Includes bibliographical references. / Whilst the benefit of adjuvant radiotherapy in gastric cancer is known, the optimal means of delivery, including two dimensional conventional, three dimensional conformal radiotherapy, intensity modulated radiotherapy and volumetric modulated arc therapy is less certain. The purpose of this study is to assess and compare volumetric modulated arc therapy (VMAT) and three dimensional conformal radiotherapy (3DCRT) plans in adjuvant radiation of gastric cancer.

Background: Predictive factors for long-term outcomes in osteosarcoma patients are still controversial. There is no literature available regarding these factors in a patient population in a developing country. Objectives: To determine the outcome of treatment of osteosarcoma patients treated at Groote Schuur Hospital from 1990-2012 in terms of local control (LRC), disease free survival (DFS) and overall survival (OS) and to determine the value of suggested predictive factors in this population. Patients and methods: Retrospective review of all patients diagnosed and treated with osteosarcoma at Groote Schuur Hospital between 1990 and 2012, considering OS, DFS and LC. This review assesses the significance of suggested predictive factors from other studies, namely, HIV status, age at diagnosis, site of primary disease, type of chemotherapy used, response to chemotherapy and type of surgery in terms of OS, DFS and LC. Results: Forty-three patients with histologically confirmed osteosarcoma were treated at Groote Schuur Hospital between 1990 and 2012. Median 5 year OS was 57.8%. On univariate analysis, the site of disease was the only statistically significant predictive factor for prognosis. Conclusion: On univariate analysis, patients with axial disease have a worse predicted prognosis than those with primary disease in their extremities. The long-term outcome in our local clinical setting correlates favourably with the available international data. Due to the limited number of patients in the review, further research into HIV status, age, type of chemotherapy, type of surgery and their predictive value for prognosis in our patients with osteosarcoma is warranted.

Objective: A retrospective review was conducted to ascertain whether there are differences in outcome or complications between node-negative patients with stage IB cervical cancer who were treated with adjuvant standard field as opposed to small pelvic field radiotherapy (RT). Study design: A retrospective observational study of patients with stage IB cervical cancer treated with radical surgery between 1984 and 2010 at Groote Schuur Hospital, Cape Town, South Africa. Two different pelvic radiation field sizes were used for adjuvant post-operative RT in node-negative patients during this period: standard whole pelvic fields (WPF), or with reduced-size, "small pelvic field" (SPF) RT since 1991. These two methods reflect changes in protocol over the period of this review. Cisplatin given concurrently with radiation has been used since 1999. Cancer control and grade 3 and 4 toxicities were compared between the two groups. The aim of this study was primarily to examine whether adjuvant SPF RT is a safe approach. A literature review was conducted on the subject of post-operative adjuvant RT, especially in node-negative patients; one aim was to discover how widely the SPF approach is used throughout the world. There was no indication in the literature that this approach has been used elsewhere in South Africa. Results: The SPF technique was first advocated by Prof Neville Hacker in Australia in 1991. The first publication by his group on SPF was in 1999, followed by several subsequent retrospective reports from Asian centers. In the current audit study, 31 patients were found in the WPF group, and 56 in the SPF group. The overall 5-year survival rate was 85%. No significant differences in survival rates were found between the WPF and SPF groups (log rank p=0.67) It was found that relapse patterns did not differ between the two groups and the same applied to the crude grade 3-4 treatment morbidity rates, although two patients in the WPF group (6%) died from their complications. Conclusions: The expected benefit of the SPF approach, which targets the central pelvic tumour bed, is a reduction in small bowel morbidity and lymphoedema. It is not possible to conclude from this study whether the SPF technique is unsafe by increasing out-of-field pelvic relapses, or whether it truly reduces complications. The literature review reveals that most studies of SPF involved relatively few patients and events were infrequent, whether recurrences or morbidity. A randomized controlled trial could theoretically settle this issue but it seems unlikely ever to be performed as a large sample size would be required. Intermittent single institution, or multi-institutional pooled comparisons, with historical WPF controls seem to be the best option.

Includes bibliographical references.

