Aromatase inhibitors are new hormone therapy drugs which proved a 

highest efficacy in adjuvant and metastatic treatment of post menopausal woman 

breast cancer. Their use is now standard in adjuvant setting, mainly in the high 

risk groups. They have rarely been used in Mbc and their therapeutic role is not 

established. Probably, the biggest series, reported by Giordano et al, studied the 

activity of anastrozole in 5 patients with metastatic Mbc refractory to tamoxifen 

in which there were 3 cases of disease stability (14). 

Conclusion 

Male breast cancer shares many similarities with female breast cancer but 

with some differences mainly in outcome and treatment response. Mbc occurs 

in older patients compared to woman and is generally diagnosed at advanced 

disease stages. Chemotherapy and post-mastectomy radiation therapy in Mbc 

are actually guided by woman breast cancer guidelines and recommendations. 

As Mbc frequently expresses hormone receptors, hormonal therapy mainly with 

tamoxifen proved its efficacy in both adjuvant and metastatic settings. Future 

studies should focus on disease biology to help understanding male breast cancer 

carcinogenesis and to optimize Mbc management. 

Tables 

Table 1: Personal and medical history of male breast cancer cases in central 

Tunisia (1996-2010) (N=36) 

Breast disease 4 cases - 3 cases with gynecomastia 

- 1 case with intragalactophoric 

papillomatosis 

Hypertension 

6 cases 

Diabetes 

3 cases 

Cardiac disease 2 cases Auricular arrhythmia 

Asthma 

1 case 

Surgical intervention 2 cases -1 operated for prostatic adenoma 

-1 operated for inguinal hernia 

Smoking 

12 cases 

Alcohol 

4 cases 

Obesity 

3 cases 

Table 2: Male breast cancer histological characteristics in central Tunisia 

(1996-2010) (N=36) 

Histological subtype 

Infiltrating ductal carcinoma 

Mucinous carcinoma 

SBR grading 

SBR I 

SBR II 

SBR III 

Hormonal receptor status 

Positive 

Negative 

Axillary lymph node involvement 

Negative 

Positive nodes 

> 4 positive nodes 

Capsular rupture 

Yes 

No 

Lymph vascular space invasion 

Yes 

No 

35 

1 

3 

23 

8 

21 

13 

14 

11 

7 

7 

25 

9 

23 

97 % 

3 % 

8.3 % 

66.7 % 

22.2 % 

62 % 

38 % 

43.7 % 

34.3 % 

22 % 

22 % 

78 % 

28 % 

72 % 

Her2-neu status no No 

Disease stage 

stage I 

stage II 

stage III 

stage IV 

(n=36) 

3 

12 

13 

8 

8.3 % 

33.3 % 

36.1 % 

22.2 % 


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Figures 

Fig 1 : Overall survival in Mbc population 

Fig 4: Survival according to tumor HR status 

References 

Fig 2 : Disease-free survival in Mbc population 

Fig 3 : Survival according to local tumor extension (T stage) 

1. Speirs V, Shaaban AM: The rising incidence of male breast cancer. Breast 

Cancer Res Treat 115: 429-430, 2009 

2. Hill TD, Khamis HJ, Tyczynski JE, et aI: Comparison of Male and Female 

Breast Cancer Incidence Trends, Tumor Characteristics, and Survival. Ann 

Epidemiol 15:773-780, 2005 

3. Anderson WF, Jatoi I, Tse J, et al: Male Breast Cancer: A Population-Based 

Comparison With female Breast Cancer. J Clin Oncol 28:232-239, 2009 

4. De Ieso PB, Potter AE, Le H, et al: Male breast cancer: A 30-year experience in 

South Australia. Asia–Pacific Journal of Clinical Oncology 8:187-193, 2012 

5. Lanitis S, Rice AJ, Vaughan A, et al: Diagnosis and management of male 

breast cancer. World J Surg 32:2471-2476, 2008 

6. Giordano SH: A Review of the diagnosis and management of male breast 

cancer. The Oncologist 10:471-479, 2005 

7. Giordano SH, Perkins GH, Broglio K, et al: Adjuvant systemic therapy for 

male breast carcinoma. CANCER 104(11): 2359-2364, 2005 

8. Chakravarthy A, Kim CR: Post-mastectomy radiation in male breast cancer. 

Radiotherapy and Oncology 65: 99-103, 2002 

9. Atahan L, Yildiz F, Selek U, et al: Postoperative radiotherapy in the 

treatment of male breast carcinoma: A single institute experience. Journal of 

the national medical association 98(4):559-563, 2006 

10. Yu E, Suzuki H, Yonus J, et al: The Impact of post mastectomy radiation 

therapy on male breast cancer patients-a case series. Int. J. Radiation 

Oncology Biol. Phys 82(2): 696-700, 2012 

11. Mouret MA, Abrial C, Ferrière J, et al: Neo adjuvant FEC 100 for operable 

breast cancer: eight-year experience at Centre Jean Perrin. Clinical Breast 

Cancer 5(4): 303-307, 2004 

12. Martin M, Villar A, Sole-Calvo A, et al: Doxorubicin in combination with 

fluorouracil and Cyclophosphamide (i.v. FAC regimen, day 1, 21) versus 

Methotrexate in combination with fluorouracil and Cyclophosphamide (i.v. 

CMF regimen, day 1, 21) as adjuvant chemotherapy for operable breast 

cancer: a study by the GEICAM group. Annals of Oncology 14: 833-842, 2003 

13. Amir H, Makwaya C, Moshiro C, et al: Carcinoma of the male breast: a sexually 

transmitted disease? East African Medical Journal 73(3):187-190, 1996 

14. Giordano S, Valero V, Buzdar U, et al: Efficacy of anastrozole in male breast 

cancer. Am J Clin Oncol 25(3): 235-237, 2002 

15. Rudlowski C, Friedrichs N, Faridi A, et al: Her-2/neu gene amplification and 

protein expression in primary male breast cancer. Breast Cancer Res Treat. 

84(3): 215-223, 2004 



Dosimetric study comparing photon and electron Beams for boosting the tumor bed 

in early-stage breast cancer 

Mohamed Mahmoud, MD 1 ; Soha Ahmed, Msc 2 ; Ehab M. Attalla, PhD 1,2 ; Hassan S. Abouelenein, PhD 2 ; Shaimaa Shoier, Bsc 2 ; 

Mohsen Barsoum, MD 1 

(1) Radiation Oncology Department, NCI, Cairo University, Egypt 

(2) Children’s Cancer Hospital, Egypt 

Corresponding Author: Dr Mohamed Mahmoud, MD 

Lecturer of Radiation Oncology 

National Cancer Institute, Cairo University 

E-mail: m_mahmoud1973@yahoo.com 

Key words: 3D-conformal radiotherapy, Electron beam, Organs at risk. 

ISSN: 2070-254X 

Abstract 

Purpose: To assess and compare the potential dosimetric advantages and 

drawbacks of photon beams and electron beams as a boost for the tumor bed in 

superficial and deep seated early-stage breast cancer. 

Materials and methods: planning CTs of 10 women with early breast cancer 

underwent breast conservative surgery were selected. Tumor bed was defined 

as superficial and deep with a cut of point 4 cm, those with less than 4 cm were 

defined as superficial tumors representing 4 patients and those with depth of 4 cm 

or more were classified as deep tumors representing 6 patients. The clinical target 

volume (CTV) was defined as the area of architectural distortion surrounded by 

surgical clips. The planning target volume (PTV) was the CTV plus margin 1 

cm. a dose of 10 Gy in 2 Gy fractions was given concurrently at the last week 

of treatment. Organs at risk (OARs) were heart, lungs, contra-lateral breast and 

a 5-mm thick skin segment of the breast surface. Dose volume histograms were 

defined to quantify the quality of concurrent treatment plans assessing target 

coverage and sparing OARs. The following treatment techniques were assessed: 

photon beam with 3D-conformal technique and a single electron beam. 

Results: for superficial tumors better coverage for CTV and PTV with good 

homogeneity with better CI was found for the 3DCRT but with no significant 

planning objectives over electron beam. For deep tumors, the 3DCRT met the 

planning objectives for CTV, PTV with better coverage and fewer hot spots with 

better homogeneity and CI. For superficial tumors, OARs were spared by both 

techniques with better sparing for the electron beam where as for deep tumors 

also OARs were well spared by both techniques. 

Conclusion: boosting the tumor bed in early-stage breast cancer with optimized 

photon may be preferred to electron beam for both superficial and deep tumors. 

The OARs dose sparing effect may allow for a potential long-term toxicity risk 

reduction and better cosmesis. 

Introduction 

[1,2] but in addition breast-conserving therapy offers an obvious cosmetic 

advantage that may enhance quality of life and lead to less psychological and 

emotional treatment-related distress [3]. 

The rationale for boosting the tumor bed is based on the hypothesis that higher 

local control rates may be achieved if a higher dose of radiation is administered 

to the region of the breast bearing the greatest tumor burden [4]. Although the 

use of a tumor bed boost (10–20 Gy, depending on tumor size and surgical 

margins) is routine practice, there is no standard treatment delivery technique. 

Some authors recommend the use of interstitial implants but most studies report 

the use of electron beams (EBs) to boost the tumor bed [5,6]. Most frequently, 

single 9–12 MeV EB with 2–3 cm margin around the estimated tumor bed is 

used. Such energy range helps to adequately treat shallow targets inside the 

breast. Deep-seated tumors, however, may not adequately be treated with EB, 

though contemporary highly conformal photon beam techniques may be able to 

reduce the dose inhomogeneity within the target while optimally decreasing the 

dose to the surrounding non-target tissues. 

The present study aimed to assess the potential dosimetric advantages and 

drawbacks of the following treatment techniques: 

Conventional approaches with conformal fields with photons (3DC) or also 

single field EB techniques for superficial and deeply seated tumors with a cutoff 

point 4 cm between superficially and deeply seated tumors. 

Methods and Materials 

This study included ten patients (age range 30–60, median 45 years) who had 

received conservative surgery for early-stage unilateral breast cancer (six rightsided 

and 4 left-sided tumors). Distal tumor margins were located at different 

depths between 2.4 to 6.4 cm below the breast surface (i.e., deep-seated tumors) 

in all patients with cutoff point was taken to be 4 cm to differentiate between 

superficially and deeply seated tumors. Tumor and target characteristics are 

summarized in Table 1. 

Breast-conserving surgery followed by whole breast radiation therapy (WBRT) 

and a boost to the tumor bed is the treatment of choice for most patients with 

stages I–II breast cancer. Not only are disease-free and overall survival rates 

after such treatment comparable with those of patients treated by mastectomy 


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Table 1: Tumor characteristics of the 10 patients included in this study: 

Characteristics 

Tumor site 

Left breast 

Right breast 

For Tumors located at a distance < 4 cm 

Proximal depth tumor (cm) 

Mean 

Std dev. 

Distal depth tumor (cm) 

Mean 

Std dev 

For Tumors located at a distance > 4 cm 

Proximal depth tumor (cm) 

Mean 

Std dev. 

.No 

4 

6 

0.5 

+/- 0.5 

3.6 

+/- 0.4 

1.4 

+/- 1.1 

Seeds implanted around the resection cavity by the surgeon or defined by 

the tumor cavity. To account for treatment set-up uncertainties and breathing 

motion the boost planning treatment volume (PTV) was defined as a 1.0-cm 

expansion of the CTV. The prescribed dose was 10 Gy in five daily fractions 

given concomitant at the last week of treatment. 

All patients were panned by 2 techniques: 3D-conformal fields and electron 

beam with calculating the dose to the CTV, PTV and organ at risk. 

3D-conformal static fields 

Multiple static fields ( 2 to 4 fields ) were used with a similar beam arrangement 

as in the conformal plans with simple field conformation to the PTV. All static 

fields included an enhanced dynamic wedge (EDW). Plans were calculated with 

the pencil beam algorithm based on the work by Sturchi et al. [7, 8]. 

Distal depth tumor (cm) 

Mean 

Std dev 


CTV (cc) 

Mean 

Std dev 


CTV (cc) 

Mean 

Std dev 


6.4 

+/- 1.5 

19.8 

+/- 9.1 

64.96 

+/- 41.8 

Electron beams 

The boost was planned with a single conformal portal. The beam energy was 

selected in order to comply with the dosimetric goal mentioned above. The entry 

angle was selected so that the entrance surface was approximately perpendicular 

to the beam central axis Seven patients were planned with 12 MeV electron 

beam and three with 16MeV, respectively. The dose distribution was computed 

with the Generalized Gaussian Pencil Beam model [9, 10]. 

PTV (cc) 

Mean 

Std dev 


45.9 

+/- 5.3 

PTV (cc) 

Mean 

Std dev 

142.1 

+/- 87 

Std dev, standard deviation; CTV, clinical target volume; PTV, planning target 

volume 

The planning CT of the breast region in a free-breathing setting was performed 

postoperatively with the patient in treatment position (i.e., patient on a breast 

board, lying supine, and with the ipsi-lateral arm above the head), radiopaque 

contrast material was placed at the superior, inferior, medial and lateral limits of 

the clinically palpable breast tissue, cuts were taken using a Semins Tomoscan 

AV Helical CT scanner. CT images were acquired in 5 mm slice intervals from 

the mandible through the lung bases. The anatomic information from the CT 

scan was used to define the target volume and normal structures at risk. 

The following organs at risk (OARs) were outlined: ipsi-lateral and contralateral 

breasts and lungs, heart, and the skin covering the ipsi-lateral breast (a 

5-mm thick segment on the breast surface). In all cases surgical clips were placed 

by the surgeon (IR) surrounding the tumor cavity at the time of lumpectomy. 

All patients were first treated with 6 MV photon beams to the entire breast with 

two tangential fields. A total dose of 50 Gy in 25 daily fractions during 5 weeks 

was delivered. The boost clinical target volume (CTV) was defined as the area of 

architectural distortion inside the breast (i.e., tumor bed) surrounded by metallic 

Fig 1: After image registration, two volumes are contoured: the CTV around 

the area of architecture distortion (red) and the PTV by extending the CTV by 

1 cm (green). 

Tools for analysis 

Quantitative evaluation of plans was performed by means of standard Dose– 

Volume Histogram (DVH). For PTV and CTV, the values of D 99% and D 

1% (dose received by 99%, and 1% of the volume) were defined as metrics 

for minimum and maximum doses and consequently reported. To complement 

the appraisal of minimum and maximum dose, V95%, V107% (the volume 



receiving at least 95% or at most 107% of the prescribed dose) were reported. 

The inhomogeneity of the treatment was expressed in terms of D5%–D 95%. 

The conformity of the plans was measured with a conformity index, (CI : ratio 

between the volume receiving at least 95% of the prescribed dose and the 

volume of the PTV). 

For OARs, the analysis included the mean dose, the maximum dose expressed a 

s D 1% and a set of appropriate V X and D Y values. 

Average cumulative DVH for PTV, OARs and healthy tissue was built from the 

individual DVHs. 

Results 

Dose distribution are displayed for one patient for superficial tumor with axial 

views, average DVH plot for the CTV, PTV, OAR and healthy tissue as shown 

in fig. 2, 3, 4 

Fig 4: DVH including CTV, PTV, OAR for superficial tumors 

The same was done for one of the patients with deep tumor where figures 5,6,7 

showed dose distribution, average DVH plots for the CTV, PTV, OAR and 

healthy tissues. 

Fig 2: Dose distribution of 3DCRT for superficial tumors 

Fig 5: Dose distribution of 3DCRT for deep tumors 

Fig 3: Dose distribution of electron beam for superficial tumors 


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V107%(%) 0.6 ± 0.7 1.1 ± 1.6 

PTV 45.9 ± 5.3 45.9 ± 13.3 

Mean(Gy) 10.2 ± 0.1 9.9 ± 0.2 

D1% (Gy) 10.7 ± 0 10.8 ± 0.1 

D5-95%(Gy) 1.2 ± 0.2 1.1 ± 0.1 

D99%(Gy) 9.1 ± 0.1 9 ± 0.2 

V95%(%) 95.9 ± 0.8 84.3 ± 13.1 

V107%(%) 1 ± 0.3 0.8 ± 0.7 

CI 95% 1.4 ± 0.4 2.1 ± 0.9 

CTV, clinical target volume; PTV, planning target volume;, 3D-conformal 

treatment. Dx %, dose received by the x % o f the volume; Vx%, volume receiving 

at least x% o f the prescribed dose; CI, ratio between the patient volume receiving 

at least 95% of the prescribed dose and the volume of the total PTV. 

Fig 6: Dose distribution of electron beam for deep tumors 

No specific planning objectives were imposed in CTV for superficial tumors 

except coverage and homogeneity in 3DCRT technique was better than that for 

electron beam. 

Also no specific planning objectives were imposed in PTV of superficial tumors, 

except better coverage with V95% for the 3DCRT in range of 95.1%- 96.7%, in 

comparison with electron beam that showed V95 between 84.3-85.2. 

Regarding the conformity index (CI), it was much better for the 3DCRT than 

for electron beam. 

Table 3: shows DVH analysis for CTV and PTV for deep tumors 

Table 3 summary of DVH analysis for CTV,PTV for Deep tumors > 4 cm 

Fig 4: DVH including CTV, PTV, OAR for deep tumors 

Data are represented as average over 4 patients with superficial tumors and 

for 6 patients with deep tumors, errors indicated inter-patient variability at one 

standard deviation level. 

Table 2: shows DVH analysis for CTV and PTV for superficial tumors 

Table 2 summary of DVH analysis for CTV,PTV for superficial tumors < 4 cm 

Mean ± SD (3DC) Mean ± SD (Electron) 

CTV 19.8 ± 9.1 19.8 ± 9.1 

Mean (Gy) 10.3 ± 0.1 10 ± 0.2 

D1% (Gy) 10.7 ± 0.1 10.6 ± 0.1 

D5-95%(Gy) 0.5 ± 0.2 0.9 ± 0.1 

D99%(Gy) 9.4 ± 0.5 9.5 ± 0.2 

V95%(%) 99.5 ± 1.4 93.1 ± 6.9 

Mean ± SD (3DC) Mean ± SD (Electron) 

CTV 64.96 ± 41.8 65 ± 41.8 

Mean (Gy) 10.04 ± 0.2 9.8 ± 0.6 

D1% (Gy) 10.4 ± 0.2 10.9 ± 0.4 

D5-95%(Gy) 0.5 ± 0.1 2.3 ± 1 

D99%(Gy) 9.6 ± 0.3 7.8 ± 1.6 

V95%(%) 98.9 ± 1.5 76.3 ± 24.8 

V107%(%) 0.6 ± 1.4 3.1 ± 3.7 

PTV 142.1 ± 87 129.8 ± 68.2 

Mean(Gy) 9.9 ± 0.2 9.6 ± 0.7 

D1% (Gy) 10.4 ± 0.2 10.8 ± 0.3 

D95/D5% 0.9 ± 0 0.7 ± 0.2 

D99%(Gy) 8.9 ± 0.4 7.2 ± 1.9 

V95%(%) 89.6 ± 7.3 70.5 ± 23 

V107%(%) 0.4 ± 0.9 2.8 ± 3.2 

CI 95% 1.4 ± 0.4 1.8 ± 0.2 

CTV, clinical target volume; PTV, planning target volume;, 3D-conformal 

treatment. Dx %, dose received by the x % o f the volume; Vx%, volume receiving 

at least x% o f the prescribed dose; CI, ratio between the patient volume receiving 

at least 95% of the prescribed dose and the volume of the total PTV. 

The 3DCRT met the planning objectives for CTV, PTV with better coverage and 

fewer hot spots with better homogeneity and CI. 



Table 4: shows DVH analysis for organs at risk including healthy tissues for 

superficial tumors. 

Table 4 summary of DVH analysis for organs at risk ( including healthy 

tissue ) for superficial Tumors < 4 cm 

superficial Mean ± SD (3DC) Mean ± SD (Electron) 

Healthy tissue 12949.3 ± 2466.9 12949.3 ± 2181.3 

Mean(Gy) 0.05 ± 0 0.05 ± 0 

V5%(Gy) 0.2 ± 0.1 0.2 ± 0.2 

Doselnt 0.6 ± 0.3 0.7 ± 0.6 

Contra-lateral lung 1160.5 ± 28.2 1160.5 ± 228.4 

Mean(Gy) 0.1 ± 0 0 ± 0 

D1% (Gy) 0.9 ± 0 0.1 ± 0.1 

V3Gy(%) 0.5 ± 0 0 ± 0 

Contra-lateral breast 571.5 ± 143.3 571.5 ± 283.5 

Mean(Gy) 0.2 ± 0 0 ± 0 

D1% (Gy) 0.7 ± 0.1 0 ± 0 

V3Gy(%) 0 ± 0 0 ± 0 

Ipsi-lateral lung 1241.2 ± 61 1241.2 ± 164.2 

Mean(Gy) 0.2 ± 0 0.6 ± 0.4 

D1% (Gy) 1.9 ± 0.1 6 ± 2.1 

V3Gy(%) 1.5 ± 0 5.3 ± 4.6 

V10Gy(%) 0 ± 0 0 ± 0.1 

Ipsi-lateral breast 853.6 ± 173.4 853.6 ± 383.4 

Mean(Gy) 2.5 ± 0.2 1.7 ± 0.5 

D1% (Gy) 10.5 ± 0 10.3 ± 0.1 

V3Gy(%) 29.7 ± 2.8 19.9 ± 5.7 

V10Gy(%) 6.6 ± 0.3 3.4 ± 0.9 

Heart 490.8 ± 24.6 490.8 ± 107.3 

Mean(Gy) 0.05 ± 0 0.1 ± 0.1 

D1% (Gy) 0.7 ± 0 0.9 ± 0.9 

V5Gy(%) 0 ± 0 0 ± 0 

Skin 

(Upr) Mean 6.8 ± 0.8 8.9 ± 0.5 

(Med) Mean 7.1 ± 0.5 8.7 ± 0.3 

(Lwr) Mean 7 ± 0.8 8.8 ± 0.3 

DoseInt, integral dose, [Gy cm 10 5 ] Dx%, dose received by the x % o f the 

volume; Vx%, volume receiving at least x Gy of the prescribed dose. 