Objectives: The objective of this study was to compare the outcome of two cohorts of patients with anal squamous carcinoma treated with split course chemoradiation as opposed to continuous chemoradiation at Groote Schuur Hospital. Demographics including age at diagnosis, gender and HIV status were reviewed. The stage at diagnosis, the acute treatment toxicities and all surgical procedures were noted. The outcomes included complete response rate, local control rate, loco-regional failure free survival, colostomy-free survival and overall survival. Design and Methods: The data was obtained from patient records of all patients with histologically confirmed anal squamous cell carcinoma seen and registered at the Department of Radiation Oncology at Groote Schuur Hospital. Patients included were those treated with radical intent that presented between the years of 2008 and 2012. This data was then compared with a similar study performed between 2000-2 004-. Results: A total of 72 patients diagnosed with anal squamous carcinoma were seen at Groote Schuur Hospital in the 5-year period, of which 4-0 patients fitted the criteria for this study. The median age was 53 years, with a slight male preponderance (55%) and 27.5% tested HIV positive. A total of 68% of patients had T3 and T4- disease, with 4-2.5% node positive disease. The complete response rate was 60%, the local control rate was 52.5% and the loco-regional failure free survival at 5 years was 56%. The colostomy-free survival was I-"4-% and the 5-year overall survival was 4-0.67%. Haematological, gastrointestinal and skin toxicities were reviewed and the most common acute side effect experienced was grade 2[32.5%] and grade 3[4-15%] skin toxicity. Conclusion: The patient characteristics and treatment toxicities are in keeping with previous study findings. However, complete response rate and overall survival were less than expected. Although there was no statistically significant difference in overall survival between the two cohorts of patients, there was a definite trend to inferior treatment outcomes of those patients treated with continuous chemoradiation. We propose radiation dose escalation for future treatment of patients presenting with anal carcinoma at Groote Schuur Hospital.

Includes abstract. Includes bibliographical references.

Background: Stereotactic radiosurgery (SRS) is the gold standard for treatment of small and medium sized tumours, although fractionated regimens are well described. Access is limited in resource-constrained settings. There are no South African data describing outcomes of AN patients treated with fractionated stereotactic radiotherapy (SRT) using photons. We describe clinical and radiological outcomes of AN patients treated with SRT at an academic centre in Cape Town, South Africa. Objectives: To describe patient demographics, tumour characteristics and patients’ symptoms and changes in symptoms at follow-up. To investigate tumour local control (LC) rates at last follow up MRI, and compare LC rates described for SRS in the literature. To correlate radiologists’ serial 2D maximum linear diameter (MLD) measurements with calculated 3D tumour volume (TV). Methods: Fifteen AN patients treated with modified SRT (18.0gy/3fractions, were identified from the planning database; 13 were included. Patient data and tumour characteristics (size, laterality and previous surgery) were retrospectively extracted from clinic folders. Initial planning data was accessed and checked. Tumour volumes were contoured by the author on all subsequent MRI’s per patient and validated by a second investigator; tumour volume (TV) was automatically calculated. Radiologist’s 2D MLDs were compared with 3D TV. Sensitivity and specificity of radiologist reported change of MLD as a measure of actual change in TV was calculated. LC was calculated, from time of treatment to time of last MRI or time of progression (defined as ≥20% increase in TV). Results: Mean age was 60.4years (range 45-79years), with 4 (30.8%) being female. Seven patients (53.8%) had left sided tumours and median tumour size was 1.15cm3 (mean 1.59 cm3; range 0.62-3.35 cm3). Nine patients (69.2%) had Koos stage 2 ANs, 3 (23.1%) had stage 3 tumours and 1 (7.7%) had a stage I tumour. Two patients had NF2.Median follow-up time 12 was 29 months (range 0-50 months). Median baseline TV, as was 1.15 cm3 (mean 1.59cm3 with range 0.62-3.35 cm3). Three patients had no follow-up MRIs: 2 demised and 1 declined further follow-up. In total 5 patients died, 4 of unrelated causes and 1 of unknown cause (median time to death after RT 24 months, range 6 - 36 months). LC was 74% at 36months. Hearing preservation rate was 67%. No new facial or trigeminal nerve symptoms were noted. Radiologists correctly reported tumour growth in 100% of tumours that grew, and specificity was 77.3% in those that were stable. Conclusion: This is the first local study in hypofractionated SRT using photons. We show lower LC rates than seen in literature; our numbers are small and short follow up time short, with high attrition rates. Acute treatment toxicities were absent. Longer term follow-up is needed to assess late RT effects. A prospective study using this method of treatment would better define LC.