There is significant differences were observed for the dose to ipsilateral breast 

according to the treatment technique whether 3DCRT or electron beam, where 

the V10 Gy and V3 Gy were in favor of the electron beam. 

Better sparing of both contralateral lung and contralateral breast was achieved 

with electron beam technique. 

The mean dose of ipsilateral lung ranged from 2% of the prescribed dose for 

3DCRT technique and 6% for the electron beam. 

The mean dose to the heart and maximum dose (D1) is worse with electron beam 

technique than 3DCRT. 

No specific planning objectives regarding skin sparing between both 3DCRT and 

electron techniques as both showed decrease in sparing of the skin with minimal 

advantage to 3DCRT over electron beam. 

Regarding the integral dose to the healthy tissue, both 3CTR and electron beam 

showed comparable results particularly in the lowest volume irradiated to mean 

low dose V5 Gy. 

Table 5 showed summary of DVH analysis to organ at risk for deep tumors 

Table 5 summary of DVH analysis for organs at risk ( including healthy 

tissue ) for deep tumors > 4 cm 

Deep Mean ± SD (3DC) Mean ± SD (Electron) 

Healthy tissue 23069.7 ± 4053.5 20822.1 ± 6592.1 

Mean(Gy) 0.1 ± 0.1 0.1 ± 0.1 

V5%(Gy) 0.3 ± 0.2 0.3 ± 0.3 

Doselnt 2 ± 2.3 1.7 ± 0.9 

Contra-lateral lung 1182.4 ± 118.8 1181.1 ± 118.9 

Mean(Gy) 0.1 ± 0.4 0.1 ± 0.1 

D1% (Gy) 0.4 ± 1 0.5 ± 0.2 

V3Gy(%) 0 ± 0 0 ± 0 

Contra-lateral breast 1344.2 ± 328.5 1344.2 ± 328.5 

Mean(Gy) 0.2 ± 0.4 0 ± 0 

D1% (Gy) 0.4 ± 0.8 0 ± 0 

V3Gy(%) 0 ± 0 0 ± 0 

Ipsi-lateral lung 1242.1 ± 225 1242.1 ± 225 

Mean(Gy) 0.4 ± 0.6 1 ± 0.8 

D1% (Gy) 2.2 ± 2.2 4.5 ± 3 

V3Gy(%) 5.3 ± 12.2 10.3 ± 10.7 

V10Gy(%) 0 ± 0 0 ± 0 

Ipsi-lateral breast 1479.5 ± 811.4 1479.4 ± 811.2 

Mean(Gy) 3.1 ± 1.1 2.4 ± 0.9 

D1% (Gy) 10.3 ± 0.3 10.5 ± 0.1 

V3Gy(%) 35.4 ± 11.6 26.8 ± 9.6 

V10Gy(%) 8.2 ± 7.3 7.5 ± 4.1 

Heart 613 ± 152.5 613 ± 152.5 

Mean(Gy) 0.3 ± 0.7 0.3 ± 0.3 

D1% (Gy) 0.8 ± 1.4 1.3 ± 1.1 

V5Gy(%) 0 ± 0 0 ± 0 

Skin 

(Upr) Mean 6.3 ± 1.5 9.6 ± 0.3 

(Med) Mean 6.3 ± 1.3 9.6 ± 0.2 

(Lwr) Mean 5.9 ± 1.4 9.6 ± 0.3 

DoseInt, integral dose, [Gy cm 10 5 ] Dx%, dose received by the x % o f the 

volume; Vx%, volume receiving at least xGy of the prescribed dose. 

There is significant differences were observed for the dose to ipsilateral breast 

according to the treatment technique whether 3DCRT or electron beam, where 

the V10 Gy and V3 Gy were in favor of the electron beam. 


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There is no difference in sparing the contra-lateral lung in both techniques with 

minimal difference regarding contra-lateral breast in favor of electron beam. 

For the ipsilateral lung the dose received by electron beam was higher for the 

electron beam than for 3DCRT. 

The mean dose to the heart is the same in comparing 3DCRT and electron beam 

for deep tumors; however the maximum dose (D1%) was higher for the electron 

beam. 

Significant difference was observed for the skin dose that showed better skin 

sparing for 3DCRT than for electron beam. 

Regarding the integral dose to the healthy tissue, both 3CTR and electron beam 

showed comparable results particularly in the lowest volume irradiated to mean 

low dose V5 Gy. 

In our study also, for deep tumors > 4 cm, coverage of both the CTV and PTV 

was much better by the 3DCRT than the electron beam with V95% > 95% for 

the CTV and about 90% for the PTV, where as the dose homogeneity was better 

for 3DCRT that( than) for the electron beam, the V107% was much lower for 

the 3DCRT than for electron beam. This is coinciding with what was reported 

by José et al [16]. where the PTV coverage was better for 3DCRT than that of 

electron beam. 

In addition to radiation-induced pneumonitis, worsening of preexisting 

cardiovascular lesions leading to death has been reported after radiation 

therapy for early-stage breast cancer, especially in women with left-sided and 

inner quadrant breast tumors [17–19]. The present study none of the patients 

developed lung or cardiac complications as the dose for both of them was very 

low by both techniques 

Discussion 

The present study addressed a comparative analysis of two techniques with 

photons and electrons to irradiate the tumor bed after surgery for superficial 

and deep-seated early-stage breast cancer patients with a cutoff point of 4 cm 

between superficial and deeply seated tumors. The rationale for this investigation 

was to search for proper coverage of the tumor bed for superficial and deeply 

seated tumors as well as studying the side effects for normal tissue for both 

photon and electron beam. 

Concerning electrons, the study design required the same dose prescription 

definition to that applied to the photon technique. This is different from the 

usual prescription definition for electrons defined by the 100% or 90% as a 

minimum dose within the PTV. The strategy of applying the same prescription 

to all techniques is necessary to perform an appropriate quantitative comparison 

between competing treatments and is standard in planning investigations. 

Single portal 9–12 MeV EB, with a 2–3 cm safety margin around the tumor 

bed has several limitations. Indeed, high EB energies are required to optimally 

cover deep-seated PTVs while overdosing the skin, the heart, the breast, and the 

underlying lung. However, in the EORTC Trial 22881–10882 the 10-year risk 

of severe fibrosis in the tumor bed region increased significantly with higher EB 

energies. [11,12]. 

Therefore, only superficial tumors may be optimally treated with EB. 

Furthermore, it has been suggested that clinical delineation of the target volume 

based only on the surgical scar may frequently miss the target, thereby impairing 

local control [13]. Fiducial markers placed around the lumpectomy cavity can be 

easily identified with imaging techniques such as CT, thus helping to optimize 

treatment planning and dosimetry with potentially better local control and 

cosmetic results [14]. 

In our study the CTV was defined as the area of architectural distortion inside the 

breast surrounded by surgical clips around the resection cavity, and thereafter a 

1.0-cm expansion was used for PTV definition, similar to the method described 

by Kirova et al. [15]. 

For superficial tumors, PTV coverage was much better also for the 3DCRT but 

the V107% was higher than that for the electron beam, with better homogeneity 

and CI for the 3DCRT. This is not going by what is traditionally done in many 

centers where electron beam is considered to be standard for boosting superficial 

tumors less than 4 cm, as in the present study showed that PTV coverage is better 

for 3DCRT by photon. 

Conclusion 

From the present study, we can conclude that tumor bed breast cancer at a 

distance less than 4 cm can be irradiated either by photon or electron, where as 

deeply seated tumors which are found at a distance more than 4 cm are better 

to be irradiated by photon as it provides better coverage with sparing of ORAs 

(OARs). 

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calculation and dose planning in therapeutic electron beams, Ph.D. Thesis, 

Stockholm University, 58p + app., Stockholm; 1986. 

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on local control and survival in breast-conserving therapy of early breast 

cancer: 10 year results of the randomized boost versus no boost EORTC 

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12. Collette S, Collette L, Budiharto T, et al. Predictors of increased risk of 

breast fibrosis at 10 years with higher radiation dose in the early breast 

cancer EORTC Boost versus no boost trial 22881–10882. Eur J Cancer 

2007;5:192 [abstract 2027]. 

13. Benda RK, Yasuda G, Sethi A, et al. Breast boost: are we missing the target? 

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demarcating the excision cavity with surgical clips. Int J Radiat Oncol Biol 

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tumor bed? A multidisciplinary approach in eight steps. Int J Radiat Oncol 

Biol Phys 2008;72:494–500. 

16. José I. Toscas, Dolors Linero, Isabel Rubio et al. Boosting the tumor bed 

from deep-seated tumors in early-stage breast cancer: A planning study 

between electron, photon, and proton beams. Radiotherapy and Oncology 

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www.amaac.org

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Three Dimensional Conformal Radiotherapy (3DCRT) for parotid gland cancer: 

Dose to cochlea, oral cavity and contralateral parotid 

Azza Helal, PhD 1 ; Mohamed Farouk Mostafa, MD 2 ; Abdel Aziz El Nekeidy, MD 3 ; Abbas Omar, MD 2 

(1) Medical Physics Unit, Diagnostic Imaging Department, Faculty of Medicine, Alexandria University 

(2) Clinical Oncology Department, Faculty of Medicine, Alexandria University 

(3) Diagnostic Imaging Department, Faculty of Medicine, Alexandria University 

Corresponding Author: Dr Azza Helal, PhD 

Lecturer of Medical Physics 

Diagnostic Imaging Department, Faculty of Medicine, Alexandria University, Egypt 

E-mail: helals2002@yahoo.com 

Key words: Parotid 3DCRT, Sparing contralateral parotid & cochlea & xerostomia. 

ISSN: 2070-254X 

Introduction 

Parotid gland tumors constitute about 80% of all salivary gland tumors. About 

80% of the tumors are located in the superficial lobe, and most of these tumors 

have an infra-auricular location. Postoperative radiation therapy is highly 

efficacious in decreasing the local recurrence in high risk patients. 

Adjuvant radiotherapy is commonly achieved with a pair of wedged oblique 

beams. However the beams may irradiate the surrounding organs at risk (OARs), 

in particular the cochlea, oral cavity, contralateral parotid, spinal cord and brain 

stem causing significant increase in the risk of oral mucositis, xerostomia, dry 

ear, ear infections, and hearing deficits on the irradiated side. So, proper selection 

of the beam direction to spare the OARs from receiving doses exceeding their 

tolerance values is considered an important factor when treating such patients. 

All CT scans were planned, calculated and treated with 6 MV photon beams on a 

Precise Elekta linear accelerator. The dose of 60Gy was prescribed to the center 

of the PTV. For two cases as the spinal cord maximum dose was high so the dose 

was reduced in a way that the dose to spinal cord did not exceed its tolerance. 

For all plans, isodose distributions and dose volume histogram (DVH) were 

generated. The coverage of PTV was evaluated using the minimum and 

maximum dose. Dose inhomogeneity within PTV was calculated for all patients. 

Sparing of OARs was assessed using the mean dose for parotid & cochlea and 

oral cavity and the maximum point dose of spinal cord, brain stem, lenses, and 

optic nerves. 

Results 

Aim of work 

This study is aiming at reporting the results of doses received by target volumes 

and surrounding organs at risk (OARs) during postoperative 3DCRT treatment of 

parotid gland cancer using ipsilateral 2 oblique wedged and direct lateral fields. 

Methods 

This study included ten patients diagnosed as having parotid cancer, underwent 

superficial parotidectomy and referred to Alexandria Clinical Oncology 

Department (ACOD), during the period from January 2011 to March 2012 

for postoperative radiotherapy to the parotid bed. All the patients had at least 

one indication for post-operative radiotherapy. All patients had computed 

tomography (CT) simulation (3 mm slice thickness) during which they were 

immobilized. The CT data transferred to treatment planning system (Precise 

Elekta). 

All required structures were contoured including GTV, PTV, contralateral 

parotid, oral cavity, ipsilateral & contralateral cochlea, spinal cord, brain stem, 

eyes, lenses and optic nerves. 


Regarding PTV dose coverage; the average of minimum dose to PTV was 57 

Gy and the average of maximum dose was 66 Gy and the percentage of the 

dose inhomogeneity within PTV was 15%. Regarding PTV dose conformity; 

95% isodose wash closely matched the shape of PTV. Regarding OARs sparing, 

the average of the mean dose to contralateral parotid, oral cavity, ipsilateral, 

contralateral cochlea and both eyes was 8Gy, 36Gy, 15Gy, 4Gy and 120cGy 

respectively. The average of the maximum point dose to spinal cord, brain stem, 

both lenses and right and left optic nerve is 32Gy, 21Gy, 180cGy, 180cGy & 

120cGy respectively. All values were far less than the corresponding organ 

tolerance. 

Conclusion 

Post-operative 3DCRT radiotherapy for parotid gland tumors using two 

oblique wedged and one direct lateral fields maintained OARs sparing without 

compromising dose coverage or conformity of PTV. So this technique may be 

considered as a class solution for the treatment of parotid gland tumors without 

the need to a complex technique as IMRT especially in radiotherapy centers 

lacking IMRT. 

www.amaac.org

Introduction 

Malignant salivary gland neoplasms accounts for 3-5% of all head and neck 

cancers. The parotid glands are one of the major salivary glands, with only 20% 

of its tumors being malignant. Mucoepidermoid carcinoma is the most common 

malignant histology affecting the parotids (1) . 

Surgery is the main line of treatment for operable parotid carcinomas, but local 

failure after surgery alone remains high (2) . Postoperative radiotherapy (usually 

60 Gy at 1.8-2 Gy/f) is indicated to decrease local recurrence rate in patients 

with high-grade histology, inadequate surgical margin, perineural invasion and 

nodal disease (3) . 

Postoperative tumor volume includes the operative bed with at least 2cm margin. 

Elective neck irradiation is indicated in certain clinical situations (4, 5) . 

Various radiotherapy techniques have been described; the most commonly used 

is the wedged pair technique with photons which produces a low radiation dose 

to the contra-lateral parotid gland, but have a high exit dose through the oral 

cavity, brain-stem, spinal cord, and the cochlea (4,5) . 

The second most common radiotherapy technique is the mixed photon electron 

beam technique, which uses high energy electron beam 12-20 MEV and low 

energy photon beam 6MV, this technique is usually associated with high dose to 

the contra-lateral parotid gland, skin and mandible, and a more inhomogeneous 

tumor dose distribution (4,5) . 

Although postoperative radiation therapy following surgery is effective in 

controlling malignant tumors of the parotid gland, the beams may irradiate 

the surrounding organs at risk (OARs), in particular the cochlea, oral cavity, 

contralateral parotid, spinal cord and brain stem. This causes a significantly 

increased risk of oral mucositis, xerostomia, infections, and sensorineural 

hearing loss on irradiated side (6) 

So to avoid occurrence of xerostomia, the mean dose to contralateral parotid 

should not exceed 24-26Gy and the mean dose to oral cavity also should be 

around 35 Gy (7) 

To avoid sensorineural hearing loss, which may lead to significant cognitive 

impairment, depression and a reduction in quality of life, the mean cochlear dose 

should not exceeds 40 Gy (8,9) . 

by different planning staff and so decrease the risk of errors in planning and 

(5, 10) 

delivery. 

Aim of work 

This study is aiming at reporting the results of doses received by target volumes 

and surrounding organs at risk (OARs) during postoperative 3DCRT treatment 

of parotid gland cancer using ipsilateral two oblique wedged and a direct lateral 

fields. 

Methods 

This study included ten patients diagnosed as having parotid cancer, underwent 

superficial parotidectomy and referred to Alexandria Clinical Oncology 

Department (ACOD), during the period from January 2011 to March 2012 for 

postoperative radiotherapy to the parotid bed. All the patients had at least one 

indication for post-operative radiotherapy (high-grade histology, inadequate 

surgical margin, presence of perineural invasion and nodal disease) (3) . All 

patients had computed tomography (CT) simulation (3 mm slice thickness) 

during which they were immobilized using individual thermoplastic head masks 

with thermoplastic shoulder fixation. The CT data transferred to treatment 

planning system (Precise Elekta). 

All required structures were contoured, surgical bed and PTV contoured by 

clinical oncologists in accordance with ICRU50 (11) . OARs including contralateral 

parotid, oral cavity, ipsilateral, contralateral cochlea, spinal cord, brain stem, 

eyes, lenses and optic nerves were contoured by consultant radiologist. 

At the start of this work, three different techniques were carried out for six patients 

to find out the optimum technique. The first technique is ipsilateral mixed photon 

electron beam, the second is ipsilateral two oblique wedged photon fields, and 

the third one is ipsilateral two oblique wedged and direct lateral photon fields. 

We decided to complete the work using the third technique. 

For each patient, optimum plan was carried out using ipsilateral two wedged 

anterior and posterior oblique and direct lateral photon fields (figure 1). A dose 

of 60 Gy was prescribed to the center of the PTV according to ICRU (11). For 

two out of the ten cases, the total dose was reduced as the spinal cord maximum 

dose was high. 

For the spinal cord and brain stem, the maximum point dose should be kept 

within their tolerance levels of 45Gy. 

So, optimum plan, which produces conformal dose distributions to the target 

volume while reducing the radiation dose to OAR, should be carried out to 

reduce the side-effects of radiotherapy at same time improve local tumor control. 

This plan should be also, a standardized treatment planning procedure using 

the same set of treatment planning parameters such as beam arrangement for 

all patients within a group for specific tumor site as a starting point. Then the 

adjustments on patient-by-patient basis include field size and the beam weights 

(class solution). Using a class solution for every patient reduces the time 

needed to plan individual patients. It also makes the planning process more 

efficient, encourage consistency between plans produced for individual patients 

For each patient, the field size was adjusted using beam eye view to improve dose 

coverage of PTV. MLCs were used to shape the PTV and to shield the close OAR 

as possible. Gantry angle, wedge angle, and beam weighting were also adjusted. 

A wedge angle of 60 0 was mostly used for oblique fields. In some patients a 

wedge was added to the lateral field with thick end inferior to compensate for 

hot spot produced by air gap at inferior part of the field (caudal). For lateral field, 

beam weight was about 50-70%. No collimation or couch rotation was used. 

Because of the superficial position of parotid bed, a bolus of 1-1.5cm thickness 

was used in all fields to improve target coverage in build up region. 

For all plans, isodose distributions and dose volume histograms (DVH) were 

generated. Plan evaluation depends on dose coverage of PTV, its conformity, 

dose homogeneity within PTV and the sparing of OARs. The coverage of 

PTV evaluated using the minimum and maximum dose. Dose inhomogeneity 



percentage within PTV was calculated for all patients by subtracting the 

minimum from the maximum dose of the PTV. Sparing of OARs was assessed 

using the mean dose for contralateral parotid, cochlea & oral cavity & the 

maximum point dose of spinal cord, brain stem, lenses, and optic nerves. 

Statistical analysis: For all patients, these dose volume parameters were 

recorded and analyzed statistically using excel sheet 2003 (table 1). 

Summary for the dose distribution in ten cases of parotid gland cancer 

For planning target volume (PTV) 

Regarding PTV dose coverage; the average of minimum dose to PTV is 57 

Gy and the average of maximum dose is 66 Gy but the percentage of the dose 

inhomogeneity within PTV is 15%. Regarding PTV dose conformity; 95% 

isodose wash closely match the shape of PTV. 

For organs at risk (OAR) 

The average of the mean dose to contralateral parotid, oral cavity, ipsilateral, 

contralateral cochlea and both eyes is 8Gy, 36Gy, 15Gy, 4Gy and 120cGy 

respectively. The average of the maximum point dose to spinal cord, brain 

stem, both lenses and right and left optic nerve is 32Gy, 21Gy, 180cGy, 180cGy 

& 120cGy respectively. All values are far less than their tolerance. This is 

confirmed by DVH of one case shown in figure 3. As the dose to eyes, lenses and 

optic nerves are comparable for all patients so we did not list it in the table we 

just mentioned the average. 

Fig 1: Left ipsilateral wedged pair & lateral beam arrangement used to generate 

3DCRT. 

Results 

The average of the volume of PTV was 121cc (ranges=42-160cc) and the 

average of the contralateral parotid was 22cc (ranges7-35cc) and the average of 

the volume of cochlea was 0.4cc (ranges 0.2-1cc). 

The three techniques were compared regarding target coverage, conformity, 

dose homogeneity within PTV and OARs sparing. The first technique showed 

underdose of PTV, unaccepted dose inhomogeneity within the PTV (mean=40%) 

and high doses to OARs. Although the dose to OARs with the second technique 

was lower compared to other techniques but the plan was not conformal with 

unaccepted dose inhomogeneity within the PTV (mean=18%). 

Fig 2: 95% isodose wash (white) match the PTV (red). It also shows both 

cochlea in pink, parotid in blue, spinal cord in green and eyes and optic nerves 

in light green 

Regarding the third technique, it showed the best dose homogeneity (15%) 

and conformity compared to other two techniques, although the dose to OARs 

was higher compared to the second technique but it was far lower than OARs 

tolerance. Typical dose distribution for 3DCRT plan using the third technique is 

shown in figure 2, it shows that PTV dose coverage & conformity is excellent as 

95% of the dose completely covers the PTV and closely match its shape. 