Purpose: To retrospectively evaluate and compare the loco-regional progression free survival (PFS), overall survival (OS) and acute effects of the two breast palliative regimes used in patients with locally advanced or metastatic breast cancer between 2010 and 2013 in a single institution. Methods: Compliance to treatment, acute skin reactions, progression free and overall survival were retrospectively evaluated in patients who received palliative breast radiotherapy for locally advanced breast cancer between 2010 and 2013. The radiotherapy regimes were either 4Gy per fraction for 5 fractions treated 4 times a week (20Gy) or 6Gy per fraction for 6 fractions treated once a week (36Gy). They may have received previous chemotherapy with minimal or no clinical response, as well as hormonal treatment. Results: Forty three patients were followed up over a median period of 24 months, 14 of which received 20Gy and 29 received 36Gy. The average age was 64 years old. Compliance was 88% in both groups. Both groups had either grade 1 (71% vs 62%), grade 2 (21% vs 24%) or grade 3 (8% vs 14%) acute skin reactions. No grade 4 skin reactions were documented. The PFS was shorter at 4.5 months in the 20Gy group compared to 7.7 months in the 36Gy group (p=0.27). The OS was also shorter at 25.8 months in the 20Gy group compared to 29.6 months in the 36Gy group (p=0.51) Conclusion: This study did not show a statistically significant difference in terms of PFS and OS between the two radiotherapy regimes. They both remain reasonable options in local palliation in patients with locally advanced breast cancer.

Includes abstract. Includes bibliographical references.

INTRODUCTION: Worldwide, there is a paradigm shift in the screening for cervical cancer with the use of high-risk human papillomavirus (hrHPV) molecular testing. Before South Africa (SA) adopts this technology in the public sector, health funders will need data on the performance of the current cytology and colposcopy-based programmes. This study was done to establish baseline data on the performance of the cytology and colposcopy based cervical cancer screening programme at the Groote Schuur Hospital (GSH) colposcopy clinic. METHODS: This was a retrospective cohort study of all the women with high grade squamous intraepithelial lesion (HSIL) Pap smears seen at GSH colposcopy clinic between 01 January 2010 and 31 December 2015. The outcome measures were; diagnostic concordance between cytology, colposcopy and histology, large loop excision of the transformation zone (LLETZ) and cone biopsy complication rates, cure rate, treatment failure and invasive cervical cancer rates, median time from treatment to recurrence, follow-up default rates. Data were managed and analysed using IBM SPSS Statistics Version 25 and Microsoft Structured Query Language (SQL) version 2014. Regression methods were used to assess the independent effect of baseline sociodemographic characteristics and clinical covariates on treatment failure and clearance of disease in those who had persistent disease after treatment. Kaplan-Meier curves were used to represent the time from treatment to recurrence and from persistence to cure. Time-to-event methods were applied to determine factors associated with treatment to recurrence and persistence to cure. RESULTS: A total of 7601 women were referred to the GSH colposcopy clinic during the study period. HSIL or worse lesions (≥HSIL) were confirmed histologically in 74.1% (2282/3081) women. At the four-month follow-up visit, 61.2% (742/1213) of the women were considered cured, and 17.0% (206/1213) had persistent/residual disease. In women considered cured at four months, recurrence was very low, and it peaked at ten months at 1.5% (11/740). By 24 months the cumulative recurrence rate was 4.6% (34/742). In women with persistent disease at the four-month follow-up visit, only 0.5% (1/202) developed invasive cervical cancer. The default rate for follow-up was very high, at 81% at 24 months. LLETZ and cone biopsy complication rate was 7.2% (117/1628). Log-rank analysis showed that parity ≥ four was significantly associated with a higher risk of disease recurrence (p=0.0004). In a Coxregression model, taking HAART was the only factor associated with a reduced risk of disease recurrence (p=0.0261). CONCLUSION: LLETZ and cone biopsy are safe procedures. After cure, recurrence rates are low. In women who are treated for HSIL, cervical cancer is very rare. Taking HAART was associated with a reduced risk of disease recurrence. There is a need to mitigate on higher default rates to follow up.