Revision of table1, confirm that 3DCRT plans of the present study produced 

excellent target coverage while keeping the dose to both cochlea, contralateral 

parotid, oral cavity, brain stem and spinal cord within acceptable levels 

Fig 3: Dose volume histograms for different OARs for a case with parotid cancer 

planned by 3DCRT. PTV is shown in red, oral cavity in yellow, brain stem in 

light blue, spinal cord in dark green, contralateral parotid in blue & right and 

left cochlea in pink and body max dose in light green. The dose is in percentage. 


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Table 1: 3DCRT dose statistics in Gy for PTV & different OARs for postoperative parotid radiotherapy. PTV dose inhomogeneity in percentage is also shown. 

Pt No 

PTV min 

dose 

PTV max 

dose 

Inhomgenity 

% 

Dose prescribed is 60Gy 

Spinal cord 

max dose 

Brain stem 

max dose 

contralateral 

Parotid 

mean dose 

Oral cavity 

mean dose 

Contral. 

cochlea mean 

dose 

Ipsil, 

cochlea mean 

dose 

1 57 67.20 17 16.8 15.6 6 43.8 1.8 8.4 

2 57 66.60 16 19.8 21 7.8 30.6 1.2 12.6 

3 57 67.20 17 57* 41.4 8.4 51.6 2.4 7.2 

4 57 63 9 18.6 15 7.2 33 1.8 16.8 

5 57 66 15 58.2* 14.4 12.6 45 3.6 3 

6 57 64.20 12 16.8 18 10.2 15 12 40.8 

7 57 67.20 17 36.6 31.8 8.4 31.8 3.6 16.8 

8 57 67.20 17 34.8 22.2 10.2 31.2 12.6 27 

9 57 67.20 17 40.2 19.2 7.8 54.6 1.8 8.4 

10 57.60 64.80 12 23.4 15.6 4.8 27.6 1.2 13.2 

Min 57 63 10 16.8 14.4 4.8 15 1.2 3 

Max 57.60 67.20 16 58.2 41.4 12.6 54.6 12.6 40.8 

Average 57 66 15 32 21 8 36 4 15 

*Patients number 3 &5 were treated with lower doses to avoid the very high dose to the spinal cord where the prescribed dose was reduced to 50Gy (the spinal cord 

dose was 47.5 and 48.5 respectively) 

Discussion 

Post-operative radiotherapy to the parotid bed is an integral part of the 

optimum management of parotid gland carcinoma. Although it reduces local 

recurrence rate, radiation to the organs adherent to the surgical bed or in the 

exit of the irradiating beams may cause serious long standing problems (5) . So, 

optimum radiotherapy technique should ensure good target coverage and dose 

conformity while maintaining the dose to OARs within their tolerance levels. 

This can be achieved by adjusting beam direction and other beam parameters 

(as done in the present study) by using two ipsilateral wedged oblique and direct 

lateral fields. 

Regarding PTV dose coverage; in our study, the average of minimum dose to 

PTV was 57 Gy (95%) and the average of maximum dose was 66 Gy (110%). 

Nutting et al (5) in his study comparing different radiotherapy techniques to the 

parotid gland found that (when using 3DCRT), the min dose to the PTV was 

55Gy (91%) and the maximum dose was 62.8 Gy (105%). Also he found that the 

percentage of the dose inhomogeneity was 13% compared to 15% in our work. 

The dose heterogeneity within PTV in the study done by Yirmibesoglu et al (12) 

was greater and unaccepted with the use of wedged pair (about 30%), compared 

to 15% with 4 fields IMRT and 11% with 7 fields IMRT. 

In spite of the higher radiation dose to the oral cavity and the contralateral 

parotid gland in our study, our results were still below the tolerance dose that 

causes xerostomia, which was determined by Eisbruch et al (13, 14) to be 24-26 

Gy to the contralateral parotid gland, and it agrees with G Studer et al (7) , who 

concluded that a mean dose of 35 Gy is enough to spare oral mucosa. 

The mean dose to ipsilateral & contralateral cochlea in the present study, were 

15Gy & 4Gy respectively. Both values were under the threshold to cause 

sensorineural hearing loss which ranges between 30 and 70 Gy (15,16) . 

Nutting et al (5) who carried out 3DCRT plan using two wedged ipsilateral oblique 

fields to irradiate the parotid, reported the mean dose to the cochlea to be 42.3Gy, 

which is much higher than we achieved. The mean dose of cotnralateral cochlea 

in the study done by Yirmibesoglu et al (12) was 4.8 Gy, 22.5 Gy & 1.6 Gy for 2 

wedged technique, 7 & 4 fields IMRT respectively. 

In the present work the maximum point dose to the brain stem was 21 Gy 

compared to 27.4Gy in the study done by Nutting et al (5) . 

The doses to the brain stem and cochlea achieved in our study were even better 

than doses achieved by IMRT in the study done by Nutting et al (5) . 

In the present work, the average of the mean dose to oral cavity was 36Gy, 

which is much higher than the mean dose to the oral cavity in the study done by 

Nutting et al (5) 

Also in our study, the mean dose to contralateral parotid was 8 Gy compared to 

1.6±0.7 in the study done by Nutting et al. Eda Yirmibesoglu et al (12) compared 

2 wedged technique with 7 & 4 fields IMRT and achieved a mean dose to 

contralateral parotid of 2.4 Gy, 18.6 Gy & 1.1 Gy. 

So, although we achieved higher dose to oral cavity and contralateral parotids 

(compared to other 3DCRT techniques) because we used lateral direct photon 

field, our values still less than the tolerance values of these organs, with better 

doses to the brain stem, ipsilateral and contralateral cochlea and without 

compromise the homogeneity and the conformity of the PTV. 



Conclusion 

Post operative 3DCRT radiotherapy for parotid gland tumors using two oblique 

wedged and direct lateral fields maintained OARs sparing without compromising 

dose coverage or conformity of PTV. So this technique may be considered as a 

class solution for the treatment of parotid gland tumors without the need to a 

complex technique as IMRT especially in radiotherapy centers lacking IMRT. 

M, Bianchi LC, Krengli M, Calabrese L, Ansarin M, Giugliano G, Orecchia 

R. Prospective study on the dose distribution to the acoustic structures during 

postoperative 3D conformal radiotherapy for parotid tumors: dosimetric and 

audiometric aspects. Strahlenther Onkol. 2011 Jun; 187(6):350-6. 2011 May 

16. 

16. Bhide SA, Harrington KJ, Nutting CM. Otological toxicity after 

postoperative radiotherapy for parotid tumours. Clin Oncol (R Coll Radiol). 

2007 Feb;19(1):77-82. 

References 

1. Boahene DK, Olsen KD, Lewis JE, et al. Mucoepidermoid carcinoma of the 

parotid gland. Arch Otolaryngol Head and Neck Surg 2004; 130:849-865. 

2. Ira J. Spiro, C. C. Wang, W. Montgomery. Carcinoma of the Parotid Gland: 

Analysis of Treatment Results and Patterns of Failure after Combined 

Surgery and Radiation Therapy. CANCER. 1993, Volume 71, No. 9 

3. Licitra L, Grandi C, Prott FJ, Schornagel JH, Bruzzi P, Molinari R: Major 

and minor salivary glands tumors. Crit RevOncol Hematol, 45: 215-225, 

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4. Chen AM, Granchi PJ, Garcia J, et al. loco-regional recurrence after surgery 

without post-operative irradiation for carcinoma of the major salivary 

gland: implications for adjuvant therapy. Int J Radiat Oncol Biol Phys 2007; 

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5. Christopher M. Nutting, Carl G. Rowbottom, Vivian P. Cosgrove, et 

al. Optimization of radiotherapy for carcinoma of the parotid gland: a 

comparison of conventional, three-dimensional conformal and intensitymodulated 

techniques. Radiother Oncol. 2001 Aug; 60(2):163-72. 

6. Spiro IJ, Wang CC, Montgomery WW. Carcinoma of the parotid gland: 

analysis of treatment results and patterns of failure after combined surgery 

and radiation therapy. Cancer 1993; 71:2699±2705. 

7. G Studer, PU Huguenin, JB Davis, G Kunz, UM Lütolf and C Glanzmann 

IMRT using simultaneously integrated boost (SIB) in head and neck cancer 

patients. Radiation Oncology 2006, 1:7 

8. Symonds RP, Evans RA, Liu KC, Azhar T. Late audio-vestibular 

consequences of radical radiotherapy to the parotid. Clin Oncol 1992; 

4:203±204. 

9. Talmi YP, Finkelstein Y, Zohar Y. Post-irradiation hearing loss. Audiology 

1989; 28:121±126. 

10. Mott, J.H., Livsey, J.E & Logue,J.P. Development of a simultaneous boost 

IMRT class solution for a hypofractionated prostate cancer protocol. Br J 

Radiol 2004. 77, 377-38 

11. International Commission on Radiation Units and Measurement. ICRU 50. 

Prescribing, recording and reporting photon beam therapy. ICRU report 50. 

Bethesda, MD: ICRU; 1993; 

12. Eda Yirmibesoglu. Dosimetric Evaluation of an Ipsilateral Intensity 

Modulated Radiotherapy Beam Arrangement for Parotid Malignancies., 

poster ASTRO2011 

13. Eisbruch A, Ten Haken RK, Kim HM, Marsh LH, Ship JA. Dose, volume, 

and function relationships in parotid salivary glands following conformal 

and intensity-modulated irradiation of head and neck cancer. Int J Radiat 

Oncol Biol Phys. 1999;45:577–587 

14. D’Hondt E, Eisbruch A, Ship JA. The influence of pre-radiation salivary 

flow rates and radiation dose on parotid salivary gland dysfunction in 

patients receiving radiotherapy for head and neck cancers. Spec Care Dent. 

1998;18:102–108 

15. Jereczek-Fossa BA, Rondi E, Zarowski A, D’Onofrio A, Alterio D, Ciocca 


www.amaac.org

notes < 



Breast cancer with bone metastasis in south of Tunisia: retrospective review 

of 225 cases 

Afef Khanfir, MD 1 ; Faiez Lahiani, MD 1 ; Ghassen Marrekchi, MD 1 ; Jamel Mnif, MD 2 ; Fafhel Guermazi, MD 3 ; 

Hassib Keskes, MD 4 ; Jamel Daoud, MD 5 ; Mounir Frikha, MD 1 

(1) Medical oncology department, Habib Bourguibla Hospital 3029 Sfax, Tunisia 

(2) Radiology department, Habib Bourguibla Hospital 3029 Sfax, Tunisia 

(3) Nuclear medicine department, Habib Bourguibla Hospital 3029 Sfax, Tunisia 

(4) Orthopaedic Surgery department, Habib Bourguibla Hospital 3029 Sfax, Tunisia 

(5) Radiation therapy department, Habib Bourguibla Hospital 3029 Sfax, Tunisia 

Corresponding Author: Dr Marrekchi Ghassen, MD 

Medical oncology Department 

Habib Bourguibla Hospital 3029 Sfax, Tunisia 

E-mail: ghassenmarrekchi@yahoo.fr 

Key words: Bone metastasis, Breast Cancer, Survival. 

ISSN: 2070-254X 

Abstract 

The aim of our study was to expose clinical characteristics, prognostic factors 

and outcome of breast cancer bone metastasis. We conducted a retrospective 

study concerning 332 cases of metastatic breast cancer treated between January 

2000 and December 2007. We reviewed patients’ clinical records, therapeutic 

modalities and survival duration. 

In our series, bone metastases were the most common metastatic site (67, 7%); 

they were isolated (with no visceral metastases) in 54% of cases. Spine, ribs and 

pelvis were more frequently involved with respectively 66%, 31% and 30% of 

cases. Bony pain was the most frequent symptom (63% of cases), followed by 

spinal cord compression and pathologic fractures. All patients received systemic 

anti cancer treatment (chemotherapy and or hormone therapy) associated to 

Biphosphonates in 41% of cases. Surgery was performed in 8 patients and 78 

patients received radiotherapy (52%). Patients with only bone metastases had 

23% five-year survival while it was 4% in those with other visceral metastases. 

Bone metastatic disease in less than 3 sites and loco regional treatment including 

surgery and/or radiotherapy were associated to a significant better survival rate. 

Clinical characteristics of breast cancer bone metastasis were not particular 

in our patients. Survival rate was similar to those of other series in literature. 

Isolated bone metastasis, reduced number of involved sites and loco regional 

treatment were significant predictive factors of better survival. 

cancer metastatic site. The aim of our study was to assess clinical characteristics 

of breast cancer bone metastases and to analyze survival prognostic factors 

according to bone metastases characteristics. 

Patients and methods 

We conducted a retrospective study throw all registered histologically confirmed 

metastatic breast cancer patients treated in the medical oncology department of 

Hbib Bourguiba hospital of Sfax in the south of Tunisia, among a period of 

eight years (from January 2000 to December 2007), whether patients presented 

metastases following a previous diagnosis of the disease or presented metastatic 

disease at the time of initial diagnosis. From 2440 breast cancer patients, 332 

had metastatic disease (13%). Two hundred and twenty-five patients (67.7%) 

had bone metastases. All patients’ files had been reviewed by members of 

medical oncology and radiation therapy departments. We have specified for 

each patient clinical and radiological characteristics, applied treatments, disease 

evolution and survival rate. Survival rate was calculated from the diagnosis 

date of bone metastases to the date of last event. The overall survival was 

obtained by the Kaplan-Meier method and a comparative analysis of prognostic 

factors independently contributing to prolonged survival after bone metastases 

presentation was made by the Log rank test. 

Background 

Results 

Breast cancer is the first gynaecologic cancer worldwide [1]. According to 

the three Tunisian cancer registries (North, centre and south), breast cancer is 

actually in the head of woman malignancies counting for almost 31% of all 

cancers [2]. Metastases are common in breast cancer as 6-10% of breast cancer 

patients had metastatic disease at diagnosis (synchronous metastases) and 60- 

70% of patients with initially localized disease will develop ulterior metastases 

[3]. The maximum of metastatic replase rate occurs in the 2 to 3 years following 

the initial breast cancer treatment [3]. Bone represents the most frequent breast 


1) Clinical, pathological and radiological characteristics 

From 332 patients with metastatic breast cancer, two hundred and twenty-five 

patients (67.7%) had bone metastases. The mean age was 50.5 years. Ductal 

invasive carcinoma was the most frequent histological type (83.1% of cases) 

followed by the lobular type (5.7%). Eight patients had mixed type (ductal and 

lobular). 

Bone was the only metastatic site in 116 patients (51.5%); 119 had bony and 

visceral metastases (liver, lung, brain…). Fifty-three patients (23.5%) had less 

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than 3 bone metastatic sites, 76.5% had more than three. Metastases occur more 

frequently in Spine (table 1). Bone metastases were generally symptomatic: 

136 patients had bony pain, 38 developed spinal cord compression. Fractures 

occurred in 8 cases: it concerns femur in 6 cases, humerus in 1 case and ribs in 1 

case. Serum calcium levels were not noted in our series. 

Osteolytic lesion was the most common radiological presentation. They were 

diagnosed on standard radiographs, CT scan or MRI. In 96 cases, standard 

radiographs did not show any abnormal images and the diagnosis of bone 

metastases was based on scintigraphy (table 2). 

2) Treatment modalities and disease evolution 

All patients received systemic therapy (chemotherapy and/or hormone therapy). 

The choice between chemotherapy and hormone therapy was made according 

to the type of metastases (bone metastases only or associated to visceral ones), 

anterior therapies, hormone receptor status and time to relapse. Ninety-four 

patients (41.7%) received biphosphonates therapy (Pamidronate, Zoledronate or 

Ibandronate). Patients received biphosphonates during a mean period of 18.6 

months (1-96 months). 

Fractures and spine cord compression occurred in 46 patients. These events 

occurred less frequently in biphosphonates treated patients compared to those 

not receiving it, but this did not reach statistical significance (p=0.5). From the 8 

cases of pathological fractures, six had surgery. Seventy-eight patients (34.6%) 

received radiation therapy which was for analgesic purpose in 33 cases (42%), 

décompressive in 32 cases (41%) and curative in 6 cases (8%). Radiation therapy 

was successful in 69% of patients suffering from spine cord compression resulting 

on bony pain control and compression neurologic symptoms improvement. The 

mean time to radiation therapy effect was 26 weeks with as result an important 

reduction in analgesic drugs consumption. 

3) Survival analysis 

Five-year overall survival was 23% in patients with only bone metastases while 

it was 4% in those with visceral and bone ones. Survival was analyzed according 

to number of bone metastatic sites (less or more than 3 sites) and to whether a 

loco regional treatment (by surgery and/or radiation therapy) was associated or 

not to systemic therapy. Patients with less than 3 bone metastatic sites and those 

who had undergone a loco regional treatment had significantly a better survival 

(table 3). 

Discussion 

Bone is the most common metastatic site in breast cancer. In our series, 67.7% 

of patients had bone metastases which is comparable to the literature as bone 

metastases prevalence in breast cancer is between 66% and 77% [4,5,6,7]. In 

breast cancer, bone metastases involve most frequently spine, pelvis and ribs 

[8,9], which is concordant with our series. These metastases can have different 

radiological presentations: ostelytic lesions are the most frequent (65-75% 

of cases); condensing or mixed lesions are rare [9]. In our series, 77.5% of 

metastatic lesions were ostelytic. 

Bone metastases can be painful so that major analgesic drugs and even analgesic 

radiation therapy can be needs. They can be also complicated fractures, spine 

cord compression and hypercalcemia. These events can deeply alter patients’ 

life quality. The data shows that these events occur in 35 to 79.9% of cases 

[10,11,12,13,14,15]. They occurred in 63.2% of our patients. 

Bone metastases in breast cancer are treated as metastatic disease using 

chemotherapy, hormone therapy and targeted therapies. The choice between these 

therapies depends on disease characteristics: associated visceral metastases, time 

to replase, anterior treatments, hormone receptors and Her2 neu status. 

In many series, biphosphonates have shown benefit in metastatic breast cancer by 

reducing bone events morbidity and by improving life quality [10]. Randomized 

trials comparing systemic therapy (chemotherapy or hormone therapy) plus 

biphosphonates versus systemic therapy plus placebo in bone metastatic breast 

cancer have shown a significant decrease in bone skeleton events [10]. In our 

series, forty-six patients experienced bone events; there was less events in the 

group of patients receiving biphosphonates than in the group not receiving it but 

this did not reach significance (p=0.5). 

Bone metastases surgery is indicated in case of pathological fracture or if there 

is an important risk of ulterior fracture [16]. In case of pathological fracture, 

patients eligible for surgery are those who have life expectancy more than 6 

months, good performance status, expected good surgical results and finally 

patients in which surgical treatment looks to have superior results than medical 

treatment alone. 

In case of menacing ostelytic metastases, surgery is indicated if lesions concern 

bearing bones (femur and pelvis mainly), if the lesion measures more than 2 cm 

and if bone cortical destruction exceed 50% [16]. After surgery, bone metastatic 

sites should be irradiated to consolidate them [17]. In our series, 8 patients had 

pathological fractures and 6 of them had undergone surgery followed in all cases 

by radiation therapy. 

Radiation therapy has an important analgesic effect for bone metastases as it 

contributes to bony pain control in 80% of metastatic patients [18,19]. Ninety 

percent of our patients had their pain controlled due to radiation therapy. Single 

doses of 6 to 8 Grays radiation are as efficient as 25 to 40 Grays of fractioned 

radiation therapy. Radiation therapy of 30 Grays in 10 fractions permitted pain 

control in 82% of our patients. The mean time for analgesic effect of radiation 

therapy is usually 11 to 24 weeks. It was 26 weeks in our series. 

Vertebral metastases have worst outcome compared to other bone metastatic 

sites as 5% of them develop spine cord compression. In a randomized trial, 

Patchell at al. [6] concluded that decompressive surgery followed by radiation 

therapy should be preferred to exclusive radiation therapy in case of spine cord 

compression. Exclusive radiation therapy should be performed in case of surgical 

contraindication: poor performance status or irreversible neurological deficit. 

From all osteophilic cancers, thyroid and prostatic carcinomas have best survival 

in case of bone metastases (with 60% and 40% 5-year survival respectively) 

[20,21] followed by breast cancer with 20% 5-year survival [22,23,24]. In our 

series, it was 23%. 

In opposite, renal and lung carcinomas have worst outcome with survival rate 

less than 5-10% [21,25]. 

In our study, the absence of visceral metastases (liver, lung, brain…) was 

significantly correlated to a better survival. In addition, better survival was 

correlated with limited bone metastases (less than 3 sites) and it was improved 

when loco regional treatments (surgery and/or radiation therapy) were associated 

to systemic therapy; these findings are concordant to literature [20,25,26]. 

Our study showed the importance of a multi disciplinary management of breast 

cancer between medical oncologists, radiotherapists and orthopedic surgeons as 

only-bone metastatic breast cancer has significantly better survival than with 

visceral metastases so that we can reach a 5-year survival up to 20%. In our 

series, we have demonstrated that, in metastatic settings, not only systemic 

therapies (chemotherapy and hormone therapy) have impact on survival but also 

loco regional treatment of bone metastases was significantly associated to better 

survival. 



Conclusion 

Metastatic breast cancer is a heterogeneous disease with survival rate depending 

on many factors (RH status, HER over expression, metastatic sites...). Bone 

represents the most frequent breast cancer metastatic site. Only-bone metastatic 

patients have better outcome and should be treated with curative intent mainly 

if there is few metastatic lesions in which local treatment is possible. Surgery 

and radiotherapy had a major role like systemic therapies and biphosphonates in 

the management of bone metastatic breast cancer as they are associated to better 

survival and quality of life. 

Conflicts of interest: no conflict of interest 

Tables 

Table 1: Bone metastatic sites distribution 

Metastatic bone site Number Frequency (%) 

Spine 148 66% 

Ribs 70 31,2% 

Pelvis 68 30,5% 

Head 40 17,7% 

Femur 39 17,4% 

Sternum 31 13,8% 

Humerus 25 11% 

Scapula 24 10,6% 

Clavicles 18 8% 

Table 2: Radiological presentation of bone metastases in standard Rx, CT scan 

and MRI 

Bone metastases characteristics Number Frequency (%) 

Osteolytic lesions 

Condensing 

Mixed 

Standard Rx 

26 

CT scan 100 16 

MRI 56 

Standard Rx 

2 

CT scan 10 4 

MRI 4 

Standard Rx 

3 

CT scan 19 10 

MRI 6 


77.5 % 

7.8 % 

14.7 % 

Rx: Radiography, CT scan: computed tomography scan, MRI: magnetic 

resonance imaging 

Table 3: Survival factors according to bone metastases presentation and 

treatment 

Prognostic factors 5-year survival p 

Only bone metastases 

Vs 

23% 

0,001 

Visceral and bone metastases 

4% 

Less than 3 bone metastatic sites 

Vs 

More than 3 bone metastatic sites 

20% 

13% 

0,037 

Loco regional treatment of bone 

metastases 

Vs 

No loco regional treatment 

References 

21% 

11% 

0,013 

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dans le sud tunisien. Cancer Radiother 10: 565–571, 2006 

2. Ben Abdallah M, Zakhama S, Maalej M, et al: Cancer du sein en Tunisie: 

caractéristiques épidémiologiques et tendance évolutive de l'incidence. 

Tunis Med 87: 417 – 425, 2009 

3. Dawood S, Broglio K, Ensor J, et al: Survival differences among women 

with de novo stage IV and relapsed breast cancer. Ann Oncol 21: 2169- 

2174, 2010 

4. Andre F, Slimane K, Bachelot T, et al : Breast cancer with synchronous 

metastases: trends in survival during a 14-year period. J Clin Oncol 22: 

3302-3308, 2004 

5. Jimeno A, Amador ML, González-Cortijo L, et al: Initially metastatic breast 

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6. Le Scodan R, Stevens D, Brain E, et al: Breast cancer with synchronous 

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8. Tubiana-Hulin M: Incidence, prevalence and distribution of bone metastases. 

Bone 12 Suppl 1: 9-10, 1991 

9. Major PP, Cook RJ, Lipton A, et al: Natural history of malignant bone 

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measure skeletal morbidity. BMC Cancer 9: 272, 2009 

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Toronto Sunnybrook Regional Cancer Centre experience. Support Care 

Cancer 12: 48-52, 2004 

11. Dearnaley DP, Sydes MR, Mason MD, et al: A double blind, placebocontrolled, 

randomized trial of oral sodium clodronate for metastatic cancer 

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study comparing clodronate versus placebo in patients with breast cancer 

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métastatique et des formes cliniques particulières. Traité EMC Gynécologie 

[871-A-10], 1997 

17. Rosseta P, Coipeaua P : Chirurgie et cimentoplastie dans la prise en charge 

www.amaac.org

des métastases osseuses. Cancer Radiother 10: 425-429, 2006 

18. Gaze MN, Kelly CG, Kerr GR, et al: Pain relief and quality of life following 

radiotherapy for bone metastases: a randomised trial of two fractionation 

schedules. Radiother Oncol 45: 109-116, 1997 

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strategy for patients with bone metastasis from thyroid carcinoma. Surgery 

147:424-431, 2010 

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metastatic breast cancer treated with Herceptin®: a place for biological 

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of skeletal metastases. Eur J Pain 6: 323- 330, 2002 

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Classification of patients with Metastatic Renal Cell Carcinoma of Bone. 

Eur Urol 52:163-169, 2007 

27. Khanfir A, Frikha M, Ghorbel A, et al: Prognostic factors in metastatic 

nasopharyngeal carcinoma. Cancer Radiother 11: 461-467, 2007 


news from the arab world < 


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Tawam Hospital 

Emirates Oncology Conference 

8 - 10 November 2012, Emirates Palace, Abu Dhabi, UAE 

“Setting Higher Standards in Cancer Care” 

Speakers from Johns Hopkins Medicine, USA, Europe, Middle East & UAE 

The conference will cover recent advances in different Oncology specialties 

Call for abstracts 

The deadline for submission will be : 31st July 2012 

Clinical Topics: 

Breast Cancer, Lung Cancer, GI Malignancies 

Urologic Malignancies, Gynecologic Malignancies, Hematologic Malignancies 

Pediatric Oncology/Hematology, Oncology Nursing, Palliative Care 

For more information & submission of abstracts, please contact: 

Jihad Kanbar. T: 00971-3-7074742 - F: 00971-3-7074837 - email: jkanbar@tawamhospital.ae 

For registrations: 

Hassan Hazime: hhazime@tawamhospital.ae 

Working towards applying for HAAD CME accreditation 

Faculty of Medicine 

and Health Sciences 




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5 th Post graduate course 

on Hepatology and Gastroenterology 

December 7-8, 2012 

Indorsed by: 

The American College of Gastroenterology (ACG) 

& 

World Gastroenterology Organization (WGO) 

Emerging Stars Award 

Learning Center 

For more details, Online sending of abstracts and Online reservations 

Kindly visit our website: www.alfamedical.org 

ALFA MEDICAL Team: 

Tel. +20-24532916 / 7 

Executive Manager: +20-1119039064 

Assistant Manager: +20-1119039065 

e-mail: alfa@alfamedical.org 

53 El-Makrizy St. Roxy, Cairo, EGYPT 



14 th International Workshop 

on Therapeutic GI Endoscopy 

December 9-10, 2012 

In collaboration with: 

The American Society for Gastrointestinal Endoscopy 

& 

European Society of Gastrointestinal Endoscopy 

For the first time in the Middle East: Hand on 

endoscopy training 

For more details, Online sending of abstracts and Online reservations 

Kindly visit our website: www.alfamedical.org 

ALFA MEDICAL Team: 

Tel. +20-24532916 / 7 

Executive Manager: +20-1119039064 

Assistant Manager: +20-1119039065 

e-mail: alfa@alfamedical.org 

53 El-Makrizy St. Roxy, Cairo, EGYPT 


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notes < 


cancer awareness calendar < 

january 

Cervical Cancer Awareness Month 

february 

Screening and Early Detection Awareness Month 

march 

Colorectal Cancer Awareness Month 

april 

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may 

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june 

National Cancer Survivors Day 

july 

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august 

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september 

Gynecologic Cancer Awareness Month 

Prostate Cancer Awareness Month 

Leukemia and Lymphoma Awareness Month 

october 

Breast Cancer Awareness Month 

november 

Lung Cancer Awareness Month 

Smoking Cessation 

december 

5 A Day Awareness Month 


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objectives & scope of the PAJO < 

The Pan Arab Journal of Oncology (PAJO) is the official Journal of the Arab Medical Association Against Cancer (AMAAC). It is a 

quarterly publication targeting health professionals interested in the oncology field. It is a multidisciplinary peer-reviewed journal that 

publishes articles addressing medical oncology, malignant hematology, surgery, radiotherapy, pediatric oncology, geriatric oncology, 

basic research and the comprehensive management of patients with malignant diseases in addition to international oncology activities, 

congresses & news. 

The journal will be addressed, as a first step, mainly to the professionals in the hematology & oncology field in the Middle East 

region and North Africa. The goal is to share local & regional research activities news and to be updated with international activities. 

We hope, with your support, to achieve our following objectives: 

1. Promote and encourage research activities in the Arab World. 

2. Disseminate & analyze epidemiological local, regional and international data. 

3. Update health professionals with the most recent advances, news & developments in the field of oncology. 

4. Improve the level of scientific publications arising form the Arab World. 

5. Keep health professionals connected and exposed to the activities of different Arab cancer societies. 

6. Share with our immigrant compatriots their activities & feedback in this field. 

7. Involve all health professionals interested in the field of Oncology within the multidisciplinary scope of the Journal. 

8. Encourage post graduates students to submit their research work. 

instructions for authors < 

1. Manuscript Categories 

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The Editor-in-Chief and an Associate Editor generally review 

Reports from clinical trials. Selected manuscripts are also reviewed 

by at least two external peer reviewers. Comments offered by 

reviewers are returned to the author(s) for consideration. 

Manuscript acceptance is based on many factors, including the 

importance of the research to the field of oncology & the quality 

of the study. Authors should focus on accuracy, clarity, and brevity 

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All manuscripts should be submitted in word and PDF format 

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2006), it is the PAJO’s intent, as previously referred, to ensure 

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manuscripts and manuscripts that have been accepted and are 

pending publication should be cited in the reference list. 

Reference Style 

º Journal article with one, two, or three authors 

1. Dolan ME, Pegg AE: O6-Benzylguanine and its role in 

chemotherapy. Clin Cancer Res 8:837-847, 1997 

º Journal article with more than three authors 

2. Knox S, Hoppe RT, Maloney D, et al: Treatment of cutaneous 

T-cell lymphoma with chimeric anti-CD4 monoclonal antibody. 

Blood 87:893-899, 1996 

º Journal article in press (manuscript has been accepted for 

publication) 

3. Scadden DT, Schenkein DP, Bernstein Z, et al: Combined 

immunotoxin and chemotherapy for AIDS-related non-Hodgkin’s 

lymphoma. Cancer (in press) 

º Supplement 

4. Brusamolino E, Orlandi E, Morra E, et al: Analysis of long-term 

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esults and prognostic factors among 138 patients with advanced 

Hodgkin’s disease treated with the alternating MOPP/ABVD 

chemotherapy. Ann Oncol 5:S53-S57, 1994 (suppl 2) 

º Book with a single author 

5. Woodruff R: Symptom Control in Advanced Cancer. Victoria, 

Australia, Asperula Pty Ltd, 1997, pp 65-69 

º Book with multiple authors 

6. Iverson C, Flanagin A, Fontanarosa PB, et al: American Medical 

Association Manual of Style (ed 9). Baltimore, MD, Williams & 

Wilkins, 1998 

º Chapter in a multiauthored book with editors 

7. Seykora JT, Elder DE: Common acquired nevi and dysplastic 

nevi as precursor lesions and risk markers of melanoma, in 

Kirkwood JM (ed): Molecular Diagnosis and Treatment of 

Melanoma. New York, NY, Marcel Dekker, 1998, pp 55-86 

º Abstract 

8. Bardia A, Wang AH, Hartmann LC, et al: Physical activity and 

risk of postmenopausal breast cancer defined by hormone receptor 

status and histology: A large prospective cohort study with 18 

years of follow up. J Clin Oncol 24:49s, 2006 (suppl; abstr 1002) 

9. Kaplan EH, Jones CM, Berger MS: A phase II, open-label, 

multicenter study of GW572016 in patients with trastuzumab 

refractory metastatic breast cancer. Proc Am Soc Clin Oncol 

22:245, 2003 (abstr 981) 

º Conference/meeting presentation 

10. Dupont E, Riviere M, Latreille J, et al: Neovastat: An 

inhibitor of angiogenesis with anti-cancer activity. Presented at 

the American Association of Cancer Research Special Conference 

on Angiogenesis and Cancer, Orlando, FL, January 24-28, 1998 

º Internet resource 

11. Health Care Financing Administration: Bureau of data 

management and strategy from the 100% MEDPAR inpatient 

hospital fiscal year 1994: All inpatients by diagnosis related groups, 

6/95 update. http://www.hcfa.gov/a1194drg.txt 

º Digital Object Identifier (DOI) 

12. Small EJ, Smith MR, Seaman JJ, et al: Combined analysis 

of two multicenter, randomized, placebo-controlled studies of 

pamidronate disodium for the palliation of bone pain in men with 

metastatic prostate cancer. J Clin Oncol 10.1200/JCO.2003.05.147 

Figures 

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Arabic numerals. Figures should be submitted in a seperate 

documen. Figure legends are required for all article types. Figure 

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text using Arabic numerals. The table’s legend may include any 

pertinent notes and must include definitions of all abbreviations 

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with multiple parts will be renumbered. Tables should be submitted 

in a seperate document. Legends must not exceed 55 words per 

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Appendices/Acknowledgments 

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of the article. 

Language: Appropriate use of the English language is encouraged 

for publication in the Journal. 

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Copyright Form 

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completed the form. 

Page Proofs 

Corresponding author will receive proofs and must carefully 

review them for data and typesetting errors. Corrections to proofs 

must be returned by e-mail, fax, or mail within 1 week. The 

corresponding author is responsible for collecting and submitting 

all author corrections into a single submission. Publication may 

be delayed if proofs are not returned by the publisher’s deadline. 

The Editor-in-Chief must approve all major alterations, which 

may delay publication of the manuscript. 

º Government Announcement/Publication 

13. Miller BA, Ries CAG, Hankey BF, et al (eds): Cancer Statistics 

Review: 1973-1989. Bethesda, MD, National Cancer Institute, 

NIH publication No. 92-2789, 1992 

º ASCO Educational Book 

14. Benson AB 3rd: Present and future role of prognostic and 

predictive markers for patients with colorectal cancer. Am Soc 

Clin Oncol Ed Book 187-190, 2006 


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Aranesp ® (darbepoetin alfa) SureClick Brief Prescribing Information. Please refer to the 

Summary of Product Characteristics before prescribing Aranesp ® . Pharmaceutical Form: 

Solution for injection presented in prefilled pens containing 150, 300, and 500 micrograms of 

darbepoetin alfa, for single-dose use only. Indication: Treatment of symptomatic anaemia in adult 

cancer patients with non-myeloid malignancies receiving chemotherapy. Dosage and 

Administration: Cancer patients: Aranesp ® should be administered by the subcutaneous route to 

patients with anaemia (e.g. haemoglobin concentration ≤10 g/dL (6.2 mmol/l)) in order to increase 

haemoglobin to not greater than 12 g/dL (7.5 mmol/l). Anaemia symptoms and sequelae may vary 

with age, gender, and overall burden of disease; a physician’s evaluation of the individual patient’s 

clinical course and condition is necessary. Due to intra-patient variability, occasional individual 

haemoglobin values for a patient above and below the desired haemoglobin level may be 

observed. Haemoglobin variability should be addressed through dose management, with 

consideration for the haemoglobin target range of 10 g/dL (6.2 mmol/l) to 12 g/dL (7.5 mmol/l). A 

sustained haemoglobin level of greater than 12 g/dL (7.5 mmol/l) should be avoided; guidance for 

appropriate dose adjustments for when haemoglobin values exceeding 12 g/dL (7.5 mmol/l) are 

observed are described below. The recommended initial dose is 500 μg (6.75 μg/kg) given once 

every three weeks, or once weekly dosing can be given at 2.25 μg/kg body weight. If the clinical 

response of the patient (fatigue, haemoglobin response) is inadequate after nine weeks, further 

therapy may not be effective. Aranesp ® therapy should be discontinued approximately four weeks 

after the end of chemotherapy. Once the therapeutic objective for an individual patient has been 

achieved, the dose should be reduced by 25 to 50% in order to ensure that the lowest approved 

dose of Aranesp ® is used to maintain haemoglobin at a level that controls the symptoms of 

anaemia. Appropriate dose titration between 500 μg, 300 μg, and 150 μg should be considered. 

Patients should be monitored closely, if the haemoglobin exceeds 12 g/dL (7.5 mmol/l), the dose 

should be reduced by approximately 25 to 50%. Treatment with Aranesp ® should be temporarily 

discontinued if haemoglobin levels exceed 13 g/dL (8.1 mmol/l). Therapy should be reinitiated at 

approximately 25% lower than the previous dose after haemoglobin levels fall to 12 g/dL (7.5 

mmol/l) or below. If the rise in haemoglobin is greater than 2 g/dL (1.25 mmol/l) in 4 weeks, the 

dose should be reduced by 25 to 50%. Contraindications: Hypersensitivity to darbepoetin alfa, 

r-HuEPO or any of the excipients. Poorly controlled hypertension. Special Warnings and 

Precautions: General: blood pressure should be monitored in all patients, particularly during 

initiation of Aranesp ® therapy. If blood pressure is difficult to control by initiation of appropriate 

measures, the haemoglobin may be reduced by decreasing or withholding the dose of Aranesp ® . 

Iron status should be evaluated for all patients prior to and during treatment and supplementary 

iron therapy may be necessary. Non-response to therapy with Aranesp ® should prompt a search 

for causative factors. Deficiencies of iron, folic acid or vitamin B12 reduce the effectiveness of 

erythropoiesis-stimulating agents and should therefore be corrected. Intercurrent infections, 

inflammatory or traumatic episodes, occult blood loss, haemolysis, severe aluminium toxicity, 

underlying haematologic diseases, or bone marrow fibrosis may also compromise the 

erythropoietic response. A reticulocyte count should be considered as part of the evaluation. If 

typical causes of non-response are excluded, and the patient has reticulocytopenia, an 

examination of the bone marrow should be considered. If the bone marrow is consistent with 

PRCA, testing for anti-erythropoietin antibodies should be performed. Pure red cell aplasia caused 

by neutralising anti-erythropoietin antibodies has been reported in association with erythropoiesisstimulating 

agents (ESAs), including darbepoetin alfa. This has been predominantly reported in 

patients with CRF treated subcutaneously. Cases have also been reported in patients with hepatitis 

C treated with interferon and ribavirin, when epoetins are used concomitantly (ESAs are not 

indicated for use in this patient population). These antibodies have been shown to cross-react with 

all erythropoietic proteins, and patients suspected or confirmed to have neutralising antibodies to 

erythropoietin should not be switched to darbepoetin alfa. Active liver disease was an exclusion 

criteria in all studies of Aranesp ® , therefore no data are available from patients with impaired liver 

function. Since the liver is thought to be the principal route of elimination of Aranesp ® and 

r-HuEPO, Aranesp ® should be used with caution in patients with liver disease. Aranesp ® should 

also be used with caution in those patients with sickle cell anaemia or epilepsy. Convulsions have 

been reported in patients receiving Aranesp ® . Misuse of Aranesp ® by healthy persons may lead to 

an excessive increase in packed cell volume. This may be associated with life-threatening 

complications of the cardiovascular system. The needle cover of the pre-filled syringe contains dry 

natural rubber (a derivative of latex), which may cause allergic reactions. In patients with chronic 

renal failure, maintenance haemoglobin concentration should not exceed the upper limit of the 

target haemoglobin concentration. In clinical studies, an increased risk of death, serious 

cardiovascular events and vascular access thrombosis was observed when ESAs were 

administered to target a haemoglobin of greater than 12 g/dL (7.5 mmol/l). Controlled clinical trials 

have not shown significant benefits attributable to the administration of epoetins when 

haemoglobin concentration is increased beyond the level necessary to control symptoms of 

anaemia and to avoid blood transfusion. Cancer patients: Effect on tumour growth. Epoetins are 

growth factors that primarily stimulate red blood cell production. Erythropoietin receptors may be 

expressed on the surface of a variety of tumour cells. As with all growth factors, there is a concern 

that epoetins could stimulate the growth of tumours. In several controlled studies, epoetins have 

not been shown to improve overall survival or decrease the risk of tumour progression in patients 

with anaemia associated with cancer. In controlled clinical studies, use of Aranesp ® and other 

ESAs have shown: shortened time to tumour progression in patients with advanced head and neck 

cancer receiving radiation therapy when administered to target a haemoglobin of greater than 14 

g/dL (8.7 mmol/l) (ESAs are not indicated for use in this patient population); shortened overall 

survival and increased deaths attributed to disease progression at 4 months in patients with 

metastatic breast cancer receiving chemotherapy when administered to target a haemoglobin of 

12-14 g/dL (7.5-8.7 mmol/l); increased risk of death when administered to target a haemoglobin 

of 12 g/dL (7.5 mmol/l) in patients with active malignant disease receiving neither chemotherapy 

nor radiation therapy (ESAs are not indicated for use in this patient population). In view of the 

above, in some clinical situations blood transfusion should be the preferred treatment for the 

management of anaemia in patients with cancer. The decision to administer recombinant 

erythropoietins should be based on a benefit-risk assessment with the participation of the 

individual patient, which should take into account the specific clinical context. Factors that should 

be considered in this assessment should include the type of tumour and its stage; the degree of 

anaemia; life-expectancy; the environment in which the patient is being treated; and patient 

preference. In patients with solid tumours or lymphoproliferative malignancies, if the haemoglobin 

value exceeds 12 g/dL (7.5 mmol/l), the dosage adaptation described in the Posology and Method 

of Administration section should be closely respected, in order to minimise the potential risk of 

thromboembolic events. Platelet counts and haemoglobin level should also be monitored at regular 

intervals. Pregnancy and Lactation: No adequate experience in human pregnancy and lactation. 

Exercise caution when prescribing Aranesp ® to pregnant women. Do not administer to women who 

are breastfeeding. When Aranesp ® therapy is absolutely indicated, breastfeeding must be 

discontinued. Undesirable Effects: General: There have been reports of serious allergic reactions 

including anaphylactic reaction, angioedema, allergic bronchospasm, skin rash and urticaria 

associated with darbepoetin alfa. Clinical Trial Experience - Cancer patients: Adverse reactions 

were determined based on pooled data from seven randomised, double-blind, placebo-controlled 

studies of Aranesp ® with a total of 2112 patients (Aranesp ® 1200, placebo 912). Patients with 

solid tumours (e.g., lung, breast, colon, ovarian cancers) and lymphoid malignancies (e.g., 

lymphoma, multiple myeloma) were enrolled in the clinical studies. Incidence of undesirable 

effects considered related to treatment with Aranesp ® from controlled clinical studies: Very 

common (≥1/10) Oedema; Common (≥1/100 to

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